alveolar ridge reconstruction method

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J ciin Periodmlol 1 9 9H: :S: Si2-S39PriiiU'd in Denmark . All rights reserved Copyright t. Mitnk^gawiiMWAIBFC l i n i c a l p e r i o d o n t D

Alveo lar r idge reconst ruc t ionand/or preservat ionus ing roo t f o rm b iog lass cones

C a s e R e pSel^uk Yrlmaz, Elvan Efeogluand Ali Riza K1I19De p a r tm e n t o f Pe r io d o n to io g y, Fa cu l ty 0Dent is t ry, Marm ara Univers i ty, Nian tai,i s t a n b u i -T u rke y

Ydtnaz S. Efeoglu E. Ktli^- .AR: Alveolar ridge reconstruction and/or preservationusing root fornt bioglass cones. Ca.se reports. J Ciin Periodontol 1 9 9 8: 25: 832-839 . Munksgaard, 1998.Abstract. Fxtraction of a tooth necessitated by factors such as developmentalproblems, trauma, severe periodontal disease and endodontic problems oftencauses deformities of the residual alveolar ridge in the maxillary anterior region.These cases are usually difficult to restore prosthetically and they result in pooresthetics and insufficient occlusal function. This study investigated the efficacy ofroot form bioactive glass cones implanted into (a) artificial sockets produced bybone splitting of previous extraction sites (group BS) and (b) fresh extractionsockets (gro up FES ), We included conv entiona l extraction sockets sutured w ith-out implanting the root form bioactive glass cones as a control (group C), .\total of 16 patie nts were treated for whom extrac tions had been indicated due tosevere periodontitis, 6 patients with 7 implant sites having Class II or III alveolarridge deformities co mp rised th e BS grou p. 5 patien ts with 10 impla nt sites com -prised the FES grou p. G rou p C, comprised 5 patients with 10 extraction sites.Alveolar ridge width and height measurements were obtained using study castspreoperatively, imm ediately p ostoperatively. and at 3 and 12 mo nth s after ope r-ation . In th e BS group , while the width of the alveolar ridge increased by 2,8 1,18mm immediately after r idge augmentation procedure and by 2.40.93 mm at Iyear after operation (/7


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Ridge reconstruction 8(Agudio et al. 1989, Hawkins et al.1991. Johnson & Leary 1992) when it isdecided to restore with only fixed pros-theses. Surgical augmentation of al-veolar ridge defects has been proposedas the treatment of choice for the prep-aration of deformed ridges prior toprosthodontic t reatment (Langer & Ca-langa 1980, Seibert 1983, Balshi 1987).Furthermore, several materials andprocedures have been used to prevent al-veolar ridge reduction, or (o reconstructdeformed residual edentulous ridges(Frame et al, 1987. Bahat & Kaplin1989. Cobbet al, 1990, Seibert & Nyman1990, Oli et al. 1991, Callon & Rohrer1993). These have involved the use ofsubmerged vita! and nonvital roots(Graver & Fenster 1980. Yilmaz et al,1981. Veldhuis et al, 1981), autologousbon e graft (C obb et al. 1990, Fram e et al,1987). guided bone regeneration (Godef-ro ye ta l, 1994. O'Brein et al, 1994. Seib-ert & Nyman 1990) and the use of bioc-ompatible m aterials in granular (G ray &Qu attlebau m 1988). root or block form(Balshi 1987. Fr am ee tal , 1987. Kw onetal, 1986. Ne ry e ta l, 1978. Oli et al. 1991.Williams et al, 1991), These biocompat-ible implant materials when placed intoextraction sockets may prevent or mini-mize collapse of the residual ridge by de-laying resorption and acting as spacefillers after extraction of the naturaltooth roots (Gra ver & Fen ster 1980, Yil-mazeta l . 1981) ,

Some investigators have placed cone-shaped dense hydroxyapatite (HA) inextraction sockets, in dogs and humans(Balshi 1987, H ann e et a l 1988, Wijs etal , 1993). Both animal and humanradiographic studies have found bonearound such graft materials adaptedclosely 12 to 18 m on ths after implan -tation, with well preserved residualridges (Boyne et al. 1984). Histologicalstudies have indicated new bone forma-tion at the reconstructed area (Callon &Ro hre r 1993, Ne ry et al, 1978, Seib-ert & Nym an 1990). Some studies withHA, however, have reported a 53-55';.!failure rate due to the development ofdehiscences within I to 2 years (Cran-in & Shpuntoff 19B4, Kwon et al, 1986),

Some studies demonstrate the suc-cessful use of 45S5 particuiate form bi-oactive glass (Bioglass*) graft materialsin periodontal defects (Wilson et al,1987, Zamet et al. 1997), This materialhas also been shown to be effective inmaintaining the alveolar ridge following

of these studies appe ar to have used thismaterial to reconstruct deformed re-sidual alveolar defects. The principalaim of this study therefore was to inves-tigate the efficacy of root form bioac-tive glass graft material for the recon-struction of alveolar ridges. Further-more, we wanted to investigate thepotential of this material for implantinginto fresh extraction sockets to preventpossible further alveolar resorption.

Material and MethodsSubjects16 adult subjects. 9 male and 7 female,mean age 38,39.40 were selected forthis study. None had any systemic dis-ease. Ail had had at least 1 ma xillaryincisor extraction site (bone splittinggroup) or a corresponding incisor ex-tracted due to severe periodontitis(fresh extraction socket and controlgroups). None of the patients wereusing any prosthetic appliances. Ali ofthe subjects had or would have had es-thetic or functional alveolar ridge de-fects as a result of the extraction. Allpatients had been instructed in oral hy-giene prior to treatment and bad under-gone the initial phase of periodontaltherapy. They had been fully informedabout possible other treatment modalit-ies, including guided bone regeneration,titanium screw implants and hybridprostheses. Each patient had volun-tarily signed an informed consent formaccording to the chosen treatment. Thestudy had the approval of MarmaraUniversity Research and Ethic Com-mittee,

Treatment ProcedureBotte splitting group (BS) (6 patients-7implant sites). The extractions had re-sulted in Class II or III ridge deform-ities (Se ibert's classification 1983) all ofwhich were treated with root form graftmaterial. On the mesial and distal sidesof the eden tulous area, vertical incisionswere made extending to just beyond themucogingival junction vestibularly andappro ximately 1 cm further palatally.The 2 vertical incisions palatally wereconnected with a horizontal incisionand the mucoperiosteal flap was re-fiected to fully expose the edentulousridge, "Bone splitting" was carried outby splitting the residual alveolar ridgeinto palatal and vestibuiar sections after

split was prised apart, as far as the etic limits of the bone would permit,order to bring the edentulous riwidth as far as possible in line with tof the neighboring teeth. Artificsockets were prepared with a suitamatching dental burr with slow speunder external irrigation to the size ashape of the root form cones. The rform cones used were the bioactglass alloplastic graft material (Endseous Ridge Maintenance ImplaERMI, US, Biomaterials Corp, AlahFlorida, USA), and they were not shaped.

In order to ensure that the graft mterial was approximated as closely possible to the bone and remained imobile, the implant was sized to sit proximately 1 mm below the ridge cGranular form graft material (PerGlass, US Biomaterials Corp. AlahFlorida, USA) was inserted into avoids which remained after the plament of cones (Figs, 2c, 3b), The resuant increased bulk of the alveolar ridresulted in a gap on the palatal swhich closed by secondary healiMucoperiosteal fiap was split at base of the defect vestibularly to factate flap sliding and decrease the gbetween the flap margins. The fiawere sutured with 3-0 silk sutures.

Fresh extraction socket group (FE(5 patients-10 implant sites). Before tracting the tooth, an intrasulcular cision was made and the mucopeosteal flaps reflected as carefully possible in order to avoid root fractand damage to the alveolar bone. granulation tissue was removed curettage. implantation of cones aflap closure were performed as for BS group, except no granular form mterial was required as the fit was snuControl group (Cj (5 patients. sites). This group served as controls the FES group. The surgical proceduwas the same as for the FES group, ecept that no material was implanted.For prophylactic purposes, the ptients were prescribed a postoperatiantibiotic (amoxycillin 500 mg 3Xday) for 10 days and instructed to pform hom e care. After 10 days suturwere removed.Temporary acryhc fixed prostheswere installed at 3 weeks. During t

following 3 mo nth s, follow-up examations were performed by the operatisurgeon and a prostho dontist . Perm


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834 Yilmaz el ai

Wi; preo perativ e alveolar ridge width W2; posto perat ive alveolar ridge widthh,; preoperative alveolar ridge height h2: postoperative alveolar ridge heightfig, / , Me tho d used to obtain ridge width and height data from study casts. The differencesw,-W| and hj-h, present the width and height increases or decreases between follow-upperiods .

Table I. Mean vestibulo-palatal dim(width) of the alveolar ridge at the tsites (mm)

3-Preop, Postop, months

BS( = 7)F E SC(fi=lC

meanSDmean

1) SDmean

1) SD

6,21,975,51.264.70.47

9.01,526,41,444,30,67

8.61.545.91.404, 20,63

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

give access for the patient to use dentalfloss and interdental brushes. Follow upwas conducted for a further 9 months(Fig 3c). Radiographs of the areas in-volved were taken preoperatively, im-mediately following the operation, andat 3 month s and 1 year postoperatively(Figs. 2f, 3d).

MeasurementsChanges in vertical and horizontal di-mensions and form of the defects weredetermined from study casts . Im-pressions were taken preoperatively, im-mediately postoperatively, at 3 mon ths,and at 1 year postoperatively. Au to-

polymerizing acrylic reference pwere obtained from the preopestudy casts . These plaques had locnotches to ensure vertical sectioniall casts along the same line (FigProfiles of the alveolar ridge wertained using linear measurements obtained from the casts on graph

Fig. 2. Case 1, Site of previously extracted left 1" and 2"'' incisors (a), Preoperative ridgecondition, (b) B one splitting proced ure using bon e chisel, (c) Bioactive root form graftmaterial ridge im plants following b one splitting, (d) Site 1 year after surgery and tem pora ry


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Ridge reconstruction 8

Fig. S. Case 2, Site of previously extractedright 1" incisor, (a) Preoperative ridge con-dition due to traumatic tooth loss, (b) Bioac-tive root form graft material ridge implantfollowing bone splitting, (c) Occlusa) view ofimplan tation site 3 mo nths after operatio n,(d) Radiograph of implant immediately fol-lowing operation (e) Sections of preoperativeand 1 year postoperative study casts showingridge augmenta t ion.

and ridge changes were calculated bycomparing the profiles at each timepoint (Fig, 1). One subject in the BSgroup underwent re-entry surgery at 1year postoperatively after obtainingvoluntary consent (Fig. 2e),

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

ridge relative to preoperative valuwere 2,8 mm immediately postopertively. 2.4 mm at 3 months, and 2,2 mat 1 year (/)


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836 Ytlmaz et al.Table 3. Mean apico-coronal dimension(height) of the alveolar ridge at thetreated sites (mm)

3 - 1-Preop, Postop, months year

BS m ea n 13.1 14,9 14,5 14,2(= 7) SD 2.91 2,68 2.84 2,98FE S me an 8,1 8.4 8.2 8.0(n =1 0) SD 2,13 1,95 1,82 1.63C m ea n 8.3 7,4 7,.3 7,0(n =1 0) SD 1.15 0,69 0,65 0,49BS: bone splitting group.FES; fresh extraction socket group,C: control group,SD: standard deviation.

though not significant, of 0.4 mm after3 m onth s and 0.6 mm after 1 year(Table 2). Similarly, increases in the ap-ico-coronal dimension (height) of thealveolar ridge relative to preoperativevalues were 1.8, 1,4, and 1.1 mm(jt>


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Ridge reconstruction 83therefore, we used another implant ma-terial, bioactive glass cones, as this ma-terial has given effective results as re-gards maintenance of alveolar ridge fol-lowing extraction (Stanley el al, 1987,Kirsh & Garg 1994, Wilson et al, 1993).In the FES group, we implanted 10 bi-oactive glass cones into fresh extractionsockets, and were thereby able to pre-serve original alveolar ridge dimensionsfor at least 1 year.

An additional aim of the study was touse this material to augment previouslyresorbed alveolar ridge to provide an im-proved base for prosthetic treatment.This was achieved by splitting the al-veolar ridge and inserting the bioactiveglass cones into the gap created betweenbuccal and lingual bone plates. In thisgroup (BS) an average alveolar ridgewidth gain of 2.8 mm was achieved withan average regression, although not sig-nificant, of 0.6 mm at 1 year. The gainwas significantly higher than that of thecontrol group at 1 year. For future treat-ment, approximately 1 mm overcontour-ed expansion of the ridge might providea solution to compensate for any post-opertive shrinkage. In the FES group,implantation of the material imo thefresh extraction sockets resulted in pres-ervation of the former alveolar ridge, theaverage collapse being only 0,1 mm(non-significant) at 1-year, Correspond-ing average ridge resorption for the Cgroup however, was 0.75 mm (/>


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838 Yilmaz et al.ment difficile de faire les restaurations prothe-tiques dans ces cas. et le rcsultat obtenu donn eune mauvaise esthetique et une fonctionocclusale insuffisante, Cette etude considereTefficacite des cones de verre bioactif en formede racine. implantes (a) dans des alveoles arti-ficielles obtenues en dissociant la partie vesti-bulaire de la partie palatine de l'os dans des si-tes d'extractions faites anterieurement (grou-pe BS) et (b) dans des alveoles de dentsfraichement extraites (groupe FES), Nousavons a titre de temoins considere aussi des al-veoles d'extractions ordinaires suturees sansimplamer de cone de verre bioactif en formede rac ine (groupe C=controi) . On a en touttraite 16 patients chez qui des extractionsavaient ete indiquees en raison d'une severeparodontite. Le groupe BS etait compose de 6patients ayant 7 sites implama ires presen tantdes deform ations du rebord alveolaire de clas-se II ou III, Le group e FE S etait compose de 5patients ayant 10 sites implantaires, Le groupeC comprenait 5 patients ayant 10 sites d'ex-traction, Les mesures de la largeur et de lahauteur du rebord alveolaire ont ete obtenuessur mode les d'emp reintes prises avant l 'op era-tion. immediatement apres f operation, puis 3mois et 12 mo is apres l 'operation, Dan s )egroupe BS. alors que la largeur du rebord al-veola ire augmenta i t de 2 .8 :1, 8 m m immedia-tement apres l 'intervention d'augmentationdu rebord. et de 2.40,93 mm un an apresI'operation lj!


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Ridge reconstruction 8in preventive prosthetic dentistry. ClinicalPreventive Dentistry 5, 13-18,Veldhuis, A, A, H,, Driessen, T, Dennissen,H. W. et al, (1984) A 5 year evaluation ofapatite tooth roots as mean to reduce re-sidual ridge resorption, Ciinicai PreventiveDentistry 5, 5-10.

Vrouwenvelder, W, C, A,, Groot, C, G, &Groot. K, (1993) Histological and bio-chemical evaluation of osteoblasts cul-tured on bioactive glass, hydroxyapatite, ti-tanium alloy, and stainless steel. Journal ofBiomedical Material Research 11 , 4 6 5 -475,

Wijs, F L, J . A, , Putter , C . Lange. G, L. &Groot, K, (1993) Local residual ridge aug-mentation with solid hydroxyapatiteblocks: Part Il-Correction of local resorp-tion defects in 50 patients. Journal of Pros-thetic Dentistry 69, 514-519.

Williams, C. W,, Meyers, J , F & Robinson,

R, R. (1991) Hydroxyapatite augmenta-tion of the anterior maxilla with a modi-fied transpositional flap technique. OralSurgery Oral Medicine Oral Pathology 72 ,375-379,Wilson, J , , Clark, A, E, , Hall, M, & Hench.L. L, (1983) Tissue response to bioglassendosseous ridge maintenance implants.Journal of Oral Implantologv 19 . 295 -

302,Wilson, J., Low, S,, Fetner, A. & Hench, L,L, (1987) Bioactive materials for peri-odontal treatment: a comparative study.In: Pizzoferrato, A,, Marchetti, P G,. Rav-aglioli. A, & Lee, A. . J, C, (eds): Bio-materials and clinical applications. Amster-dam: Elsevier, pp, 223-228,

Wilson, J, & Low, S, B, (1992) Bioactive cer-amics for periodonta l t rea tment: com para-tive studies in the patus monkey. Journalof Applied Biomaterials 3. 123-129,

Yilmaz. S,, Beyii, M, & Efeoglu, A, (19Koklerin canli olarak korunmasi ile alvkemiji rezorbsiyonunu onleme, Turk Podontoloji Dergisi 6. 77-86,Zamet, J, S., Darbar, U. R,, Griffiths, G. Bulman. J. S,. Bragger, U,, Blirgin, WNewman, H, N, (1997 Particuiate bglass* as a grafting material in the trement of periodontal intrabony defe

Journal Clinical Periodomohgy 24 , 4418,

Address :Sei^uk YilmazMarmara University. Faculty of DentistryDepartment of PeriodontologyBiiyakgiftlik sokak no . 6, 80200Nifantai:, IstanbulTurkey


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alveolar ridge reconstruction method

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