Preliminary evaluation of a three-dimensional, customized, and preformed titanium mesh in peri-implant alveolar bone regeneration
Identifieur interne : 003224 ( Pmc/Corpus ); précédent : 003223; suivant : 003225Preliminary evaluation of a three-dimensional, customized, and preformed titanium mesh in peri-implant alveolar bone regeneration
Auteurs : Gyu-Un Jung ; Jae-Yun Jeon ; Kyung-Gyun Hwang ; Chang-Joo ParkSource :
- Journal of the Korean Association of Oral and Maxillofacial Surgeons [ 2234-7550 ] ; 2014.
Abstract
The purpose of this preliminary study is to evaluate the effectiveness of a customized, three-dimensional, preformed titanium mesh as a barrier membrane for peri-implant alveolar bone regeneration.
Ten patients were recruited for this study. At the time of implant placement, all patients had fenestration or a dehiscence defect around the implant fixture. A mixture of particulate intraoral autologous bone and freeze-dried bone allograft was applied to the defect in a 1 : 1 volume ratio and covered by the preformed titanium mesh. A core biopsy specimen was taken from the regenerated bone four months postoperatively. Patients were followed for 12 months after the definitive prosthesis was placed.
Satisfactory bone regeneration with limited fibrous tissue was detected beneath the preformed titanium mesh. Histologic findings revealed that newly formed bones were well-incorporated into the allografts and connective tissue. New growth was composed of approximately 80% vital bone, 5% fibrous marrow tissue, and 15% remaining allograft. All implants were functional without any significant complications.
The use of preformed titanium mesh may support bone regeneration by maintaining space for new bone growth through its macro-pores. This preliminary study presents the efficacy of a preformed titanium mesh as a ready-to-use barrier membrane around peri-implant alveolar bone defect. This preformed mesh is also convenient to apply and to remove.
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DOI: 10.5125/jkaoms.2014.40.4.181
PubMed: 25247148
PubMed Central: 4170664
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Preliminary evaluation of a three-dimensional, customized, and preformed titanium mesh in peri-implant alveolar bone regeneration</title><author><name sortKey="Jung, Gyu Un" sort="Jung, Gyu Un" uniqKey="Jung G" first="Gyu-Un" last="Jung">Gyu-Un Jung</name><affiliation><nlm:aff id="A1">Department of Periodontology, Ewha Womans University Mokdong Hospital, Seoul, Korea.</nlm:aff></affiliation></author><author><name sortKey="Jeon, Jae Yun" sort="Jeon, Jae Yun" uniqKey="Jeon J" first="Jae-Yun" last="Jeon">Jae-Yun Jeon</name><affiliation><nlm:aff id="A2">Division of Oral and Maxillofacial Surgery, Department of Dentistry, Hanyang University College of Medicine, Seoul, Korea.</nlm:aff></affiliation></author><author><name sortKey="Hwang, Kyung Gyun" sort="Hwang, Kyung Gyun" uniqKey="Hwang K" first="Kyung-Gyun" last="Hwang">Kyung-Gyun Hwang</name><affiliation><nlm:aff id="A2">Division of Oral and Maxillofacial Surgery, Department of Dentistry, Hanyang University College of Medicine, Seoul, Korea.</nlm:aff></affiliation></author><author><name sortKey="Park, Chang Joo" sort="Park, Chang Joo" uniqKey="Park C" first="Chang-Joo" last="Park">Chang-Joo Park</name><affiliation><nlm:aff id="A2">Division of Oral and Maxillofacial Surgery, Department of Dentistry, Hanyang University College of Medicine, Seoul, Korea.</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">25247148</idno><idno type="pmc">4170664</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4170664</idno><idno type="RBID">PMC:4170664</idno><idno type="doi">10.5125/jkaoms.2014.40.4.181</idno><date when="2014">2014</date><idno type="wicri:Area/Pmc/Corpus">003224</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">003224</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Preliminary evaluation of a three-dimensional, customized, and preformed titanium mesh in peri-implant alveolar bone regeneration</title><author><name sortKey="Jung, Gyu Un" sort="Jung, Gyu Un" uniqKey="Jung G" first="Gyu-Un" last="Jung">Gyu-Un Jung</name><affiliation><nlm:aff id="A1">Department of Periodontology, Ewha Womans University Mokdong Hospital, Seoul, Korea.</nlm:aff></affiliation></author><author><name sortKey="Jeon, Jae Yun" sort="Jeon, Jae Yun" uniqKey="Jeon J" first="Jae-Yun" last="Jeon">Jae-Yun Jeon</name><affiliation><nlm:aff id="A2">Division of Oral and Maxillofacial Surgery, Department of Dentistry, Hanyang University College of Medicine, Seoul, Korea.</nlm:aff></affiliation></author><author><name sortKey="Hwang, Kyung Gyun" sort="Hwang, Kyung Gyun" uniqKey="Hwang K" first="Kyung-Gyun" last="Hwang">Kyung-Gyun Hwang</name><affiliation><nlm:aff id="A2">Division of Oral and Maxillofacial Surgery, Department of Dentistry, Hanyang University College of Medicine, Seoul, Korea.</nlm:aff></affiliation></author><author><name sortKey="Park, Chang Joo" sort="Park, Chang Joo" uniqKey="Park C" first="Chang-Joo" last="Park">Chang-Joo Park</name><affiliation><nlm:aff id="A2">Division of Oral and Maxillofacial Surgery, Department of Dentistry, Hanyang University College of Medicine, Seoul, Korea.</nlm:aff></affiliation></author></analytic><series><title level="j">Journal of the Korean Association of Oral and Maxillofacial Surgeons</title><idno type="ISSN">2234-7550</idno><idno type="eISSN">2234-5930</idno><imprint><date when="2014">2014</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Objectives</title><p>The purpose of this preliminary study is to evaluate the effectiveness of a customized, three-dimensional, preformed titanium mesh as a barrier membrane for peri-implant alveolar bone regeneration.</p></sec><sec><title>Materials and Methods</title><p>Ten patients were recruited for this study. At the time of implant placement, all patients had fenestration or a dehiscence defect around the implant fixture. A mixture of particulate intraoral autologous bone and freeze-dried bone allograft was applied to the defect in a 1 : 1 volume ratio and covered by the preformed titanium mesh. A core biopsy specimen was taken from the regenerated bone four months postoperatively. Patients were followed for 12 months after the definitive prosthesis was placed.</p></sec><sec><title>Results</title><p>Satisfactory bone regeneration with limited fibrous tissue was detected beneath the preformed titanium mesh. Histologic findings revealed that newly formed bones were well-incorporated into the allografts and connective tissue. New growth was composed of approximately 80% vital bone, 5% fibrous marrow tissue, and 15% remaining allograft. All implants were functional without any significant complications.</p></sec><sec><title>Conclusion</title><p>The use of preformed titanium mesh may support bone regeneration by maintaining space for new bone growth through its macro-pores. This preliminary study presents the efficacy of a preformed titanium mesh as a ready-to-use barrier membrane around peri-implant alveolar bone defect. This preformed mesh is also convenient to apply and to remove.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Br Nemark, Pi" uniqKey="Br Nemark P">PI Brånemark</name></author><author><name sortKey="Zarb, Ga" uniqKey="Zarb G">GA Zarb</name></author><author><name sortKey="Albrektsson, T" uniqKey="Albrektsson T">T Albrektsson</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Misch, Cm" uniqKey="Misch C">CM Misch</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="H Mmerle, Ch" uniqKey="H Mmerle C">CH Hämmerle</name></author><author><name sortKey="Karring, T" uniqKey="Karring T">T Karring</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Simion, M" uniqKey="Simion M">M Simion</name></author><author><name sortKey="Baldoni, M" uniqKey="Baldoni M">M Baldoni</name></author><author><name sortKey="Zaffe, D" uniqKey="Zaffe D">D 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<front><journal-meta><journal-id journal-id-type="nlm-ta">J Korean Assoc Oral Maxillofac Surg</journal-id><journal-id journal-id-type="iso-abbrev">J Korean Assoc Oral Maxillofac Surg</journal-id><journal-id journal-id-type="publisher-id">JKAOMS</journal-id><journal-title-group><journal-title>Journal of the Korean Association of Oral and Maxillofacial Surgeons</journal-title></journal-title-group><issn pub-type="ppub">2234-7550</issn><issn pub-type="epub">2234-5930</issn><publisher><publisher-name>The Korean Association of Oral and Maxillofacial Surgeons</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">25247148</article-id><article-id pub-id-type="pmc">4170664</article-id><article-id pub-id-type="doi">10.5125/jkaoms.2014.40.4.181</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original Article</subject></subj-group></article-categories><title-group><article-title>Preliminary evaluation of a three-dimensional, customized, and preformed titanium mesh in peri-implant alveolar bone regeneration</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Jung</surname><given-names>Gyu-Un</given-names></name><xref ref-type="aff" rid="A1">1</xref><xref ref-type="author-notes" rid="FN1">*</xref></contrib><contrib contrib-type="author"><name><surname>Jeon</surname><given-names>Jae-Yun</given-names></name><xref ref-type="aff" rid="A2">2</xref><xref ref-type="author-notes" rid="FN1">*</xref></contrib><contrib contrib-type="author"><name><surname>Hwang</surname><given-names>Kyung-Gyun</given-names></name><xref ref-type="aff" rid="A2">2</xref></contrib><contrib contrib-type="author" corresp="yes"><name><surname>Park</surname><given-names>Chang-Joo</given-names></name><xref ref-type="aff" rid="A2">2</xref></contrib></contrib-group><aff id="A1"><label>1</label>Department of Periodontology, Ewha Womans University Mokdong Hospital, Seoul, Korea.</aff><aff id="A2"><label>2</label>Division of Oral and Maxillofacial Surgery, Department of Dentistry, Hanyang University College of Medicine, Seoul, Korea.</aff><author-notes><corresp>Corresponding author: Chang-Joo Park. Division of Oral and Maxillofacial Surgery, Department of Dentistry, Hanyang University College of Medicine, 222 Wangsimni-ro, Seongdong-gu, Seoul 133-791, Korea. TEL: +82-2-2290-8646, FAX: +82-2-2290-8673, <email>fastchang@hanyang.ac.kr</email></corresp><fn id="FN1" fn-type="equal"><p><sup>*</sup>These authors contributed equally to this work.</p></fn></author-notes><pub-date pub-type="ppub"><month>8</month><year>2014</year></pub-date><pub-date pub-type="epub"><day>26</day><month>8</month><year>2014</year></pub-date><volume>40</volume><issue>4</issue><fpage>181</fpage><lpage>187</lpage><history><date date-type="received"><day>15</day><month>5</month><year>2014</year></date><date date-type="rev-recd"><day>13</day><month>7</month><year>2014</year></date><date date-type="accepted"><day>17</day><month>7</month><year>2014</year></date></history><permissions><copyright-statement>Copyright © 2014 The Korean Association of Oral and Maxillofacial Surgeons. All rights reserved.</copyright-statement><copyright-year>2014</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc/3.0/"><license-p>This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc/3.0/">http://creativecommons.org/licenses/by-nc/3.0/</ext-link>) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p></license></permissions><abstract><sec><title>Objectives</title><p>The purpose of this preliminary study is to evaluate the effectiveness of a customized, three-dimensional, preformed titanium mesh as a barrier membrane for peri-implant alveolar bone regeneration.</p></sec><sec><title>Materials and Methods</title><p>Ten patients were recruited for this study. At the time of implant placement, all patients had fenestration or a dehiscence defect around the implant fixture. A mixture of particulate intraoral autologous bone and freeze-dried bone allograft was applied to the defect in a 1 : 1 volume ratio and covered by the preformed titanium mesh. A core biopsy specimen was taken from the regenerated bone four months postoperatively. Patients were followed for 12 months after the definitive prosthesis was placed.</p></sec><sec><title>Results</title><p>Satisfactory bone regeneration with limited fibrous tissue was detected beneath the preformed titanium mesh. Histologic findings revealed that newly formed bones were well-incorporated into the allografts and connective tissue. New growth was composed of approximately 80% vital bone, 5% fibrous marrow tissue, and 15% remaining allograft. All implants were functional without any significant complications.</p></sec><sec><title>Conclusion</title><p>The use of preformed titanium mesh may support bone regeneration by maintaining space for new bone growth through its macro-pores. This preliminary study presents the efficacy of a preformed titanium mesh as a ready-to-use barrier membrane around peri-implant alveolar bone defect. This preformed mesh is also convenient to apply and to remove.</p></sec></abstract><kwd-group><kwd>Alveolar bone loss</kwd><kwd>Histology</kwd><kwd>Surgical mesh</kwd></kwd-group></article-meta></front><body><sec><title>I. Introduction</title><p>Dental implantation is an effective therapeutic option to replace missing teeth in modern dentistry. In order for an implant to successfully sustain functional loads, there must be sufficient alveolar bone around the implant. Implants must be at least 5 mm wide and 7-10 mm in length<xref rid="B1" ref-type="bibr">1</xref>. After implantation, dehiscence or fenestration defects frequently occur because of insufficient residual bone volume. Bone augmentation should be performed prior to and/or simultaneously with implant placement when the preoperative examination shows a lack of alveolar bone volume at the implant placement site. Alveolar bone defects may be treated with various bone regeneration techniques including block bone graft, guided bone regeneration (GBR), ridge splitting, and distraction osteogenesis<xref rid="B2" ref-type="bibr">2</xref>,<xref rid="B3" ref-type="bibr">3</xref>,<xref rid="B4" ref-type="bibr">4</xref>,<xref rid="B5" ref-type="bibr">5</xref>. GBR is one of the most predictable methods, which mostly uses a barrier membrane to separate the grafted defect and the surrounding connective tissue for successful bone regeneration<xref rid="B3" ref-type="bibr">3</xref>. Barrier membranes are either resorbable or non-resorbable membranes. Two major types of non-resorbable barrier membranes are expanded polytetra-fluoroethylene (e-PTFE) and titanium mesh<xref rid="B6" ref-type="bibr">6</xref>. Despite many advantages of GBR, it is difficult to maintain suitable space for ideal bone regeneration because unless there is a hard structure to support the space, soft tissue collapses into it.</p><p>Titanium mesh has been widely used for oral and maxillofacial defect reconstruction<xref rid="B7" ref-type="bibr">7</xref>. It is biocompatible and rigid enough to maintain the grafted space<xref rid="B6" ref-type="bibr">6</xref>. It has been applied to various defects indicated for GBR, including sinus augmentation sites<xref rid="B8" ref-type="bibr">8</xref>,<xref rid="B9" ref-type="bibr">9</xref>. Several studies have used GBR procedures with titanium mesh and various bone graft materials including autologous bone, bovine bone mineral, alloplastic materials, and their combinations<xref rid="B8" ref-type="bibr">8</xref>,<xref rid="B10" ref-type="bibr">10</xref>,<xref rid="B11" ref-type="bibr">11</xref>,<xref rid="B12" ref-type="bibr">12</xref>,<xref rid="B13" ref-type="bibr">13</xref>,<xref rid="B14" ref-type="bibr">14</xref>. However, studies that have used titanium mesh and allogeneic graft, especially freeze-dried bone allograft (FDBA), are rare. Few of these studies present histologic evidence of bone maturation on the grafted site with titanium mesh and FDBA.</p><p>One complication related to titanium mesh is the high risk of exposure following repeated mucosal irritation. Although titanium mesh exposure does not always lead to bone augmentation failure in a clinical setting<xref rid="B8" ref-type="bibr">8</xref>,<xref rid="B13" ref-type="bibr">13</xref>, the bone quality of GBR would be adversely affected<xref rid="B15" ref-type="bibr">15</xref>. Before its application, titanium mesh should be cut, bent, and trimmed. Any prominent, sharp edges resulting from these manipulations may cause membrane exposure. Recently, preformed titanium mesh with round and blunt edges were developed to prevent mucosal irritation.</p><p>We used a customized, three-dimensional, preformed titaniumn mesh (SMARTbuilder; Osstem, Busan, Korea) to reconstruct the peri-implant defects occurring immediately after implant placement. Clinical and histologic investigations were used to evaluate the preformed titanium mesh's efficacy as a barrier membrane against a mixture of autologous and FDBA in localized alveolar bone regeneration.</p></sec><sec><title>II. Materials and Methods</title><sec><title>1. Patient selection</title><p>A total of 10 patients (5 male and 5 female, aged 17-87 years) who were partially edentulous participated in this study between August 2012 and June 2014 at Hanyang University Hospital. Preoperative clinical and radiologic evaluations indicated that the GBR procedure should be performed simultaneously with the implant placement in all patients. Guidelines of the Helsinki Declaration were followed during all treatment phases. This study was approved by the Institutional Review Board of Hanyang University Hospital (HYH IRB 2012-06-014).</p></sec><sec><title>2. Surgical technique</title><p>Implant were placed under local anesthesia using a trapezoidal full-thickness flap with two vertical releasing incisions. A total of 12 implants (TS III CA; Osstem) in 10 patients were inserted by the standard procedure. In all cases, the implant threads were partially exposed and the GBR procedure was performed for these peri-implant defects. The preformed titanium mesh was selected according to the defect size and its configurations.(<xref ref-type="fig" rid="F1">Fig. 1</xref>) The height (or anchor) was connected to the implant fixture. Then, the preformed titanium mesh was located on that height and immobilized by cover cap for a staged approach or by healing abutment for transmucosal GBR. The height, cover cap, and healing abutment were specifically designed for the preformed titanium mesh.(<xref ref-type="fig" rid="F1">Fig. 1</xref>)</p><p>All 10 patients demonstrated alveolar bone fenestration or dehiscence after implant placement.(<xref ref-type="fig" rid="F2">Fig. 2</xref>) An Autobone Collector (Osstem) was used to harvest autologous bone chips were either from the mandibular ramus or from an area adjacent to the surgical site. The bone chips were mixed with FDBA (Sure-Oss; HansBiomed, Seoul, Korea) in 1 : 1 volume ratio. A mixture of the graft materials was placed on the dehiscence or fenestration defect (<xref ref-type="fig" rid="F3">Fig. 3</xref>) and covered with the preformed titanium mesh.(<xref ref-type="fig" rid="F4">Fig. 4</xref>) Primary flap closure was accomplished without tension. Antibiotics and analgesics were administered three times daily for ten days in addition to 0.12% chlorhexidine mouth rinse. The sutures were removed two weeks after surgery, and the patients were followed every four weeks after surgery for wound assessment.</p><p>After approximately four months of the healing period, re-entry surgery was performed to uncover the implant under the minimum flap reflection. The preformed titanium mesh was removed and the regenerated bone was examined carefully.(<xref ref-type="fig" rid="F5">Fig. 5</xref>) A trephine drill with a 2.2 mm internal diameter was used to obtain the core biopsy from the regenerated site.(<xref ref-type="fig" rid="F6">Fig. 6</xref>) Next, a routine healing abutment and sutures were placed. Two months after the re-entry surgery, both the osseointegration and the integrity of the peri-implant tissue were evaluated. Patients were referred to the prosthodontic department. The complications and implant success rate were investigated for twelve months after the definite prosthesis was placed.</p></sec><sec><title>3. Histologic and histomorphometric analysis</title><p>The specimen obtained at re-entry was immediately fixed in 10% buffered formalin, dehydrated in a series of ethanol baths, and embedded in methyl methacrylate for histologic evaluation. The polymerized blocks were sectioned with a diamond saw microtome, micro-grinded and polished using sandpaper. Final sections were approximately 40 µm thick. The sections were stained with H&E. Histomorphometric analysis was performed with light microscope. The areas of vital bone, residual graft materials, and soft tissue were grossly measured and analyzed.</p></sec></sec><sec><title>III. Results</title><p>Patient characteristics and their surgical records are summarized in <xref ref-type="table" rid="T1">Table 1</xref>. Newly regenerated bone at the augmented sites was confirmed by re-entry at four months after the initial surgery. After removing the preformed titanium mesh, a thin connective tissue layer called "pseudoperiosteum" was observed, but not debrided<xref rid="B16" ref-type="bibr">16</xref>. Underneath the pseudoperiosteum, FDBA particles were found to be embedded and incorporated in the regenerated bone. Postsurgical complications were observed in three of the 10 patients (30%). In two of these patients, the titanium mesh became exposed and there was small flap dehiscence on the cover cap in one patient. During the healing period, the exposed titanium meshes and cover caps were frequently irrigated with 0.12% chlorhexidine until fibrous tissue formed beneath the titanium mesh and graft materials were no long lost into the oral cavity. No signs of infection or suppuration were identified in the soft tissue around the exposed area. In all cases, the quality and quantity of the regenerated bone was clinically acceptable; however, at the exposed site, there was some resorption of graft materials. All implants were functional without significant complications. Radiologic evaluation at mesh insertion, removal and 12 months after definitive prostheses were placed showed stable marginal bone in all implants.(<xref ref-type="fig" rid="F7">Fig. 7</xref>)</p><p>Histologic findings of the core specimen from patient #2 revealed that the allograft particles are well-incorporated and surrounded by newly formed vital bone and connective tissue.(<xref ref-type="fig" rid="F8">Fig. 8</xref>) Vital bone surrounded ~80% of the allograft, while fibrous marrow tissue surrounded 5% of the graft, and inflammatory cell infiltrates made up the remaining 15%.</p></sec><sec><title>IV. Discussion</title><p>Adequate bone volume is a prerequisite for the long-term success of endosseous implants. Insufficient bone must be reconstructed with various hard tissue augmentation procedures<xref rid="B2" ref-type="bibr">2</xref>,<xref rid="B3" ref-type="bibr">3</xref>,<xref rid="B4" ref-type="bibr">4</xref>. In order for augmentation procedures to be successful, it is imperative to stabilize the graft during healing, support the osteogenic potential of the graft materials, and close the primary soft tissue.</p><p>GBR is often performed during implant placement to correct the peri-implant alveolar defects, and is considered a favorable procedure. The GBR technique uses a barrier membrane to prevent soft tissue cells from entering the grafted space, maintaining the space for successful bone regeneration. Actually, the most important ability of GBR is its ability to maintain space under the membrane. This preliminary study focused on a titanium mesh, which is one of the most reliable barrier membranes in ridge augmentation. The titanium mesh was first proposed for alveolar ridge reconstruction in 1969 by Boyne<xref rid="B7" ref-type="bibr">7</xref>. It is remarkably biocompatible and resists corrosion and thermal effects. Based on these qualities, titanium mesh has been useful in the reconstruction and augmentation of oral and maxillofacial defects. Another advantage of the titanium mesh is its inherent rigidity that maintains the space needed to allow new bone growth. Membrane stability is necessary to maintain graft volume during wound healing<xref rid="B17" ref-type="bibr">17</xref>. The titanium mesh's rigidity was ideal for vertical and horizontal augmentation<xref rid="B14" ref-type="bibr">14</xref>. Several studies have demonstrated that titanium mesh supports the grafted space and prevents soft tissue collapse better than does e-PTFE<xref rid="B6" ref-type="bibr">6</xref>,<xref rid="B14" ref-type="bibr">14</xref>. In contrast, although some cross-linked collagen membranes are also rigid resorbable barrier membranes, they only protect the grafted space at the beginning of regeneration and gradually lose their rigidity<xref rid="B6" ref-type="bibr">6</xref>.</p><p>One of the prerequisites of successful GBR is a barrier mem brane that restricts epithelial cell migration. Unlike other barrier membranes, titanium mesh has a macro-pore structure. This distinguishing feature is thought to induce the biological activity of the graft materials<xref rid="B6" ref-type="bibr">6</xref>. The macro-pores allow sufficient blood flow and diffusion of nutrients and oxygen that consequently enhance the regeneration of the bone and soft tissue. As the membrane pore size of increases, so does the regenerative capacity. Despite concern that epithelial cells and bacteria could infiltrate through large pores, space maintenance was found to actually play a greater role in bone regeneration than does cell occlusiveness<xref rid="B18" ref-type="bibr">18</xref>. When blood clot stabilization is achieved with the titanium mesh, epithelial tissue may be excluded during GBR<xref rid="B13" ref-type="bibr">13</xref>. In addition, the titanium mesh with large pores demonstrates more osseous formation and less soft tissue attachment than does a titanium mesh with small pores<xref rid="B12" ref-type="bibr">12</xref>. We found that easily removable titanium meshes tend to have less adhesive fibrous tissue formation. The titanium meshes used in this study have two different pore sizes that permit the migration of bone-forming cells, but block the grafted materials from leaking.</p><p>A major limitation of the titanium mesh is the fairly high rate of mesh exposure through the tissue. Corinaldesi et al.<xref rid="B8" ref-type="bibr">8</xref> reported a exposure rate of 14.8% after particulated bone augmentation in the mandible. Louis et al.<xref rid="B14" ref-type="bibr">14</xref> reported 52% exposure of the maxilla and mandible with a range of 43%-55%. Three of the 10 patients (30%) in this study experienced titanium mesh exposure during the healing period (with one in the maxilla and two in the mandible). However, even in cases of membrane exposure, there was satisfactory bone regeneration and successful implant survival. The most common cause of mesh exposure is continuous mucosal irritation by the titanium mesh. Sharp edges produced by improper mesh adjustment may increase the risk of exposure. Using a preformed titanium mesh is ideal because there is no need to cut or bend the mesh. Having a preformed mesh not only shortens the duration of surgery, but also reduces the risk of mesh exposure. In our study, there were no titanium mesh edge exposures because the preformed titanium meshes had optimal round and blunt edges. Ciocca et al.<xref rid="B10" ref-type="bibr">10</xref> also prepared a customized titanium mesh using computer-aided design and computer-aided manufacturing (CAD/CAM) technology to augment the atrophic alveolar ridge and demonstrated satisfactory bone regeneration.</p><p>Few studies have reported the histological results of new bone formation with titanium mesh use in humans. Proussaefs and Lozada<xref rid="B19" ref-type="bibr">19</xref> demonstrated ~36% new bone formation after 8 months in a histologic study of cases augmented by mixed grafts of autologous and inorganic bovine bone (in a 1 : 1 volume ratio). Using the mesh with either a combination graft (of 70% autologous bone and 30% bovine bone matrix) or a graft of autologous bone alone produces similar amounts of total bone volume 8-9 months after grafting<xref rid="B11" ref-type="bibr">11</xref>. In accordance with previous studies using allogeneic grafts<xref rid="B20" ref-type="bibr">20</xref>,<xref rid="B21" ref-type="bibr">21</xref>, preliminary histologic analysis in our study demonstrated a satisfactory amount of new bone formation with limited allograft particle embedding. The newly formed bone was surrounded and focally merged with FDBA particles. It is thought that FDBA scaffolding connects with marrow trabeculae, providing favorable osteoconductivity for new bone formation. Moreover, marginal bone levels around the implant remained stable for 12 months after the final prostheses were placed. There were no failures of osseointegration or GBR in this experiment.</p></sec><sec><title>V. Conclusion</title><p>The customized, three-dimensional, and preformed titanium mesh used in combination with autologous bone and FDBA induced successful bone regeneration in peri-implant defects occurring after implant placement. Even in the cases of titanium mesh exposure, this preformed titanium mesh produced reliable outcomes as a barrier membrane. This preliminary study shows histologic evidence of satisfactory vital bone formation in the augmented area. 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Part 1: Mineralized freeze-dried bone allograft</article-title><source>Int J Periodontics Restorative Dent</source><year>2003</year><volume>23</volume><fpage>29</fpage><lpage>35</lpage><pub-id pub-id-type="pmid">12617366</pub-id></element-citation></ref><ref id="B21"><label>21</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Wang</surname><given-names>HL</given-names></name><name><surname>Tsao</surname><given-names>YP</given-names></name></person-group><article-title>Histologic evaluation of socket augmentation with mineralized human allograft</article-title><source>Int J Periodontics Restorative Dent</source><year>2008</year><volume>28</volume><fpage>231</fpage><lpage>237</lpage><pub-id pub-id-type="pmid">18605598</pub-id></element-citation></ref></ref-list></back><floats-group><fig id="F1" orientation="portrait" position="float"><label>Fig. 1</label><caption><p>Components and types of the customized, three-dimensional, and preformed titanium mesh (SMARTbuilder; Osstem). Type I is designed for 1-wall augmentation, type II for 2-wall augmentation, and type III for 3-wall augmentation.</p></caption><graphic xlink:href="jkaoms-40-181-g001"></graphic></fig><fig id="F2" orientation="portrait" position="float"><label>Fig. 2</label><caption><p>After implant placement on #12 missing area, labial fenestration defect was found.</p></caption><graphic xlink:href="jkaoms-40-181-g002"></graphic></fig><fig id="F3" orientation="portrait" position="float"><label>Fig. 3</label><caption><p>After connecting the height on the implant fixture, the defect was covered with a mixture of particulated autologous bone harvested from the mandibular ramus and freeze-dried bone allograft.</p></caption><graphic xlink:href="jkaoms-40-181-g003"></graphic></fig><fig id="F4" orientation="portrait" position="float"><label>Fig. 4</label><caption><p>A customized, 3-dimensional, and preformed titanium mesh (SMARTbuilder type II; Osstem) was connected to the height, placed over the graft material, and stabilized by the cover cap.</p></caption><graphic xlink:href="jkaoms-40-181-g004"></graphic></fig><fig id="F5" orientation="portrait" position="float"><label>Fig. 5</label><caption><p>The preformed titanium mesh was easily removed under the minimum flap elevation at postoperatively 4-month re-entry.</p></caption><graphic xlink:href="jkaoms-40-181-g005"></graphic></fig><fig id="F6" orientation="portrait" position="float"><label>Fig. 6</label><caption><p>Bone core biopsy was carried out on the labial regenerated bone by a trephine drill (arrow). Note that there was a superficial thin fibrous tissue layer over the regenerated bone.</p></caption><graphic xlink:href="jkaoms-40-181-g006"></graphic></fig><fig id="F7" orientation="portrait" position="float"><label>Fig. 7</label><caption><p>Comparison of periapical radiographs taken at the application (A) and removal (B) of the preformed titanium mesh and at 1 year after delivery of the final prosthesis (C).</p></caption><graphic xlink:href="jkaoms-40-181-g007"></graphic></fig><fig id="F8" orientation="portrait" position="float"><label>Fig. 8</label><caption><p>Histological findings of the core specimen obtained from patient #2. Note that the residual allograft (RA) particles were encapsulated and incorporated with vital bone (VB). Fibrous marrow (FM) tissues were also observed (H&E staining, ×40).</p></caption><graphic xlink:href="jkaoms-40-181-g008"></graphic></fig><table-wrap id="T1" orientation="portrait" position="float"><label>Table 1</label><caption><p>Overview of patients and their surgical records</p></caption><graphic xlink:href="jkaoms-40-181-i001"></graphic><table-wrap-foot><fn><p>(M: male, F: female, C: cover cap, H: healing abutment)</p><p><sup>1</sup>Mesh exposure or flap dehiscence on the cover cap.</p></fn></table-wrap-foot></table-wrap></floats-group></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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