andrea panigalli GB -...
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Fresh allogenic bone, also known as Fresh Frozen Bone (hereinafter called FFB), has been recently adopted for use in dental and maxillofacial reconstructions. This type of bone, has been used for years in complex orthopaedic surgical procedures based on a sound clinical experience.¹ On the other hand, the number of studies present in the literature on its use in major preprosthetic surgery is only limited.² Allogenic bone from tissue banks presents a number of advantages, including the ready availability of grafts in suitable quantity and quality, limited costs, and the possibility of avoiding the morbidity related to autogenous-graft harvesting. This tissue is of human origin and may be obtained from living donors or cadavers³. FFB has osteoconductive properties and can act as a scaffold by providing structural support during the bone replacement phase. When performed correctly, freezing does not affect the BMP’s contained in the bone, so its osteoconductive properties are left unchanged. However, similarly to autogenous grafts, such osteoinductivity should be regarded as merely potential in non-decalcified tissue (it is through the osteoclast activity that BMP’s will be exposed at a later stage).⁴ The purpose of this work is to show the use of fresh frozen homologous bone for bony augmentation of the maxilla and mandible in preparation for dental reconstruction with endoosseous implants, as an effective alternative to harvesting and grafting autogenous bone from intra or extraoral donor sites. Topic: clinical case report USE OF FRESH FROZEN BONE GRAFT IN REHABILITATION OF MAXILLAR ATROPHY Abstract Background and Aim Methods and Materials Results Conclusions References Objective: purpose of this work is to show the use of fresh frozen homologous bone (FFB) for bony augmentation of the maxilla and mandible. Method: the cases presented demonstrates the use of FFB grafts in the vertical augmentation of a maxillary atrophy, implants insertion and prosthetic restoration. Result: histologic and clinical evaluation shows good volumetric and morphological reconstruction and excellent graft integration. Conclusion: use of FFB may be an acceptable therapeutic alternative. Case 1The patient, Mr B.G., is a 43-year-old male who came to our observation complaining of edentulism and severe maxillary alveolar atrophy in the first quadrant. The teeth 15, 16 and 17 were missing. The bone deficit was corrected by means of a major sinus lift and an onlay graft using a pre-contoured allogenic cancellous bone (FFB) block harvested from a femoral epiphysis. The graft was then fixated with osteosynthesis screws. The subantral cavity and the gaps between the graft and the alveolar bone were then filled with allogenic bone (FFB) chips. The whole thing, including the screws, were then covered with the same morcellized bone, which was maintained in situ by means of resorbable collagen membranes. The wound was closed by sutures after releasing and passivating the flaps. At five months the surgical site was reopened, showing limited graft resorption (< 1 mm, as measured in relation to the transcortical screw heads at two different points). The fixation screws were removed and 3 endosseous implants were placed at the level of 1.5, 1.6 and 1.7 (blueSKY, bredent medical, Senden Germany). The final prosthetic rehabilitation was performed 11 months after the grafting procedure. Case 2The patient C.A., a no smoker 57 years old male came to our observation complaining partial edentulism and maxillary alveolar atrophy of first quadrant with 1.6 and 1.7 missing teeth. The patient was recently submitted to a right sinus lift surgery with an onlay graft in 1.4 1.5 area. Not integrated implants and graft were removed in second surgical phase and then placed 2 implants in 1.6 1.7 position. The planned treatment included the removal of implant in 16 position, extraction of 13 and a homologous bone graft performed under general anaesthetic. After the extraction of 13 and implant in 16 position the exposed spyres of implant in 17 position were cleaned and decontaminated. A particulate graft of homologous bone (femoral epiphysis) was placed in maxillary sinus and the protected with a collagen resorbable membrane. The graft was placed in order to be compacted on the surface of implant in 17 position. An onlay homologous graft was placed in vestibular and crestal position and then fixed with 4 osteosynthesis screws. Gaps between onlay grafts were filled with particulated bone graft and then covered with a resorbable collagen membrane. After surgery an x-ray control (opt) was performed 1 and 5 month after surgery. No signs of infection or adverse events were noticed during this period. After 5 months healing a second surgery was performed. The graft appeared well integrated, in good conditions and with no or minimal bone resorption with values from 0 to 1 mm. After removal of osteosynthesis screws 3 implants (blueSKY, bredent medical, Senden, Germany) were placed in 13, 14, 15 area by the use of a surgical stent. The final prosthetic rehabilitation was performed with a metal-ceramic crown after 12 month. Clinical results showed in both cases a successful bone regeneration who allowed to rebuilt the original bone volume and shape without using extra-oral surgical sites. After 5 month form graft placement, during second surgery, bone showed a good blood support that shows a process of bone turnover with new bone osteogenesis. Measurement taken during first and second surgery showed no relevant bone resorption. During implant placement (12 fixture: Blue Sky ®, Bredent, Senden Germany) was noticed a good quality bone and implants were placed with a insertion toque of 35 n. Histological analysis of bone biopsy performed 6 months after bone regeneration showed a good bone quality in which was evident a new bone placement process with calcificated bone areas with a well organized structure and osteonic matrix areas where new bone formation process was in act. Soft tissue healing was fast and without any complication. An implant and prosthetic treatment must be chosen in order to be the best treatment for the patient at the most affordable price or, at least, proportionated to the kind of treatment. Moreover treatment choice must be supported by scientific evidence and documentation. When, after a severe bone resorption, a large bone regeneration is planned, surgeon must chose best regeneration material for each case. Fresh frozen bone has to be compared, when analyzing his performance, with autogenous bone. This two materials are in fact the only that owns all three processes of bone formation: osteoinduction, osteoconduction and osseointegration proprieties. In conclusion, in light of his excellent osteoconductive and osteoinductive qualities, the possibility to use it without an extra-oral donation site in any quantity and the possibility to reduce operating time preparing the graft on stereolithographic models it’s possible to consider fresh frozen bone is a good alternative, in oro- maxillo surgery practice, to autologous bone. Case 1 Case 2 1.Tanzawa Y, Tsuchiya H, Yamamoto N, Sakayama K, Minato H, Tomita K. Histological examination of frozen autograft treated by liquid nitrogen removed 6 years after implantation. J Orthop Sci. 2008 May;13(3):259-64. Epub 2008 Jun 6. 2.Carinci F, Brunelli G, Zollino I, Franco M, Viscioni A, Rigo L, Guidi R, Strohmenger L. Mandibles grafted with fresh-frozen bone: an evaluation of implant outcome. Implant Dent. 2009 Feb;18(1):86- 95.D'Aloja E, Santi E, Aprili G, Franchini M. Fresh frozen homologous bone in oral surgery: case reports. Cell Tissue Bank. 2008 Mar;9(1):41-6. Epub 2007 Oct 1Burchardt H. The biology of bone graft repair. Clin Orthop Relat Res. 1983 Apr;(174):28-42. Carinci F, Brunelli G, Zollino I, Franco M, Viscioni A, Rigo L, Guidi R, Strohmenger L. Mandibles grafted with fresh-frozen bone: an evaluation of implant outcome. Implant Dent. 2009 Feb;18(1):86- 95.D'Aloja E, Santi E, Aprili G, Franchini M. Fresh frozen homologous bone in oral surgery: case reports. Cell Tissue Bank. 2008 Mar;9(1):41-6. Epub 2007 Oct 1Burchardt H. The biology of bone graft repair. Clin Orthop Relat Res. 1983 Apr;(174):28-42. Andrea Panigalli Department of Oral Surgery, Dental Clinic, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
Transcript of andrea panigalli GB -...
Fresh allogenic bone, also known as Fresh Frozen Bone (hereinafter called FFB), has been recently adopted for use in dental and maxillofacial reconstructions. This type of bone, has been used for years in complex orthopaedic surgical procedures based on a sound clinical experience.¹ On the other hand, the number of studies present in the literature on its use in major preprosthetic surgery is only limited.²Allogenic bone from tissue banks presents a number of advantages, including the ready availability of grafts in suitable quantity and quality, limited costs, and the possibility of avoiding the morbidity related to autogenous-graft harvesting. This tissue is of human origin and may be obtained from living donors or cadavers³.FFB has osteoconductive properties and can act as a scaffold by providing structural support during the bone replacement phase. When performed correctly, freezing does not affect the BMP’s contained in the bone, so its osteoconductive properties are left unchanged. However, similarly to autogenous grafts, such osteoinductivity should be regarded as merely potential in non-decalcified tissue (it is through the osteoclast activity that BMP’s will be exposed at a later stage).⁴The purpose of this work is to show the use of fresh frozen homologous bone for bony augmentation of the maxilla and mandible in preparation for dental reconstruction with endoosseous implants, as an effective alternative to harvesting and grafting autogenous bone from intra or extraoral donor sites.
Topic: clinical case report
USE OF FRESH FROZEN BONE GRAFT IN REHABILITATION OF MAXILLAR ATROPHY
Abstract
Background and Aim
Methods and Materials
Results
Conclusions
References
Objective: purpose of this work is to show the use of fresh frozen homologous bone (FFB) for bony augmentation of the maxilla and mandible. Method: the cases presented demonstrates the use of FFB grafts in the vertical augmentation of a maxillary atrophy, implants insertion and prosthetic restoration.Result: histologic and clinical evaluation shows good volumetric and morphological reconstruction and excellent graft integration.Conclusion: use of FFB may be an acceptable therapeutic alternative.
Case 1The patient, Mr B.G., is a 43-year-old male who came to our observation complaining of edentulism and severe maxillary alveolar atrophy in the first quadrant. The teeth 15, 16 and 17 were missing. The bone deficit was corrected by means of a major sinus lift and an onlay graft using a pre-contoured allogenic cancellous bone (FFB) block harvested from a femoral epiphysis. The graft was then fixated with osteosynthesis screws. The subantral cavity and the gaps between the graft and the alveolar bone were then filled with allogenic bone (FFB) chips. The whole thing, including the screws, were then covered with the same morcellized bone, which was maintained in situ by means of resorbable collagen membranes. The wound was closed by sutures after releasing and passivating the flaps. At five months the surgical site was reopened, showing limited graft resorption (< 1 mm, as measured in relation to the transcortical screw heads at two different points). The fixation screws were removed and 3 endosseous implants were placed at the level of 1.5, 1.6 and 1.7 (blueSKY, bredent medical, Senden Germany). The final prosthetic rehabilitation was performed 11 months after the grafting procedure. Case 2The patient C.A., a no smoker 57 years old male came to our observation complaining partial edentulism and maxillary alveolar atrophy of first quadrant with 1.6 and 1.7 missing teeth. The patient was recently submitted to a right sinus lift surgery with an onlay graft in 1.4 1.5 area. Not integrated implants and graft were removed in second surgical phase and then placed 2 implants in 1.6 1.7 position. The planned treatment included the removal of implant in 16 position, extraction of 13 and a homologous bone graft performed under general anaesthetic. After the extraction of 13 and implant in 16 position the exposed spyres of implant in 17 position were cleaned and decontaminated. A particulate graft of homologous bone (femoral epiphysis) was placed in maxillary sinus and the protected with a collagen resorbable membrane. The graft was placed in order to be compacted on the surface of implant in 17 position. An onlay homologous graft was placed in vestibular and crestal position and then fixed with 4 osteosynthesis screws. Gaps between onlay grafts were filled with particulated bone graft and then covered with a resorbable collagen membrane. After surgery an x-ray control (opt) was performed 1 and 5 month after surgery. No signs of infection or adverse events were noticed during this period. After 5 months healing a second surgery was performed. The graft appeared well integrated, in good conditions and with no or minimal bone resorption with values from 0 to 1 mm. After removal of osteosynthesis screws 3 implants (blueSKY, bredent medical, Senden, Germany) were placed in 13, 14, 15 area by the use of a surgical stent. The final prosthetic rehabilitation was performed with a metal-ceramic crown after 12 month.
Clinical results showed in both cases a successful bone regeneration who allowed to rebuilt the original bone volume and shape without using extra-oral surgical sites. After 5 month form graft placement, during second surgery, bone showed a good blood support that shows a process of bone turnover with new bone osteogenesis. Measurement taken during first and second surgery showed no relevant bone resorption. During implant placement (12 fixture: Blue Sky ®, Bredent, SendenGermany) was noticed a good quality bone and implants were placed with a insertion toque of 35 n.Histological analysis of bone biopsy performed 6 months after bone regeneration showed a good bone quality in which was evident a new bone placement process with calcificated bone areas with a well organized structure and osteonic matrix areas where new bone formation process was in act.Soft tissue healing was fast and without any complication.
An implant and prosthetic treatment must be chosen in order to be the best treatment for the patient at the most affordable price or, at least, proportionated to the kind of treatment. Moreover treatment choice must be supported by scientific evidence and documentation.When, after a severe bone resorption, a large bone regeneration is planned, surgeon must chose best regeneration material for each case.Fresh frozen bone has to be compared, when analyzing his performance, with autogenous bone. This two materials are in fact the only that owns all three processes of bone formation: osteoinduction, osteoconduction and osseointegration proprieties.In conclusion, in light of his excellent osteoconductive and osteoinductive qualities, the possibility to use it without an extra-oral donation site in any quantity and the possibility to reduce operating time preparing the graft on stereolithographic models it’s possible to consider fresh frozen bone is a good alternative, in oro-maxillo surgery practice, to autologous bone.
Case 1
Case 2
1.Tanzawa Y, Tsuchiya H, Yamamoto N, Sakayama K, Minato H, Tomita K. Histological examination offrozen autograft treated by liquid nitrogen removed 6 years after implantation. J Orthop Sci. 2008 May;13(3):259-64. Epub 2008 Jun 6.2.Carinci F, Brunelli G, Zollino I, Franco M, Viscioni A, Rigo L, Guidi R, Strohmenger L. Mandiblesgrafted with fresh-frozen bone: an evaluation of implant outcome. Implant Dent. 2009 Feb;18(1):86-95.D'Aloja E, Santi E, Aprili G, Franchini M. Fresh frozen homologous bone in oral surgery: case reports. Cell Tissue Bank. 2008 Mar;9(1):41-6. Epub 2007 Oct 1Burchardt H. The biology of bone graft repair. Clin Orthop Relat Res. 1983 Apr;(174):28-42.Carinci F, Brunelli G, Zollino I, Franco M, Viscioni A, Rigo L, Guidi R, Strohmenger L. Mandiblesgrafted with fresh-frozen bone: an evaluation of implant outcome. Implant Dent. 2009 Feb;18(1):86-95.D'Aloja E, Santi E, Aprili G, Franchini M. Fresh frozen homologous bone in oral surgery: case reports. Cell Tissue Bank. 2008 Mar;9(1):41-6. Epub 2007 Oct 1Burchardt H. The biology of bone graft repair. Clin Orthop Relat Res. 1983 Apr;(174):28-42.
Andrea Panigalli
Department of Oral Surgery, Dental Clinic, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
