460 ADVANCED TREATMENT FOR ALVEOLAR BONE RESORPTION + NARUSE ET AL Advanced Alveolar Bone Resorption Treated With Implants, Guided Bone Regeneration, and Synthetic Grafting: A Kei-Ichi Narus Case Report ODS," Masayuki Fukuda, DDS, PhD, + Hiromasa Hasegawa, DDS, PhD.t Kimitoshi Yagami, DS, PhD,§ and Nobuyuki Udagawa, DDS, PhDIl he conventional surgical method I in the presence of insufficient al- veolar bone to position implants involves collecting autogenous bone as block or cancellous bone from the iliac crest, mentum, or mandibular ramus. The extraoral collection of autogenous bone requires a quantity of bone ex- ceeding the defective bone volume, and collection from the iliac bone results in extensive surgical inva- sion, requiring hospital admission The extracted bone quantity is also limited on intraoral bone collection, and surgery for the donor site is re- quired. The level of surgical inva- sion at the donor site is often the same or greater than that at the sur gical site, resulting in an increase in the risk of infections, accidents, and morbidity. Unpredictable, signifi- cant bone resorption of 16% to 60% has been reported, and there is a lack eprint requests and coreipondence Dr vicki 2amuagen inptant Cone, Yamagata Ci, Yamagata 200-0033 Japan, Phone Wht e882925, Pa, Bt (25-008 Cal marsefltonse Purpose: To present a vertical ridge augmentation with a compos ite synthetic bone graft by the mixed bone-filling materials and autoge- nous bone chips retrieved from the implant osteotomy site for a case for esthetic implant prosthesis on the at~ rophied alveolar bone. Materials: Nonresorbable and resorbable hydroxyapatite and demin- eralized freeze-dried bone allograft particles were used at ratio of 1:2:2 (volume ratio). Titanium micromesh was used for alveolar ridge configu. ration and retention. After 8 months, implant placement and interimplant bone augmentation were performed. Results: 15-mm vertical and 10-mm horizontal bone augmentation hhas been achieved. Marginal bone heights and periimplant mucosa re- ‘mained stable in cases of loading after years of follow-up. Conclusion: These results sug gest that this method has the po- tential for use in esthetic implant rehabilitation on the highly atro- Phied alveolar bone. (Implant Dent 2010;19:460-467) Key Words: advanced bone resorp- tion, vertical bone construction, syn- thetic bone-filling material, titanium ‘micromesh, guided bone regeneration ————— of reliability regarding autogenous bone grafts."* Guided bone regeneration (GBR) using bone-grafting materials is one way to overcome these problems. Bone- grafting materials are classified into de- mineralized freeze-dried bone allograft (DFDBA), xenograft, and artificial bone (hydroxyapatite [HAl), depending on the materials, and the difference in the bone forming ability is considered to be derived from the biological and struc- tural properties of these materials?" Therefore, itis important to use these materials in the proper ratio to achieve the desired bone shape. Without using autograft, Yamamichi et al"? reported that the combination of DEDBA, resorb- able HA (rFIA), and nonresorbable HA (orHA) (11:1) grafts had the best su vival rte for sinus augmentation. On the other hand, the combination of autoge- nous bone, DFDBA, and rHA (1:3:3) showed gradual bone loss around im- plant, which was observed during 6 yeas after Ioading.'" This bone resorp- tion positively correlated with implant failure. Histologically, new bone form- tion and the presence of the HA. were evidenced between 9 and 44 months after bone grafting.” The nrHA incor- porated into regenerated bone and main- tained the volume for a long time." This advantage may be related to the control of the bone resorption in this case Another problem in extensive bone augmentation is retaining the de- signed bone shape. It has been re-ported that the mixture of HA, B-calcium phosphate, and collagen Positively affects bone formation after bone augmentation.!* For such cases, simultaneous and two-step bone aug” mentation methods at the implant placement site have been developed. These are bone augmentation methods with a wide clinical application using ‘itanium-reinforced_polytetrafluoro: ethylene membrane (GORE-TEX; W.L. Gore & Associates, Inc., Flag- staff, AZ) and bone grafting materials such as autogenous bone and DFDBA'S*" Tinti er al!® reported that ‘7-mm vertical alveolar bone augmen- tation was achieved using autogenous bone and membranes. ‘Activation agents used in clinical settings include bone grafting materi- als, platelet-rich plasma, recombinant human platelet-derived growth factor- BB, fibrin, atelocollagen, membranes, and a titanium micromesh.''*" ‘Among these activation agents, tita- nium micromesh is considered partic ularly effective for retaining the bone grafting material shape in extensive bone augmentation sites because of its firm retention property and low risk of postoperative complications, such as ‘mucosal dehiscence.” This article describes a continuous implant treatment, introducing newly mixed bone grafting materials, consid- ering the different timing of bone n sorption and bone augmentation using titanium micromesh for a severe bone resorption case, Case Rerorr Preoperative Examination and Diagnosis The patient was a 52-year-old man. Radiographic and periodontal examinations at the initial visit dem- onstrated bleeding and pus discharge from all periodontal pockets, and the patient was diagnosed with advanced chronic periodontitis. The patient was advised to undergo extraction of non- preservable teeth and was referred to his family dentist. He revisited our clinic on February 13, 2002, with up- per and lower dentures after having his nonpreservable teeth extracted. Au- togenous bone graft was required to place the implant because of severe bone resorption. GBR using the com- bination of DFDBA, rHA, and nrHA (2:1: bone grafting materials was se- lected. Fifteen-millimeter vertical and 10-mm horizontal bone augmentation ‘were planned for severe bone resorp- tion in the left lower molar area (Fig. 1). The patient gave informed consent on the basis of this treatment plan, MATERIALS Bone grafting materials included rH (Osteograit S-D; Japan Medical Materials, Japan), FHA (Osteogen, Im- pladent), and DFDBA (Osteodemin; Impladent) at a ratio of 1:2:2 mixed with gentamicin sulfate solution (Gen- tacin; Schering-Plough). The combi- nation of DEDBA, rHA, and nrHA (L:1s1) gratis had the best Survival rate for sinus augmentation. 19, Numper 6 2010 461 Mernons (March 26, 2005) ‘Conduction anesthesia in the man- Gibular foramen and local infiltration anesthesia were used with 2% Xylo- caine. A full-thickness flap was eh vated from the ascending branch of the mandible in the alveolar crest to the distal of the second premolar, fol- lowed by the erevicular incision to the medial side of the left lower first pre- ‘molar and vertical incision The periosteum was carefully sepa- rated to the lower border of the ‘mental foramen anteriorly and the man- dibular angle posteriorly. The bone grafting materials were placed at ~15 ‘mm, the same height as the distal al olar bone crest of the left lower second premolar (Fig. 2) to the retromolar pad, and covered with molded titanium miz cromesh (Fig, 3). The periosteum was Fig. 1. Preoperative intraoral view (eft lateral view). Fig. 2. Compoate bone substitutes including nonresorbable hydroxyapatte, resorbable hy: ‘ronyapatte, and demineralized freeze-dried bone allogratt were filed vertcaly up to the ‘alveolar bone erest of the adjacent teeth, Fig 3. Titanium micromesh was placed on the bone-fiing materials to fx and maintain the helght ofthe materials. Fig, image of the second surgery. Vertical rdge augmentation of 3 mm from the implant platiorm was achieved. This enabled the reconstruction of interdental papila-ike tissue. Fig. 5. Free gngva was extracted trom the maxilary palate, and was transplanted to the ‘buccal side of the implant. Fig. 6. Hematoxyln-eosin-stained image. New bone formation was observed around the ‘nonresorbable hydroxyapatite decalicaton space (’). Fig. 7. An x-ray image taken 3 years and 2 months after final upper structure placement (5 years and 9 months after bone augmentation). No bone resorption was observed, Intraoral image immediately after superstructure placement,462. AbvaNcep TREATMEN FoR AL /BOLAR BONE RESORPTION * NARt ET AL denuded to the base of the mandible, followed by releasing incision, upper traction, and suture to achieve complete closure’ with a loose mucoperiosteal flap. Removal of Titanium Micromesh, First Implant Surgery, and Second GBR (November 28, 2003) Titanium micromesh removal and first implant surgery were performed simultaneously 8 months after the bone augmentation surgery. Two- percent Xylocaine was administered for local anesthesia, An incision was made, and the titanium micromesh was removed. Sufficient bone aug: mentation for implant placement was achieved. An implant base was formed by drilling without irrigation 10 coll the bone tissue from the implant place: ment site The lengths of implant bodies were 14, 14, and 12 mm from ‘medial to distal, considering the depth from the superior cortical ridge to the inferior alveolar canal after bone aug- mentation, Bone tissue attached to a drill was collected, mixed with the ame bone-filling materials used in the previous bone augmentation surgery, and used for vertical bone augmenta- tion between implants. The grafted site was covered with a nonresorbable Gore-Tex membrane. ‘Second Implant Surgery (July 14, 2008) Second implant surgery was per- formed 8 months after the first implant surgery and second bone augmenta- tion (16 months after the first bone augmentation), and a 5-mm_ upper structure (healing cap) was positioned, Vertical bone augmentation of 3 mm ‘was achieved above the implant plat- form afier the previous bone augmen- tation (Fig. 4). Minor loadings such as lingual pressure were applied for 2 ‘months after the second implant sur gery, followed by the fabrication of a provisional restoration with quick- Free Gingival Graft and Bone Biopsy (August 22, 2005) Because vertical bone augmenta- tion was performed for the severely resorbed residual ridge, the buccal mu- cosa was attached t0 the alveolar crest after healing of the mucosa because of the lack of keratinized mucosa (Fig. 5). ‘The attachment of buccal mucosa to the alveolar crest may cause abrasion of the mucosa during brushing and periim- planttis. Keratinized gingiva is neces- sary around the implant to avoid these problems. Free gingival graft was per- formed to achieve keratinized gingival tissue. A graft bed was formed by sep- arating mobile mucosa around the im plant, and free gingiva extracted from the palate was grafted and sutured, Biopsy of the posterior part of the implant embedded in the augmented bone with composite bone substitutes was performed using a trephine burr G-mm inner diameter), followed by histological observation, The rHA was filled in the space where the tissue was extracted. Histological Observation Bone-like tissue obtained from the bone biopsy was decalcified with eth- ylenediaminetetraacetic acid and em- bedded in paraffin according to the conventional method. Paraffin se tions were stained with hematoxylin eosin and microscopically observed (Fig. 6). Bone grafting materials were surrounded by mature trabecular bone, and consisted of small bone tissue, and adipose tissue containing nrHA space. New bone formation was observed around the nrHA space. Mild lympho- cyte infiltration was noted in the adi- pose tissue, which consisted of small blood vessels and mature adipocytes. These histological examinations showed that bone grafting materials were replaced by relatively mature bone tissue containing fatty marrow. Prognosis Bone-like tissue around the im- plant was examined radiographically after healing cap placement. No bone resorption was observed in x-ray im- ages immediately after healing cap placement (Fig. 7) and 3 years and 2 months after the placement. At present, 5 years and 9 months have passed since the bone augmenta tion, Three years and 11 months have passed since the provisional restora- ion placement and 3 years and 2 months since the final upper structure placement. A comparison of intraoral images immediately after the upper structure placement (Fig. 8) and at present demonstrated no. significant chang Discussion In this case, new bone height in- duction with synthetic bone-grafting materials was used to achieve vertical and horizontal bone augmentation for the alveolar bone resorption caused by advanced periodontitis. Bone augmen- tation was achieved 5 mm vertically and 10 mm horizontally. The aug- mented bone mass was sufficient for appropriate implant placement and was also used (0 reconstruct the inter dental papilla between implants with bone tissue New bone induction at the alveo- lar crest is required for vertical bone augmentation. Osteoblasts making. up bone are derived from undifferentiated ‘mesenchymal cells.” Undifferentiated ‘mesenchymal cells are multipotential cells that can differentiate into connec- tive tissue, fat, muscle, and bone.” The periosteum in the alveolar crest plays an important role in new bone regeneration. It is considered that os- teoblasts.in the periosteum derived from undifferentiated mesenchymal cells hold the key." ‘There are some advantages to per- forming bone augmentation using only bone-grafting materials. Autoge- nous bone grafting is the conventional treatment method in cases with signif icant bone resorption. However, jaw construction using this method) re- quires. grafting bone collection from the iliac bone, resulting in extensive surgical invasion and an increased risk of infection, Jaw bone reconstruction using only bone-grafting materials re- duces these risks aid, therefore, is of ‘great benefit to patient. von Arx et af reported that aug- mented bone is resorbed over time when rafting materials were used alone for lateral bone augmentation. Handschel et af reviewed thatthe total bone volume of histomorphometric meta-analysis of autogenous bone, DFDBA, HA, B-calcium phosphate, anorganic’ depro- teinized bovine bone and combination