Titanium Membranes in Prevention of
Alveolar Collapse After Tooth Extraction
Márcia N. Pinho, MS,* Virgı́lio M. Roriz, MS,* Arthur B. Novaes, Jr., DDS, PhD,† Mário Taba, Jr., DDS, PhD,‡
Márcio F. M. Grisi, DDS, PhD,‡ Sérgio L. S. de Souza, DDS, PhD,‡ and Daniela B. Palioto, DDS, PhD‡
he resorption of alveolar bone following tooth extraction results in
a narrowing and shortening of the
residual ridge. Alveolar bone resorption
is a common finding following tooth
extraction, and it poses a problem for the
clinician in 2 distinct manners: (1) it
creates an esthetic problem for the fabrication of conventional or implantsupported prostheses, and (2) it can
make the placement of endosseous implants difficult or even impossible.
These patterns of resorption reduce the
bone volume available for implant
therapy.1-4
There are many techniques available to improve alveolar ridge collapse
after tooth extraction, including connective tissue grafts, acellular dermal
matrix grafts, and guided bone regeneration with or without the association
of different bone grafts.5-8 The alveolar ridge preservation procedures are
recommended at the extraction to prevent loss of tissue, reduce the number
of surgeries, and increase the predictability of esthetic reconstruction.9
Guided bone regeneration is used
to prevent alveolar ridge resorption or
enlarge the alveolar ridge.10 The membrane acts as a mechanical barrier, the
blood clot is protected from the overlying tissue, and bone promoting cells
are the only cells allowed to repopulate the bone defect. The amount of
T
*Graduate student of Periodontology, School of Dentistry of
Ribeirão Preto, University of São Paulo, Ribeirão Preto, São
Paulo, Brazil.
†Chairman of Periodontology, School of Dentistry of Ribeirão
Preto, University of São Paulo, Ribeirão Preto, São Paulo,
Brazil.
‡Professor of Periodontology, School of Dentistry of Ribeirão
Preto, University of São Paulo, Ribeirão Preto, São Paulo,
Brazil.
ISSN 1056-6163/06/01501-053
Implant Dentistry
Volume 15 • Number 1
Copyright © 2006 by Lippincott Williams & Wilkins
DOI: 10.1097/01.id.0000202596.18254.e1
Background and Purpose: The
resorption of alveolar bone following tooth extraction results in a
narrowing and shortening of the residual ridge, which leads to esthetic
and restorative problems, and reduces the bone volume available for
implant therapy. The aim of this
study was to evaluate the prevention
of alveolar collapse after tooth extraction, using titanium membrane
(Frios Boneshield; DENTSPLY
Friadent, Mannheim, Germany), associated (or not) with autologous
bone graft.
Materials and Methods: A total
of 10 nonsmoking healthy subjects,
ranging from 35 to 60 years old, were
selected for this study. Each patient
had a minimum of 2 uni-radicular periodontally hopeless teeth, which were
scheduled for extraction. After the
procedure, 2 titanium pins were fixed
on the vestibular bone surfaces that
were used as references for the initial
measures (depth, width, and height) of
the socket. Of the sockets,1 was randomly chosen to be filled with autologous bone graft (test) removed from
superior maxillary tuber, and the
other one did not receive the graft
(control). A titanium membrane was
adapted and fixed, covering the sockets, which remained for at least 10
weeks. After a 6-month healing, the
final measures were performed.
Results: There was exposure of
the membrane in 5 of the 10 treated
subjects. Average bone filling (⫾standard deviation) among the 10 subjects
was 8.80 ⫾ 2.93 mm (range 4-13) in
the control group and 8.40 ⫾ 3.35 mm
(range 4-13) in the test group. Average bone loss in width in both group
was 1.40 ⫾ 1.97 mm (range ⫺4-1) in
the control group and 1.40 ⫾ 0.98 mm
(range ⫺4-0) in the test group. There
was no significant statistical difference between groups considering the
evaluated standards.
Conclusion: The use of titanium
membrane, alone or in association
with autogenous bone, favored the
prevention of alveolar ridge after
tooth extraction. This membrane
seems to be a possible and safe alternative to other nonresorbable membranes when the prevention of alveolar ridge resorption is the objective.
(Implant Dent 2006;15:53– 61)
Key Words: prevention, alveolar
ridge resorption, bone graft, bone resorption, titanium membrane, guided
bone regeneration
regenerated bone is limited by the
space available under the membrane.
Autogenous bone or bone substitutes
have been suggested as space maintainers under the membrane, and are considered the gold standard because there
is the possibility of retaining cell viability, faster graft revascularization, and
there is no possibility of disease
transmission.11-13 Using autogenous
bone, Becker et al14 observed the presence of osteocytes inside empty spaces,
blood vessels, and secondary bone formation, proving its superiority in relation to lyophilized human bone grafts.
Considering that both nonresorbable membranes and absorbable membranes tend to collapse into the defects,
IMPLANT DENTISTRY / VOLUME 15, NUMBER 1 2006
53
more rigid membranes in association
with grafts are required. The use of titanium membranes has been suggested
instead of absorbable or expanded polytetrafluoroethylene (e-PTFE) membranes, with or without the association
with grafts. The titanium membranes
have micro-porosities small enough to
prevent the penetration of cells and fibers but that allow the diffusion of
interstitial fluid.11 Because of their rigidity, these barriers promote better
space maintenance, favoring the formation and stability of the blood clot
that is essential for cell proliferation
and tissue regeneration. This article
proposes a clinical, randomized controlled comparison of the use of titanium membranes associated with, and
not associated with, autogenous bone
grafts in the prevention of alveolar
ridge resorption after extraction.
MATERIALS
AND
METHODS
After the Universities Human Research Committee approved the study
protocol, 10 healthy subjects, ranging
from 35 to 60 years old (average age
46.3), were selected. Each subject presented with at least 2 anterior maxillary teeth or premolars for extraction
as a result of advanced periodontal
disease (Fig. 1). The lost teeth were to
be replaced following the healing period by osseointegrated implants. A
temporary removable partial prosthesis was made for each subject to replace the missing teeth during the
healing phase.
Systemic antibiotics were given for
10 days (500 mg amoxicillin, 3 times/
day), beginning 24 hours before the surgical procedures. After local anesthesia,
an intrasulcular incision with 2 vertical
releasing incisions at the proximal angles of the teeth were made, and a mucoperiosteal flap was raised. A partial
thickness flap was raised up to the mucogingival junction to guarantee the
flexibility of the flap that is essential
to cover the membranes without tension. The teeth were extracted as atraumatically as possible, without damaging
the cortical bone using the Periotome
(DENTSPLY Friadent, Mannheim,
Germany).
After the procedure, 2 membrane
fixating tacks were placed on the buccal
bone surfaces to be used as references
54
TITANIUM MEMBRANES
IN
Fig. 1. Teeth 11, 21, and 23 selected for
extraction.
Fig. 2. Illustration showing the socket measurements: internal vertical measurement
(IVM), horizontal measurement (HM), and external vertical measurement (EVM).
Fig. 3. Internal vertical measurement (IVM).
Fig. 4. Horizontal measurement (HM).
marks for the initial measurements,
which were made with a periodontal
probe to the nearest millimeter: (1) internal vertical measurement, distance
from most apical end of the socket and
the coronal border of the buccal bony
wall (Figs. 2 and 3); (2) horizontal
measurements, distance from the coronal border of the buccal bony wall to
the coronal border of the lingual or
PREVENTION
OF
Fig. 5. External vertical measurement (EVM).
Fig. 6. Filling the test socket with the autogenous bone graft.
Fig. 7. Test socket filled with the autogenous
bone graft.
Fig. 8. Titanium membrane adapted and
fixed onto the alveolar ridge.
palatal bony wall (Figs. 2 and 4); and
(3) external vertical measurement, distance from the most coronal aspect of
the pin to the coronal border of the
buccal bony wall (Figs. 2 and 5).15
Of the sockets, 1 was randomly
chosen to be filled with an autogenous
bone graft (test), which was removed
from superior maxillary tuberosity,
while the other one remained as a control and did not receive a graft (Figs. 6
ALVEOLAR COLLAPSE AFTER TOOTH EXTRACTION
Table 2. Vertical Bone Fill (N ⫽ 10 sites)
Fig. 9. Flaps sutured using nonresorbable
interrupted suture.
Fig. 10. Six months after titanium membrane
placement.
Patient
No.
Control
(mm)
Test
(mm)
1
2
3
4
5
6
7
8
9
10
Mean (SD)
12
9
10
11
4
7
9
13
5
8
8.80 (2.93)
13
9
7
10
4
5
8
10
11
7
8.40 (3.35)
using a similar design to the one used
in the initial surgical procedures.
Comparisons between control and experimental sites at baseline and the
6-month postoperative period were
performed using the Mann-Whitney
test with the significance level set at
5% (P ⫽ 0.05).
RESULTS
and 7). A titanium membrane (Frios
Boneshield; DENTSPLY Friadent)
was adapted to cover the sockets and
fixed with membrane fixating tacks
(Fig. 8). Buccal and lingual flaps were
approximated to achieve complete
wound closure over the membranes. In
some cases, cutback incisions were
made into the periosteum of the buccal
mucosa to eliminate tension present at
the suture line. Flaps were sutured using nonresorbable single U-shaped interrupted sutures (Fig. 9). Subjects
were prescribed the aforementioned
medication plus oral antiseptics (10
mL rinses of 0.12% chlorhexidine gluconate for 2 minutes for 15 days).
Subjects were also instructed not to
wear any type of prosthesis, which
could come in contact with the surgical area for 2 weeks following the
surgical procedure. Sutures were removed 2 weeks after the surgery.
After 6 months of membrane
placement (Fig. 10), the final measurements were made during the reentry
surgical procedures performed to remove the membranes. Buccal and lingual full-thickness flaps were elevated
The subjects tolerated the surgical
procedures well, and there were no
postoperative complications, or clinical signs of inflammation or infection.
There was exposure of the membrane
in 5 of the 10 treated subjects between
the sixth and tenth week of the placements. Patients were instructed to apply
a daily a solution of 0.12% chlorhexidine to the exposed membrane until removal 30 days after the exposure. In
addition, patients with membrane exposure came in for weekly appointments for bacterial plaque control and
to verify the status of the clinical healing. The titanium tacks were left in
place for the final measurements in the
sixth postoperative month. Regardless
of membrane exposure (or not), all 10
subjects were submitted to a reentry
procedure after 6 months of membrane
placement.
Vertical Bone Fill
The reentry procedures revealed
that when the amount of existing bone
tissue in the areas of the sockets was
compared, before the placement and
after the removal of the membranes,
Table 1. Bone Fill (N ⫽ 10 sites)
Control Group
Test Group
8.80 ⫾ 2.93 mm (range 4-13)
8.40 ⫾ 3.35 mm (range 4-13)
Data are presented as mean ⫾ SD.
bone fill was observed but without
statistical significance. In the control
group, mean relative bone fill (⫾standard deviation [SD]) was 8.80 ⫾ 2.93
mm (range 4-13) and in the test group,
8.40 ⫾ 3.35 mm (range 4-13) (Tables
1 and 2). These values were relative,
considering the tacks in the buccal surfaces of the bone as reference.
Socket Depth
In relation to socket depth, all
sockets showed complete fill, so that
at the measurement, the result was
zero.
Ridge Width
Considering the width, both groups
presented the same mean values of
bone fill after 6 months of healing,
1.40 ⫾ 1.97 mm (range ⫺4-1) in the
control group and 1.40 ⫾ 0.98 mm
(range ⫺4-0) in the test group (Tables
3, 4). Although there was no difference between groups, there was statistical intra-group differences before and
after the titanium membrane placements, but only in the test group, presenting the values: initial mean 8.3 ⫾
1.41 mm (range 7-11) and final mean
6.9 ⫾ 1.85 (range 4- 11) (P ⫽ 0.04).
Vertical Bone Fill and Horizontal
Bone Loss
The amount of new bone formation in each site was calculated by
taking the socket (depth), adding or
diminishing the bone height, depending on an increase or decrease in bone
height 6 months after membrane
placement (Tables 2, 4, and 5).
DISCUSSION
The deformities of the alveolar
ridge in the anterior maxillary area
caused by extraction normally leads to
functional and esthetic problems, and
can be difficult to solve. Considering
the results of this study, the titanium
membranes can be used to preserve the
alveolar ridge with minimum bone remodeling after tooth extraction. In the
present, and apparently first controlled
randomized, clinical study using titanium membranes, the autogenous bone
graft did not favor bone formation in
height or width in the subjects that had
no membrane exposure.15-20 When the
values of ridge width were compared
IMPLANT DENTISTRY / VOLUME 15, NUMBER 1 2006
55
Table 3. Bone Loss (width)
Control
Test
1.40 ⫾ 1.97 mm (range ⫺4-1)
1.40 ⫾ 0.98 mm (range ⫺4-0)
Data are presented as mean ⫾ SD (N ⫽ 10 sites).
Table 4. Horizontal Bone Loss
Patient
No.
Control
Test
1
⫺2
⫺1
2
⫺3
0
3
1
⫺1
4
⫺4
⫺3
5
0
⫺1
6
0
⫺1
7
⫺1
⫺1
8
0
0
9
⫺1
⫺2
10
⫺4
⫺4
Mean (SD) ⫺1.40 (1.97) ⫺1.40 (0.98)
Data are presented in mm ⫾ SD (Sinal –: bone loss) (N ⫽ 10
sites).
before and after membrane placement,
the bone loss observed was statistically significant in the test group.
One explanation for this result is
that the titanium membranes were
rigid enough to favor space maintenance, protecting the blood clot from
the overlying tissue and allowing only
bone promoting cells to repopulate the
bone defect. In this situation, the additional use of grafting materials may
not be necessary. According to Becker
et al,14 the association is needed only
when the selected membrane does not
maintain space well. Therefore, autogenous bone, or bone substitutes, has
been suggested as space maintainers
Table 5. Relative Bone Fill: Initial and Final Measurements
Initial and Final Measures of the 10 Subjects
Control
Patient No.
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
6
6
6
7
7
7
8
8
8
9
9
9
10
10
10
Measures Initial
SD
RW
RH
SD
RW
RH
SD
RW
RH
SD
RW
RH
SD
RW
RH
SD
RW
RH
SD
RW
RH
SD
RW
RH
SD
RW
RH
SD
RW
RH
Test
Final
Difference
Initial
Final
Difference
0
7
10
0
7
6
0
9
7
0
5
4
0
7
5
0
9
7
0
6
8
0
12
5
0
7
3
0
4
6
11
2
⫺1
10
3
1
10
⫺1
0
13
4
2
5
0
1
5
0
⫺2
8
1
⫺1
13
⫺1
0
6
1
1
11
4
3
9
7
6
9
7
7
8
9
6
10
9
4
6
7
6
6
7
7
7
8
6
10
11
4
12
10
8
9
8
6
0
6
10
0
7
7
0
8
5
0
6
4
0
6
4
0
6
6
0
7
7
0
11
4
0
8
7
0
4
4
9
1
⫺4
9
0
0
8
1
1
10
3
0
6
1
2
6
1
1
7
1
⫺1
10
0
0
12
2
1
9
4
2
11
9
9
10
10
7
10
8
7
13
9
6
5
7
6
5
9
5
8
7
7
13
11
5
6
8
4
11
8
9
Control indicates membrane; final, 6 months; initial, time 0; RH, ridge height (mm); RW, ridge width (mm); SD, socket depth (mm); Test,
membrane ⫹ bone graft.
56
TITANIUM MEMBRANES
IN
PREVENTION
OF
under the membrane to ensure adequate space for regeneration and promote bone growth. Autogenous bone
grafts are considered the gold standard
because there is the possibility of retaining cell viability, faster graft revascularization, and there is no possibility of
disease transmission.11-13 Using autogenous bone, Becker et al14 observed the
presence of osteocytes inside empty
spaces, blood vessels, and secondary
bone formation, proving its superiority
in relation to lyophilized human bone
grafts.
Mean bone loss in width in both
groups (1.40 mm) was similar to values found by Lekovic et al15 when
absorbable membranes were used.
When our results were compared to
another study by Lekovic et al,16 in
which e-PTFE membranes were used,
30% more bone loss in width (1.80
mm) was found in their study. This
finding is relevant and significant because of the fact that using e-PTFE
membranes, 3 of 10 cases were exposed, and, in this study, 5 of 10 were
exposed. Although membrane exposure in this study was more frequent,
the mean value of bone loss in width
was smaller. This fact could be explained by the lower contamination of
the titanium membranes.21-25
The comparison of our findings in
bone fill to other studies is difficult because our results are reported using the
membrane fixating tacks as references.15-17 Therefore, relative bone formation was measured and not absolute
bone gain in terms of millimeters. However, the present results show maintenance of alveolar ridge and prevention
of resorption after extraction.
Titanium membranes are not as
flexible as other membranes, and this
could favor its increased exposure.11,26
The value of exposure (50%) of this
study is similar to studies in which
absorbable membranes were used.16,19
Another factor that could contribute to
the exposure is the suturing technique,
and in this study, a simple, interrupted
suturing technique was used. Maybe a
more elaborate technique could reduce
the exposure.
Absorbable membranes have the
advantage over nonresorbable ones of
not needing a second procedure for removal but, similar to e-PTFE membranes, require the association with bone
ALVEOLAR COLLAPSE AFTER TOOTH EXTRACTION
grafts because, in some cases, space
maintenance can be a problem. In addition, e-PTFE membranes are highly
contaminated when exposed, and,
considering the results of this study, titanium membranes may be a good alternative for ridge preservation.
CONCLUSION
Based on these findings, it can be
concluded that titanium membranes
associated (or not) with bone grafts
can prevent resorption of the alveolar
ridge following tooth extraction,. This
membrane can be used as a safe alternative to other membranes in guided
bone regeneration.
Disclosure
The author claims to have no financial interest in any company or any of
the products mentioned in this article.
ACKNOWLEDGMENT
The authors thank DENTSPLY
Friadent Brazil for supplying the
membranes.
REFERENCES
1. Johnson K. A study of the dimensional changes occurring in the maxilla following tooth extraction. Aust Dent J. 1969;
14:241-244.
2. Johnson K. A study of the dimensional changes occurring in the maxilla following closed face immediate denture
treatment. tooth extraction. Aust Dent J.
1969;14:371-376.
3. Seibert JS, Cohen DW. Periodontal
considerations in preparation for fixed and
removable prosthodontics. Dent Clin
North Am. 1987;31:529-538.
4. Allen EP, Gainza CS, Farthing GG, et
al. Improved technique for localized ridge
augmentation. A report of 21 cases. J Periodontol. 1985;56:195-199.
5. Abrams L. Augmentation of the deformed residual edentulous ridges for fixed
prosthesis. Compend Contin Educ Dent.
1980;1:205-209.
6. Jonck LM, Grobbelaar CJ. A glass
ionomer for reconstructive surgery.
Ionogran-Na ionomeric micro implant. A
biological evaluation. Clin Mater. 1992;9:
85-103.
7. Dahlin C, Lekholm U, Linde A.
Membrane-induced bone augmentation at
titanium implants. A report of 10 fixtures
followed from 1 to 3 years after loading. Int
J Periodontics Restorative Dent. 1991;11:
273-281.
8. Simion M, Dahlin C, Trisi P, et al.
Qualitative and quantitative comparative
study on different filling materials used in
bone tissue regeneration. A controlled clinical study. Int J Periodontics Restorative
Dent. 1994;14:199-215.
9. Sottosanti J. Aesthetic extractions
with calcium sulfate and the principles of
guided tissue regeneration. Pract Periodontics Aesthet Dent. 1993;5:61-69.
10. Fugazzotto PA. Report of 302 consecutive ridge augmentation procedures:
Technical considerations and clinical results. Int J Oral Maxillofac Implants. 1998;
13:358-368.
11. Watzinger F, Luksch J, Millesi W, et
al. Guided bone regeneration with titanium
membranes: A clinical study. Br J Oral
Maxillofac Surg. 2000;38:312-315.
12. Proussaefs P, Lozada J, Kleinman
A, et al. The use of titanium mesh in conjunction with autogenous bone graft and
inorganic bovine bone mineral (Bio-Oss)
for localized alveolar ridge augmentation: A
human study. Int J Periodontics Restorative Dent. 2003;23:185-195.
13. Goldberg VM, Stevenson S. Natural history of autografts and allografts. Clin
Orthop. 1987;225:7-16.
14. Becker W, Becker BE, Caffesse R.
A comparison of demineralized freezedried bone and autologous bone to induce
bone formation in human extraction sockets. J Periodontol. 1994;65:1128-1133.
15. Lekovic V, Camargo PM, Klokkevold
PR, et al. Preservation of alveolar bone in
extraction sockets using bioabsorbable
membranes. J Periodontol. 1998;69:10441049.
16. Lekovic V, Kenney EB, Weinlaender
M, et al. A bone regenerative approach to
alveolar ridge maintenance following tooth
extraction. Report of ten cases. J Periodontol.
1997;68:563-570.
17. Dies F, Etienne D, Abboud NB, et
al. Bone regeneration in extraction sites after immediate placement of an e-PTFE
membrane with or without a biomaterial. A
report on 12 consecutive cases. Clin Oral
Implants Res. 1996;7:277-285.
18. Fowler EB, Breault LG, Rebitski G.
Ridge preservation utilizing an acellular dermal allograft and demineralized freeze-dried
bone allograft: Part I. A report of 2 cases.
J Periodontol. 2000;71:1353-1359.
19. Zubillaga G, Von Hagen S, Simon
BI, et al. Changes in alveolar bone height
and width following post-extraction ridge
augmentation using a fixed bioabsorbable
membrane and demineralized freeze-dried
bone osteoinductive graft. J Periodontol.
2003;74:965-975.
20. Fugazzotto PA. GBR using bovine
bone matrix and resorbable and nonresorbable membranes. Part 2: Clinical results. Int J Periodontics Restorative Dent.
2003;23:599-605.
21. Lundgren AK, Sennerby L, Lundgren D. Guided jaw-bone regeneration
using an experimental rabbit model. Int
J Oral Maxillofac Surg. 1998;27:135-140.
22. Simion M, Baldoni M, Rossi P, et al.
A comparative study of the effectiveness of
e-PTFE membranes with and without early
exposure during the healing period. Int J
Periodontics Restorative Dent. 1994;14:
166-180.
23. Nowzari H, Slots J. Microbiologic
and clinical study of polytetrafluoroethylene membranes for guided bone regeneration around implants. Int J Oral Maxillofac
Implants. 1995;10:67-73.
24. Fritz ME, Eke PI, Malmquist J, et al.
Clinical and microbiological observations
of early polytetrafluoroethylene membrane
exposure in guided bone regeneration.
Case reports in primates. J Periodontol.
1996;67:245-249.
25. Arpak MN, Alkan A, Nergiz I. A
case of localized ridge augmentation from
using a titanium membrane: a pilot study.
J Oral Sci. 2000;42:133-138.
26. Jovanovic SA, Schenk RK, Orsini
M, et al. Supracrestal bone formation
around dental implants: An experimental
dog study. Int J Oral Maxillofac Implants.
1995;10:23-31.
Reprint requests and correspondence to:
Arthur B. Novaes, Jr., DDS, PhD
Faculdade de Odontologia de Ribeirão Preto
Universidade de São Paulo
Av. do Café S/N
14040-904, Ribeirão Preto, SP, Brazil
Fax: (5516) 633-0999
E-mail: [email protected]
IMPLANT DENTISTRY / VOLUME 15, NUMBER 1 2006
57
Abstract Translations [German, Spanish, Portugese, Japanese]
AUTOR(EN): Márcia N. Pinho, MS*, Virgilio
M. Roriz, MS**, Arthur B. Novaes Jr., DDS,
PhD***, Mário Taba Jr., DDS, PhD#, Márcio
F. M. Grisi, DDS, PhD##, Sérgio L. S. de
Souza, DDS, PhD###, Daniela B. Palioto,
DDS, PhD⫹. *Student mit Graduiertenstatus
im Bereich der Parodontologie, zahnmedizinische Fakultät von Ribeirão Preto, Universität von São Paulo, Ribeirão Preto, São
Paulo, Brasilien. **Student mit Graduiertenstatus im Bereich der Parodontologie, zahnmedizinische Fakultät von Ribeirão Preto,
Universität von São Paulo, Ribeirão Preto,
São Paulo, Brasilien. ***Leiter des Parodontologie, zahnmedizinische Fakultät von Ribeirão Preto, Universität von São Paulo,
Ribeirão Preto, São Paulo, Brasilien. #Professor für Parodontologie, zahnmedizinische
Fakultät von Ribeirão Preto, Universität von
São Paulo, Ribeirão Preto, São Paulo, Brasilien. ##Professor für Parodontologie, zahnmedizinische Fakultät von Ribeirão Preto,
Universität von São Paulo, Ribeirão Preto,
São Paulo, Brasilien. ###Professor für Parodontologie, zahnmedizinische Fakultät von
Ribeirão Preto, Universität von São Paulo,
Ribeirão Preto, São Paulo, Brasilien. ⫹Professorin für Parodontologie, zahnmedizinische
Fakultät von Ribeirão Preto, Universität von
São Paulo, Ribeirão Preto, São Paulo, Brasilien. Schriftverkehr: Arthur B. Novaes Junior,
DDS, PhD, Faculdade de Odontologia de
Ribeirão Preto, Universidade de São Paulo,
Av. do Café S/N, 14040-904, Ribeirão Preto,
SP, Brasilien. Fax: ⫹5516 633-0999, eMail:
[email protected]
58
TITANIUM MEMBRANES
IN
Titanmembrane im Einsatz zur Verhütung eines der Zahnextraktion folgenden alveolären Kollapses
ZUSAMMENFASSUNG: Hintergrund und Zielsetzung: Die Resorption des Alveolarknochens nach einer Zahnextraktion führt zu einer Verringerung und Verkürzung des
verbleibenden Kamms, was wiederum in ästhetischen sowie Wiederherstellungstechnischen Problemen resultiert und eine Verringerung des für eine Implantierung zur Verfügung stehenden Knochenvolumens nach sich zieht. Die vorliegende Studie zielte darauf
ab, die Möglichkeiten der Verhütung eines alveolären Kollapses nach Zahnextraktion
durch Einsatz von Titanmembranen /Frios Boneshield, Dentsply Friadent, Mannheim,
Deutschland) zu erheben, sowohl in Verbindung mit wie auch ohne autologes
Knochengewebstransplantat. Materialien und Methoden: Insgesamt wurden 10 gesunde,
nicht rauchende Teilnehmer im Alter von 35 bis 60 Jahren für diese Studie ausgewählt.
Jeder dieser Patienten hatte mindestens 2 einwurzelige Zähne, die aus parodontaler Sicht
nicht mehr zu retten und daher für eine Zahnextraktion vorgesehen waren. Nach dem
Eingriff wurden zwei Stifte auf der Oberfläche des vestibulären Knochens angebracht, um
als Referenz für die Ursprungsmessungen (Tiefe, Weite, Höhe) der Pfanne zu fungieren.
Eine der Höhlen wurde nach dem Zufallsprinzip zur Füllung mit autologem, aus dem
oberen Tuber maxillare gewonnenem Knochentransplantat (Testgruppe) ausgewählt,
während die andere ohne Transplantat blieb (Kontrollgruppe). Eine Titanmembran wurde
zur Abdeckung der Pfannen angepasst und befestigt und für mindestens 10 Wochen dort
belassen. Nach einer 6-monatigen Membranplatzierungszeit wurden die abschließenden
Maßnahmen durchgeführt. Ergebnisse: Eine Exposition der Membran war in 5 von 10
Fällen der behandelten Patienten zu beobachten. Die durchschnittliche Anfüllung mit
Knochen für die 10 Patienten lag bei 8,80 ⫾ 2,93 (im Bereich von 4 bis 13 mm) für die
Kontrollgruppe und bei 8,40 ⫾ 3,35 mm (im Bereich von 4 bis 13 mm) für die Testgruppe.
Der durchschnittliche Knochengewebsverlust in der Breite lag für die Kontrollgruppe bei
1,40 ⫾ 1,97 mm (im Bereich von ⫺2 bis 4 mm) und für die Testgruppe bei 1,40 ⫾ 0,98
mm (im Bereich von ⫺4 bis 0 mm). Bezüglich der bewerteten Standards konnten
keine bedeutenden Unterschiede zwischen den Studiengruppen festgestellt werden.
Schlussfolgerung: Der Einsatz einer Titanmembran, entweder allein oder in Verbindung
mit autologem Knochengewebe, begünstigt die Erhaltung des Aleolarkamms nach Zahnextraktion. Diese Membran scheint eine realistische und sichere Alternative zu anderen
nicht resorbierbaren Membranen darzustellen, wenn es darum geht, eine Resorption des
Alveolarkamms zu verhindern.
SCHLÜSSELWÖRTER: Verhinderung, Resorption des Alveolarkamms, Knochentransplantat, Knochengewebsresorption, Titanmembran, geleitete Knochenregeneration
PREVENTION
OF
ALVEOLAR COLLAPSE AFTER TOOTH EXTRACTION
AUTOR(ES): Márcia N. Pinho, MS*, Virgı́lio
M. Roriz, MS**, Arthur B. Novaes Jr., DDS,
PhD***, Mário Taba Jr., DDS, PhD#, Márcio
F. M. Grisi, DDS, PhD##, Sérgio L. S. de
Souza, DDS, PhD***. Daniela B. Palioto,
DDS, PhD†. *Estudiante graduado de Periodontologı́a, Facultad de Odontologı́a de Riberão Preto, Universidad de San Pablo,
Riberão Preto, San Pablo, Brasil. **Estudiante graduado de Periodontologı́a, Facultad
de Odontologı́a de Riberão Preto, Universidad de San Pablo, Riberão Preto, San Pablo,
Brasil. ***Jefe de Periodontologı́a, Facultad
de Odontologı́a de Riberão Preto, Universidad de San Pablo, Riberão Preto, San Pablo,
Brasil. #Profesor de Periodontologı́a, Facultad de Odontologı́a de Riberão Preto, Universidad de San Pablo, Riberão Preto, San
Pablo, Brasil. ##Profesor de Periodontologı́a,
Facultad de Odontologı́a de Riberão Preto,
Universidad de San Pablo, Riberão Preto, San
Pablo, Brasil. ###Profesor de Periodontologı́a, Facultad de Odontologı́a de Riberão
Preto, Universidad de San Pablo, Riberão
Preto, San Pablo, Brasil. †Profesor de Periodontologı́a, Facultad de Odontologı́a de Riberão Preto, Universidad de San Pablo, Riberão
Preto, San Pablo, Brasil. Correspondencia a:
Arthur B. Novaes Junior, DDS, PhD, Faculdade
de Odontologı́a, Riberão Preto, Universidade de
São Paulo, Av. Do Café S/N, 14040-904, Ribeirão Preto, SP, Brazil. Fax: 5516 633-0999,
Correo electrónico
Las membranas de titanio en la prevención del colapso alveolar luego de la extracción
de un diente
ABSTRACTO: Antecedentes y Propósito: La reabsorción del hueso alveolar luego de la
extracción de un diente resulta en el angostamiento y acortamiento de la cresta residual lo
que lleva a problemas estéticos y restaurativos y reduce el volumen de hueso disponible
para la terapia de implantes. El objetivo de este estudio fue evaluar la prevención del
colapso alveolar luego de la extracción del diente, usando una membrana de titanio (Frios
Boneshield, Dentsply Friadent, Mannhein, Alemania) asociado (o no) con un injerto de
hueso autólogo. Materiales y Métodos: Se seleccionaron un total de 10 sujetos saludables
que no fumaban, con una variación de 35 a 60 años de edad para el estudio. Cada paciente
tenı́a un mı́nimo de 2 dientes uniradiculares sin esperanza periodóntica que fueron
programados para su extracción. Después del procedimiento, se colocaron dos clavijas de
titanio en las superficies del hueso vestibular que se usaron como referencias para las
mediciones iniciales (profundidad, ancho, alto) de la cavidad. Una de las cavidades fue
elegida al azar para ser llenada con un injerto de hueso autólogo (prueba) sacado de la
tuberosidad del maxilar superior y el otro no recibió el injerto (control). Se adaptó y fijó
una membrana de titanio, cubriendo los receptáculos que se mantuvieron por lo menos
durante 10 semanas. Luego de la colocación de la membrana durante seis meses, se
completaron las mediciones finales. Resultados: Ocurrió una exposición de la membrana
en cinco de los 10 sujetos tratados. El promedio de rellenado de hueso entre los 10 sujetos
fue 8,80 ⫾ 2,93 (variación de 4 a 13 mm) en el grupo de control y 8,40 ⫾ 3,35 mm
(variación de 4 a 13 mm) en el grupo de prueba. El promedio de pérdida de hueso en
anchura en ambos grupos fue 1,40 ⫾ 1,97 mm (variación de ⫺4 a 1 mm) en el grupo de
control y 1,40 ⫾ 0,98 mm (variación de ⫺4 a 0 mm) en el grupo de prueba. No existió
una diferencia estadı́sticamente significativa entre los dos grupos considerando las normas
evaluadas. Conclusión: El uso de una membrana de titanio, sola o asociada al hueso
autógeno, favoreció la prevención de una cresta alveolar luego de la extracción de un
diente. Esta membrana parece ser una alternativa segura y posible a otras membranas no
reabsorvibles cuando el objetivo es la prevención de la reabsorción de la cresta alveolar.
PALABRAS CLAVES: prevención, reabsorción de la cresta alveolar, injerto de hueso,
reabsorción del hueso, membrana de titanio, regeneración guiada del hueso.
IMPLANT DENTISTRY / VOLUME 15, NUMBER 1 2006
59
AUTOR(ES): Márcia N. Pinho, Mestre em
Ciência*, Virgı́lio M. Roriz, Mestre em
Ciência**, Arthur B. Novaes Jr., CirurgiãoDentista, PhD***, Mário Taba Jr., CirurgiãoDentista, PhD#, Márcio F. M. Grisi,
Cirurgião-Dentista, PhD##, Sérgio L. S. de
Souza, Cirurgião-Dentista, PhD###, Daniella B.
Palioto, Cirurgião-Dentista, PhD⫹. *Estudante de
Pós-Graduação em Periodontologia, Faculdade de Odontologia de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São
Paulo, Brasil. **Estudante de Pós-Graduação
em Periodontologia, Faculdade de Odontologia de Ribeirão Preto, Universidade de São
Paulo, Ribeirão Preto, São Paulo, Brasil.
***Chefe de Periodontologia, Faculdade de
Odontologia de Ribeirão Preto, Universidade
de São Paulo, Ribeirão Preto, São Paulo, Brasil. #Professor de Periodontologia, Faculdade
de Odontologia de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São
Paulo, Brasil. ##Professor de Periodontologia, Faculdade de Odontologia de Ribeirão
Preto, Universidade de São Paulo, Ribeirão
Preto, São Paulo, Brasil. ###Professor de Periodontologia, Faculdade de Odontologia de
Ribeirão Preto, Universidade de São Paulo,
Ribeirão Preto, São Paulo, Brasil. ⫹Professor
de Periodontologia, Faculdade de Odontologia de Ribeirão Preto, Universidade de São
Paulo, Ribeirão Preto, São Paulo, Brasil. Correspondência para: Arthur B. Novaes Júnior,
DDS, PhD, Faculdade de Odontologia de Ribeirão Preto, Universidade de São Paulo, Av. do
Café s/n, 14040-904, Ribeirão Preto, SP, Brasil.
Fax: ⫹55 16 6330999, E-mail: novaesjr@forp.
usp.br
60
TITANIUM MEMBRANES
IN
Membranas de Tita៮ nio na Prevenção de Colapso Alveolar após Extração de Dente
RESUMO: Antecedentes e Propósito: A reabsorção de osso alveolar em seguida à extração
de dente resulta num estreitamento e encurtamento do rebordo residual que leva a problemas
estéticos e de restauração e reduz o volume do osso disponı́vel para terapia de implante.
O objetivo deste estudo era avaliar a prevenção de colapso alveolar após a extração de
dente, usando membrana de tita៮ nio (Frios Boneshield, Dentsply Friadent, Mannheim,
Alemanha), associada (ou não) a enxerto ósseo autólogo. Materiais e Métodos: Um total
de 10 indivı́duos saudáveis não-fumantes, entre 35 e 60 anos de idade, foram selecionados
para este estudo. Cada paciente tinha um mı́nimo de 2 dentes uni-radiculares periodontalmente inúteis que foram escalados para extração. Após o procedimento, dois pinos de
tita៮ nio foram fixados nas superfı́cies do osso vestibular que foram usados como referências para as medidas iniciais (profundidade, largura, altura) do alvéolo. Um dos alvéolos
foi escolhido aleatoriamente para ser obturado com enxerto ósseo autólogo (teste) removido da tuberosidade maxilar superior, e o outro não recebeu o enxerto (controle). Uma
membrana de tita៮ nio foi adaptada e fixada, cobrindo os alvéolos, que permaneceram por
pelo menos 10 semanas. Depois de seis meses de colocação da membrana, as medidas
finais foram tomadas. Resultados: Houve exposição da membrana em cindo dos 10
indivı́duos tratados. A média de obturação óssea entre os 10 indivı́duos foi de 8,80 ⫾ 2,93
(de 4 a 13 mm) no grupo de controle e de 8,40 ⫾ 3,35 (de 4 a 13 mm) no grupo de teste.
A média de perda óssea em largura em ambos os grupos foi de 1,4 ⫾ 1,97 (de – 4 a 1 mm)
no grupo de controle e de 1,4 ⫾ 0,98 (de – 4 a 0 mm) no grupo de teste. Não houve
diferença estatı́stica significativa entre os grupos, considerando os padrões avaliados.
Conclusão: O uso de membrana de tita៮ nio, sozinha ou em associação com osso autógeno,
favoreceu a prevenção de rebordo alveolar após a extração de dente. Esta membrana
parece ser uma alternativa possı́vel e segura a outras membranas não-reabsorvı́veis
quando a prevenção de reabsorção do rebordo alveolar for o objetivo.
PALAVRAS-CHAVE: prevenção, reabsorção do rebordo alveolar, enxerto ósseo, reabsorção óssea, membrana de tita៮ nio, regeneração óssea guiada.
PREVENTION
OF
ALVEOLAR COLLAPSE AFTER TOOTH EXTRACTION
IMPLANT DENTISTRY / VOLUME 15, NUMBER 1 2006
61