J ciin Periodmlol 199H: :S: Si2-S39 PriiiU'd in Denmark .

All rights reserved

Copyright t. Mitnk^gawii 1
MWAIBF

Clinical periodontDloyy
Case Report

Alveolar ridge reconstruction and/or preservation using root form bioglass cones
Ydtnaz S. Efeoglu E. Ktli^- .AR: Alveolar ridge reconstruction and/or preservation using root fornt bioglass cones. Ca.se reports. J Ciin Periodontol 1998: 25: 832839. Munksgaard, 1998. Abstract. Fxtraction of a tooth necessitated by factors such as developmental problems, trauma, severe periodontal disease and endodontic problems often causes deformities of the residual alveolar ridge in the maxillary anterior region. These cases are usually difficult to restore prosthetically and they result in poor esthetics and insufficient occlusal function. This study investigated the efficacy of root form bioactive glass cones implanted into (a) artificial sockets produced by bone splitting of previous extraction sites (group BS) and (b) fresh extraction sockets (group FES), We included conventional extraction sockets sutured without implanting the root form bioactive glass cones as a control (group C), .\ total of 16 patients were treated for whom extractions had been indicated due to severe periodontitis, 6 patients with 7 implant sites having Class II or III alveolar ridge deformities comprised the BS group. 5 patients with 10 implant sites comprised the FES group. Group C, comprised 5 patients with 10 extraction sites. Alveolar ridge width and height measurements were obtained using study casts preoperatively, immediately postoperatively. and at 3 and 12 months after operation. In the BS group, while the width of the alveolar ridge increased by 2,8 1,18 mm immediately after ridge augmentation procedure and by 2.40.93 mm at I year after operation (/7<0,01), the height of the alveolar ridge increased by 1.8l.99 mm and 1,41,74 mm respectively (p<0.05). In the FES group, the differences between preoperative originai ridge height and width and postoperative measurements were not statistically significant, which demonstrated the efficiency of this method in preserving the alveolar ridge. In group C, while alveolar ridge width after 12 months had not Significantly changed, alveolar ridge height decreased significantly (1.35I.O5 mm. p<0.0\). After 12 months, no dehiscences were detected and the differences in height between the groups remained significant. The results of this study indicate that this procedure is efficient in reconstructing alveolar ridges deformed as a result of extraction, particularly relevant in relation to preparation for subsequent restorative treatment.

Sel^uk Yrlmaz, Elvan Efeoglu and Ali Riza K1I19 Department of Periodontoiogy, Faculty 0I Dentistry, Marmara University, Niantai, istanbui-Turkey

Key words: aiveolar ridge augmentation; ridge deformities; root form bioactive giass; bone splitting Accepted for pubiication 26 January 1998

Destruction of periodontal hard and soft tissues in the anterior region can result in unsatisfactory esthetics and function. Extraction may result in a severely deformed alveolar ridge, especially if there is extensive bone loss due to periodontal disease. Ridge resorption is a result of the natural healing process. Ridge resorption may be particularly severe in the presence of

periodontitis. periapical problems or fractured roots. Alveolar ridge defects may also result from trauma (Langer & Calanga 1980. Seibert & Cohen 1987), The resultant defects can be categorized according to their vertical and/or horizontal components {Seibert & Cohen 1987), In 1983, Seibert classified such defects as follows: Class I; bucco-lingual loss of tissue with normal ridge

height in an apico-coronal dimension; Class II: apico-coronal loss of tissue with normal ridge width in a bucco-lingual dimension; Class III: combination bucco-lingual and apico-coronal loss of tissue resulting in a loss of normal height and width. Restoration of these cases is usually difficult, not least because of possible esthetic and oral hygiene problems

Ridge reconstruction (Agudio et al. 1989, Hawkins et al. 1991. Johnson & Leary 1992) when it is decided to restore with only fixed prostheses. Surgical augmentation of alveolar ridge defects has been proposed as the treatment of choice for the preparation of deformed ridges prior to prosthodontic treatment (Langer & Calanga 1980, Seibert 1983, Balshi 1987). Furthermore, several materials and procedures have been used to prevent alveolar ridge reduction, or (o reconstruct deformed residual edentulous ridges (Frame et al, 1987. Bahat & Kaplin 1989. Cobbet al, 1990, Seibert & Nyman 1990, Oli et al. 1991, Callon & Rohrer 1993). These have involved the use of submerged vita! and nonvital roots (Graver & Fenster 1980. Yilmaz et al, 1981. Veldhuis et al, 1981), autologous bone graft (Cobb et al. 1990, Frame et al, 1987). guided bone regeneration (Godefroyetal, 1994. O'Brein et al, 1994. Seibert & Nyman 1990) and the use of biocompatible materials in granular (Gray & Quattlebaum 1988). root or block form (Balshi 1987. Frameetal, 1987. Kwonet al, 1986. Nery etal, 1978. Oli et al. 1991. Williams et al, 1991), These biocompatible implant materials when placed into extraction sockets may prevent or minimize collapse of the residual ridge by delaying resorption and acting as space fillers after extraction of the natural tooth roots (Graver & Fenster 1980, Yilmazetal. 1981), Some investigators have placed coneshaped dense hydroxyapatite (HA) in extraction sockets, in dogs and humans (Balshi 1987, Hanne et a l 1988, Wijs et al, 1993). Both animal and human radiographic studies have found bone around such graft materials adapted closely 12 to 18 months after implantation, with well preserved residual ridges (Boyne et al. 1984). Histological studies have indicated new bone formation at the reconstructed area (Callon & Rohrer 1993, Nery et al, 1978, Seibert & Nyman 1990). Some studies with HA, however, have reported a 53-55';.! failure rate due to the development of dehiscences within I to 2 years (Cranin & Shpuntoff 19B4, Kwon et al, 1986), Some studies demonstrate the successful use of 45S5 particuiate form bioactive glass (Bioglass*) graft materials in periodontal defects (Wilson et al, 1987, Zamet et al. 1997), This material has also been shown to be effective in maintaining the alveolar ridge following extraction (Stanley et al. 1987, Kirsh & Garg 1994, Wilson et al, 1993), None of these studies appear to have used this material to reconstruct deformed residual alveolar defects. The principal aim of this study therefore was to investigate the efficacy of root form bioactive glass graft material for the reconstruction of alveolar ridges. Furthermore, we wanted to investigate the potential of this material for implanting into fresh extraction sockets to prevent possible further alveolar resorption.
Material and Methods Subjects

833

16 adult subjects. 9 male and 7 female, mean age 38,39.40 were selected for this study. None had any systemic disease. Ail had had at least 1 maxillary incisor extraction site (bone splitting group) or a corresponding incisor extracted due to severe periodontitis (fresh extraction socket and control groups). None of the patients were using any prosthetic appliances. Ali of the subjects had or would have had esthetic or functional alveolar ridge defects as a result of the extraction. All patients had been instructed in oral hygiene prior to treatment and bad undergone the initial phase of periodontal therapy. They had been fully informed about possible other treatment modalities, including guided bone regeneration, titanium screw implants and hybrid prostheses. Each patient had voluntarily signed an informed consent form according to the chosen treatment. The study had the approval of Marmara University Research and Ethic Committee,

split was prised apart, as far as the elastic limits of the bone would permit, in order to bring the edentulous ridge width as far as possible in line with that of the neighboring teeth. Artificial sockets were prepared with a suitable matching dental burr with slow speed under external irrigation to the size and shape of the root form cones. The root form cones used were the bioactive glass alloplastic graft material (Endosseous Ridge Maintenance Implant, ERMI, US, Biomaterials Corp, Alahua, Florida, USA), and they were not reshaped. In order to ensure that the graft material was approximated as closely as possible to the bone and remained immobile, the implant was sized to sit approximately 1 mm below the ridge crest. Granular form graft material (PerioGlass, US Biomaterials Corp. Alahua, Florida, USA) was inserted into any voids which remained after the placement of cones (Figs, 2c, 3b), The resultant increased bulk of the alveolar ridge resulted in a gap on the palatal side which closed by secondary healing, Mucoperiosteal fiap was split at the base of the defect vestibularly to facilitate flap sliding and decrease the gap between the flap margins. The fiaps were sutured with 3-0 silk sutures. Fresh extraction socket group (FES) (5 patients-10 implant sites). Before extracting the tooth, an intrasulcular incision was made and the mucoperiosteal flaps reflected as carefully as possible in order to avoid root fracture and damage to the alveolar bone. All granulation tissue was removed by curettage. implantation of cones and flap closure were performed as for the BS group, except no granular form material was required as the fit was snug. Control group (Cj (5 patients. 10 sites). This group served as controls for the FES group. The surgical procedure was the same as for the FES group, except that no material was implanted. For prophylactic purposes, the patients were prescribed a postoperative antibiotic (amoxycillin 500 mg 3X a day) for 10 days and instructed to perform home care. After 10 days sutures were removed. Temporary acryhc fixed prostheses were installed at 3 weeks. During the following 3 months, follow-up examinations were performed by the operating surgeon and a prosthodontist. Permanent prostheses were placed 3 months later. Each prosthesis was designed to

Treatment Procedure

Botte splitting group (BS) (6 patients-7 implant sites). The extractions had resulted in Class II or III ridge deformities (Seibert's classification 1983) all of which were treated with root form graft material. On the mesial and distal sides of the edentulous area, vertical incisions were made extending to just beyond the mucogingival junction vestibularly and approximately 1 cm further palatally. The 2 vertical incisions palatally were connected with a horizontal incision and the mucoperiosteal flap was refiected to fully expose the edentulous ridge, "Bone splitting" was carried out by splitting the residual alveolar ridge into palatal and vestibuiar sections after cutting the ridge horizontally with a periodontal bone chisel (Fig, 2b). The

834

Yilmaz el ai
Table I. Mean vestibulo-palatal dimension (width) of the alveolar ridge at the treated sites (mm) 31Preop, Postop, months year BS mean ( = 7) SD FES mean 1) SD 6,2 1,97 5,5 1.26 4.7 0.47 9.0 1,52 6,4 1,44 4,3 0,67 8.6 1.54 5.9 1.40 4,2 0,63 8,4 1,37 5.7 1.24 3,9 0,81

mean C (fi=lC1) SD Wi; preoperative alveolar ridge width h,; preoperative alveolar ridge height W2; postoperative alveolar ridge width h2: postoperative alveolar ridge height

fig, /, Method used to obtain ridge width and height data from study casts. The differences w,-W| and hj-h, present the width and height increases or decreases between follow-up periods.

BS: bone splitting group, FES; fresh extraction socket group, C; control group, SD: standard deviation.

give access for the patient to use dental floss and interdental brushes. Follow up was conducted for a further 9 months (Fig 3c). Radiographs of the areas involved were taken preoperatively, immediately following the operation, and at 3 months and 1 year postoperatively (Figs. 2f, 3d).

Measurements

Changes in vertical and horizontal dimensions and form of the defects were determined from study casts. Impressions were taken preoperatively, immediately postoperatively, at 3 months, and at 1 year postoperatively. Auto-

polymerizing acrylic reference plaques were obtained from the preoperative study casts. These plaques had location notches to ensure vertical sectioning of all casts along the same line (Fig. 3e). Profiles of the alveolar ridge were obtained using linear measurements (mm) obtained from the casts on graph paper.

Fig. 2. Case 1, Site of previously extracted left 1" and 2"'' incisors (a), Preoperative ridge condition, (b) Bone splitting procedure using bone chisel, (c) Bioactive root form graft material ridge implants following bone splitting, (d) Site 1 year after surgery and temporary fixed prosthesis, (e) 2 implant sites at 1 year- re-entry, (0 Radiograph of implant 1 year after operation.

Ridge reconstruction

835

Fig. S. Case 2, Site of previously extracted right 1" incisor, (a) Preoperative ridge condition due to traumatic tooth loss, (b) Bioactive root form graft material ridge implant following bone splitting, (c) Occlusa) view of implantation site 3 months after operation, (d) Radiograph of implant immediately following operation (e) Sections of preoperative and 1 year postoperative study casts showing ridge augmentation.

and ridge changes were calculated by comparing the profiles at each time point (Fig, 1). One subject in the BS group underwent re-entry surgery at 1 year postoperatively after obtaining voluntary consent (Fig. 2e),
Statlstlcal Analysis

the ridge preoperatively, immediately postoperatively, at 3 months and at 1 year postoperatively were 6.2, 9.0, 8.6, and 8.4 mm respectively (Table 1), That is, the increases in average width of the

ridge relative to preoperative values were 2,8 mm immediately postoperatively. 2.4 mm at 3 months, and 2,2 mm at 1 year (/)<0,01), This indicates some postoperative loss of this width gain, ai-

Table 2. Differences (mm) in changes in width of the alveolar ridge at the treated sites Intragroup comparisons BS FES C lntergroups BS versus FES BS versus C FES versus C mean SD mean SD mean SD Postoppreop. 2,8** 1,18 1,0** 0,47 0,47 **
**

Changes over time within groups were measured by the Wilcoxon signed ranks test and differences between the groups by the Mann-Whitney L'-test, using the SPSS statistics computer program. Results All of the 17 root form bioactive glass implants were inserted without clinical complication. No dehiscences were observed over the 12 month study period. Changes in alveolar ridge dimensions, including ridge height and width for all subjects, are presented in Tables 1-4. In the BS group, the existing ridge dimensions were significantly increased. The average vestibulo-palatal widths of

3 mthpreop. 2,4'* 0,93 0,47 0.48 **

3 mthpostop. 0,47 -0.6" 0.66 0,23

NS NS

1 yearpreop. 2 2** 0.95 0,1 f'S 0,52 -0.75* 0.59 *** ***
NS

1 yearpostop. 0.53 -0.8** 0.66 0,48

NS NS *

1 year3 mth. 0,49 -0,3^5 0,25 0,42

NS NS NS

BS; bone splitting group, FES; fresh extraction socket group, C: control group, SD; standard deviation. Intragroup Wilcoxon matched pairs signed rank test; "p<O.Ql, 'p<0.Q5, NS: not significant, Intergroup Mann-Whitney t/'-test: ' V < 0 . 0 0 1 , **;><0,01, *p<0.05, NS; not significant.

836

Ytlmaz et al. width (relative to the preoperative value) at 3 months was not significant but was significant at I year (0,75 mm, /><0.05) (Table 2), Decreases in height however were significant immediately postoperatively (0.9 mm, /;<0,05) as well as at 3 months (1.0 mm) and 1 year (1.35 mm, p<Q.m) (Table 4), When comparing FES and C groups, the differences between the changes in width relative to preoperative values were significant (/)<0,01) at 3 but not significant at 12 months (Table 2), However the difference between changes in height remained significant at 12 months (/7<0.01) (Table 4). Typical postoperative radiographs are shown in Figs, 2e. 3d. In each radiograph the bone and graft material areas were clearly distinguishable from one another. 1 year postoperative radiographs showed no migration or dislocation, and graft material in all sites was surrounded with bone. The disappearance of radiolucency visible at the coronal thirds of implants immediately following operation demonstrates the bone fill tn that area. At 1 year, the implant sites were found to be resistant to finger pressure showing the material to be immobile. In the BS group patient on whom I year postoperative re-entry surgery was performed, the left 1st incisor was found to be completely covered and the 2nd incisors partially covered with bone and all of the original spaces in the split were filled with new bone (Fig. 2e), The main esthetic criterion evaluated was the similarity of the crown length of the pontics to that of the neighboring teeth. Because of the ridge width and height increases in the BS group and ridge contour maintenance in the FES group, this criterion was met to the satisfaction of all patients in the augmentation groups. Discussion Our method of using bone splitting and implanting bioactive glass cones into existing bone deformities was a departure from the normal practice of implanting bioactive glass cones into fresh extraction sockets. Bone splitting for augmentation of knife edge alveolar ridges improves the treatment outcome of patients who have had previous bucco-palata! resorption and,/or extraction or trauma-related bone loss prior to restorative treatment. Where the elastic limits of the bone permitted, it was possible to prise the gap open wide enough to bring the w idth of the edentulous area in line with that of the neighboring teeth, Severa! researchers have found that implants used as space-fillers after tooth extraction also serve to delay resorption of residual alveolar ridge (Quinn et al. 1985), Such implants provide mechanical support and prevent the collapse of both the labial and lingual plates of bone (Denissen & DeGroot 19791, Previous studies have reported favorable results using HA implants in fresh extraction sockets. Quinn et al, (1985) reported that implanted HA roots maintained approximately twice as much alveolar bone as did unimplanted contralateral control sites. Dennissen & De Groot (1979) also reported successful results with HA implants. Some HA studies however have reported less success. One using comparative cephalometric radiographs and study casts reported an average vertical loss of 0,6 mm of alveolar bone in the anterior mandible (Crum & Roney 1978). A 1-year followup reported the loss of 55% of the implants (Cranin & Shpuntoff 1984), while a 5-year follow-up study reported dehiscence of almost one third of the root implants (Veldhuis et al, 1984). Kwon et al. (1986) implanted HA ceramic cones. After an average of 21 months, they reported no preservation of alveolar bone and that 53% of the implants had become exposed, 19 (27%) having had to be removed. Even though they reported better results using HA roots, with 3.3 mm vertical bone loss compared to the control group, with mean 5.7 mm vertical bone loss, the difference was not statistically significant. In the present study.

Table 3. Mean apico-coronal dimension (height) of the alveolar ridge at the treated sites (mm) 31Preop, Postop, months year BS mean 13.1 (=7) SD 2.91 FES mean (n=10) SD C mean (n=10) SD 8,1 2,13 8.3 1.15 14,9 2,68 8.4 1,95 7,4 0,69 14,5 2.84 8.2 1,82 7,.3 0,65 14,2 2,98 8.0 1.63 7,0 0,49

BS: bone splitting group. FES; fresh extraction socket group, C: control group, SD: standard deviation.

though not significant, of 0.4 mm after 3 months and 0.6 mm after 1 year (Table 2). Similarly, increases in the apico-coronal dimension (height) of the alveolar ridge relative to preoperative values were 1.8, 1,4, and 1.1 mm (jt><0.05) indicating decrease postoperatively. also not significantly, by 0.4 mm after 3 months and 0.6 mm after 1 year (Table 4). In the FES group, the dimensions of the alveolar ridge were preserved. The average widths were 5.5, 6,4, 5.9 and 5.6 mm respectively a( the for measurement points (Table 1). The differences in these widths relative to preoperative values were not significant. However the regressions of 0.6 in 3 months and 0.8 mm in one year were significant (Table 2). Height changes were 0.3, 0 1, -0,1 mm and regressions 0.2 and 0,4 mm (Table 4), Neither were significant. In the C group, a decrease in average

Table 4. Differences (mm) in changes in height of the alveolar ridge al the treated sites Intragroups comparisons BS FES C lntergroups BS versus FES BS versus C FES versus C mean SD mean SD mean SD Postpreop. 1.8* 1.99 0.82 -0,9* 1.20
if

3 mthpreop. 1,4* 1,74 0,69 1.0** 1.17

3 mthpostop. 0.41 0,58 0,52

NS

1 yearpreop. 1,95 0,87 - 1,35** 1,05 *** ***

1 yearpostop. 0.78 0.84 0,76

NS NS NS

1 year3 mth. 0,56 0,34 -0.4* 0.41

NS NS NS

**

NS NS

BS: bone splitting group. FES: fresh extraction socket group. C: control group. SD: standard deviation. Intragroup Wilcoxon matched pairs signed rank test; **/J<O,OI, / J < 0 , 0 5 . NS: not significant, Intergroup Mann-Whitney U-iesX, ***p<0,001. **p<0.01, V<0,05, NS: not significant.

Ridge reconstruction therefore, we used another implant material, bioactive glass cones, as this material has given effective results as regards maintenance of alveolar ridge following extraction (Stanley el al, 1987, Kirsh & Garg 1994, Wilson et al, 1993). In the FES group, we implanted 10 bioactive glass cones into fresh extraction sockets, and were thereby able to preserve original alveolar ridge dimensions for at least 1 year. An additional aim of the study was to use this material to augment previously resorbed alveolar ridge to provide an improved base for prosthetic treatment. This was achieved by splitting the alveolar ridge and inserting the bioactive glass cones into the gap created between buccal and lingual bone plates. In this group (BS) an average alveolar ridge width gain of 2.8 mm was achieved with an average regression, although not significant, of 0.6 mm at 1 year. The gain was significantly higher than that of the control group at 1 year. For future treatment, approximately 1 mm overcontoured expansion of the ridge might provide a solution to compensate for any postopertive shrinkage. In the FES group, implantation of the material imo the fresh extraction sockets resulted in preservation of the former alveolar ridge, the average collapse being only 0,1 mm (non-significant) at 1-year, Corresponding average ridge resorption for the C group however, was 0.75 mm (/><0.05), In the BS group the initial average increase in ridge height of 1.8 mm was reduced to 1.1 mm in 1 year. This mean 0,6 mm reduction was not statistically significant, A similar 0,4 mm reduction occurred for the FES group, resulting in an overall not significant height loss of 0.1 mm. Ridge height in the control group decreased by mean 0.9 mm postoperatively (/!<0.05) and by 1,35 mm at
12 months (/J<0.01).

837

ridge height, guided bone regeneration is suggested in addition to this technique. Height augmentation involving protruding root form grafts above alveolar crest in conjunction with granular alloplastic or other types of graft material and membranes, therefore might be recommended as the subject of a further study. The bioactive glass materials have been found to bond to both bone (Hench et al. 1971) and soft tissue (Hench & Andersson 1993), This binding occurs by bioactive fixation involving the bonding of collagen fibers into the polycrystalline matrix on the surface of the implant material by means of a hydroxy-carbonate apatite layer (Fujita et al, 1992, Hench & Andersson 1993. Vrouwenveider et ai, 1993), Rapid surface reaction of Bioglass and the formation of the biologically active hydrated calcium phosphate layer at the surface of the material appear to be responsible for much more rapid bone formation around the implants than around other calcium phosphate ceramics (Wilson & Low 1992). In the reentry procedure 12 months after insertion, such bone formation and attachment were clearly visible. The success of our study in one year would appear to provide evidence of the superiority of this mode of bonding compared to those of other implant materials, in summary, this study has shown that bone splitting in combination with root form bioactive glass implants resulted in significant improvement in residual ridge dimensions with regard to future prosthetic treatment. Such combined treatment is therefore recommended for correcting alveolar ridge deformities due to previous tooth extraction, to increase the success of the multidisciplinary treatment of these patients. Acknowledgments The authors wish to thank Mr. 1, McLure, Dr, Kemal N. Kose and Professor Dr, Hubert N. Newman for their assistance with the text.

Studies using submerged tooth roots report varying result as regards ridge augmentation. Graver & Fenster (1980) and Yilmaz et al, (1981) found submerged tooth roots to increase retention of the residual bony ridge, whereas Veldhuis et al. (1981) and Masterson (1971) found that vital roots produced dehiscences. Although the root form graft material implants appeared to adequately preserve ridge level, it may not be advisable to use this technique alone to increase ridge height, as the devices have to be placed below the crest level of the surrounding bone. To assure increase in

anterioren Oberkieferbereich oft Deformationen des Alveoiarfortsatzes, Diese Falle sind gewohnlich prothetisch schwierig zu restaurieren und haben eine schlechte Asthetik sowie ungenugende okklusaie Funktion zur Folge, Die.se Studie untersuchte die Wirksamkeit von Bioglaskegein mit Wurzelibrm. die entweder in (a) klinstliche durch Knochenspreizung erzeugte .Mveolen fruherer Extraktionsalveolen (Gruppe BS) Oder (b) in frische Extraktionsalveolen (Gruppe FES) implantiert wurden, Als Kontrollgruppe (Gruppe C) schlossen wir konventionelle Extraktionsalveolen, die zugenaht jedoch ohne Wurzeiform-Implantat versehen waren. mit in die Studie ein, 1nsgesamt wurden 16 Patienten behandelt. bei denen die Extraktion auf Grund einer schweren Parodontitis indiziert war, Sechs Patienten mit sieben lmplantaten. die Deformationen des Alveoiarfortsatzes von Klasse II und 111 hatten. bildeten die BSGruppe, Fiinf Patienten mil 10 Implantaten bildeten die FES-Gruppe, Gruppe C bestand aus 5 Patienten mil 10 Extraktionsalveolen. Die Breite und Hohe des Alveoiarfortsatzes ergab sich aus Messungen an Studienmodellen. die praoperativ, unmittelbar postoperativ sowie nach 3 und 12 Monaten gewonnen wurden. In der BS-Gruppe nahm die Breite des Alveoiarfortsatzes unmittelbar nach der Kammaugmentation um 2,81,18 mm und \ Jahr nach der Operation um 2.40,93 mm zu (/i<0,011. wahrend die Hohe des Alveoiarfortsatzes entsprechend um i,8l,99 mm und l , 4 r l , 7 4 mm zunahm (/i<0.05l. In der FES-Gruppe waren die Unterschiede zwischen der ursprUnglichen praoperativen Ivammhohe und Breite und den postoperativen Messungen nicht statistisch signifikant. was die Wirksamkeit dieser Methode beim Erhalt des Alveolarkammes zeigte, in der Gruppe C ergab sich nach 12 Monaten keine signifikante Veranderung in der Breite des Alveolarkammes. jedoch verminderte sich die Hohe des Alveolarkammes signifikant (1.35=1,05 mm. ;><0,01), Nach 12 Monaten ergaben sich keine Dehiszenzen und die Unterschiede zwischen den Gruppen biieben signifikant. Die Ergebnisse dieser Studie zeigen. daB dieses Vorgehen wirkungsvoll die Deformationen des Alveoiarfortsatzes. die durch Extraktionen hervorgerufen wurden. wiederherstellen kann. Dies ist insbesondere hinsichtlich der folgenden restaurativen Behandlung relevant.

Resume
Reconstruction et/ou preservation du rebord alveolaire a I'aide de cones en verre bioactifen forme de racine. Coniptes rendus de cas L'extraction d'une dent, rendue necessaire par des facteurs tels que des problemes au cours du developpement, des traumatismes, une maladie parodontale severe ou des problemes endodontiques. cause souvent des deformations dans la region anterieure du rebord alveoiaire restant au maxillaire superieur. II est generale-

Zusammenfassung
Rekonstruktion und/oder Erlialt des Alveolarfortsatzes unter Verwendung von Bioglaskegcln mit Wurzelform. Fallberiehte Eine durch Probleme bei der Zahnentwicklung, ein Trauma, eine schwere Parodontitis Oder endodontische Probleme notwendig gewordene Zahnextraktion verursacht im

838

Yilmaz et al.
thodontics. Journal of Prosthetic Dentistry 58, 266-270, Boyne, P. J,, Rothstein, S, S,, Gumaer, K, I, & Drobeck, H. P (1984) Long-term study of hydroxyapatite implants in canine alveolar bone. Journal of Oral Maxdlofacial Siirgerv 42. 589-594, Callon. D, P & Rohrer. M, D. (1993) Use of bovine-derived hydroxyapatne in the treatment of edentulous ridge defects: A human clinical and histological case report, Journai of Periodontology 64, 575-582, Cobb, C, M,, Eick. J, D , Barker, B, F. Mosby, E, L, & Hiatt, W, R, (1990) Restoration of mandibular continuity defects using combinations of hydroxyapatite and autogenous bone: Microscopic observations. Journal of Oral Maxillofaeial Surgery 48. 268-275, Cranin. N, & Shpuntoff. R, (I9g4) Hydroxyapatite (HA) bone implants for alveolar ridge maintenance; 1 year follow up (Abstract 269), Journal of Dental Re.iearch (special issue) 63, 200. Crum. R, J, & Rooney, G, E, (1978) Alveolar bone ioss m overdentures; a 5 year study. Journal of Prosthetic Dentistry 26, 266172, Dennissen. H, W, & DeGroot, K, (1979) Immediate dental roots implants from synthetic dense calcium hydroxyapatite. Journal of Prosthetic Dentistry 42, 551558, Frame, J, W.. Rout. P, G, J, & Browne, R. M, (1987) Ridge augmentation using solid and porous hydroxyapatite particles with and without autogenous bone or plaster. Journal of Oral Maxiiiofacial Surgery 45, 771-777. Fujita, Y,, Yamamuro. T.. Nakamura. T. Kitsugi. T, & Kotani. S, (1992) Mechanism and strength of bonding between two bioactive ceramics in vivo. Journal of Biomedical Materials Research 26, 1311 -1324, Godefroy, J, N,, Laroche. N,, Fourcart, J, & Boivin, G, (1994) Ridge reconstruction after implant failure using a resorbable membrane. Report of a case and histologic study. International Journal of Oral Maxillofacial Implants 9, 431^36, Graver, D, ). & Fenster, R, K, (1980) Vital root retention in humans; a final report. Journal of Prosthetic Dentistry 43, 368374. Gray, J, L, & Quattlebaum, J, B, (1988) Correction of localized alveolar ridge defects utilizing hydroxyapatite and a "tunnelling" approach; A case report. International Journal of Periodontics & Restorative Dentistry 3. 73-78, Hanne. E,, Sonis. S,. Gallagher, G. & Atwood, D, (1988) Preservation of alveolar ridge with hydroxyapatite-collagen implants in rats. Journal of Prosthetic Dentistry 60, 729-734, Hawkins, C, H,, Sterrett, J, D,, Murphy. H. J. & Thomas, J, C. (1991) Ridge contour related to esthetics and function. Journal of Prosthetic Dentistry 66, 165-168, Hench, L, L,, Splinter, R. J., Allen. W, C. & Greenlee. T, K, (1971) Bonding mechanisms at the interface of ceramic prosthetic material. Journal of Biomateriais Research 2. 117-141. Hench. L, L, & Andersson. 6 . (1993) Bioaetive gias.\es. In; Hench, L, L, & Wilson, J. (eds); .4n Introduction to bioceramics. Singapore. New Jersey. London, Hong Kong; World Scientific pp, 41-62, Johnson, G, K, & Leary, J, M, (1992) Pontic design and localized ridge augmentation in fixed partial denture design. Dental Clinics of North America 36, 591-605, Krish, E, R. & Garg, A, K. (1994) Postextraction ridge maintenance using the endosseous ridge maintenance implant ( E R M P ) , Compendium of Continuing Education in Dentistry 15. 234-242, Kwon, H, J,. Deeb, M,, Morstad, T & Waite, D, (1986) Alveolar ridge maintenance with hydrcxyapatite ceramic cones in humans. Journal of Oral Ma.xiiiofacial Surgery 44, 503-508, Langer, B, & Calanga, L, (1980) The sub-epithelial connective tissue graft. Journal of Prosthetic Dentistry 44, 363-367, Masterson, M. R (1971) Retention of vital submerged roots under complete dentures; reports of 10 patients. Journal of Pro.*,ihetie Dentistry 41. 12-18, Nery, E, B,, Lynch. K, L, & Rooney, G, E, (1978) Alveolar ridge augmentation with tricalcium phosphate ceramic. Journal of Prosthetic Dentistry 40. 668-675, O'Brien, T, P. Hinrichs. J, E, & Schaffer. E, M, (1994) The prevention of localized ridge deformities using guided tissue regeneration. Journal of Periodontology 65, 17-24. Oli. P S., Ettel, R. G, & Schaffer. E, M, (1991) Improved pontic'tissue relationships using porous coralline hydroxyapatite blocks. Journal of Pro.'sthetic Dentistry 66. 234-238, Quinn, J, H,. Kent, J, N,, Hunter, R, G & Schaffer, C, M, (1985) Preservation of the alveolar ridge with hydroxyapatite tooth root substitutes. Journal of American Dentat Association 110, 189-196, Seiberl, J, S. & Cohen, D, W, (1987) Periodontal consideration for fixed and removable prosthodontics. Dental Clinics of North America 4, 437-453, Seibert, J, S. (1983) Reconstruction of deformed, partially edentulous ridges, using full thickness onlay grafts. Part I, Technique and wound healing Compendium of Continuing Education in Dentistry 4, 437453, Seibert, J. S, & Nyman, S, (1990) Localized ridge augmentation in dogs; A pilot study using membranes and hydroxyapatite. Journal of Periodontology 61, 157-165, Stanley, H, R,, Hall, M, B,, Coaizzi, F & Clark, A, E, (1987) Residual alveolar ridge maintenance with a new endosseous implant material. Journal of Prosthetic Dentistry 58, 607-613. Veldhuis. A, A, H., Schade, G, J.. Dennissen, H. W et al, (1981) Submerged tooth roots

ment difficile de faire les restaurations prothetiques dans ces cas. et le rcsultat obtenu donne une mauvaise esthetique et une fonction occlusale insuffisante, Cette etude considere Tefficacite des cones de verre bioactif en forme de racine. implantes (a) dans des alveoles artificielles obtenues en dissociant la partie vestibulaire de la partie palatine de l'os dans des sites d'extractions faites anterieurement (groupe BS) et (b) dans des alveoles de dents fraichement extraites (groupe FES), Nous avons a titre de temoins considere aussi des alveoles d'extractions ordinaires suturees sans implamer de cone de verre bioactif en forme de racine (groupe C=controi). On a en tout traite 16 patients chez qui des extractions avaient ete indiquees en raison d'une severe parodontite. Le groupe BS etait compose de 6 patients ayant 7 sites implamaires presentant des deformations du rebord alveolaire de classe II ou III, Le groupe FES etait compose de 5 patients ayant 10 sites implantaires, Le groupe C comprenait 5 patients ayant 10 sites d'extraction, Les mesures de la largeur et de la hauteur du rebord alveolaire ont ete obtenues sur modeles d'empreintes prises avant l'operation. immediatement apres f operation, puis 3 mois et 12 mois apres l'operation, Dans )e groupe BS. alors que la largeur du rebord alveolaire augmentait de 2.8:1,8 mm immediatement apres l'intervention d'augmentation du rebord. et de 2.40,93 mm un an apres I'operation lj!<O.Ol). la hauteur du rebord alveolaire augmentait respectivement de 1.8 1.99 mm et) ,4:t 1,74 mm (;j<0,05), Dans le groupe FES. les differences entre les mesures preoperatoires de la hauteur et de la largeur d'origine et les mesures postoperatoires n'etaient pas statistiquement significatives, ce qui mettait en evidence l'efficacite de cette methode pour preserver le rebord alveolaire, Dans le groupe C, alors que la largeur du rebord alveolaire n'avait pas change significativement apres 12 mois, la hauteur du rebord aiveolaire diminuait significativement (l,35l,05 mm, p<O.Ol). Apres 12 mois, on ne constatait pas de dehiscence et les differences entre la hauteur dans les differents groupes restaient significatives, Les resultats de cette etude indiquent que cette methode est efficace pour reconstruire les rebords alveolaires deformes a la suite d'extractions, ce qui etait particulierement important pour )a preparation en vue d'une restauration ulterieure.

References
Agudio, G, Pini Prato, G, P., Nevins, M., Cortellini, P & Ona, Y, (1989) Esthetic modifications in periodontal therapy. International Journal of Periodontics & Restorative Dentistry 9. 289-299. Bahat. O. & Kaplin, L. M, (1989) Pantographic lip expansion and bone grafting for ridge augmentation. International Journal of Periodontics & Restorative Dentistry 9. 345-353. Balshi. T J, (1987) Preventive durapatite ridge augmentation for esthetic fixed pros-

Ridge reconstruction
in preventive prosthetic dentistry. Clinical Preventive Dentistry 5, 13-18, Veldhuis, A, A, H,, Driessen, T , Dennissen, H. W. et al, (1984) A 5 year evaluation of apatite tooth roots as mean to reduce residual ridge resorption, Ciinicai Preventive Dentistry 5, 5-10. Vrouwenvelder, W, C, A,, Groot, C, G, & Groot. K, (1993) Histological and biochemical evaluation of osteoblasts cultured on bioactive glass, hydroxyapatite, titanium alloy, and stainless steel. Journal of Biomedical Material Research 11, 465475, Wijs, F L, J. A,, Putter, C . Lange. G, L. & Groot, K, (1993) Local residual ridge augmentation with solid hydroxyapatite blocks: Part Il-Correction of local resorption defects in 50 patients. Journal of Prosthetic Dentistry 69, 514-519. Williams, C. W,, Meyers, J, F & Robinson, R, R. (1991) Hydroxyapatite augmentation of the anterior maxilla with a modified transpositional flap technique. Oral Surgery Oral Medicine Oral Pathology 72, 375-379, Wilson, J,, Clark, A, E,, Hall, M, & Hench. L. L, (1983) Tissue response to bioglass endosseous ridge maintenance implants. Journal of Oral Implantologv 19. 295302, Wilson, J., Low, S,, Fetner, A. & Hench, L, L, (1987) Bioactive materials for periodontal treatment: a comparative study. In: Pizzoferrato, A,, Marchetti, P G,. Ravaglioli. A, & Lee, A.. J, C, (eds): Biomaterials and clinical applications. Amsterdam: Elsevier, pp, 223-228, Wilson, J, & Low, S, B, (1992) Bioactive ceramics for periodontal treatment: comparative studies in the patus monkey. Journal of Applied Biomaterials 3. 123-129,

839

Yilmaz. S,, Beyii, M, & Efeoglu, A, (1981) Koklerin canli olarak korunmasi ile alveol kemiji rezorbsiyonunu onleme, Turk Periodontoloji Dergisi 6. 77-86, Zamet, J, S., Darbar, U. R,, Griffiths, G. S,, Bulman. J. S,. Bragger, U,, Blirgin, W, & Newman, H, N, (1997 Particuiate bioglass* as a grafting material in the treatment of periodontal intrabony defects. Journal Clinical Periodomohgy 24, 410418,

Address: Sei^uk Yilmaz Marmara University. Faculty of Dentistry Department of Periodontology Biiyakgiftlik sokak no. 6, 80200 Nifantai:, Istanbul Turkey