Journal of Oral Implantology Minimally invasive approaches to optimize block grafting: a case report --Manuscript Draft-Manuscript Number:
aaid-joi-D-14-00076R1
Full Title:
Minimally invasive approaches to optimize block grafting: a case report
Short Title: Article Type:
Clinical Case Letter
Keywords:
tunnel technique, block grafting, bone augmentation, fresh frozen bone, PRF
Corresponding Author:
Gilberto Sammartino, M.D., D.D.S University of Naples "Federico II" Naples, Italy ITALY
Corresponding Author Secondary Information: Corresponding Author's Institution:
University of Naples "Federico II"
Corresponding Author's Secondary Institution: First Author:
Gilberto Sammartino, M.D., D.D.S
First Author Secondary Information: Order of Authors:
Gilberto Sammartino, M.D., D.D.S Giuseppe Pantaleo, D.D.S. Paolo Nuzzolo, D.D.S., PhD student Massimo Amato, M.D., D.D.S Francesco Riccitiello, M.D., D.D.S.
Order of Authors Secondary Information: Abstract:
In narrow alveolar ridge many surgical approaches exist, and the most frequently used is bone grafting The subperiosteal tunneling approach is a minimal safety procedure that allows to allocate the graft in a space that is obtained between the soft tissues and the underlying bone, through an access rapresented by one single incision on the mesial limit of the bone defect. A 55-year-old caucasian woman with a severe bone atrophy in the maxillary arch was treated with horizontal bone augmentation. A mucoperiosteal tunnel with a periosteal elevator through one single incision of moderate dimensions per hemiarch, insertion of tissue bank ilium bicortical bone(FFB) and a consequent complete prosthetic-implant rehabilitation was realized. The tunnel technique provided primary intention closure of the surgical wound, avoiding dehiscences and infections, and reducing the edema and the post-operative discomfort for the patient. Clinical and histological studies support the use of FFB and it has been suggested that the results of a graft with homologous and with autologus bone can be comparable, even though the healing phase is more critical and longer for the allograft. The combination of homologous grafts with the tunnel technique reduces significantly the surgical trauma and the postoperative discomfort, as well as the risk of exposure of the graft during the healing phase, with the risk of graft failiure. In our experience, onlay grafting with frozen bone is a predictable technique for horizontal augmentation.
Response to Reviewers:
The text has been changed to yellow for reviewer 1, and green for reviewer 2. Reviewers' comments Reviewer #1: General comments: Grammar and sentence structure can be improved to enhance manuscript.
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Grammar and sentence structure have been improved Introduction: Sentence 5: "minimal safety" Does that mean it has high risk. The sentence has been changed in "minimally invasive" Sentence 8: "Perfect" Select less absolute term. The sentence has been changed Sentence 19-20: "reach out" Define? Clarify. The concept were clarified Sentence 28: "Atrophy" Horizontal? Vertical?. The kind of atrophy was added Sentence 28: "Elements" Define. Can we include radiographs in case report?. Elements were defined. Pre-operative and post-operative CT were added to the manuscript Sentence 32: "Lateral-posterior sectors?" Uncommon dimension. The sentence was changed to "posterior sectors" Sentence 38: "Top" "Bottom" Scientific word?. The sentence was changed using scientific words Sentence 36, 44: "receiving bone" Define. The words were defined Sentence 47: basculation? Define. The word has been defined Sentence 50: "Two 11.5 x 4m" ..more commonly (2) 4x11.5mm. The change was made Sentence 53: "Yet" retained?. The concept was clarified
Sentence 55: The patient was scheduled for regular... The sentence has been changed. Sentence 60: Did it prove integration? Supported, or proved? the concept. The concept was clarified Sentence 66-69: Rework sentence or wake into a concise sentence. The sentence has been reworked. Sentence 70: A full arch...Implants for 1 month followed by a def. metal ceramic prosthesis. The sentence was modified. Sentence 79: "and possibility to place the dental implants" Explain. The concept has been developed in a better way Sentence 89: "BMP" spell out sentence. The change was made Sentence 90: New paragraph and new topic sentence "PCR" spell out. The change was made Sentence 93: readily available source of... The sentence has been changed
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Sentence 97: Platelet rich fibrin can increase the predictability of bone Foundation. The change was made Sentence 101: Start sentence with Although. The change was made Sentence 105-110: rewrite, concise sentence. The concept has been developed in a better way Sentence 113-115: run on, a lot of thoughts, make into two concise sentences (It will be better). The concept has been developed in a better way Sentence 116-118: The utilization of homologous...reduces surgical trauma and post-operative discomfort...expose and failure...phase. The concept has been developed in a better way Sentence 119: PRF can enhance bone...healing when used to cover the graft. The change was made Sentence 122: In case...grafting... The change was made OMIT I do not think we need to recite 4, 6, 8, 3, 19 in conclusion. They have been deleted
Reviewer #2: Some risks must be discussed respect to use FFB, as a possible immunization to blood group or other antigens. In addition to this, other of the main concerns with the use of bone allograft (although rare) is transmission of infection, (most notably hepatitis and acquired immunodeficiency syndrome). I suggest some paragraph like: "The risk of viral transmission by unprocessed deep-frozen, nonirradiated grafts from screened donors is currently less than 1:200,000 for hepatitis C virus and 1:1 million for human immunode?ciency virus 0 It is virtually nonexistent for processed bone grafts". The concept has been developed in a better way and the additions were made
Page 2 line 28 replace elements by teeth. The word was corrected The reference to the prf is not the subject of the article and is treated superficially (reference 19). The concept has been clarified and expanded Reference 18 is incomplete. The reference has been changed in the correct way. The images are of poor quality. Images have been improved in quality. Pre-operative and post-operative CT were added to the manuscript
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Article File
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Minimally invasive approaches to optimize block grafting: a case report G. Sammartino1, G. Pantaleo1, P. Nuzzolo1, M. Amato2, F. Riccitiello1 1 2
Unit of Oral Surgery and Implantology, Naples, Italy Department of Medicine and Surgery, Salerno, Italy
Author of correspondence: Gilberto Sammartino [email protected]
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Abstract In narrow alveolar ridge many surgical approaches exist, and the most frequently used is bone grafting. The subperiosteal tunneling approach is a minimal safety procedure that allows to allocate the graft in a space that is obtained between the soft tissues and the underlying bone, through an access rapresented by one single incision on the mesial limit of the bone defect. A 55-year-old caucasian woman with a severe bone atrophy in the maxillary arch was treated with horizontal bone augmentation. A mucoperiosteal tunnel with a periosteal elevator through one single incision of moderate dimensions per hemiarch, insertion of tissue bank ilium bicortical bone(FFB) and a consequent complete prosthetic-implant rehabilitation was realized. The tunnel technique provided primary intention closure of the surgical wound, avoiding dehiscences and infections, and reducing the edema and the post-operative discomfort for the patient. Clinical and histological studies support the use of FFB and it has been suggested that the results of a graft with homologous and with autologus bone can be comparable, even though the healing phase is more critical and longer for the allograft. The combination of homologous grafts with the tunnel technique reduces significantly the surgical trauma and the postoperative discomfort, as well as the risk of exposure of the graft during the healing phase, with the risk of graft failiure. In our experience, onlay grafting with frozen bone is a predictable technique for horizontal augmentation. Keywords:
tunnel technique, block grafting, bone augmentation, fresh frozen bone, PRF 2
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1. Introduction
A narrow alveolar ridge is a challenging situation that surgeons may face when considering implant oral rehabilitation. Many surgical approaches exist, and the most frequently used is bone grafting.1 The subperiosteal tunneling approach is a minimally invasive procedure that allows to allocate the graft in a space that is obtained between the soft tissues and the underlying bone, through an access rapresented by one single incision on the mesial limit of the bone defect.2,3 This approach ensures minimal discomfort for the patient after the surgery and, mostly, steady coverage of the graft during the healing time, with minimal risk of exposure, infection and failiure.4,5 The subperiosteal tunneling technique uses autologous bone that is still considered the gold standard for bone regeneration.6 On the other hand, autologous bone grafting requires donor site surgery, which often means donor site surgery complications, especially when larger amounts of bone are needed and extraoral sites are accessed for the harvest. Moreover, they need general anaesthesia.7,8 Homologous grafting refers to the use of bone from living donors of the same species or from cadavers. The bone is processed and stored in tissue banks. Depending on the type of treatment, Fresh Frozen Bone (FFB), Freeze-Dried Bone (FDB) and Demineralized 3
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Freeze-Dried Bone (DFDB) can be obtained. 4,9,10 The case presented combines the tunnel flap technique and the use of homologous bone to achieve the least possible invasive approach to bilateral block grafting of an upper maxillary affected by severe horizontal bone atrophy, in order to allow a full arch implant rehabilitation.
2. Case presentation
A 55-year-old caucasian woman was referred to the Dental School of the University Federico II of Naples. No significant clinical data (diabetes, hypertension, allergies) were present in her clinical history; laboratory investigations were substantially normal. The patient was partially edentolous and showed severe horizontal bone atrophy in the maxillary arch. The only teeth in the arch were the canines and the second molars, already treated. Due to the periodontal and endodontic condition of the remaining teeth, implant therapy and a full arch prosthetic restoration were chosen for the patient. Horizontal bone augmentation was necessary, as the ridge showed no sufficient horizontal dimensions for the placement of implants in the posterior sectors – both right and left, and block grafting was a mandatory option, because of the degree of the atrophy and the noncontentive anatomy of the defect. There was no need for an additional vertical augmentation (Figure 1-2). 4
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A minimally invasive approach was chosen for the exposure of the receiving sites. This consisted in avoiding a traditional flap, realizing instead a mucoperiosteal tunnel with a periosteal elevator through one single incision of moderate dimensions per hemiarch, on the mesial edge of each of the two defects (right and left), from the occlusal to the apical limit of the ridge on its vestibular side(Figure 3). As for the grafting material, tissue bank ilium bicortical bone was chosen (FFB). After being defreezed in sterile saline solution, each block was split, obtaining cortical on one side and trabecular on the other one. The cortical bone was to be positioned on the interface with the soft tissues, the trabecular bone was to be placed on the interface with the host site (Figure 4). The host site had been previuosly drilled to facilitate bleeding, start the RAP (regional acceleratory process) and expose trabecular bone. Three microscrews, fixed on the mesial side of the graft, allowed the complete fixation of the block, avoiding any movement or tilting (Figure 5). Instead, PRF (Platelet Rich Fibrin) was placed upon the graft. Besides block grafting on the right and left posterior regions, a flap was elevated in the frontal region, which showed good bone quality, quantity and anatomy, and two 4x11,5 mm submerged tapered implants were placed(Figure 6). Polygalactin 910 (Vycril) 4/0 resorbable sutures were used for flaps closure. The four remaining teeth were not extracted in this phase, in order to use them to support a fixed provisional prosthesis (Figure 7). 5
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The patient was scheduled for regular follow-ups for the next five months. After 5 months of healing, the CT follow-up and surgical re-entry were performed (Figure 8). After the removal of the provisional prosthesis and the infiltration of local anaesthesia, mucoperiosteal flaps were raised to expose both the grafted areas. The grafted areas showed minimal bone resorption: the bone was still at the level of the top of the microscrews, which were removed. The bleeding during the removal of the screws supported the successful integration of the graft. After a slight osteoplasty to give right conformation to the ridge, measurements were taken showing an horizontal gain between 2 and 4 mm. Three implants per side were placed, of the same type of the ones used for the frontal region (4x11,5mm). No immediate prosthetical load was realized and the provisional prosthesis was cemented on the remaining teeth again. After a healing period of four months, the implants were uncovered and healing abutments were placed, the four remaining teeth were extracted and a second provisional –removable- prosthesis, was delivered for the following 2 weeks, during soft tissues healing. Afterwards, a full arch resin restoration was loaded on the implants for one month followed by a definitive metal ceramic prosthesis. A 16 months follow up showed no marginal bone loss, soft tissues stability, no bone resorption on the grafted areas. 6
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3. Discussion
Success criteria for a bone graft have been estabilished by Barone et. al: absence of exposure and infection of the graft in the post-operative period, incorporation of the graft to the receptor bed, absence of radiolucent areas, bleeding of the grafted bone when removing the fixation screws, and the achievement of adequate volume and density to place the dental implants. In our case these criteria were all satisfied.8 The tunnel technique provided primary intention closure of the surgical wound, avoiding dehiscences and infections, and reducing the edema and the post-operative discomfort for the patient. Dehiscences are reported to be among the most frequent complications of bone grafting, so that preventing them can result in a higher predictability of the graft.3,11,12 Clinical and histological studies support the use of FFB 6,10,13, and it has been suggested that the results of a graft with homologous and with autologus bone can be comparable, even though the healing phase is more critical and longer for the allograft 14. FFB is believed to have both osteocondutive properties, thanks to its solid structure and midollar spaces that allow the blood vessels invasion and the bone ingrowth, as well as osteoinductive action, as freezing does not affect the bone morphogenetic proteins (BMPs) contained in the bone15. In addition, polimerase chain reaction (PCR) serological tests effected on the donor 7
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tissue ensure the safety of the graft: viral infections trasmission is believed to be the main potential disadvantage of the use of allografts16,17. To date, however, no such occurences have been reported in the dental literature. The risk of viral transmission by unprocessed deep-frozen, nonirradiated grafts from screened donors is currently less than 1:200,000 for hepatitis C virus and 1:1 milion for human immunodeficiency virus. Such risk is virtually nonexistent for processed bone grafts. Homologous bone from tissue banks offers obvious advantages: readily available source of large volumes of material, extremely low antigenic potential, unblemished safety record in dentistry, and, of course, the absence of a donor site surgery fot the patient, with the risk of surgical complications7,18. Also, platelet rich fibrin (PRF) can increase the predictability of bone foundation. Osteoblasts show high affinity for PRF membranes19 and the constant release of growth factors guides the healing and remodeling of connective tissues20,21. Choukroun et al. have demonstrated that PRF, through constant a release of growth factors in the time, has the double action of enhancing soft tissues healing and stimulating blood vessels ingrowth, cellular migration and differentiation into bone forming cellular lines22. Furthermore, the presence of cytokines that control the inflamation lowers the risk of infection within the graft23 Although no evidence is given that a delayed placement in the grafted areas is more predictable, the data obtained so far24,25, and the use of allograft which proved to have a 8
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longer and more critical healing phase 26, were the reasons why a delayed placement was chosen. For the same reason, delayed prosthetical loading was chosen, even though primary stability of the implants was good. The possibility of using a provisional fixed prosthesis balanced the choice of a longer therapy.
4. Conclusions When the surgical protocol is accurate and it is provided that no complications occur during the healing phase, homologus bone grafting is a valid alternative to autografts. The obvious advantage of this technique is sparing the patient a donor site surgery. The utilization of homologus grafts with the tunnel technique reduces surgical trauma and post-operative discomfort, as well as the risk of expose and failure of the graft during the healing phase. PRF can enhance bone formation and soft tissues healing when used to cover the graft. In our experience, onlay grafting with frozen bone is a predictable technique for horizontal augmentation. In case of a vertical augmentation, however, our advise is grafting with a sandwich interpositional technique.
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References.
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4. Maestre-Ferrín L., Boronat-López A., Peñarrocha-Diago M., Peñarrocha-Diago M. Augmentation procedures for deficient edentulous ridges, using onlay autologous grafts: An update. Med Oral Patol Oral Cir Bucal. 2009 Aug 1;14 (8):e402-7.
5. de Macedo L. G., de Macedo N. L., do Socorro Ferreira Monteiro A., Freshfrozen human bone graft for repair of defect after adenomatoid odontogenic tumour removal. Cell and Tissue Banking, 2009 vol. 10, no. 3, pp. 221–226. 10
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6. S. N. Khan, F. P. Cammisa Jr., H. S. Sandhu, A. D. Diwan, F. P. Girardi, and J. M. Lane. The biology of bone grafting. The Journal of the American Academy of Orthopaedic Surgeons. 2005 vol. 13, no. 1, pp. 77–86.
7. F. Carinci, G. Brunelli, I. Zollino, Franco M, Viscioni A, Rigo L, Guidi R, Strohmenger L. Mandibles grafted with fresh-frozen bone: an evaluation of implant outcome. Implant Dentistry. 2009 vol. 18, no. 1, pp. 86–95.
8. Barone A, Covani U. Maxillary alveolar ridge reconstruction with nonvascularized autogenous block bone: clinical results. J Oral Maxillofac Surg. 2007;65:2039-46.
9. Quattlebaum SB,Mellonig JT,Hansel NF. Antigenicity of freeze-dried cortical bone allograft in human periodontal osseous defects. J Periodontol 1988;59:394– 397.
10.Keith JD Jr, Petrungaro P, Leonetti JA, Elwell CW, Zeren KJ, Caputo C, Nikitakis NG, Schöpf C, Warner MM. Clinical and Histologic evaluation of a Mineralized Block Allograft: results from the developmental period (2001-2004). Int J Periodontics Restorative Dent. 2006 Aug;26(4):321-7. 11
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11.Mellonig JT. Autogenous and allogeneic bone grafts in periodontal therapy. Crit Rev Oral Biol Med 1992;3:333–352.
12.Gomes KU, Carlini JL, Biron C, Rapoport A, Dedivitis RA. Use of Allogeneic Bone Graft in Maxillary Reconstruction for Installation of Dental Implants. J Oral Maxillofac Surg. 2008 Nov;66(11):2335-8.
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ndell PA, Mattsson T, Astrand P: Immunological responses to maxillary onlay allogeneic bone grafts. Clin Oral Implants Res 1996 7:373,
14.Heard RH, Mellonig JT. Regenerative materials: An overview. Alpha Omegan 2000;93:51–58. 15.Perrott DH, Smith RA, Kaban LB: The use of fresh frozen allogeneic bone for maxillary and mandibular reconstruction. Int J Oral Maxillofac Surg 1992. 21:260,
16.Buck BE, Resnick L, Shah SM, Malinin TI. Human immunodeficiency virus cultured from bone. Implications for transplantation. Clin Orthop Relat Res 1990. 249-53.
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17.MellonigJT. Donorselection,testing,and inactivation of the HIV virus in freezedried bone allografts. Pract Periodontics Aesthet Dent 1995;7:13–22.
18.Morelli T, Neiva R, Wang HL. Human Histology of Allogeneic Block Grafts for Alveolar Ridge Augmentation: Case Report . Int J Periodontics Restorative Dent. 2009;29(6):649-56.
19. Gassling V, Hedderich J, Açil Y, Purcz N, Wiltfang J, Douglas T. Comparison of platelet rich fibrin and collagen as osteoblast-seeded scaffolds for bone tissue engineering applications. Clin Oral Implants Res. 201;24(3):320-8.
20. Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, Gogly B. Platelet-rich fibrin (PRF): a second-generation platelet concentrate. Part III: leucocyte activation: a new feature for platelet concentrates? Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101(3):e51-5. 21. Choukroun J, Simonpieri A, Del Corso M, Mazor Z, Sammartino G, Dohan Ehrenfest DM. Controlling systematic perioperative anaerobic contamination during sinus-lift procedures by using metronidazole: an innovative approach. Implant Dent. 2008;17(3):257-70 22.Dohan Ehrenfest DM, de Peppo GM, Doglioli P, Sammartino G. Slow release of 13
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growth factors and thrombospondin-1 in Choukroun's platelet-rich fibrin (PRF): a gold standard to achieve for all surgical platelet concentrates technologies. Growth Factors. 2009;27(1):63-9. 23. Choukroun J, Diss A, Simonpieri A, Girard MO, Schoeffler C, Dohan SL, Dohan AJ, Mouhyi J, Dohan DM. Platelet-rich fibrin (PRF): a second-generation platelet concentrate. Part IV: clinical effects on tissue healing. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006; 101(3):e56-60.
24.Clementini M, Morlupi A, Agrestini C, Barlattani A. Immediate versus delayed positioning of dental implants in guided bone regeneration or onlay graft regenerated areas: a systematic review. Int J Oral Maxillofac Surg. 2013 May;42(5):643-50.
25.Peñarrocha-Diago M, Aloy-Prósper A, Peñarrocha-Oltra D, Guirado JL, Peñarrocha-Diago M. Localized lateral alveolar ridge augmentation with block bone grafts: simultaneous versus delayed implant placement: a clinical and radiographic retrospective study.Int J Oral Maxillofac Implants. 2013 MayJun;28(3):846-53.
26.Mulliken JB, Glowacki J, Kaban LB, Folkman J, Murray JE. Use of
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demineralized allogeneic bone implants for the correction of maxillocranio-facial deformities. Ann Surg 1981. Sep;194(3):366-72.
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Figure Captions Fig. 1 CT showing severe horizontal atrophy Fig. 2 Clinical case with severe bone atrophy Fig. 3 A minimally approach with a single incision realizing instead a mucoperiosteal tunnel Fig. 4 Positioning of tissue bank ilium bicortical bone(FFB)
Fig. 5 complete fixation of the block with three microscrews Fig. 6 Positioning of two submerged implants in the frontal region Fig. 7 Fixed provisional prosthesis Fig. 8 CT follow up after 5 months
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aaid-joi-D-14-00076R1
Full Title:
Minimally invasive approaches to optimize block grafting: a case report
Short Title: Article Type:
Clinical Case Letter
Keywords:
tunnel technique, block grafting, bone augmentation, fresh frozen bone, PRF
Corresponding Author:
Gilberto Sammartino, M.D., D.D.S University of Naples "Federico II" Naples, Italy ITALY
Corresponding Author Secondary Information: Corresponding Author's Institution:
University of Naples "Federico II"
Corresponding Author's Secondary Institution: First Author:
Gilberto Sammartino, M.D., D.D.S
First Author Secondary Information: Order of Authors:
Gilberto Sammartino, M.D., D.D.S Giuseppe Pantaleo, D.D.S. Paolo Nuzzolo, D.D.S., PhD student Massimo Amato, M.D., D.D.S Francesco Riccitiello, M.D., D.D.S.
Order of Authors Secondary Information: Abstract:
In narrow alveolar ridge many surgical approaches exist, and the most frequently used is bone grafting The subperiosteal tunneling approach is a minimal safety procedure that allows to allocate the graft in a space that is obtained between the soft tissues and the underlying bone, through an access rapresented by one single incision on the mesial limit of the bone defect. A 55-year-old caucasian woman with a severe bone atrophy in the maxillary arch was treated with horizontal bone augmentation. A mucoperiosteal tunnel with a periosteal elevator through one single incision of moderate dimensions per hemiarch, insertion of tissue bank ilium bicortical bone(FFB) and a consequent complete prosthetic-implant rehabilitation was realized. The tunnel technique provided primary intention closure of the surgical wound, avoiding dehiscences and infections, and reducing the edema and the post-operative discomfort for the patient. Clinical and histological studies support the use of FFB and it has been suggested that the results of a graft with homologous and with autologus bone can be comparable, even though the healing phase is more critical and longer for the allograft. The combination of homologous grafts with the tunnel technique reduces significantly the surgical trauma and the postoperative discomfort, as well as the risk of exposure of the graft during the healing phase, with the risk of graft failiure. In our experience, onlay grafting with frozen bone is a predictable technique for horizontal augmentation.
Response to Reviewers:
The text has been changed to yellow for reviewer 1, and green for reviewer 2. Reviewers' comments Reviewer #1: General comments: Grammar and sentence structure can be improved to enhance manuscript.
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Grammar and sentence structure have been improved Introduction: Sentence 5: "minimal safety" Does that mean it has high risk. The sentence has been changed in "minimally invasive" Sentence 8: "Perfect" Select less absolute term. The sentence has been changed Sentence 19-20: "reach out" Define? Clarify. The concept were clarified Sentence 28: "Atrophy" Horizontal? Vertical?. The kind of atrophy was added Sentence 28: "Elements" Define. Can we include radiographs in case report?. Elements were defined. Pre-operative and post-operative CT were added to the manuscript Sentence 32: "Lateral-posterior sectors?" Uncommon dimension. The sentence was changed to "posterior sectors" Sentence 38: "Top" "Bottom" Scientific word?. The sentence was changed using scientific words Sentence 36, 44: "receiving bone" Define. The words were defined Sentence 47: basculation? Define. The word has been defined Sentence 50: "Two 11.5 x 4m" ..more commonly (2) 4x11.5mm. The change was made Sentence 53: "Yet" retained?. The concept was clarified
Sentence 55: The patient was scheduled for regular... The sentence has been changed. Sentence 60: Did it prove integration? Supported, or proved? the concept. The concept was clarified Sentence 66-69: Rework sentence or wake into a concise sentence. The sentence has been reworked. Sentence 70: A full arch...Implants for 1 month followed by a def. metal ceramic prosthesis. The sentence was modified. Sentence 79: "and possibility to place the dental implants" Explain. The concept has been developed in a better way Sentence 89: "BMP" spell out sentence. The change was made Sentence 90: New paragraph and new topic sentence "PCR" spell out. The change was made Sentence 93: readily available source of... The sentence has been changed
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Sentence 97: Platelet rich fibrin can increase the predictability of bone Foundation. The change was made Sentence 101: Start sentence with Although. The change was made Sentence 105-110: rewrite, concise sentence. The concept has been developed in a better way Sentence 113-115: run on, a lot of thoughts, make into two concise sentences (It will be better). The concept has been developed in a better way Sentence 116-118: The utilization of homologous...reduces surgical trauma and post-operative discomfort...expose and failure...phase. The concept has been developed in a better way Sentence 119: PRF can enhance bone...healing when used to cover the graft. The change was made Sentence 122: In case...grafting... The change was made OMIT I do not think we need to recite 4, 6, 8, 3, 19 in conclusion. They have been deleted
Reviewer #2: Some risks must be discussed respect to use FFB, as a possible immunization to blood group or other antigens. In addition to this, other of the main concerns with the use of bone allograft (although rare) is transmission of infection, (most notably hepatitis and acquired immunodeficiency syndrome). I suggest some paragraph like: "The risk of viral transmission by unprocessed deep-frozen, nonirradiated grafts from screened donors is currently less than 1:200,000 for hepatitis C virus and 1:1 million for human immunode?ciency virus 0 It is virtually nonexistent for processed bone grafts". The concept has been developed in a better way and the additions were made
Page 2 line 28 replace elements by teeth. The word was corrected The reference to the prf is not the subject of the article and is treated superficially (reference 19). The concept has been clarified and expanded Reference 18 is incomplete. The reference has been changed in the correct way. The images are of poor quality. Images have been improved in quality. Pre-operative and post-operative CT were added to the manuscript
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Minimally invasive approaches to optimize block grafting: a case report G. Sammartino1, G. Pantaleo1, P. Nuzzolo1, M. Amato2, F. Riccitiello1 1 2
Unit of Oral Surgery and Implantology, Naples, Italy Department of Medicine and Surgery, Salerno, Italy
Author of correspondence: Gilberto Sammartino [email protected]
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Abstract In narrow alveolar ridge many surgical approaches exist, and the most frequently used is bone grafting. The subperiosteal tunneling approach is a minimal safety procedure that allows to allocate the graft in a space that is obtained between the soft tissues and the underlying bone, through an access rapresented by one single incision on the mesial limit of the bone defect. A 55-year-old caucasian woman with a severe bone atrophy in the maxillary arch was treated with horizontal bone augmentation. A mucoperiosteal tunnel with a periosteal elevator through one single incision of moderate dimensions per hemiarch, insertion of tissue bank ilium bicortical bone(FFB) and a consequent complete prosthetic-implant rehabilitation was realized. The tunnel technique provided primary intention closure of the surgical wound, avoiding dehiscences and infections, and reducing the edema and the post-operative discomfort for the patient. Clinical and histological studies support the use of FFB and it has been suggested that the results of a graft with homologous and with autologus bone can be comparable, even though the healing phase is more critical and longer for the allograft. The combination of homologous grafts with the tunnel technique reduces significantly the surgical trauma and the postoperative discomfort, as well as the risk of exposure of the graft during the healing phase, with the risk of graft failiure. In our experience, onlay grafting with frozen bone is a predictable technique for horizontal augmentation. Keywords:
tunnel technique, block grafting, bone augmentation, fresh frozen bone, PRF 2
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1. Introduction
A narrow alveolar ridge is a challenging situation that surgeons may face when considering implant oral rehabilitation. Many surgical approaches exist, and the most frequently used is bone grafting.1 The subperiosteal tunneling approach is a minimally invasive procedure that allows to allocate the graft in a space that is obtained between the soft tissues and the underlying bone, through an access rapresented by one single incision on the mesial limit of the bone defect.2,3 This approach ensures minimal discomfort for the patient after the surgery and, mostly, steady coverage of the graft during the healing time, with minimal risk of exposure, infection and failiure.4,5 The subperiosteal tunneling technique uses autologous bone that is still considered the gold standard for bone regeneration.6 On the other hand, autologous bone grafting requires donor site surgery, which often means donor site surgery complications, especially when larger amounts of bone are needed and extraoral sites are accessed for the harvest. Moreover, they need general anaesthesia.7,8 Homologous grafting refers to the use of bone from living donors of the same species or from cadavers. The bone is processed and stored in tissue banks. Depending on the type of treatment, Fresh Frozen Bone (FFB), Freeze-Dried Bone (FDB) and Demineralized 3
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Freeze-Dried Bone (DFDB) can be obtained. 4,9,10 The case presented combines the tunnel flap technique and the use of homologous bone to achieve the least possible invasive approach to bilateral block grafting of an upper maxillary affected by severe horizontal bone atrophy, in order to allow a full arch implant rehabilitation.
2. Case presentation
A 55-year-old caucasian woman was referred to the Dental School of the University Federico II of Naples. No significant clinical data (diabetes, hypertension, allergies) were present in her clinical history; laboratory investigations were substantially normal. The patient was partially edentolous and showed severe horizontal bone atrophy in the maxillary arch. The only teeth in the arch were the canines and the second molars, already treated. Due to the periodontal and endodontic condition of the remaining teeth, implant therapy and a full arch prosthetic restoration were chosen for the patient. Horizontal bone augmentation was necessary, as the ridge showed no sufficient horizontal dimensions for the placement of implants in the posterior sectors – both right and left, and block grafting was a mandatory option, because of the degree of the atrophy and the noncontentive anatomy of the defect. There was no need for an additional vertical augmentation (Figure 1-2). 4
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A minimally invasive approach was chosen for the exposure of the receiving sites. This consisted in avoiding a traditional flap, realizing instead a mucoperiosteal tunnel with a periosteal elevator through one single incision of moderate dimensions per hemiarch, on the mesial edge of each of the two defects (right and left), from the occlusal to the apical limit of the ridge on its vestibular side(Figure 3). As for the grafting material, tissue bank ilium bicortical bone was chosen (FFB). After being defreezed in sterile saline solution, each block was split, obtaining cortical on one side and trabecular on the other one. The cortical bone was to be positioned on the interface with the soft tissues, the trabecular bone was to be placed on the interface with the host site (Figure 4). The host site had been previuosly drilled to facilitate bleeding, start the RAP (regional acceleratory process) and expose trabecular bone. Three microscrews, fixed on the mesial side of the graft, allowed the complete fixation of the block, avoiding any movement or tilting (Figure 5). Instead, PRF (Platelet Rich Fibrin) was placed upon the graft. Besides block grafting on the right and left posterior regions, a flap was elevated in the frontal region, which showed good bone quality, quantity and anatomy, and two 4x11,5 mm submerged tapered implants were placed(Figure 6). Polygalactin 910 (Vycril) 4/0 resorbable sutures were used for flaps closure. The four remaining teeth were not extracted in this phase, in order to use them to support a fixed provisional prosthesis (Figure 7). 5
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The patient was scheduled for regular follow-ups for the next five months. After 5 months of healing, the CT follow-up and surgical re-entry were performed (Figure 8). After the removal of the provisional prosthesis and the infiltration of local anaesthesia, mucoperiosteal flaps were raised to expose both the grafted areas. The grafted areas showed minimal bone resorption: the bone was still at the level of the top of the microscrews, which were removed. The bleeding during the removal of the screws supported the successful integration of the graft. After a slight osteoplasty to give right conformation to the ridge, measurements were taken showing an horizontal gain between 2 and 4 mm. Three implants per side were placed, of the same type of the ones used for the frontal region (4x11,5mm). No immediate prosthetical load was realized and the provisional prosthesis was cemented on the remaining teeth again. After a healing period of four months, the implants were uncovered and healing abutments were placed, the four remaining teeth were extracted and a second provisional –removable- prosthesis, was delivered for the following 2 weeks, during soft tissues healing. Afterwards, a full arch resin restoration was loaded on the implants for one month followed by a definitive metal ceramic prosthesis. A 16 months follow up showed no marginal bone loss, soft tissues stability, no bone resorption on the grafted areas. 6
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3. Discussion
Success criteria for a bone graft have been estabilished by Barone et. al: absence of exposure and infection of the graft in the post-operative period, incorporation of the graft to the receptor bed, absence of radiolucent areas, bleeding of the grafted bone when removing the fixation screws, and the achievement of adequate volume and density to place the dental implants. In our case these criteria were all satisfied.8 The tunnel technique provided primary intention closure of the surgical wound, avoiding dehiscences and infections, and reducing the edema and the post-operative discomfort for the patient. Dehiscences are reported to be among the most frequent complications of bone grafting, so that preventing them can result in a higher predictability of the graft.3,11,12 Clinical and histological studies support the use of FFB 6,10,13, and it has been suggested that the results of a graft with homologous and with autologus bone can be comparable, even though the healing phase is more critical and longer for the allograft 14. FFB is believed to have both osteocondutive properties, thanks to its solid structure and midollar spaces that allow the blood vessels invasion and the bone ingrowth, as well as osteoinductive action, as freezing does not affect the bone morphogenetic proteins (BMPs) contained in the bone15. In addition, polimerase chain reaction (PCR) serological tests effected on the donor 7
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tissue ensure the safety of the graft: viral infections trasmission is believed to be the main potential disadvantage of the use of allografts16,17. To date, however, no such occurences have been reported in the dental literature. The risk of viral transmission by unprocessed deep-frozen, nonirradiated grafts from screened donors is currently less than 1:200,000 for hepatitis C virus and 1:1 milion for human immunodeficiency virus. Such risk is virtually nonexistent for processed bone grafts. Homologous bone from tissue banks offers obvious advantages: readily available source of large volumes of material, extremely low antigenic potential, unblemished safety record in dentistry, and, of course, the absence of a donor site surgery fot the patient, with the risk of surgical complications7,18. Also, platelet rich fibrin (PRF) can increase the predictability of bone foundation. Osteoblasts show high affinity for PRF membranes19 and the constant release of growth factors guides the healing and remodeling of connective tissues20,21. Choukroun et al. have demonstrated that PRF, through constant a release of growth factors in the time, has the double action of enhancing soft tissues healing and stimulating blood vessels ingrowth, cellular migration and differentiation into bone forming cellular lines22. Furthermore, the presence of cytokines that control the inflamation lowers the risk of infection within the graft23 Although no evidence is given that a delayed placement in the grafted areas is more predictable, the data obtained so far24,25, and the use of allograft which proved to have a 8
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longer and more critical healing phase 26, were the reasons why a delayed placement was chosen. For the same reason, delayed prosthetical loading was chosen, even though primary stability of the implants was good. The possibility of using a provisional fixed prosthesis balanced the choice of a longer therapy.
4. Conclusions When the surgical protocol is accurate and it is provided that no complications occur during the healing phase, homologus bone grafting is a valid alternative to autografts. The obvious advantage of this technique is sparing the patient a donor site surgery. The utilization of homologus grafts with the tunnel technique reduces surgical trauma and post-operative discomfort, as well as the risk of expose and failure of the graft during the healing phase. PRF can enhance bone formation and soft tissues healing when used to cover the graft. In our experience, onlay grafting with frozen bone is a predictable technique for horizontal augmentation. In case of a vertical augmentation, however, our advise is grafting with a sandwich interpositional technique.
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demineralized allogeneic bone implants for the correction of maxillocranio-facial deformities. Ann Surg 1981. Sep;194(3):366-72.
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Figure Captions Fig. 1 CT showing severe horizontal atrophy Fig. 2 Clinical case with severe bone atrophy Fig. 3 A minimally approach with a single incision realizing instead a mucoperiosteal tunnel Fig. 4 Positioning of tissue bank ilium bicortical bone(FFB)
Fig. 5 complete fixation of the block with three microscrews Fig. 6 Positioning of two submerged implants in the frontal region Fig. 7 Fixed provisional prosthesis Fig. 8 CT follow up after 5 months
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