Use of HTR in tooth extraction sockets to maintain alveolar ridge height and increase concentration of alveolar bone matrix.
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A case is reported in which an intruded incisor was initially treated by an endodontic dressing with calcium hydroxide and then extruded using a removable orthodontic appliance. A follow-up examination seven years after completion of endodontic therapy and bleaching showed a favourable response. A review of the relevant literature indicates that intrusion occurs in five to twelve per cent of luxation cases. In this type of injury maximum damage occurs to the pulp and all supporting structures because the tooth is driven into the alveolar process. Complications which have been reported include: pulp necrosis, apical radiolucencies, partial or total pulp calcification, root resorption (surface, inflammatory or replacement), marginal periodontal bone breakdown, and arrested or disturbed root development. The prognosis for pulp survival after intrusion is much more favourable for teeth with incomplete root formation than for teeth with complete root formation. Treatment options available to bring an intruded tooth into alignment are: to await spontaneous re-eruption which may occur if root formation is incomplete, uncovering of the intruded crown, orthodontic extrusion which is allied with gentle luxation if the tooth does not move, and immediate surgical repositioning.
A new biogenic composite material based on hydroxyapatite and collagen with silamine was effectively used in dental implantology. Use of this material was conductive to a better course of the implant integration in the adjacent tissue structures and prevented the development of resorptive and atrophic changes in the alveolar process. Use of composite material in patients with relative indications for implantation precluded the development of complications in the early postoperative period and in remote periods of the follow-up.
Six hundred twenty-six titanium plasma-sprayed cylindrical implants that had been functioning in regenerated bone for a period of up to 51 months were evaluated according to Albrektsson's criteria. These implants had been placed either with concomitant guided bone regeneration procedures or in bony ridges that had previously been augmented. According to Albrektsson's criteria, absolute success rates of 97.6% overall, 98.8% in the maxilla, and 98.2% in the mandible were recorded, as were cumulative success rates of 94.9% in the maxilla and 91.9% in the mandible. The overall cumulative success rate was 93.8%. One patient, who underwent protracted chemotherapy 14 months after implant function began, accounted for 33% (3 of 9) of the total implant loss in the study. If this patient is excluded from the study, the cumulative success rates are 94.9% (maxilla), 96.7% (mandible), and 95.8% (overall). These findings support the theory that regenerated bone will achieve osseointegration with titanium plasma-sprayed cylindrical implants, and that this osseointegration can be maintained under function over time.
Sixty patients (31 male and 29 female) with thalassemia major, aged between 6 and 26 years, 18 of which were splenectomized, were observed in this study evaluating the oro-maxillo-facial alterations and correlating them to transfusion indexes, serum ferritin levels, splenectomy and age. For each patient a haematologic and odontostomatologic card was filed with a view to report the medical and clinical history regarding: the haematologic picture, the prevention of caries and parodontal disease, the facies characteristics, the odonto-stomatologic examination, the orthodontic diagnosis, the skull X-rays and the orthopantomography. Poor oral hygiene as well as misknowledge of prevention were generally observed. All the patients showed carious lesions but most of them had never seen a dentist for therapy. The disharmonious growth of splanchnocranium, with the enlargement of the jaw and of its alveolar process, induced by the bone marrow hyperplasia, produced various and serious malocclusion stages (Angle's II class, deep bite, open bite), gnathologic alterations, hypodiaphanous paranasal sinuses and orbital hypertelorism, with a typical oriental-like facies. Malocclusion and the poor oral hygienic conditions determined the occurrence of marginal gingivitis, mainly localized at the level of the lower frontal teeth. In only 3 patients the oral mucous membrane was pale and atrophic. During this investigation agenesia and dental retention were reported in 30% and in 26% of the examined cases respectively, while no patients had supernumerary teeth. Tooth volume, position and shape abnormalities rarely occurred. Only in two patients was enamel hypoplasia described. The caries frequency greatly varied in number and in degree. Only five patients did not show any carious lesions. The caries index (DMF) for the permanent teeth calculated in all the 60 subjects was 5, 12 +/- 4.76. By utilizing Spearman's rank test the number of teeth with caries in the permanent dentition (DFM) and in the mixed dentition (DFM + dmf) was correlated to the average value of ferritin, with the ferritin peak, with transfusion requirements and with the age of the patient at the date of the clinical examination. A significant inverse correlation was therefore demonstrated between transfusion requirements and caries in the mixed dentition. The chi 2 test was used to assess the different frequency of the caries index (above 5) between splenectomized and non-splenectomized patients. Splenectomy proved to be associated only apparently to the total number of patients with more than 5 caries. Conversely, in the non-splenectomized group the frequency of patients with more than 5 caries was definitely lower. Indeed the overall number of caries in both groups of splenectomized and non-splenectomized subjects, of the same average age, was almost identical. Consequently, splenectomy and the higher number of caries are statistically more probable in individuals affected by thalassemia, of increasing age, without however being mutually correlated.
The purpose of this study was to assess the osseous response to implanted particles of an anorganic xenograft bone mineral. Bio-Oss, in six patients with severely resorbed alveolar ridges. The observation period varied between 9 and 44 months; in five of six patients, long-term bone regeneration around the implants was observed. Histologic examination of biopsy material obtained from the graft area showed Bio-Oss particles still present in all patients after the varying observation periods. This raises the question whether Bio-Oss may be regarded as a resorbable material, as previously reported.
Polylactic membranes were evaluated for vertical ridge augmentation around immediate implants in periodontally compromised extraction sites. Ligature-induced periodontitis was produced in 10 adult beagle dogs. The periodontium was allowed to heal for 6 weeks. All premolar teeth were extracted and three implants were placed immediately into the extraction sockets on either side of the mandible so that the polished cone extended above the alveolar bone level. On one side of the mandible, the implants were covered with a 0.2-mm-thick polylactic membrane (DL-lactide-co-trimethylene carbonate in a ratio of 7:3). Histologic and morphometric analyses performed after 3 and 5 months revealed that the membrane group did not exhibit significantly greater bone-implant contact than the controls. The occurrence of dehiscences correlated significantly with use of the membrane. Use of the membrane was associated with significantly less peri-implant bone height after 5 months. No remnants of the membrane material could be identified after 3 or 5 months, indicating rapid resorption during the first weeks of implantation. The tested membrane material did not fulfill the requirements of resorption kinetics and space maintenance for guided bone regeneration in vertical ridge augmentation.
As a result of a fracture to the cemented post and core, a pure titanium implant was extracted from a 54-year-old patient after 4 years of clinical loading. At implantation, the implant was positioned into an extraction socket and the defect was treated with an e-PTFE membrane associated with a DFDBA graft. At retrieval the implant underwent histologic and histochemical examination to assess the characteristics of the regenerated bone after 4 years of prosthetic loading. The implant showed an angular bony defect at the smooth collar, but the bone-implant direct contact rate seemed to be elevated in the remaining implant surface. Normal transmitted and polarized light examinations demonstrated that most of the DFDBA particles were resorbed and substituted by vital newly formed bone. The regenerated bone appeared compact with secondary osteons and large haversian canals; however, some partially mineralized remnants residuated in the spaces, between the osteons. Within the limits of this study, the authors concluded that DFDBA can be substituted by the host bone, but the rate of substitution is very slow and not complete after 4 years. From a clinical point of view, however, the load-bearing capacity of the bone regenerated with the membrane technique associated with DFDBA appeared to be similar to that of normal bone.
The results of 5 years follow-up of 84 cases of mandibular residual ridge augmented with hydroxlapatite (HA), followed by ridge extension, are reported. The first surgical procedures, subperiosteal HA insertion, and the second stage of total lowering of the floow of the mouth, vestibuloplasty and skin graft are detailedly described. The ridge is augmented by the first surgery, disturbance of the fraenums of the lip, buccal and tongue and muscles are eliminated by the second surgery, to increase denture retention and stability, improve wear resisting of tissue covered over the artifical ridge and eliminate pain and uncomfort when wearing denture. The results of five years follow-up show that two stages reconstruction are better than HA insertion only. HA is a kind of ideal material of bone replacement, which is not resorbed in most cases.
Three case studies from the patient population of the University Hospital of Aachen (RWTH) are used to describe indications for primary surgical intervention in skeletal dysgnathia. Such preconditions may apply in the case of mandibulo-alveolar protrusion, anomalies where there is little or no option to fixing orthodontic appliances (enamel hypoplasia or shortened crowns), severe transversal discrepancies and skeletal dysgnathia with pronounced malpositioning in the alveolar process and the teeth. The advantages are improved compliance (through the patient experiencing success at the outset of treatment) and limitation of postoperative orthodontic treatment to occlusive fine adjustments of the occlusion, resulting in an appreciable reduction in both the degree and duration of tooth movement and tissue damage.
We report an osteotomy technique for the maxilla using an iliac graft and simultaneous implantation for correction of atrophic class III dysmorphosis of the maxilla. The advantages and disadvantages of this technique are discussed on the bases of a 3-year experience.
Based on clinical experience, the minimum required alveolar ridge width must be of 5-6 mm in patient evaluation for the placement of endosseous dental implants. In comparison with other techniques, the use of autogenous mandibular chin grafts to enlarge thin alveolar ridges seems to be very efficient with a success rate of 88.57%. Advantages are: only one surgical field; minimal resorption after grafting; good predictability; minimum postoperative complications. The surgical technique is described step by step and a longitudinal study in 35 patients shows the high predictability of the method.
This two-center human clinical trial evaluated recombinant human bone morphogenetic protein-2 delivered in an absorbable collagen sponge (rhBMP-2/ACS) for either alveolar ridge preservation after tooth extraction or augmentation of localized osseous defects. This 24-month study comprised two parts: a 4-month acute safety and bone induction period (Part I) followed by a 20-month, osseointegration, functional restoration, and long-term safety evaluation (Part II). The primary objective of Part I, discussed in this article, was to evaluate the short-term safety and technical feasibility of the rhBMP-2 device implantation. Twelve patients (six preservation and six augmentation) were enrolled in the investigation. Patient safety was monitored by oral examinations, radiographs, and the collection of blood samples to measure serum chemistries, hematology, and potential antibody formation. Technical feasibility was evaluated by collecting information relating to the handling properties of the rhBMP-2/ACS device. The ability of various evaluative tools to measure the bone-inducing activity of the rhBMP-2/ACS device was also assessed. The clinical results suggested that rhBMP-2/ACS was well tolerated locally and systemically, with no serious adverse events. The device was found to be easily handled and adapted to the ridge and extraction socket. Using direct measurements, all sites demonstrated firmness and fullness to palpation at 4 weeks; however, a loss of volume was noted in some treatment areas between 4 and 8 weeks. Augmentation of the alveolar ridge was not observed in the patients as assessed by the evaluation techniques. This trial indicated that the use of rhBMP-2/ACS to preserve alveolar ridge after tooth extraction or augmentation of localized defects is safe and feasible. Bone fill was observed in all alveolar sockets filled with the rhBMP-2 device.
The placement of endosseous implants in the atrophic posterior mandible has presented a challenge to the surgeon and restorative dentist. Traditional procedures either require nerve transposition or utilization of implants placed at less than favorable angles. A technique is presented for the three-dimensional augmentation of the atrophic alveolar ridge utilizing microplate-enhanced guided bone regeneration technology. The applications of this technique in other intraoral and extraoral sites are currently under investigation by the authors.
Guided bone regeneration and bone grafting have been used to reconstruct defective alveolar ridges in preparation for implant placement. This phase of implant treatment is critical to a successful overall result. Remarkable advances that have occurred in techniques and materials enable us to place and restore implants in cases where previously it was not feasible. Three case reports are presented to illustrate successful management of different alveolar defects.
When cleft lip and palate treatment was introduced at Gothenburg in 1957, the procedure used was early bone grafting (EBG). By 1965, EBG had been omitted from the regimen, bone grafting being postponed until the appearance of mixed dentition. Analysis of the results of both techniques showed maxillary retrusion of different degrees. Accordingly, this routine was abandoned in 1975, being replaced by a procedure which is characterised by delayed closure of the hard palate (DCHP). Thus, the surgical procedure comprised the following steps: 1, lip closure at 1-2 months of age; 2, soft palate repair at 6-8 months; 3, final lip-nose surgery at 12 months; and 4, closure of the left in the hard palate, and bone grafting to the alveolar process during mixed dentition at about 8-10 years of age. Follow-up has shown the majority of patients to manifest acceptable speech development during childhood, though problems may occur in some cases. Maxillary growth has been found to be improved after DCHP, and at present the need of maxillary advancement surgery has been reduced to approximately 5% of cases, as compared with the former rates of 50% of cases among those treated with EBG, and of 25% among those treated with the vomer flap procedure.
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The viability of Ridge Preservation as achieved by practicing Advanced Extraction Therapy (AET) and Replacement Therapy (R.T.), will impact the future practice of Dentistry. With the availability of clinically proven materials such as implants (titanium) and synthetic bone substitutes (Bioplant HTR), a practical solution exists to solve a very old clinical problem. Treatment modalities are available today making the atrophic jaw-bone a malady of the past. Imagine no more "dental cripples," and no more inadequate bone situations for implant placements. Ridge Preservation and Replacement Therapy should be practiced regularly: "when we take something out, we should put something back." Our practices will grow. Our patients will thank us.