Reconstruction of the Extraction Socket: Methods, Manipulations, and Management.

Extensive reviews have concluded that grafting of the socket reduces bone loss regardless of product or method. However, nothing has been shown to reliably and completely maintain alveolar dimensions. We advocate a biologically driven and anatomically based approach for reconstruction of the socket. There are various socket manipulations that we have found to predictably prepare a site for dental implant. The combination of graft construct design and socket management maximizes graft success for any practitioner. Each socket should be treated individually, and products or methods used that are coincident with the complexity of the defect in question.

Bone Reconstruction Planning Using Computer Technology for Surgical Management of Severe Maxillomandibular Atrophy.

Digital imaging technology and refined software programs have significantly improved a clinician's ability to assess and evaluate anatomic structures and quantify both defect size and required graft volume. This article summarizes the computed tomography-based technology used in these applications to illustrate their current use as exemplified by computer-assisted planning and treatment of severe maxillofacial atrophy treated using both interpositional and mesh-onlay grafting methodology.

Tissue Engineering for Vertical Ridge Reconstruction.

This article provides an overview of basic tissue engineering principles as they are applied to vertical ridge defects and reconstructive techniques for these types of deficiencies. Presented are multiple clinical cases ranging from office-based dentoalveolar procedures to the more complex reconstruction of postresection mandibular defects. Several different types of regenerative tissue constructs are presented; either used alone or in combination with traditional reconstructive techniques and procedures, such as maxillary sinus augmentation, Le Fort I osteotomy, and microvascular free tissue transfer. The goal is to also familiarize the reconstructive surgeon to potential future strategies in vertical alveolar ridge augmentation.

Biologics and Cell Therapy Tissue Engineering Approaches for the Management of the Edentulous Maxilla: A Systematic Review.

PURPOSE: The aim of this systematic review was to evaluate current and emerging regenerative approaches for implant site development in the edentulous atrophic maxilla using tissue engineering and regenerative medicine (TERM) principles and to identify priorities for future research. MATERIALS AND METHODS: Two independent examiners conducted a comprehensive search using specific keywords to identify original clinical studies using TERM for implant site development in the edentulous atrophic maxilla including indications for alveolar ridge preservation, horizontal alveolar augmentation, maxillary sinus augmentation, and augmentation of severe vertical or combined defects. Endpoints included clinical, radiographic, histologic, and patient-centered outcomes. RESULTS: The initial search identified 3,061 articles. The final selection included 89 articles, of which 12 evaluated alveolar ridge preservation, 6 horizontal defects, 61 maxillary sinus augmentation, and 11 management of severe vertical or combined defects. A summary of the main findings relative to the effect of TERM-based approaches applied for implant site development in the atrophic maxillary segments is presented. Marked heterogeneity among included studies prevented meaningful quantitative analysis. The following relevant effects of TERM-based therapies for site development in the edentulous atrophic maxilla were observed: (1) recombinant human bone morphogenetic protein-2 in an absorbable collagen sponge carrier increased bone augmentation; (2) recombinant human platelet-derived growth factor BB in combination with freeze-dried bone allograft or beta tricalcium phosphate accelerated bone formation through accelerated remodeling of carrier biomaterials; (3) autologous cell therapy enhanced clinical and radiographic outcomes; (4) autologous cell therapy in alveolar ridge preservation provided superior histomorphometric outcomes (vital bone formation) at 6 weeks; and (5) platelet-rich plasma formulations combined with autologous bone grafts for maxillary sinus augmentation increased radiographic density and accelerated bone mineralization at 6 months. CONCLUSION: Clinical success has been demonstrated with the application of different TERM modalities for implant site development in the edentulous atrophic maxilla. However, indications are narrow and further study is needed. Clinical trials assessing meaningful outcomes, involving larger populations, and with longer follow-up are warranted to discern the effectiveness of the achieved results compared with a valid control.

Tissue engineering for lateral ridge augmentation with recombinant human bone morphogenetic protein 2 combination therapy: a case report.

This case report describes a tissue-engineered reconstruction with recombinant human bone morphogenetic protein 2/acellular collagen sponge (rhBMP-2/ ACS) + cancellous allograft and space maintenance via Medpor Contain mesh in the treatment of a patient requiring maxillary and mandibular horizontal ridge augmentation to enable implant placement. The patient underwent a previously unsuccessful corticocancellous bone graft at these sites. Multiple and contiguous sites in the maxilla and in the mandibular anterior, demonstrating advanced lateral ridge deficiencies, were managed using a tissue engineering approach as an alternative to autogenous bone harvesting. Four maxillary and three mandibular implants were placed 9 and 10 months, respectively, after tissue engineering reconstruction, and all were functioning successfully after 24 months of follow-up. Histomorphometric analysis of a bone core obtained at the time of the maxillary implant placement demonstrated a mean of 76.1% new vital bone formation, 22.2% marrow/cells, and 1.7% residual graft tissue. Tissue engineering for lateral ridge augmentation with combination therapy requires further research to determine predictability and limitations.

Uso da proteína morfogenética óssea recombinante humana-2 em levantamento de assoalho de seio maxilar / Recombinant human bone morphogenetic protein-2 in maxillary sinus floor augmentation

Pacientes desdentados posteriores frequentemente apresentam pneumatização dos seios maxilares, dificultando a colocação de implantes dentários. Atualmente, o material mais utilizado para o preenchimento de seio maxilar é o enxerto ósseo autógeno retirado de sítios intra ou extrabucais. Apesar desse procedimento ter sua eficácia comprovada clínica e histologicamente, nem sempre é bem tolerado pelos pacientes devido à morbidade associada à manipulação da área doadora. Por isso, vários substitutos ósseos vêm sendo desenvolvidos. A proteína óssea morfogenética recombinante humana-2 surgiu recentemente como uma alternativa aos enxertos autógenos, oferecendo excelente padrão de reparo e/ou neoformação óssea, quando utilizada na reconstrução de rebordos alveolares, possibilitando a reabilitação com próteses implantossuportadas. Nesse trabalho foi feita uma revisão da literatura e apresentação de caso de levantamento de assoalho de seio maxilar bilateral com o uso da proteína óssea morfogenética.

Edentulous patients in the posterior maxillary region frequently present pneumatization of maxillary sinuses, which makes difficult installation of dental implants. Nowadays, most commonly used materials for maxillary sinus filling are autogenous bone grafts from intra- or extra-oral donor sites. Despite the elevated clinical and histologic success rates of this procedure, it is always not well-tolerated by patients due to morbidity seen after donor site manipulation. For this, many bone substitutes have been developed. Recombinant human bone morphogenetic protein-2 appeared recently as an alternative to autogenous bone grafts, offering excellent patterns of bone repair and/or neoformation when used for reconstruction of alveolar ridges, allowing rehabilitation with implant-supported prostheses. The aim of this article is to perform a literature review and also to report a case in which bilateral elevation of maxillary sinus floor was performed along with rhBMP-2.

Dental implants and the use of rhBMP-2.

Tissue engineering is an emerging field of medicine and dentistry that combines the body's natural biologic response to tissue injury with engineering principles. The goal is to replicate or reconstruct the natural form and function of missing tissues and organs. Tissue-engineered bone with native qualities will be necessary for implantation or migration of engineered teeth in the future, and is currently required for the osseointegration of dental implants. This article addresses the role of bone morphogenetic proteins (BMP) in native bone healing for implant osseointegration and the application of BMP for de novo bone regeneration.

Dental implants and the use of rhBMP-2.

Tissue engineering is an emerging field of medicine and dentistry that combines the body's natural biologic response to tissue injury with engineering principles. The goal is to replicate or reconstruct the natural form and function of missing tissues and organs. Tissue-engineered bone with native qualities will be necessary for implantation or migration of engineered teeth in the future, and is currently required for the osseointegration of dental implants. This article addresses the role of bone morphogenetic proteins (BMP) in native bone healing for implant osseointegration and the application of BMP for de novo bone regeneration.

Bifocal distraction in patient with rheumatoid arthritis and severe condylar degeneration: report of case / Distracción bifocal en paciente con artritis reumatoide y degeneración condilar severa: reporte de un caso

Facial involvement in patients with rheumatoid arthritis is variable depending on the type, onset, and duration of the disease. The treatment of patients with open bite resulting from degenerative changes on the condyles can be a challenge for the surgeon. Rheumatoid arthritis is a systemic disorder of unknown etiology characterized by chronic inflammation and proliferation of synovial tissue. Studies showed that patients with rheumatoid arthritis can developed progressive osteoarthrosis that result in gross radiographic changes in the condyles. With the development of distraction osteogénesis for treatment of mandible hypoplasia a new chapter has been opened in the surgical management of patients with rheumatoid arthritis associated with skeletal deficiency. The aim of this paper is to evaluate osteogenesis distraction for treatment of anterior open bite in patients with rheumatoid arthritis and severe condylar degeneration.

El compromiso facial en pacientes con artritis reumatoide es variable dependiendo del inicio, tipo y duración de la enfermedad. El tratamiento del paciente con mordida abierta resultante de procesos degenerativos condilares son desafiantes para los cirujanos. La artritis reumatoide es una enfermedad sistémica de etiología desconocida caracterizada por inflamación crónica y proliferación del tejido sinovial. Algunos estudios han demostrado que pacientes con artritis reumatoide pueden desarrollar osteoartrosis progresiva que resulta en importantes cambios condilares. Con el desarrollo de la distracción osteogénica para el tratamiento de la hipoplasia mandibular se abrió un nuevo capítulo en el manejo quirúrgico de pacientes con artritis reumatoide asociada a deficiencias esqueletales. El objetivo de este artículo es evaluar la aplicación de distracción osteogénica en un caso de mordida abierta anterior en paciente con artritis reumatoide y degeneración condilar severa.

Papillary synovial metaplasia-like change in oral mucoceles: a rare and previously undescribed histopathologic variant of a common oral lesion.

The development of synovial membrane-like structures has been described previously only in association with breast implants, the bone-cement interface of hip prostheses, tendon implants, testicular implants, and traumatized skin. Previous investigators have theorized that this phenomenon-referred to as "synovial metaplasia"-develops in response to gliding trauma. In some cases, these lesions can exhibit a papillary growth pattern. We report 2 unusual cases of oral mucoceles exhibiting papillary synovial metaplasia-like change: the first arising in the lower lip of an 11-year old African-American boy and the second in the lower lip of a 12-year-old European-American girl. We propose that these cases represent a rare and previously undescribed histopathologic variant of the oral mucocele. These lesions should be distinguished from other oral lesions that may exhibit a papillary cystic growth pattern.

Pivotal, randomized, parallel evaluation of recombinant human bone morphogenetic protein-2/absorbable collagen sponge and autogenous bone graft for maxillary sinus floor augmentation.

PURPOSE: The purpose of this prospective study was to evaluate the safety and effectiveness of recombinant human morphogenetic protein-2 (rhBMP-2) on an absorbable collagen sponge (ACS) compared with an autogenous bone graft when used for 2-stage maxillary sinus floor augmentation. The study assessed new bone formation, placement integration, and functional loading after 6 months and long term for 2 years. MATERIALS AND METHODS: A total of 160 subjects were randomized, enrolled, and followed from January 1999 to February 2004 at 21 centers in the United States. The subjects with less than 6 mm of native bone height were treated with 1.50 mg/mL rhBMP-2/ACS or with an autograft. The height and density measurements were quantified by computed tomography scans. Core biopsies were obtained at dental implant placement and used for histological analysis. Safety was evaluated by oral examinations, radiographs, serum chemistries, and hematology. RESULTS: A significant amount of new bone was formed by 6 months postoperatively in each group. The mean change in bone height in the rhBMP-2/ACS subjects was 7.83 +/- 3.52 mm versus 9.46 +/- 4.11 mm for the bone graft subjects. At 6 months after dental restoration, the induced bone in the rhBMP-2/ACS group was significantly denser than that in the bone graft group. No marked differences were found in the histologic parameters evaluated between the 2 groups. The new bone was comparable to the native bone in density and structure in both groups. The success rate for the rhBMP-2/ACS group was 79% (64 of 81 subjects), and 201 of 251 implants placed in the bone graft group and 199 of 241 implants placed in the rhBMP-2/ACS group were integrated, retained, and functional at 6 months after loading. No adverse events were deemed related to the rhBMP-2/ACS treatment. The autograft group was noted to have a 17% rate of long-term parasthesia, pain, or gait disturbance related to the bone graft harvest. CONCLUSIONS: The results of our multicenter, randomized, prospective, clinical trial have shown the effectiveness and safety of rhBMP-2/ACS compared with bone graft for sinus floor augmentation. The study's primary endpoint was exceeded, and the implants placed in rhBMP-2/ACS and bone graft groups performed similarly after functional loading.

Uso da proteína morfogenética óssea recombinante humana-2 em levantamento de assoalho de seio maxilar / Recombinant human bone morphogenetic protein-2 in maxillary sinus floor augmentation

Pacientes desdentados posteriores freqüentemente apresentam pneumatização dos seios maxilares, dificultando a colocação de implantes dentários. Atualmente o material mais utilizado para o preenchimento de seio maxilar é o enxerto ósseo autógeno retirado de sítios intra ou extrabucais. Apesar desse procedimento ter sua eficácia comprovada clínica e histologicamente, nem sempre é bem tolerado pelos pacientes devido à morbidade associada à manipulação da área doadora. Por isso, vários substitutos ósseos vêm sendo desenvolvidos. A proteína óssea morfogenética recombinante humana-2 surgiu recentemente como uma alternativa aos enxertos autógenos, oferecendo excelente padrão de reparo e/ou neoformação óssea quando utilizada na reconstrução de rebordos alveolares, possibilitando a reabilitação com próteses implantossuportadas. Nesse trabalho foi feita uma revisão da literatura e apresentação de caso de levantamento de assoalho de seio maxilar bilateral com o uso da proteína óssea morfogenética.

Distraction osteogenesis in reconstruction of the mandible and temporomandibular joint.

The purpose of this article is to review the origins of temporomandibular joint disease that require joint reconstruction. We discuss our experience with this alternative procedure as an option in patients with pre-existing failed total joints, autoimmune degeneration, traumatic destruction, or congenital hypoplasia or aplasia. We also discuss the procedure as an autogenous alternative to prosthetic reconstruction in patients in whom reconstruction of the mandibular condyle and meniscus is indicated.

De novo bone induction by recombinant human bone morphogenetic protein-2 (rhBMP-2) in maxillary sinus floor augmentation.

PURPOSE: This phase II study was designed to evaluate 2 concentrations of recombinant human bone morphogenetic protein-2 (rhBMP-2) for safety and efficacy in inducing adequate bone for endosseous dental implant in patients requiring staged maxillary sinus floor augmentation. MATERIALS AND METHODS: Patients were treated with rhBMP-2 (via an absorbable collagen sponge [ACS]), at concentrations of 0.75 mg/mL (n = 18), 1.50 mg/mL (n = 17), or with bone graft (n = 13). Bone induction was assessed by alveolar ridge height, width, and density measurements from computed tomography scans obtained before and 4 months after treatment and 6 months post-functional loading of dental implants (density only). RESULTS: Mean increases in alveolar ridge height at 4 months after treatment were similar among the groups; 11.3 mm, 9.5 mm, and 10.2 mm, respectively, in the bone graft, 0.75 mg/mL, and 1.50 mg/mL rhBMP-2/ACS treatment groups. Mean increases in alveolar ridge width (buccal to lingual) at the crest of the ridge were statistically different among the treatment groups; 4.7 mm, 2.0 mm, and 2.0 mm, respectively, in the bone graft, 0.75 mg/mL, and 1.50 mg/mL treatment groups (P

Randomized study evaluating recombinant human bone morphogenetic protein-2 for extraction socket augmentation.

BACKGROUND: Conventional dentoalveolar osseous reconstruction often involves the use of grafting materials with or without barrier membranes. The purpose of this study was to evaluate the efficacy of bone induction for the placement of dental implants by two concentrations of recombinant human bone morphogenetic protein-2 (rhBMP-2) delivered on a bioabsorbable collagen sponge (ACS) compared to placebo (ACS alone) and no treatment in a human buccal wall defect model following tooth extraction. METHODS: Eighty patients requiring local alveolar ridge augmentation for buccal wall defects (> or =50% buccal bone loss of the extraction socket) of the maxillary teeth (bicuspids forward) immediately following tooth extraction were enrolled. Two sequential cohorts of 40 patients each were randomized in a double-masked manner to receive 0.75 mg/ml or 1.50 mg/ml rhBMP-2/ACS, placebo (ACS alone), or no treatment in a 2:1:1 ratio. Efficacy was assessed by evaluating the amount of bone induction, the adequacy of the alveolar bone volume to support an endosseous dental implant, and the need for a secondary augmentation. RESULTS: Assessment of the alveolar bone indicated that patients treated with 1.50 mg/ml rhBMP-2/ACS had significantly greater bone augmentation compared to controls (P < or =0.05). The adequacy of bone for the placement of a dental implant was approximately twice as great in the rhBMP-2/ACS groups compared to no treatment or placebo. In addition, bone density and histology revealed no differences between newly induced and native bone. CONCLUSION: The data from this randomized, masked, placebo-controlled multicenter clinical study demonstrated that the novel combination of rhBMP-2 and a commonly utilized collagen sponge had a striking effect on de novo osseous formation for the placement of dental implants.

Uso de modelos estereolitográficos em cirurgia buco-maxilo-facial / Stereolithographic models in oral and maxillofacial surgery

Os recentes progressos no campo da informática e nas técnicas de processamento de imagens tornaram possível a visualizaçäo estereolitográfica das estruturas anatômicas. O diagnóstico, planejamento e a simulaçäo cirúrgica que utilizam os modelos estereolitográficos já säo uma realidade no campo da cirurgia buco-maxilo-facial. O objetivo deste artigo é mostrar os benefícios da utilizaçäo dos modelos tridimensionais e descrever algumas aplicaçöes clínicas dessa tecnologia

Artroscopia para o tratamento dos desarranjos internos da articulaçäo temporomandibular / Arthroscopy for the treatment of internal derangements of the temporomandibular joint

Com o desenvolvimento da artroscopia e a possibilidade de uma visualizaçäo direta dos componentes da articulaçäo temporomandibular, o papel da osteoartrite e da sinovite como principais causadoras das disfunçöes da ATM é agora conhecido. A intervençäo cirúrgica via artroscopia é normalmente reservada para os casos que näo responderam bem à terapia conservadora e para os casos de degeneraçöes avançadas do disco com grandes perfuraçöes, dor e restriçäo de abertura bucal. Como modalidade clínica, a artrospocia da ATM é uma técnica segura e eficaz, com invasividade mínima e complicaçöes pós-operatórias mínimas, apresentando elevados índices de sucesso