Individualized Titanium Mesh Combined With Platelet-Rich Fibrin and Deproteinized Bovine Bone: A New Approach for Challenging Augmentation
Autologous bone transfer is regarded as the gold standard for ridge augmentation before dental implantation, especially in severe bony defects caused by tumor resection or atrophy. In addition to the advantages of autologous bone, transplantation has several disadvantages, such as secondary operation, increased morbidity and pain. The present study reports, for the first time, a combination of a xenogeneic bone substitute (BO) with platelet-rich fibrin (PRF), which is a fully autologous blood concentrate derived from the patient's own peripheral blood by centrifugation. Solid A-PRF+ and liquid i-PRF together with an individualized 3-D planned titanium mesh were used for reconstruction of a severe tumor-related bony defect within the mandible of a former head and neck cancer patient. The BO enriched with regenerative components from PRF allowed the reconstruction of the mandibular resective defect under the 3-D mesh without autologous bone transplantation. Complete rehabilitation and restoration of the patient's oral function were achieved. Histological analysis of extracted bone biopsies confirmed that the new bone within the augmented region originated from the residual bone. Within the limitations of the presented case, the applied concept appears to be a promising approach to increase the regenerative capacity of a bone substitute material, as well as decrease the demand for autologous bone transplantation, even in cases in which autologous bone is considered the golden standard. PRF can be considered a reliable source for increasing the biological capacities of bone substitute materials.
Figure 1. Autologous fibrin matrix platelet rich fibrin after centrifugation and subsequent compression. Figures 2 and 3. Radiographic (Figure 2) and clinical (Figure 3) baseline situations after tumor therapy and before augmentative reconstruction. Figure 4. Three-dimensional design of the titanium mesh according to the ideal anatomy of the mandible and the position of the foramen mentale. Figures 5 and 6. Augmentation process with the titanium mesh, a combination of the xenogeneic Bio-Oss, advanced platelet rich fibrin, and injectable platelet rich fibrin. Figure 7. Postoperative X-ray image after reconstruction of the mandibular defect.
Figure 8. Clinical situation after removal of the titanium mesh and insertion of the implants in the regenerated mandible after a mean integration phase of the augmentation (8 months). Implants could be placed with high primary stability and in full length. Figure 9. Postoperative X-ray image after implant insertion in the regenerated mandible. Figure 10. Final prosthetic rehabilitation of the regenerated mandible. Figure 11. Histological analysis of the extracted bone biopsies. (a) Total scan of the biopsy with new bone formation reaching all parts of the biopsy (Azan staining, total scan ×4 magnification, scale bar = 500 μm). (b) New bone formation in direct contact with the BO granules at a higher magnification (Azan staining, ×200 magnification, scale bar: 100 μm). (c) granules embedded in vessel-rich connective tissue (Azan staining, ×400 magnification, scale bar = 20 μm). BO indicates Bio-Oss particles; NB, newly built bone; CT, connective tissue, black arrows, newly built bone; red arrows, newly formed vessel.
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