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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 4  |  Issue : 1  |  Page : 42-45

Use of titanium mesh for staged 3D localized alveolar ridge augmentation


1 Department of Periodontics, Bapuji Dental College and Hospital, Davangere, Karnataka, India
2 Department of Periodontics, Gurgaon, Haryana, India

Date of Web Publication18-Feb-2015

Correspondence Address:
Sajith Abdul Lathif
Senior Lecturer, Room No. 5, Department of Periodontics, Bapuji Dental College and Hospital, Davangere, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2231-6027.151626

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  Abstract 

Guided bone regeneration has been used successfully for the regeneration of bone for the placement of oral implants when ridge deformities are present. The present case provides a clinical description of the use of titanium mesh along with bone graft for anterior maxillary bone reconstruction. Bone augmentation with titanium mesh and autogenous particulate bone graft is a successful technique and a predictable approach for the regeneration of bone.

Keywords: Autogenous bone graft, guided bone regeneration, ridge augmentation, titanium mesh


How to cite this article:
Lathif SA, Tarun Kumar A B, Choudhary S, Gowda TM, Mehta DS. Use of titanium mesh for staged 3D localized alveolar ridge augmentation. Int J Oral Health Sci 2014;4:42-5

How to cite this URL:
Lathif SA, Tarun Kumar A B, Choudhary S, Gowda TM, Mehta DS. Use of titanium mesh for staged 3D localized alveolar ridge augmentation. Int J Oral Health Sci [serial online] 2014 [cited 2019 Oct 23];4:42-5. Available from: http://www.ijohsjournal.org/text.asp?2014/4/1/42/151626


  Introduction Top


An adequate bone volume for complete circumferential coverage of the implants is very important for obtaining long-term success of oral implants. [1] Many techniques are available for the treatment of localized ridge augmentation: Different surgical techniques (guided bone regeneration [GBR], bone splitting osteotomy, inlay and onlay grafting), different fixation devices (bone screws, pins, titanium mesh), different augmentation materials and different barrier membranes. [2],[3] GBR has been used successfully for the regeneration of bone in conjunction with the placement of oral implants, augmentation of resorbed alveolar ridges and treatment of localized ridge deformities. [4],[5]

An adequate bone volume for complete circumferential coverage of the implants is important for obtaining long-term success of oral implants. [1] Recently, the use of titanium micromesh has been advocated for GBR. [1],[2],[6] The current case report provides a clinical description of the use of titanium mesh along with bone graft for anterior maxillary bone reconstruction utilizing the principles of GBR.


  Case Report Top


A 24-year-old healthy female patient reported to the Bapuji Implant Centre seeking fixed replacement for her partially edentulous maxillary anterior region. Clinical examination revealed missing left maxillary central and lateral incisors with horizontal and vertical deficiencies in the anterior region [Figure 1]. Her medical history was irrelevant and the past dental history revealed that the patient lost her teeth due to trauma. The patient desired an implant-retained prosthesis. The clinical and radiographic findings depicted the necessity for a bone grafting procedure before dental implant placement in the maxillary anterior region in relation to teeth 21 and 22.
Figure 1: Missing left maxillary central

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Surgical procedure

Before administration of local anesthesia, the patient rinsed with 15 mL of 0.2% chlorhexidine gluconate to reduce the bacterial load. A loading dose of augmentin 1.2 mg I.V. was given 1 h before the procedure and 10 mL of venous blood was obtained to prepare the platelet-rich fibrin (PRF) using Choukroun's protocol. [7] A mid-crestal incision along the edentulous ridge followed by two oblique incisions were given mesial and distal to the adjacent teeth. A full-thickness flap reflection was performed at the recipient site. Periosteal releasing incision was performed along the labial flap such that it enabled in primary closure. The pre-operative ridge width was 2-3 mm, with a 2 mm vertical deficiency [Figure 2].
Figure 2: Pre-operative ridge width

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For donor site preparation, a sulcular incision was given from teeth 21 to 26, which was followed by a full-thickness flap reflection. The autogenous bone graft was harvested from the anterior palate utilizing a bone scraper (Safescraper® curve, Meta, Italy). The autogenous graft was mixed with PRF, which was minced into small pieces along with alloplastic bone graft (Novabone Morsels, USA).

Decortication was performed on the recipient host bone using a large round fissure bur (Brasseler, H71052, USA) to achieve bleeding points. Two tent screws were placed, which helped to guide the grafting procedure [Figure 3]. The particulate graft was placed on the recipient site [Figure 4]. The sterilized titanium mesh was trimmed, pre-formed to the desired shape and secured in place [Figure 5] using titanium tacks and screws (1.2 mm × 4 mm). To get a dual-layered closure and to prevent the incision line opening and exposure of titanium mesh at the recipient site, vascularized interpositional periosteal connective tissue grafting was carried out from the palatal flap [Figure 6]. The flap was then sutured using polytetrafluoroethylene 5-0 (ePTFE) suture material.
Figure 3: Tent screws placed

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Figure 4: Graft placed

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Figure 5: Titanium mesh secured using tacks

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Figure 6: Vascularized interpositional periosteal connective tissue grafting

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Post-operative instructions, analgesics (combination of paracetamol-500 mg and diclofenac-50 mg thrice daily for 3 days) and antibiotics (amoxicillin 500 mg thrice daily for 5 days) were given. Healing was uneventful and within normal limits. The sutures were removed 2 weeks after the surgery. After 3 months of healing, titanium mesh exposure (3 mm × 3 mm) was seen [Figure 7] and the patient was given oral hygiene instructions. Patient was advised to use a soft baby brush to clean the exposed mesh area and apply chlorhexidine gluconate gel (0.25%) to prevent infection. Further, the patient was kept under regular recall evaluation of the exposed area every week. The operated site was then re-entered after 4 months. After the removal of the titanium mesh and screws, around 7 mm of ridge width was revealed [Figure 8].
Figure 7: Titanium mesh exposure

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Figure 8: Post-operative ridge width after 4 months

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  Discussion Top


The four main surgical approaches for the augmentation of atrophic ridges include GBR, block grafting, expansion and distraction techniques and a combination of these methods. [8] The present clinical case report signifies the potential of bone grafting technique to attain horizontal and vertical ridge augmentation in the maxillary alveolar ridge utilizing the principles of GBR. Although animal studies have offered the opportunity to evaluate histologically the results of this method of bone grafting, [9] only two papers have reported histologic evidence of bone formation in humans after performing alveolar ridge augmentation by using a titanium mesh.

An important key for predictable bone augmentation is the presence of autogenous bone graft. Autogenous bone grafts have been used for many years for ridge augmentation and is still considered the gold standard for jaw reconstruction. [10] Autogenous bone is the only graft material that directly forms bone from transplanted trebacular bone cells. It also contributes to bone growth with several growth factors. These growth factors also help the soft tissue healing on the outside and accelerate blood vessel growth into the graft site of the host bone on the inside of the graft.

Alloplastic graft accelerates bone formation process characterized by the active stimulation of osteoblast proliferation and differentiation due to cellular interaction with ionic dissolution released during absorption. It can be easily combined with autograft, allograft or autogenous growth factors to extend surgical options and promote accelerated healing.

PRF, which is a strictly autologous fibrin matrix containing a large quantity of platelet and cytokines, is an optimal matrix for migration of endothelial cells and fibroblasts. It certificates rapid angiogenesis and improved remodeling of fibrin into a more resistant connective tissue. The effortlessly applied PRF membrane acts much like a fibrin bandage, serving as a matrix to hasten the healing of wound edges.

One of the main problems in using occlusive membranes is their lack of stiffness, which can produce a collapse of the barrier toward the bone defect, reducing in such a way the space needed for the bone regeneration. Von Arx and Kurt used a titanium micromesh to protect and preserve densely packed bone grafted in the defects without the use of a barrier membrane, and they demonstrated that there was no invasion or displacement of the graft by the soft tissues overlying the titanium mesh. Von Arx and Kurt found that, even if the titanium mesh presented a degree of stiffness, the perforations of the mesh allowed three-dimensional adaptation into the residual ridge. [2] Titanium mesh in contrast, if exposed, might not require immediate removal because this material does not interfere with the blood flow to the underlying tissues owing to the presence of pores within the mesh. [11]

In the present case, a staged approach was carried out. A major complication of the titanium mesh technique is mesh exposure during the healing period. Membrane exposure of non-resorbable membrane barriers would result in infection, which can jeopardize the results. [12] Conversely, titanium mesh exposure did not appear to affect the final outcome. One drawback in the use of this type of membrane is the necessity for its removal with a second stage surgical procedure. However, this disadvantage may be overshadowed by the advantages offered. Even though there was a small mesh exposure in the present case, it was well maintained by reinforcing the oral hygiene instructions to the patient and also by the periodic recalls for evaluation.


  Conclusion Top


Bone graft augmentation with titanium mesh and autogenous particulate bone graft is a successful technique and a predictable approach for the regeneration of bone to form an ideal ridge for implant placement. Exposure of the titanium mesh did not affect the successful regenerative outcomes of treatment in the present study.

 
  References Top

1.
Simion M, Trisi P, Piattelli A. Vertical ridge augmentation using a membrane technique associated with osseointegrated implants. Int J Periodontics Restorative Dent 1994;14:497-511.  Back to cited text no. 1
    
2.
Von Arx T, Kurt B. Implant placement and simultaneous peri-implant bone grafting using a microtitanium mesh for graft stabilization. Int J Periodontics Restorative Dent 1998;18:117-27.  Back to cited text no. 2
    
3.
Von Arx T, Wallkamm B, Hardt N. Localized ridge augmentation using a microtitanium mesh: A report on 27 implants followed from 1 to 3 years after functional loading. Clin Oral Implant Res 1998;9:123-30.  Back to cited text no. 3
    
4.
Jovanovic SA, Nevins M. Bone formation utilizing titanium-reinforced barrier membranes. Int J Periodontics Restorative Dent 1995;15:57-69.  Back to cited text no. 4
    
5.
Jovanovic SA, Schenk RK, Orsini M, Kenney EB. Supracrestal bone formation around dental implants: An experimental dog study. Int J Oral Maxillofac Implants 1995;10:23-31.  Back to cited text no. 5
    
6.
Maiorana C, Santoro F, Rabagliati M, Salina S. Evaluation of the use of iliac cancellous bone and anorganic bovine bone in the reconstruction of the atrophic maxilla with titanium mesh: A clinical and histologic investigation. Int J Oral Maxillofac Implants 2001;16:427-32.  Back to cited text no. 6
    
7.
Toffler M, Toscano N, Holtzclaw D, Corso MD, Ehrenfest DD. Introducing Choukroun's platelet rich fibrin (PRF) to the reconstructive surgery milieu. J Implant Adv Clin Dent 2009;1:21-31.  Back to cited text no. 7
    
8.
Bravi F, Bruschi GB, Ferrini F. A 10-year multicenter retrospective clinical study of 1,715 implants placed with the edentulous ridge expansion technique. Int J Periodontics Restorative Dent 2007;27:557-65.  Back to cited text no. 8
    
9.
Cobb CM, Eick JD, Barker BF, Mosby EL, Hiatt WR. Restoration of mandibular continuity defects using combination of hydroxyapatite and autogenous bone: Microscopic observations. J Oral Maxillofac Surg 1990;48:268-75.  Back to cited text no. 9
    
10.
Pikos MA. Mandibular block autografts for alveolar ridge augmentation. Atlas Oral Maxillofac Surg Clin North Am 2005;13;91-107.  Back to cited text no. 10
    
11.
Her S, Kang T, Fien MJ. Titanium mesh as an alternative to a membrane for ridge augmentation. J Oral Maxillofac Surg 2012;70:803-10.  Back to cited text no. 11
    
12.
Buser D, Dula K, Hirt HP, Schenk RK. Lateral ridge augmentation using autografts and barrier membranes: A clinical study with 40 partially edentulous patients. J Oral Maxillofac Surg 1996;54:420-32.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]


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