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Distraction Osteogenesis Using Bone Matrix Osteotensors in Ectodermal Dysplasia: A Case Report Guillaume Odin, MD, PhD,* Renaud Petitbois, DDS,† Philippe Cotten, DDS,‡ and Patrick Philip, MD§
utologous bone grafts, allografts, and xenografts all give excellent results and are indispensable in demanding anatomical situations requiring an adequate bone volume for predictable functional and esthetic results with implant placement. However, there are cases where such techniques are neither desired nor desirable or have already been attempted but without complete success. A promising approach developed in 2005 using purpose-designed instruments (Osteotensors; Victory, Nice, France) for mini-distraction osteogenesis that is followed by a posttrauma bone callus often obviates the need for grafting before implant placement.1–5 This technique was first introduced in 2005 by Gérard Scortecci during the basal implant program at the Medical School in Nice, France. In brief, the concept is activation of the patient’s bioreaction to trauma to improve the initial blood supply, bone volume, and bone density. This method is useful for preparation of the recipient bone site before an autologous bone
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*Chairman, Department of Maxillo-Facial Surgery, Institut Universitaire de la Face et du Cou and School of Medicine, University of Nice Sophia Antipolis, Nice, France. †Private Practice, Antibes, France. ‡Private Practice, Barcelona, Spain. §Department of Histology, School of Medicine, University of Nice Sophia Antipolis, Nice, France.
Reprint requests and correspondence to: Guillaume Odin, MD, PhD, Institut Universitaire de la Face et du Cou, 31 Avenue de Vallombose, 06, 103 Nice cedex 2, France, Phone: +33-4-92-03-17-18, Fax: +33-4-92-0317-17, E-mail: [email protected] ISSN 1056-6163/15/02405-612 Implant Dentistry Volume 24 Number 5 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/ID.0000000000000310
Introduction: Ectodermal dysplasia patients require complex oral rehabilitation. Bone matrix Osteotensors activate the patient’s own stem cells to promote new bone formation through an autogenous growth factor cascade generated by a targeted flapless bone distraction before implant and/or bone graft therapy. Materials and Methods: The maxillary and mandibular bone were activated 21 (for type I bone) to 45 days (for type IV bone) before implant and/or bone substitute installation. Purpose-designed Osteotensors initiated massive recruitment of stem cells in the intended bone recipient site, thereby triggering neoangiogenesis and osteogenesis. After new bone formation, rootform implants and Diskimplants were installed. Functional loading was obtained at 48 hours using
highly rigid, screw-secured fixed upper and lower full-arch prostheses. Results: At 3 years, all implants appeared clinically and radiologically osseointegrated with an excellent functional and esthetic outcome. Conclusion: Flapless distraction osteogenesis using bone matrix Osteotensors several weeks before surgery improved the initial quality and volume of the recipient bone bed. This minimally invasive approach allows future successful immediate implant-supported complete maxillomandibular fixed rehabilitation without preliminary grafting procedures in patients with an unfavorable initial bone anatomy. (Implant Dent 2015;24:612–619) Key Words: bone matrix Osteotensor, autogenous growth factors, disc implant, distraction osteogenesis
graft and for placement of bone substitute filling materials, membranes, and dental implants with more predictable results. It is also helpful for orthodontic tooth mobilization,6,7 sinus lifts, and distraction. Research on use of osteotensors in periodontics is in progress. Application of the osteotensor 21 to 45 days or more (depending on initial bone density) before implant placement initiates massive recruitment of stem cells and an autologous growth factor cascade in the intended bone recipient
site, thereby triggering neoangiogenesis and osteogenesis. This minimally invasive, purely mechanical microdistraction osteogenesis8–11 is performed without flap elevation. The osteotensor is a flapless mechanotherapy, with creation of a transmatrix channel ranging in size from 200 to 500 mm that sets up communication pathways between the endosteum, the bone marrow, and the periosteum. The resultant bone distraction phenomenon leads to modification of internal bone matrix tensions. This activation causes cell mobilization
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IMPLANT DENTISTRY / VOLUME 24, NUMBER 5 2015 locally, in the periosteum, endosteum, bone marrow, and along the vascular walls where progenitor cells are recruited. Formation of a blot clot followed by a bony callus reinforces the local architecture. In the sinus regions, where bone is initially type IV, this generally results in transformation into active type II bone. Bleeding under the Schneiderian membrane has a balloonlike effect that elevates the membrane, allowing formation of a callus and a bone gain of 2 to 6 mm as demonstrated by CT scans.12 Available in manual and rotary versions, osteotensors (Fig. 1) are specifically designed to initiate bone activation without causing any collateral damage such as bone debris or damage to vital elements. Their smooth mirror-polished surface coated with diamond-like carbon has been proven biocompatible in human cell culture tests (Fig. 2). The dimensions of the manual osteotensor tip are of paramount importance and correspond to the size of an osteon unit (200 mm). Manual osteotensors are a very simple tool for probing and mapping the remaining bone area and to check the corresponding initial bone density.13–16 Contraindications
Activation of osteogenesis and angiogenesis using bone matrix osteotensors is a natural process that initiates a cascade of biochemical reactions.17–23 Because implantology is not an emergency procedure, this regenerative therapy is applicable only to healthy compliant patients with no oral pathologies or sinusitis. Individuals with osteonecrosis of the jaw, local oral infections such as acute periodontitis, or poor oral hygiene are thus not candidates for osteotensor use. Osteotensor Use: Timing
1. Type I bone (rotary osteotensor only): implant placement, bone grafting, distraction, bone splitting, and removal of a fractured implant or impacted tooth should all be performed during the catabolic phase, that is, between 10 and 21 days after application of a rotary osteotensor (Fig. 3). 2. Type IV bone (manual osteotensor only): a waiting period of at
Fig. 1. Manual and rotary Osteotensors. Type I and II bone require rotary Osteotensors that are used under copious irrigation at 3000 rpm (a single impact 5–10 mm deep per future implant site). Type III and IV bone are treated solely with manual Osteotensors (3–4 impacts per implant site).
Fig. 2. Unit for testing the best state of surface of various coating materials for the active portion of the Osteotensor so as to avoid metal pollution. Human cell cultures were used to test rough titanium, rough carbon, porous carbon, and diamond-like carbon surfaces.
least 45 to 120 days must be respected after manual osteotensor application so that the bone has completed the anabolic phase before a dental implant is installed. The new density of the recipient area must be checked with a manual osteotensor before proceeding with treatment. Manual osteotensor application can be repeated every 45 to 60 days until the desired bone density is obtained (Table 1).
CASE REPORT This 25-year-old ectodermal dysplasia patient,24–27 who appears much younger and has the mental development of a 12-year-old, had been treated in the Lenval Foundation Pediatric
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Service (Nice, France) since the age of 5. Early prosthetic rehabilitation had consisted in the fabrication of a small telescope-retained prosthesis on the few deciduous teeth present (Figs. 4 and 5). A relation of confidence was established over the years between the patient and the hospital staff, and the prosthesis was modified as needed as the patient grew. After 2 decades of service, however, the limits of a conventional prosthesis were reached. The situation was compounded by communication problems. During the initial consultation, R.J. had difficulties not only for mastication but also for speech. As he was permanently obliged to maintain his removable mini-prosthesis in place with the dorsum of the tongue, he spoke only in very short hard to understand phrases. He did his best to cooperate but the majority of exchanges occurred with the assistance of his mother. Despite his undeniable mental handicap, he understood the main lines of the project and clearly manifested his desire for fixed teeth. The treatment plan was thus extensively discussed with and accepted by his parents, his legal caretakers. Implant surgery under general anesthesia was essential for this timid and very apprehensive young patient. Iliac and cranial graft techniques were excluded owing to the complexity and number of operations that would have been involved, the associated waiting period before implants could be installed, and the patient’s handicap that precluded rigorous postoperative compliance.28–31 After bone matrix activation using osteotensors, root-form implants and Diskimplants32,33 were placed under general anesthesia. Highly rigid titanium/cobalt-chromium/resin screw– retained maxillary and mandibular fixed prostheses were placed 48 hours later and served as external fixators guaranteeing absolute initial implant stability.34 The prostheses were retrieved 6 months later and all implants, tested individually, were clinically osseointegrated. Clinical and radiological reevaluation after 3 years of function confirmed osseointegration. Clinical and Radiological Workup
CT scans revealed total agenesis of all permanent teeth, which is fairly rare
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Fig. 3. Osteotensor-induced growth factor cascade after ignition of the patient’s bioreactor with bone matrix Osteotensors.
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Table 1. Functional Bone Gain After Use of Osteotensors Was Evaluated by Comparing the Cone Beam Results Before and 3 Years After Implant Placement Jaw Bone Gain Maxilla Cone beam preoperative Cone beam postoperative (3 y) Total bone gain at 3 y Maxilla Cone beam preoperative Cone beam postoperative (3 y) Total bone gain at 3 y
Bone Thickness
Bone Height
I, C: 4 mm PM, M: 3 mm I, C: 8 mm I, C: 5.8 mm I, C: 1.8 mm
PM, M: 4.8 mm PM, M: 1.8 mm
I, C: 8.9 mm I, C: 0.9 mm
I, C: 1.8 mm I, C: 3.4 mm I, C: 1.6 mm
PM, M: 2.8 mm PM, M: 3.2 mm PM, M: 1.4 mm
I, C: 12 mm I, C: 12.8 I, C: 0.8 mm
PM, M: 2 mm PM, M: 8 mm PM, M: 6 mm PM, M: 6 mm PM, M: 6 mm PM, M: 0 mm
Bone gain varied from 0 to 6 mm, depending on the site (mean 3 mm). C, canine area; I, incisor area; M, molar area; PM, premolar area.
in dysplasia, where several permanent teeth are usually present on at least one of the jaws (Figs. 6–8). R.J. has the skeletal age of a 12-year-old child, with very small jaws and a reduced bite level. Stereolithographic models (Simplant, France) revealed a thin mini maxilla and a knife-edge mandible. Impressions were taken, and 2 full dentures were fabricated to evaluate the extent of the prosthetic space and anticipate the esthetic outcome. Surgical guides were prepared accordingly.
Nice, France) were installed in the maxilla using a flapless approach. Five laterally inserted disc-form implants and 2 narrow root-form implants35–38 specially designed for crestal bone expansion were placed in the mandible using
Bone Activation
All the painful and mobile deciduous teeth were extracted 60 days before implant placement4 (Fig. 9). Manuel osteotensors were used for bone preparation during the same session in the maxilla. For the thin dense mandibular ridge, rotary osteotensors were applied 21 days before implant placement. The entire procedure was performed under local anesthesia without flap elevation, and the postoperative course was uneventful.
Fig. 4. Intraoral view: a 25-year-old ectodermal dysplasia patient with only several deciduous teeth; no permanent teeth seen on a panoramic radiograph.
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a gentle full-thickness flap procedure taking care not to injure the periosteal membrane. The lateral osteotomy sites for disc implant installation were filled with autologous bone saved from maxillary bone drilling that was mixed with Interpore 200 and covered with autologous platelet-rich fibrin membranes.39 The full-thickness flap was meticulously sutured around the implant necks. Impressions were taken in the surgical suite under general anesthesia. Full dentures prepared in advance that had been hollowed out at the implant emergence sites and relined with impression paste allowed bite registration at the same time (Figs. 10 and 11). Fixed screw-retained maxillary and mandibular prostheses (titanium-chromium/cobalt-resin) were placed 48 hours after surgery. A transpalatal bar was an integral component of the highly rigid monobloc maxillary framework. This
Fig. 6. A complete trial denture showing the future implant emergence sites was prepared before surgery. This mandatory step allows verification of the esthetics and the amount of space left for the tongue to allow normal speech.
Prosthetic Approach
The patient was required to wear his 2 full dentures to maintain the vertical dimension and to allow evaluation of speech and esthetics. Implant Placement
Surgery was performed under general anesthesia and lasted 3.5 hours. A total of 8 root-form implants (Victory,
Fig. 5. The pediatric dentistry department treated this patient from age 5 to 25. The removable denture was progressively modified as the patient grew.
Fig. 7. CT scan data were used to fabricate stereolithographic models (SimPlant/Dentsply, Rueil-Malmaison, France) of the upper and lower jaws (accuracy 1/100 mm). This 3D reconstruction helps the surgeon select the most appropriate type of implant.
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Fig. 10. Fixed, screw-secured-to-implant, immediately loaded (48 hours) prosthesis with a transpalatal bar. This appliance provides the initial absolute and long-lasting stability required to guarantee osseointegration of the titanium implants.
Fig. 12. Panoramic view showing the transpalatal bar and the rigid framework. The lower jaw was so thin that only 1 smalldiameter root-form implant could be placed at the canine level on the left side of the mandible. Single- and double-disc Diskimplants were able to be placed after lateral osteotomy in other sites.
Fig. 11. Screw-secured fixed mandibular prosthesis. Because the top of the alveolar crest was under 3 mm, basal Diskimplants inserted after a lateral osteotomy procedure were selected for this atrophic knife edge.
Fig. 13. Panoramic view 3 years postoperatively. The transpalatal bar was removed 1 year postoperatively. All implants appeared osseointegrated on radiographs. In particular, periapical radiographs did not show any bone loss around the implant shafts.
thanks to the care provided by his mother. The gingival appeared healthy, and the transpalatal bar did not cause any irritation.
measurable bone loss at implant level in this young patient. Bone gain ranged from 0 to 6 mm (mean 3 mm) after 3 years of function. Successful oral rehabilitation was accompanied by a tremendous increase in psychological development. Whereas speech had been difficult because he previously had to constantly maintain the position of his removable upper denture with the dorsum of the tongue, he was now free to speak, sing, laugh, and express himself more naturally.
Fig. 8. Kit of 4 identical manual Osteotensors and 4 rotary Osteotensors (2 diameters, each in short and long versions) (Victory, Nice, France).
Fig. 9. Flapless application of a rotary Osteotensor with local anesthesia for orthodontic corticotomy was first presented by Dr Gerard Scortecci at the Annual Scientific Session of the Academy of Prosthodontics in Chicago (April 30, 2009).
device, which ensured the required absolute primary stability, was removed 6 months after all implants had become osteointegrated.40 Follow-up and Maintenance
The postoperative course was uneventful, and psychofunctional acceptation of the 2 fixed implant-anchored restorations was excellent (Figs. 12 and 13). This last point was of particular importance because it involved lingual, phonetic, and psychological adaptation. The patient was seen every 2 months the first year, then every 6 months. Oral hygiene was considered satisfactory
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RESULTS Six months after surgery, clinical and radiological examination revealed satisfactory osseointegration and periimplant gingival adaptation along with an excellent esthetico-functional outcome. The transpalatal bar was removed 6 months later. Three years postoperatively, torque testing (32 N/cm) of all implants individually after retrieval of the 2 screw-retained fixed prostheses confirmed long-lasting osseointegration (no pain or mobility). Periapical radiographs showed no evidence of bone loss. Bone gain was measured by comparing the cone beam results obtained before osteotensor application and 3 years after implant placement and functional loading. There was no
DISCUSSION What Does the Osteotensor Represent for the Professional and for the Patient?
1. Used before implant surgery, osteotension triggers and regulates bone regeneration by mechanisms of distraction osteogenesis elucidated by research in the fields of
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IMPLANT DENTISTRY / VOLUME 24, NUMBER 5 2015 mechanotransduction and mechanobiology.41,42 2. Microsurgical matrix osteotension performed using a transparietal approach makes it possible to initiate and to restore a process of natural osteogenesis in the future implant site. The entire operation is flapless and performed under local anesthesia. The bone repair observed is superposable to that observed after bone distraction. 3. It can be used as a transparietal probe for manual verification of the initial quality of the future recipient bone site (type I, II, III, and IV). This reassures the patient and renders the outcome of the practitioner’s surgical act more reliable. 4. From a financial standpoint, this inexpensive and simple technology allows a larger population to access more predictable results with implant dentistry. For the patient described in this case report, this meant that multiple long, painful, and costly surgeries were avoided. What About Other Approaches for the Stimulation of Tissue Repair (Shockwaves, Piezosurgery, Laser, etc.)?
These techniques based on undulatory and/or vibratory phenomena respond to specifications that differ greatly from the concept of “tensegrity.” Above all, these phenomena cannot induce distraction osteogenesis. The Osteotensor can be classified in the category of matrix mechanotensors. Three observations served as a basis for their development: 1. All vertebrates are “programmed” to resist the forces of gravity thanks to their bony skeleton on which muscles and tendons are inserted. 2. After a trauma such as a bone fracture and/or distraction, this bony architecture is also capable of selfrepair and regeneration by activation of stem cells, autologous release of bone morphogenetic protein, and neoangiogenesis.43–46 3. The physiological process of permanent bone renewal can be slowed or accelerated as a function of muscle activity or certain pathologies.
4. The maxillomandibular region is particularly well irrigated and contains many easy and safe to activate sources of stem cells. The Osteotensor takes these fundamental parameters into account to promote natural bone regeneration that is mechanically induced by the operator. Mechanical distraction osteogenesis by means of a targeted microtrauma is spatially oriented as a function of the therapeutic goal. What Are the Indications and Limits of this Procedure?
Preimplant osteogenic activation using an Osteotensor requires strict respect of the protocol and procedures. Only carefully selected and motivated healthy patients free of oral disease and capable of satisfactory oral hygiene are acceptable candidates. In the clinical case presented here, application of the Osteotensor permitted immediate loading of a fixed prosthesis 48 to 72 hours after implant installation. This is the minimum amount of time required by our local dental laboratory to fabricate a good quality, screw-retained, boneanchored esthetico-functional fixed bridge with a highly rigid framework (machined titanium cylinders/chromium-cobalt framework/resin teeth) made to ensure long-lasting absolute primary stability. However, caution is required and immediate loading should generally be reserved for the totally edentulous maxilla or mandible to obtain predictable cross-arch stability during function. Use of an Osteotensor does not mean that waiting periods no longer have to be observed. Delayed loading remains the standard when occlusal and anatomical conditions risk compromising an implant or implants placed in function too soon. This is particularly true for single-tooth replacements and partial arch rehabilitations, which require that implants remain submerged for 4 to 6 months. In our experience, immediate loading is preferable for completely edentulous patients at risk for implant failure due to injury caused by a removable denture during the waiting period. The immediate highly rigid screw-secured bridge acts as an external fixator, just as in orthopedic surgery.47
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Current progress in medical imaging allows the detection of potential pitfalls to be avoided during the various operative sequences and optimization of implant selection for each sector. Osteogenic preparation clearly improves the initial bone volume by strengthening it and making it more reactive thanks to the formation of a new, more solid, and better irrigated bone matrix. As with any osteotomy,34 the induced posttrauma neoangiogenesis and massive recruitment of stem cells (in situ and at a distance) regenerate and reinforce the region thanks to bony callus formation. Possible per-operative effractions, postoperative dehiscences, or even implant losses, which, in most cases, are due to the presence of poorly vascularized type I bone, are avoided thanks to the previous transformation of the site into active living bone. The duration of the “Osteotensor effect” is about 4 months. This is the period during which is it advisable to place implants. If the region is not equipped during this period within this interval, use of the Osteotensor must be repeated. In brief, the Osteotensor triggers posttraumatic osteogenesis while the balanced functional implant-supported prostheses continuously stimulate physiological osteogenesis that maintains the bone capital. For our patient, this was revealed by radiographs and cone beam scans taken at an interval of several months. Thanks to bone preparation using the Osteotensor, the surgeon disposes of a simple minimally invasive tool that gives reproducible results. This strictly natural autologous and mechanical approach is without risk provided the procedure is respected. No product is injected other than the anesthetic agent. When placement of filling material in the sinus or an autologous intraoral bone graft is planned, osteogenic preparation is useful for both the donor and recipient sites: recruitment of the stem cells necessary for neoangiogenesis is indispensable for successful incorporation of the bone graft. Applications are already underway in orthodontics and periodontology. Specific procedures are required owing to the
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presence of the teeth and the periodontal ligament. This innovative strategy, based on the modification of intraosseous tensions by microtrauma, widens the field of therapeutic applications for implantologists and reduces costs. In the case presented here, without previous use of the Osteotensor, we would probably not have been able to propose immediate functional loading of the atrophic jaws for this patient for whom bone grafting techniques and multiple surgeries were unacceptable. There was no room for error in his case; irreversible aggravation of his initial condition had to be avoided.
CONCLUSION R.J. was the first patient with ectodermal dysplasia involving absence of all permanent teeth in both jaws to have benefitted from complete maxillomandibular implant installation and immediate functional loading of implant-supported fixed teeth 48 hours later. This was made possible without previous bone grafting because of bone augmentation with osteotensors and use of laterally inserted titanium disc implants in this extremely thin knife-edge mandible. Initial osteogenic preparation using bone matrix osteotensors is a novel approach for the treatment of atrophic jaws based on augmentation of the initial bone volume without the need for preimplant surgery. When bone grafts prove indispensable, osteotensors can optimize graft incorporation by improving angiogenesis of the donor and recipient bone sites. Minimally invasive flapless osteotensor use generates distraction osteogenesis that improves bone mass and bone quality. Since 2005, the osteotensor procedure has become an integral part of our preimplant bone bed preparation protocol, reducing recourse to invasive surgical procedures and ultimately reducing implant and bone loss. The most bone gain in height was observed in the sinus area. The least occurred in the high thin mandibular ridge. One important parameter is the modification of the type I bone in the mandible that softens after osteotensor application to become active type II bone at 15 days. In the maxilla, the low-
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density type IV bone in the sinus area becomes active type II bone 60 days after osteotension.
DISCLOSURE The authors claim to have no financial interest, either directly or indirectly, in the products or information listed in the article.
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Distraction Osteogenesis Using Bone Matrix Osteotensors in Ectodermal Dysplasia: A Case Report Guillaume Odin, MD, PhD,* Renaud Petitbois, DDS,† Philippe Cotten, DDS,‡ and Patrick Philip, MD§
utologous bone grafts, allografts, and xenografts all give excellent results and are indispensable in demanding anatomical situations requiring an adequate bone volume for predictable functional and esthetic results with implant placement. However, there are cases where such techniques are neither desired nor desirable or have already been attempted but without complete success. A promising approach developed in 2005 using purpose-designed instruments (Osteotensors; Victory, Nice, France) for mini-distraction osteogenesis that is followed by a posttrauma bone callus often obviates the need for grafting before implant placement.1–5 This technique was first introduced in 2005 by Gérard Scortecci during the basal implant program at the Medical School in Nice, France. In brief, the concept is activation of the patient’s bioreaction to trauma to improve the initial blood supply, bone volume, and bone density. This method is useful for preparation of the recipient bone site before an autologous bone
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*Chairman, Department of Maxillo-Facial Surgery, Institut Universitaire de la Face et du Cou and School of Medicine, University of Nice Sophia Antipolis, Nice, France. †Private Practice, Antibes, France. ‡Private Practice, Barcelona, Spain. §Department of Histology, School of Medicine, University of Nice Sophia Antipolis, Nice, France.
Reprint requests and correspondence to: Guillaume Odin, MD, PhD, Institut Universitaire de la Face et du Cou, 31 Avenue de Vallombose, 06, 103 Nice cedex 2, France, Phone: +33-4-92-03-17-18, Fax: +33-4-92-0317-17, E-mail: [email protected] ISSN 1056-6163/15/02405-612 Implant Dentistry Volume 24 Number 5 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/ID.0000000000000310
Introduction: Ectodermal dysplasia patients require complex oral rehabilitation. Bone matrix Osteotensors activate the patient’s own stem cells to promote new bone formation through an autogenous growth factor cascade generated by a targeted flapless bone distraction before implant and/or bone graft therapy. Materials and Methods: The maxillary and mandibular bone were activated 21 (for type I bone) to 45 days (for type IV bone) before implant and/or bone substitute installation. Purpose-designed Osteotensors initiated massive recruitment of stem cells in the intended bone recipient site, thereby triggering neoangiogenesis and osteogenesis. After new bone formation, rootform implants and Diskimplants were installed. Functional loading was obtained at 48 hours using
highly rigid, screw-secured fixed upper and lower full-arch prostheses. Results: At 3 years, all implants appeared clinically and radiologically osseointegrated with an excellent functional and esthetic outcome. Conclusion: Flapless distraction osteogenesis using bone matrix Osteotensors several weeks before surgery improved the initial quality and volume of the recipient bone bed. This minimally invasive approach allows future successful immediate implant-supported complete maxillomandibular fixed rehabilitation without preliminary grafting procedures in patients with an unfavorable initial bone anatomy. (Implant Dent 2015;24:612–619) Key Words: bone matrix Osteotensor, autogenous growth factors, disc implant, distraction osteogenesis
graft and for placement of bone substitute filling materials, membranes, and dental implants with more predictable results. It is also helpful for orthodontic tooth mobilization,6,7 sinus lifts, and distraction. Research on use of osteotensors in periodontics is in progress. Application of the osteotensor 21 to 45 days or more (depending on initial bone density) before implant placement initiates massive recruitment of stem cells and an autologous growth factor cascade in the intended bone recipient
site, thereby triggering neoangiogenesis and osteogenesis. This minimally invasive, purely mechanical microdistraction osteogenesis8–11 is performed without flap elevation. The osteotensor is a flapless mechanotherapy, with creation of a transmatrix channel ranging in size from 200 to 500 mm that sets up communication pathways between the endosteum, the bone marrow, and the periosteum. The resultant bone distraction phenomenon leads to modification of internal bone matrix tensions. This activation causes cell mobilization
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IMPLANT DENTISTRY / VOLUME 24, NUMBER 5 2015 locally, in the periosteum, endosteum, bone marrow, and along the vascular walls where progenitor cells are recruited. Formation of a blot clot followed by a bony callus reinforces the local architecture. In the sinus regions, where bone is initially type IV, this generally results in transformation into active type II bone. Bleeding under the Schneiderian membrane has a balloonlike effect that elevates the membrane, allowing formation of a callus and a bone gain of 2 to 6 mm as demonstrated by CT scans.12 Available in manual and rotary versions, osteotensors (Fig. 1) are specifically designed to initiate bone activation without causing any collateral damage such as bone debris or damage to vital elements. Their smooth mirror-polished surface coated with diamond-like carbon has been proven biocompatible in human cell culture tests (Fig. 2). The dimensions of the manual osteotensor tip are of paramount importance and correspond to the size of an osteon unit (200 mm). Manual osteotensors are a very simple tool for probing and mapping the remaining bone area and to check the corresponding initial bone density.13–16 Contraindications
Activation of osteogenesis and angiogenesis using bone matrix osteotensors is a natural process that initiates a cascade of biochemical reactions.17–23 Because implantology is not an emergency procedure, this regenerative therapy is applicable only to healthy compliant patients with no oral pathologies or sinusitis. Individuals with osteonecrosis of the jaw, local oral infections such as acute periodontitis, or poor oral hygiene are thus not candidates for osteotensor use. Osteotensor Use: Timing
1. Type I bone (rotary osteotensor only): implant placement, bone grafting, distraction, bone splitting, and removal of a fractured implant or impacted tooth should all be performed during the catabolic phase, that is, between 10 and 21 days after application of a rotary osteotensor (Fig. 3). 2. Type IV bone (manual osteotensor only): a waiting period of at
Fig. 1. Manual and rotary Osteotensors. Type I and II bone require rotary Osteotensors that are used under copious irrigation at 3000 rpm (a single impact 5–10 mm deep per future implant site). Type III and IV bone are treated solely with manual Osteotensors (3–4 impacts per implant site).
Fig. 2. Unit for testing the best state of surface of various coating materials for the active portion of the Osteotensor so as to avoid metal pollution. Human cell cultures were used to test rough titanium, rough carbon, porous carbon, and diamond-like carbon surfaces.
least 45 to 120 days must be respected after manual osteotensor application so that the bone has completed the anabolic phase before a dental implant is installed. The new density of the recipient area must be checked with a manual osteotensor before proceeding with treatment. Manual osteotensor application can be repeated every 45 to 60 days until the desired bone density is obtained (Table 1).
CASE REPORT This 25-year-old ectodermal dysplasia patient,24–27 who appears much younger and has the mental development of a 12-year-old, had been treated in the Lenval Foundation Pediatric
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Service (Nice, France) since the age of 5. Early prosthetic rehabilitation had consisted in the fabrication of a small telescope-retained prosthesis on the few deciduous teeth present (Figs. 4 and 5). A relation of confidence was established over the years between the patient and the hospital staff, and the prosthesis was modified as needed as the patient grew. After 2 decades of service, however, the limits of a conventional prosthesis were reached. The situation was compounded by communication problems. During the initial consultation, R.J. had difficulties not only for mastication but also for speech. As he was permanently obliged to maintain his removable mini-prosthesis in place with the dorsum of the tongue, he spoke only in very short hard to understand phrases. He did his best to cooperate but the majority of exchanges occurred with the assistance of his mother. Despite his undeniable mental handicap, he understood the main lines of the project and clearly manifested his desire for fixed teeth. The treatment plan was thus extensively discussed with and accepted by his parents, his legal caretakers. Implant surgery under general anesthesia was essential for this timid and very apprehensive young patient. Iliac and cranial graft techniques were excluded owing to the complexity and number of operations that would have been involved, the associated waiting period before implants could be installed, and the patient’s handicap that precluded rigorous postoperative compliance.28–31 After bone matrix activation using osteotensors, root-form implants and Diskimplants32,33 were placed under general anesthesia. Highly rigid titanium/cobalt-chromium/resin screw– retained maxillary and mandibular fixed prostheses were placed 48 hours later and served as external fixators guaranteeing absolute initial implant stability.34 The prostheses were retrieved 6 months later and all implants, tested individually, were clinically osseointegrated. Clinical and radiological reevaluation after 3 years of function confirmed osseointegration. Clinical and Radiological Workup
CT scans revealed total agenesis of all permanent teeth, which is fairly rare
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Fig. 3. Osteotensor-induced growth factor cascade after ignition of the patient’s bioreactor with bone matrix Osteotensors.
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Table 1. Functional Bone Gain After Use of Osteotensors Was Evaluated by Comparing the Cone Beam Results Before and 3 Years After Implant Placement Jaw Bone Gain Maxilla Cone beam preoperative Cone beam postoperative (3 y) Total bone gain at 3 y Maxilla Cone beam preoperative Cone beam postoperative (3 y) Total bone gain at 3 y
Bone Thickness
Bone Height
I, C: 4 mm PM, M: 3 mm I, C: 8 mm I, C: 5.8 mm I, C: 1.8 mm
PM, M: 4.8 mm PM, M: 1.8 mm
I, C: 8.9 mm I, C: 0.9 mm
I, C: 1.8 mm I, C: 3.4 mm I, C: 1.6 mm
PM, M: 2.8 mm PM, M: 3.2 mm PM, M: 1.4 mm
I, C: 12 mm I, C: 12.8 I, C: 0.8 mm
PM, M: 2 mm PM, M: 8 mm PM, M: 6 mm PM, M: 6 mm PM, M: 6 mm PM, M: 0 mm
Bone gain varied from 0 to 6 mm, depending on the site (mean 3 mm). C, canine area; I, incisor area; M, molar area; PM, premolar area.
in dysplasia, where several permanent teeth are usually present on at least one of the jaws (Figs. 6–8). R.J. has the skeletal age of a 12-year-old child, with very small jaws and a reduced bite level. Stereolithographic models (Simplant, France) revealed a thin mini maxilla and a knife-edge mandible. Impressions were taken, and 2 full dentures were fabricated to evaluate the extent of the prosthetic space and anticipate the esthetic outcome. Surgical guides were prepared accordingly.
Nice, France) were installed in the maxilla using a flapless approach. Five laterally inserted disc-form implants and 2 narrow root-form implants35–38 specially designed for crestal bone expansion were placed in the mandible using
Bone Activation
All the painful and mobile deciduous teeth were extracted 60 days before implant placement4 (Fig. 9). Manuel osteotensors were used for bone preparation during the same session in the maxilla. For the thin dense mandibular ridge, rotary osteotensors were applied 21 days before implant placement. The entire procedure was performed under local anesthesia without flap elevation, and the postoperative course was uneventful.
Fig. 4. Intraoral view: a 25-year-old ectodermal dysplasia patient with only several deciduous teeth; no permanent teeth seen on a panoramic radiograph.
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a gentle full-thickness flap procedure taking care not to injure the periosteal membrane. The lateral osteotomy sites for disc implant installation were filled with autologous bone saved from maxillary bone drilling that was mixed with Interpore 200 and covered with autologous platelet-rich fibrin membranes.39 The full-thickness flap was meticulously sutured around the implant necks. Impressions were taken in the surgical suite under general anesthesia. Full dentures prepared in advance that had been hollowed out at the implant emergence sites and relined with impression paste allowed bite registration at the same time (Figs. 10 and 11). Fixed screw-retained maxillary and mandibular prostheses (titanium-chromium/cobalt-resin) were placed 48 hours after surgery. A transpalatal bar was an integral component of the highly rigid monobloc maxillary framework. This
Fig. 6. A complete trial denture showing the future implant emergence sites was prepared before surgery. This mandatory step allows verification of the esthetics and the amount of space left for the tongue to allow normal speech.
Prosthetic Approach
The patient was required to wear his 2 full dentures to maintain the vertical dimension and to allow evaluation of speech and esthetics. Implant Placement
Surgery was performed under general anesthesia and lasted 3.5 hours. A total of 8 root-form implants (Victory,
Fig. 5. The pediatric dentistry department treated this patient from age 5 to 25. The removable denture was progressively modified as the patient grew.
Fig. 7. CT scan data were used to fabricate stereolithographic models (SimPlant/Dentsply, Rueil-Malmaison, France) of the upper and lower jaws (accuracy 1/100 mm). This 3D reconstruction helps the surgeon select the most appropriate type of implant.
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Fig. 10. Fixed, screw-secured-to-implant, immediately loaded (48 hours) prosthesis with a transpalatal bar. This appliance provides the initial absolute and long-lasting stability required to guarantee osseointegration of the titanium implants.
Fig. 12. Panoramic view showing the transpalatal bar and the rigid framework. The lower jaw was so thin that only 1 smalldiameter root-form implant could be placed at the canine level on the left side of the mandible. Single- and double-disc Diskimplants were able to be placed after lateral osteotomy in other sites.
Fig. 11. Screw-secured fixed mandibular prosthesis. Because the top of the alveolar crest was under 3 mm, basal Diskimplants inserted after a lateral osteotomy procedure were selected for this atrophic knife edge.
Fig. 13. Panoramic view 3 years postoperatively. The transpalatal bar was removed 1 year postoperatively. All implants appeared osseointegrated on radiographs. In particular, periapical radiographs did not show any bone loss around the implant shafts.
thanks to the care provided by his mother. The gingival appeared healthy, and the transpalatal bar did not cause any irritation.
measurable bone loss at implant level in this young patient. Bone gain ranged from 0 to 6 mm (mean 3 mm) after 3 years of function. Successful oral rehabilitation was accompanied by a tremendous increase in psychological development. Whereas speech had been difficult because he previously had to constantly maintain the position of his removable upper denture with the dorsum of the tongue, he was now free to speak, sing, laugh, and express himself more naturally.
Fig. 8. Kit of 4 identical manual Osteotensors and 4 rotary Osteotensors (2 diameters, each in short and long versions) (Victory, Nice, France).
Fig. 9. Flapless application of a rotary Osteotensor with local anesthesia for orthodontic corticotomy was first presented by Dr Gerard Scortecci at the Annual Scientific Session of the Academy of Prosthodontics in Chicago (April 30, 2009).
device, which ensured the required absolute primary stability, was removed 6 months after all implants had become osteointegrated.40 Follow-up and Maintenance
The postoperative course was uneventful, and psychofunctional acceptation of the 2 fixed implant-anchored restorations was excellent (Figs. 12 and 13). This last point was of particular importance because it involved lingual, phonetic, and psychological adaptation. The patient was seen every 2 months the first year, then every 6 months. Oral hygiene was considered satisfactory
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RESULTS Six months after surgery, clinical and radiological examination revealed satisfactory osseointegration and periimplant gingival adaptation along with an excellent esthetico-functional outcome. The transpalatal bar was removed 6 months later. Three years postoperatively, torque testing (32 N/cm) of all implants individually after retrieval of the 2 screw-retained fixed prostheses confirmed long-lasting osseointegration (no pain or mobility). Periapical radiographs showed no evidence of bone loss. Bone gain was measured by comparing the cone beam results obtained before osteotensor application and 3 years after implant placement and functional loading. There was no
DISCUSSION What Does the Osteotensor Represent for the Professional and for the Patient?
1. Used before implant surgery, osteotension triggers and regulates bone regeneration by mechanisms of distraction osteogenesis elucidated by research in the fields of
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IMPLANT DENTISTRY / VOLUME 24, NUMBER 5 2015 mechanotransduction and mechanobiology.41,42 2. Microsurgical matrix osteotension performed using a transparietal approach makes it possible to initiate and to restore a process of natural osteogenesis in the future implant site. The entire operation is flapless and performed under local anesthesia. The bone repair observed is superposable to that observed after bone distraction. 3. It can be used as a transparietal probe for manual verification of the initial quality of the future recipient bone site (type I, II, III, and IV). This reassures the patient and renders the outcome of the practitioner’s surgical act more reliable. 4. From a financial standpoint, this inexpensive and simple technology allows a larger population to access more predictable results with implant dentistry. For the patient described in this case report, this meant that multiple long, painful, and costly surgeries were avoided. What About Other Approaches for the Stimulation of Tissue Repair (Shockwaves, Piezosurgery, Laser, etc.)?
These techniques based on undulatory and/or vibratory phenomena respond to specifications that differ greatly from the concept of “tensegrity.” Above all, these phenomena cannot induce distraction osteogenesis. The Osteotensor can be classified in the category of matrix mechanotensors. Three observations served as a basis for their development: 1. All vertebrates are “programmed” to resist the forces of gravity thanks to their bony skeleton on which muscles and tendons are inserted. 2. After a trauma such as a bone fracture and/or distraction, this bony architecture is also capable of selfrepair and regeneration by activation of stem cells, autologous release of bone morphogenetic protein, and neoangiogenesis.43–46 3. The physiological process of permanent bone renewal can be slowed or accelerated as a function of muscle activity or certain pathologies.
4. The maxillomandibular region is particularly well irrigated and contains many easy and safe to activate sources of stem cells. The Osteotensor takes these fundamental parameters into account to promote natural bone regeneration that is mechanically induced by the operator. Mechanical distraction osteogenesis by means of a targeted microtrauma is spatially oriented as a function of the therapeutic goal. What Are the Indications and Limits of this Procedure?
Preimplant osteogenic activation using an Osteotensor requires strict respect of the protocol and procedures. Only carefully selected and motivated healthy patients free of oral disease and capable of satisfactory oral hygiene are acceptable candidates. In the clinical case presented here, application of the Osteotensor permitted immediate loading of a fixed prosthesis 48 to 72 hours after implant installation. This is the minimum amount of time required by our local dental laboratory to fabricate a good quality, screw-retained, boneanchored esthetico-functional fixed bridge with a highly rigid framework (machined titanium cylinders/chromium-cobalt framework/resin teeth) made to ensure long-lasting absolute primary stability. However, caution is required and immediate loading should generally be reserved for the totally edentulous maxilla or mandible to obtain predictable cross-arch stability during function. Use of an Osteotensor does not mean that waiting periods no longer have to be observed. Delayed loading remains the standard when occlusal and anatomical conditions risk compromising an implant or implants placed in function too soon. This is particularly true for single-tooth replacements and partial arch rehabilitations, which require that implants remain submerged for 4 to 6 months. In our experience, immediate loading is preferable for completely edentulous patients at risk for implant failure due to injury caused by a removable denture during the waiting period. The immediate highly rigid screw-secured bridge acts as an external fixator, just as in orthopedic surgery.47
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Current progress in medical imaging allows the detection of potential pitfalls to be avoided during the various operative sequences and optimization of implant selection for each sector. Osteogenic preparation clearly improves the initial bone volume by strengthening it and making it more reactive thanks to the formation of a new, more solid, and better irrigated bone matrix. As with any osteotomy,34 the induced posttrauma neoangiogenesis and massive recruitment of stem cells (in situ and at a distance) regenerate and reinforce the region thanks to bony callus formation. Possible per-operative effractions, postoperative dehiscences, or even implant losses, which, in most cases, are due to the presence of poorly vascularized type I bone, are avoided thanks to the previous transformation of the site into active living bone. The duration of the “Osteotensor effect” is about 4 months. This is the period during which is it advisable to place implants. If the region is not equipped during this period within this interval, use of the Osteotensor must be repeated. In brief, the Osteotensor triggers posttraumatic osteogenesis while the balanced functional implant-supported prostheses continuously stimulate physiological osteogenesis that maintains the bone capital. For our patient, this was revealed by radiographs and cone beam scans taken at an interval of several months. Thanks to bone preparation using the Osteotensor, the surgeon disposes of a simple minimally invasive tool that gives reproducible results. This strictly natural autologous and mechanical approach is without risk provided the procedure is respected. No product is injected other than the anesthetic agent. When placement of filling material in the sinus or an autologous intraoral bone graft is planned, osteogenic preparation is useful for both the donor and recipient sites: recruitment of the stem cells necessary for neoangiogenesis is indispensable for successful incorporation of the bone graft. Applications are already underway in orthodontics and periodontology. Specific procedures are required owing to the
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presence of the teeth and the periodontal ligament. This innovative strategy, based on the modification of intraosseous tensions by microtrauma, widens the field of therapeutic applications for implantologists and reduces costs. In the case presented here, without previous use of the Osteotensor, we would probably not have been able to propose immediate functional loading of the atrophic jaws for this patient for whom bone grafting techniques and multiple surgeries were unacceptable. There was no room for error in his case; irreversible aggravation of his initial condition had to be avoided.
CONCLUSION R.J. was the first patient with ectodermal dysplasia involving absence of all permanent teeth in both jaws to have benefitted from complete maxillomandibular implant installation and immediate functional loading of implant-supported fixed teeth 48 hours later. This was made possible without previous bone grafting because of bone augmentation with osteotensors and use of laterally inserted titanium disc implants in this extremely thin knife-edge mandible. Initial osteogenic preparation using bone matrix osteotensors is a novel approach for the treatment of atrophic jaws based on augmentation of the initial bone volume without the need for preimplant surgery. When bone grafts prove indispensable, osteotensors can optimize graft incorporation by improving angiogenesis of the donor and recipient bone sites. Minimally invasive flapless osteotensor use generates distraction osteogenesis that improves bone mass and bone quality. Since 2005, the osteotensor procedure has become an integral part of our preimplant bone bed preparation protocol, reducing recourse to invasive surgical procedures and ultimately reducing implant and bone loss. The most bone gain in height was observed in the sinus area. The least occurred in the high thin mandibular ridge. One important parameter is the modification of the type I bone in the mandible that softens after osteotensor application to become active type II bone at 15 days. In the maxilla, the low-
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density type IV bone in the sinus area becomes active type II bone 60 days after osteotension.
DISCLOSURE The authors claim to have no financial interest, either directly or indirectly, in the products or information listed in the article.
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