Journal of Oral Implantology CLINICAL, HISTOLOGICAL AND CELLULAR EVALUATION OF VERTICO-LATERAL MAXILLARY RECONSTRUCTION ASSOCIATING ALVEOLAR OSTEOGENIC DISTRACTION AND FRESH-FROZEN BONE ALLOGRAFT --Manuscript Draft-Manuscript Number:
AAID-JOI-D-13-00102R1
Full Title:
CLINICAL, HISTOLOGICAL AND CELLULAR EVALUATION OF VERTICO-LATERAL MAXILLARY RECONSTRUCTION ASSOCIATING ALVEOLAR OSTEOGENIC DISTRACTION AND FRESH-FROZEN BONE ALLOGRAFT
Short Title:
Evaluation of vertico-lateral maxillary reconstruction after 5 years
Article Type:
Clinical Case Letter
Keywords:
osteogenic distraction; fresh-frozen bone allograft; maxillary reconstruction; dental implants
Corresponding Author:
Samuel Porfirio Xavier, PhD Faculty of Dentistry of Ribeirao Preto of University of Sao Paulo Ribeirao Preto, Sao Paulo BRAZIL
Corresponding Author Secondary Information: Corresponding Author's Institution:
Faculty of Dentistry of Ribeirao Preto of University of Sao Paulo
Corresponding Author's Secondary Institution: First Author:
Emanuela Prado Ferraz, MD
First Author Secondary Information: Order of Authors:
Emanuela Prado Ferraz, MD Adalberto Luiz Rosa, PhD Paulo Tambasco de Oliveira, PhD Thiago de Santana Santos, MD Cassio de Barros Pontes, PhD Danilo Maeda Reino, MD Samuel Porfirio Xavier, PhD
Order of Authors Secondary Information: Abstract:
Despite advances in bone reconstruction and rehabilitation techniques, treatment of partially edentulous patients with atrophic anterior maxilla remains a challenge. Alveolar osteogenic distraction and allografts have been used as an alternative to autografts, avoiding use of a donor area, while minimizing morbity of the procedure. The aim of this case letter was to report a reconstruction of maxillary defect with these techniques using clinical, histological and cellular parameters. A 42-year old female patient presented an "U-shaped" maxillary bone defect that was repaired by alveolar osteogenic distraction (AOD) to gain bone height followed by fresh-frozen human bone allograft (FFBA) to gain thickness. The reconstructed area was rehabilitated by implant-supported prosthesis. At 5-year follow-up clinical and radiographic evaluations were carried out and biopsies from reconstructed area and autogenous bone were taken for histological and cellular evaluations. Clinically the rehabilitation was very satisfactory. Histological analysis showed bone formation in close contact with residual FFBA. Cells harvested from allograft and autogenous sites displayed similar proliferation, alkaline phosphatase activity and mineralization. These analyses indicate that AOD and FFBA can represent a reliable strategy to reconstruct maxillary defects for clinical successful rehabilitation.
Response to Reviewers:
Ref.: Ms. No. AAID-JOI-D-13-00102
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CLINICAL, HISTOLOGICAL AND CELLULAR EVALUATION OF VERTICO-LATERAL MAXILLARY RECONSTRUCTION ASSOCIATING ALVEOLAR OSTEOGENIC DISTRACTION AND FRESH-FROZEN BONE ALLOGRAFT Journal of Oral Implantology Dear Dr. Samuel Xavier, Thank you very much for submitting your manuscript for review by Journal of Oral Implantology. Based on the reviews, we will not immediately be able to accept this manuscript for publication in the journal, although we would be willing to reconsider a revised version, based on the review comments. We cannot of course promise publication at that time. Should you decide to revise the manuscript for further consideration here, your revisions should address the specific points made by each reviewer. Please highlight any changes you make in the manuscript itself. You should also send along a cover letter, indicating your response to the review comments and the changes you have made in the manuscript. If you choose to revise your submission, your revision is due by 11/10/2013. To submit a revision, go to http://aaid-joi.edmgr.com/ and log in as an Author. You will see a menu item call Submission Needing Revision. You will find your submission record there. Yours sincerely, Jim Rutkowski, DMD, PhD Editor-in-Chief Journal of Oral Implantology Reviewers' comments: Reviewer #1: 1. Is the title of the manuscript clear, concise, and descriptive? If not, please suggest an appropriate title? YES 2. Does the abstract accurately summarize the content of the investigation? YES 3. Can the Abstract stand alone? YES 4. Does the abstract provide a succinct and accurate summary of the manuscript? YES 5. Has the author completed a comprehensive and critical discussion of recent literature? YES 6. Has the author stated a clear and concise purpose for his/her manuscript? YES 7. Are the procedures described in enough detail to permit a reader to understand them? YES 8. Are the data presented appropriately? 9. Does the case report section contain only pertinent information describing the patient's condition and treatment? YES 10. Does the case report section begin with a description of how the patient presented for treatment, the patient's chief complaint, and history? YES 11. Are all diagnostic procedures, treatment, and results of treatment adequately described? YES 12. If a technique is described in the manuscript, is it accurately described? YES 13. Are the study limitations described? NO. I SUGGEST THE AUTHORS DESCRIBE THE ADO TECHNIQUE IN THE CASE REPORT 14. Has the author acknowledged important alternative points of view? YES 15. Is the interpretation of data consistent with results? YES 16. Are the results compared with other relevant and similar investigations? YES 17. Do the author's conclusions and generalizations logically follow from the text? YES 18. Are the conclusions reflective of the data and data analysis? YES 19. Are the conclusions succinct? YES 20. Are the references current and pertinent? YES 21. Are the references adequate in number? YES 22. Are the references accurately cited? YES 23. Are tables and figures adequately described with legends? YES 24. Should any or all of the illustrations be printed in color? YES Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation
25. Are there tables or figures that should be eliminated? NO 26. Should some sections of the manuscript be expanded, condensed, or omitted? YES. I SUGEST THAT THE AUTHORS GIVE MORE DETAIL ABOUT ADO TECHNIQUE AND BONE GRAFT TECHNIQUE 27. Does the manuscript present original material? YES
The article is well written and the case is well documented. I suggest that the authors give more emphasis on describing surgical procedures, because I believe that within the category that the paper is, it would be of much value this information. In my opinion, few patches are required.
August 14, 2013 James Rutkowski Editor-in-Chief Journal of Oral Implantology Dear Dr: Please find attached the revised version of the manuscript entitled “Clinical, histological and cellular evaluation of vertico-lateral maxillary reconstruction associating alveolar osteogenic distraction and fresh-frozen bone allograft” - Ms. No. AAID-JOI-D-1300102. As requested by reviewer, we have included a detailed description of ADO and bone graft techniques that are highlighted in the Ms. We believe that this revised version address the reviewer suggestion and hope that the Ms will now be deemed acceptable for publication in the Journal of Oral Implantology. Sincerely, Samuel Porfírio Xavier *Correspondence to: Professor Samuel Porfírio Xavier Department of Oral and Maxillofacial Surgery and Periodontology School of Dentistry of Ribeirao Preto, University of Sao Paulo Av. do Cafe, s/n – 14040-904 – Ribeirao Preto, SP, Brazil Phone: + 55 16 3602-4053 Fax: + 55 16 3602-4788 E-mail: [email protected]
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Rebuttal Letter (for revisions) Click here to download Rebuttal Letter (for revisions): Rebuttal Letter JOI.doc
Article File
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1
CLINICAL,
2
VERTICO-LATERAL MAXILLARY RECONSTRUCTION ASSOCIATING
3
ALVEOLAR OSTEOGENIC DISTRACTION AND FRESH-FROZEN BONE
4
ALLOGRAFT
5
Emanuela Prado Ferraz1; Adalberto Luiz Rosa1, Paulo Tambasco de Oliveira2, Thiago
6
de Santana Santos1, Danilo Maeda Reino1, Cássio Barros Pontes3, Samuel Porfírio
7
Xavier1*
8
1
9
Dentistry of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, SP, Brazil
HISTOLOGICAL
AND
CELLULAR
EVALUATION
Department of Oral and Maxillofacial Surgery and Periodontology, School of
10
2
11
Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, SP, Brazil
12
3
13
Paulo, Ribeirao Preto, SP, Brazil
Department of Morphology, Stomatology and Basic Pathology, School of Dentistry of
Department of Prosthodontics, School of Dentistry of Ribeirao Preto, University of Sao
14 15
OF
Short Title: Evaluation of vertico-lateral maxillary reconstruction after 5 years
16 17
*Correspondence to:
18
Samuel Porfirio Xavier
19
Department of Oral and Maxillofacial Surgery and Periodontology
20
School of Dentistry of Ribeirao Preto, University of Sao Paulo
21
Av. do Cafe, s/n – 14040-904 – Ribeirao Preto, SP, Brazil
22
Phone: + 55 16 3602-4053
23
Fax: + 55 16 3602-4788
24 25
E-mail: [email protected]
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26
Abstract
27
Despite advances in bone reconstruction and rehabilitation techniques, treatment of
28
partially edentulous patients with atrophic anterior maxilla remains a challenge.
29
Alveolar osteogenic distraction (AOD) and allografts have been used as an alternative
30
to autografts, avoiding the use of a donor area and minimizing morbidities. The aim of
31
this case lette is to report a reconstruction of maxillary defect by these techniques using
32
clinical, histological and cellular parameters. A 42-year-old female patient presented an
33
“U-shaped” maxillary bone defect that was repaired by AOD to gain bone height
34
followed by fresh-frozen human bone allograft (FFBA) to gain thickness. The
35
reconstructed area was rehabilitated by implant-supported prosthesis. At 5-year follow-
36
up, clinical and radiographic evaluations were carried out and biopsies from
37
reconstructed area and autogenous bone were taken for histological and cellular
38
evaluations. The rehabilitation was well succeeded from the clinical point-of-view.
39
Histological analysis showed bone formation in close contact with residual FFBA.
40
Cultures of cells harvested from allograft and autogenous sites displayed similar
41
proliferation rate, alkaline phosphatase activity and extracellular matrix mineralization.
42
These findings indicate that AOD and FFBA may represent a reliable strategy to
43
reconstruct maxillary defects for a successful clinical rehabilitation.
44 45
Keywords:
46
reconstruction; dental implants
47 48
osteogenic
distraction;
fresh-frozen
bone
allograft;
maxillary
3
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49
Introduction
50
The rehabilitation of edentulous anterior maxillary defects with implant-
51
supported prosthesis remains a challenge, since loss of teeth can lead to extensive
52
vertical and horizontal bone resorption, compromising the aesthetical and functional
53
results(1,2,3).
54
Vertical alveolar defects higher than 5 mm are the most difficult to restore with
55
high incidence of failure mainly due to either resorption or dehiscence. Several
56
modalities of treatment have been proposed, such as autografts from distinct donor sites,
57
allografts, xenografts, osteogenic distraction and titanium meshes among others(4).
58
Although autografts are considered the gold standard based on their osseoinduction,
59
osseoconduction and osteogenesis properties, some disadvantages like morbidity, time
60
consuming and cost should be taken onto consideration before selecting this technique(3).
61
In this context, alveolar osteogenic distraction (AOD) is a good alternative to gain both
62
bone and soft tissue augmentation(4) and fresh-frozen bone allograft (FFBA) has been
63
successfully grafted to reconstruct bone defects in oral implantology(5). Beyond the
64
unlimited availability, FFBA avoids the morbidity commonly associated with autograft
65
harvesting(6).
66
The selection of treatment should be based on adequate quality and amount of
67
hard and soft tissues to get a suitable rehabilitation(7). U-shaped defects, usually present
68
in the anterior maxilla area, are characterized by lack of structures that prevents initial
69
soft tissue closure over a large bone graft(2). Considering that a tension-free closure
70
must be performed to prevent incision breakdown on a large onlay bone graft(8,9,10),
71
strategies to increase the soft tissue drape over a bone defect include free grafts, tissue
72
expanders, and the use of gradual distraction of the residual bone(2,10).
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73
The purpose of this letter is to report a case presenting clinical, histological and
74
cellular evidences to support the combination of AOD and cortico-cancellous FFBA as
75
a good alternative for reconstructing a vertico-lateral maxillary defect, allowing
76
implant-supported rehabilitation.
77
Case Report
78
A 42-year-old patient had been referred to the Department of Oral and
79
Maxillofacial Surgery of the School of Dentistry of Ribeirão Preto, University of São
80
Paulo, for implant-supported rehabilitation. Clinical and radiographic evaluation
81
revealed a 9-mm U-shaped bone defect in the left anterior maxilla (Figure 1 A-B). The
82
proposed treatment was AOD to increase bone height and soft tissue availability
83
followed by FFBA to improve lateral dimension. All surgical procedures were
84
performed under local anesthesia with the patient agreement based on signed informed
85
consent. Surgical AOD technique consisted of a horizontal incision and a full thickness
86
mucoperiosteal flap (Figure 1C). Horizontal and vertical osteotomies were created with
87
a sagittal saw and the crest segment was gently mobilized. The osteogenic distractor
88
(OD - Conexão, São Paulo, SP, Brazil) device was fixed in the original position with
89
monocortical screws (1.5 mm in diameter and 5 mm in length), activated to check the
90
osteotomies (Figure 1 D) and deactivated to the initial position. After one-week latency
91
period, the OD device was activated at a ratio of 0.5 mm/day to obtain both vertical
92
bone and soft tissue augmentation until obtaining a suitable crest level (Figure 1 E-H).
93
After the consolidation period of four months, a crest incision and two vertical incisions
94
allowed to raise a full thickness mucoperiosteal flap. The OD device was removed and
95
the recipient bed was prepared by decortication holes using a 1-mm drill (Figure 2 A).
96
A cortico-cancellous FFBA (Musculoskeletal Tissue Bank of Marilia Hospital, Unioss,
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97
Marília, SP, Brazil) was shaped to get passive adaptation and fixed with non-
98
compressive two bicortical titanium screws (Synthes, West Chester, PA, USA, 1.5 mm
99
in diameter and 12 mm in length) with the cancellous portion facing the recipient bed
100
(Figure 2 B). FFBA allowed a width gain of 5 mm resulting in a reconstructed alveolar
101
ridge with 8 mm in width. Through a periosteal releasing incision the wound was
102
passively closed with 5.0 nylon sutures (Figure 2 C). Six months later (Figure 2 D),
103
fixation screws were removed and two dental implants (Nobel Biocare, Yorba Linda,
104
CA, USA) were installed (Figure 3 A-B) and kept unloaded during six months previous
105
to prosthetic rehabilitation. At 5-year follow-up, clinical and radiographic evaluation
106
evidenced that the prosthetic rehabilitation was very satisfactory in terms of functional,
107
periodontal and aesthetic parameters (Figure 3 C-F). At this time-point, bone biopsies
108
from grafted area and maxillary tuberosity (autogenous bone: AB) were taken and
109
processed for histological and cellular analysis. Light microscopy of block biopsies
110
revealed trabeculae of cancellous bone intermingled with a vascularized, fibrous
111
connective tissue. The bone trabeculae were composed of areas of lamellar bone with
112
empty osteocytic lacunae surrounded by either a viable lamellar bone or bundle bone,
113
with Sharpey’s fibers (Figure 4 A-B). Osteoblastic cells from grafted and AB sites were
114
harvested by enzymatic digestion and cultured as described elsewhere(11). Cell
115
proliferation,
116
mineralization were evaluated to compare cultures derived from both sites. The data
117
were compared by ANOVA followed by Tukey test or t-test when appropriated and the
118
level of significance was set at p0.05. Cell proliferation was not affected by cell source
119
(p=0.710), but was affected by time (p=0.001) and by the interaction cell source vs.
120
time (p=0.001; Figure 5A). The culture growth peaked at day 10 for cells from both
alkaline
phosphatase
(ALP)
activity
and
extracellular
matrix
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121
sites. ALP activity was not affected by either cell source (p=0.964) or time (p=0.505
122
Figure 5B). Extracellular matrix mineralization evaluated at day 17 was similar
123
(p=0.223) in cultures derived from both sites (Figure 5C).
124 125
Discussion
126
Adequate bone volume in the anterior maxilla is essential for a proper aesthetic
127
and functional implant-supported oral rehabilitation. Vertico-lateral ridge augmentation
128
remains a challenging situation in reconstruction of maxillary defects, particularly due
129
to the combination of bony defect with the lack of soft tissue(4). Here, we presented a
130
case report in which a vertico-lateral defect had been successfully managed by
131
combining AOD and FFBA.
132
AOD is a biologic process originally applied in orthopedic procedures by which
133
new bone is generated through incremental lengthening of osseous segments(12). One of
134
the advantages of this technique is the promotion of concomitant increase of bone and
135
soft tissues avoiding donor site morbity(13). Preclinical studies reported mandibular
136
vertical augmentation as large as 9 mm, with histological evidences of new bone
137
formation at both sides of the distraction gap and maintenance of crest levels after load
138
application(14,15). Furthermore, there is clinical evidence that implants placed into
139
autogenous grafted or AOD reconstructed areas present the same success rate(13).
140
FFBA has been successfully used for horizontal and vertical improvement in
141
ridge augmentation that allowed implant placement(16). The good osseoconductive
142
capacity of allografts allowing new bone formation adjacent to residual graft after 6
143
months is in agreement with our histological findings at 5-years post-grafting(17). This
144
case report supports previous conclusions that allografts are biocompatible and
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145
osseocondutive, allowing new bone formation after anterior maxilla augmentation and
146
implant placement(18).
147
In addition to clinical and histological evidences, here we present data of
148
cultured osteoblastic cells harvested from graft compared with those from AB. In
149
general, graft and autogenous-derived cells were capable of proliferation with
150
increasing cell growth along the culture progression. Both cultures presented the same
151
level of ALP activity and production of extracellular matrix mineralization suggesting
152
they displayed similar osteoblastic phenotype expression. At least in part it could be
153
attributed to the homolog origin of this graft as different bovine bones have been
154
showed to impair osteoblastic phenotype expression(19,20). These cellular analyses
155
strengthen clinical and histological outcomes showing the suitable biocompatibility and
156
osseoconductive properties of FFBA.
157 158
Conclusion
159
This case report showed that the association of osteogenic distraction and allograft
160
represent a feasible strategy to repair anterior maxillary defects for successful
161
rehabilitation.
162 163
References
164
1. MacAfee KA. Reconstruction of the trauma patient. In: Fonseca RJ, Davis WH,
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editors. Reconstructive Preprosthetic Oral and Maxillofacial Surgery. 2 ed.
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Philadelphia: Saunders; 1995. p. 959-976.
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2. Block MS, Baughman DG. Reconstruction of severe anterior maxillary defects using
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distraction osteogenesis, bone grafts, and implants. J Oral Maxillofac Surg.2005;63:
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291-297.
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3. Goh BT, Lee S, Tideman H, Stoelinga PJ. Mandibular reconstruction in adults: a
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review. Int J Oral Maxillofac Surg. 2008;37:597-605.
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4. Louis PJ. Vertical ridge augmentation using titanium mesh.Oral Maxillofac Surg Clin
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North Am. 2010;22:353-368.
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5. Stacchi C, Orsini G, Di Iorio D, Breschi L, Di Lenarda R. Clinical, histologic, and
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histomorphometric analyses of regenerated bone in maxillary sinus augmentation using
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fresh frozen human bone allografts. J Periodontol. 2008;79:1789-1796.
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6. Chiapasco M, Romero E. La riabilitazione implantoprotesica nei casi complessi.
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Milano: UTET; 2002.
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7. Jovanovic SA, Paul SJ, Nishimura RD. Anterior implant-supported reconstructions: a
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surgical challenge. Pract Periodontics Aesthet Dent. 1999;11:551-558.
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8. Politi M, Robiony M. Localized alveolar sandwich osteotomy for vertical
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augmentation of the anterior maxilla. J Oral Maxillofac Surg. 1999;57:1380-1382.
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9. Ribeiro C, Bittencourt TC, Ferreira CF, Assis NM. An alternative approach for
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augmenting the anterior maxilla using autogenous free gingival bone graft for implant
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retained prosthesis. J Oral Implantol 2012. doi:10.1563/AAID-JOI-D-12-00016.1
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10. Kaner, D. Friedmann A Kaner D, Friedmann A. Soft tissue expansion with self-
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filling osmotic tissue expanders before vertical ridge augmentation: a proof of principle
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study. J Clin Periodontol. 2011; 38:95-101.
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11. Rosa AL, Beloti MM. Development of the osteoblast phenotype of serial cell
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subcultures from human bone marrow. Braz Dent J. 2005;16:225-230.
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12. Castro-Núñez J, González MD. Maxillary reconstruction with bone transport
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distraction and implants after partial maxillectomy. J Oral Maxillofac Surg.
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2013;71:137-42.
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13. Elo JA, Herford AS, Boyne PJ: Implant success in distracted bone versus
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autogenous bone-grafted sites. J Oral Implantol. 2009;35:181-184.
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14. Block M, Chang A, Crawford C. Mandibular alveolar ridge augmentation in the dog
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using distraction osteogenesis. J Oral Maxillofac Surg. 1996;54:309-314.
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15. Block M, Almerico B, Crawford C, Gardiner D, Chang A. Bone response to
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functioning implants in dog mandibular alveolar ridges augmented with distraction
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osteogenesis. Int J Oral Maxillofac Implants. 1998;13:342-351.
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16. Nissan J, Mardinger O, Calderon S, Romanos GE, Chaushu G. Cancellous bone
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block allografts for the augmentation of the anterior atrophic maxilla. Clinical Implant
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Dentistry &Related Research. 2011;13:104-111.
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17. Buffoli B, Boninsegna R, Rezzani R, Poli PP, Santoro F, Rodella LF.
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Histomorphometrical Evaluation of Fresh Frozen Bone Allografts for Alveolar Bone
222
Reconstruction: Preliminary Cases Comparing Femoral Head with Iliac Crest Grafts.
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Clin Implant Dent Relat Res. 2013. doi: 10.1111/cid.12028.
224 225
18. Borgonovo AE, Tommasi F, Panigalli A, Bianchi AC, Boninsegna R, Santoro F.
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Use of fresh frozen bone graft in rehabilitation of maxillar atrophy. Minerva Stomatol.
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2012;61:141-54.
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19. Beloti MM, Martins W Jr, Xavier SP, Rosa AL. In vitro osteogenesis induced by
230
cells derived from sites submitted to sinus grafting with anorganic bovine bone. Clin
231
Oral Implants Res. 2008;19:48-54.
232 233
20. de Melo WM, de Oliveira FS, Marcantonio E Jr, Beloti MM, de Oliveira PT, Rosa
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AL. Autogenous bone combined with anorganic bovine bone for maxillary sinus
235
augmentation: analysis of the osteogenic potential of cells derived from the donor and
236
the grafted sites. Clin Oral Implants Res. 2013. doi: 10.1111/clr.12100.
237 238
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239
Figure Legends
240
Figure 1 Clinical (A) and radiographic (B) aspects of vertico-lateral defect. Surgical
241
exposure of the defect prior to osteotomies (C) and osteogenic distractor placement.
242
Distractor activated and in position (D). Clinical aspect after 4 months prior to remove
243
the distractor (E). Amount of vertical bone improvement (F). Clinical (G) and CT scan
244
(H) aspects of residual lateral defect.
245 246
Figure 2 Clinical aspect of residual lateral defect (A). Fresh-frozen bone allograft
247
(FFBA) settled with positional screws (B) and sutures (C). Clinical aspect 1 month after
248
the grafting procedure exhibiting lateral volume improvement (D).
249 250
Figure 3 Clinical aspect of graft after 6 months (A) and implants in position (B).
251
Prosthetic rehabilitation restoring function and aesthetics (C-D). Periapical radiograph
252
after 5 years (E). CT scan (coronal view) evidencing the profile maintenance 5 years
253
after the grafting procedure (F).
254 255
Figure 4 Histological findings 5 years after grafting procedure. The presence of
256
acellular areas (bone block) surrounded by new bone is noticed. Scale bar for A=50 µm,
257
B=100 µm.
258 259
Figure 5 Proliferation at days 3, 7 and 10 of cells derived from autogenous bone (AB)
260
and fresh-frozen bone allograft (FFBA) (A); ALP activity at 7, 10 and 14 days of cells
261
derived from AB and FFBA (B); extracellular matrix mineralization at day 17 of cells
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262
derived from AB and FFBA (C). Bars with the same letter are not statistically
263
significant different (p>0.05).
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AAID-JOI-D-13-00102R1
Full Title:
CLINICAL, HISTOLOGICAL AND CELLULAR EVALUATION OF VERTICO-LATERAL MAXILLARY RECONSTRUCTION ASSOCIATING ALVEOLAR OSTEOGENIC DISTRACTION AND FRESH-FROZEN BONE ALLOGRAFT
Short Title:
Evaluation of vertico-lateral maxillary reconstruction after 5 years
Article Type:
Clinical Case Letter
Keywords:
osteogenic distraction; fresh-frozen bone allograft; maxillary reconstruction; dental implants
Corresponding Author:
Samuel Porfirio Xavier, PhD Faculty of Dentistry of Ribeirao Preto of University of Sao Paulo Ribeirao Preto, Sao Paulo BRAZIL
Corresponding Author Secondary Information: Corresponding Author's Institution:
Faculty of Dentistry of Ribeirao Preto of University of Sao Paulo
Corresponding Author's Secondary Institution: First Author:
Emanuela Prado Ferraz, MD
First Author Secondary Information: Order of Authors:
Emanuela Prado Ferraz, MD Adalberto Luiz Rosa, PhD Paulo Tambasco de Oliveira, PhD Thiago de Santana Santos, MD Cassio de Barros Pontes, PhD Danilo Maeda Reino, MD Samuel Porfirio Xavier, PhD
Order of Authors Secondary Information: Abstract:
Despite advances in bone reconstruction and rehabilitation techniques, treatment of partially edentulous patients with atrophic anterior maxilla remains a challenge. Alveolar osteogenic distraction and allografts have been used as an alternative to autografts, avoiding use of a donor area, while minimizing morbity of the procedure. The aim of this case letter was to report a reconstruction of maxillary defect with these techniques using clinical, histological and cellular parameters. A 42-year old female patient presented an "U-shaped" maxillary bone defect that was repaired by alveolar osteogenic distraction (AOD) to gain bone height followed by fresh-frozen human bone allograft (FFBA) to gain thickness. The reconstructed area was rehabilitated by implant-supported prosthesis. At 5-year follow-up clinical and radiographic evaluations were carried out and biopsies from reconstructed area and autogenous bone were taken for histological and cellular evaluations. Clinically the rehabilitation was very satisfactory. Histological analysis showed bone formation in close contact with residual FFBA. Cells harvested from allograft and autogenous sites displayed similar proliferation, alkaline phosphatase activity and mineralization. These analyses indicate that AOD and FFBA can represent a reliable strategy to reconstruct maxillary defects for clinical successful rehabilitation.
Response to Reviewers:
Ref.: Ms. No. AAID-JOI-D-13-00102
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CLINICAL, HISTOLOGICAL AND CELLULAR EVALUATION OF VERTICO-LATERAL MAXILLARY RECONSTRUCTION ASSOCIATING ALVEOLAR OSTEOGENIC DISTRACTION AND FRESH-FROZEN BONE ALLOGRAFT Journal of Oral Implantology Dear Dr. Samuel Xavier, Thank you very much for submitting your manuscript for review by Journal of Oral Implantology. Based on the reviews, we will not immediately be able to accept this manuscript for publication in the journal, although we would be willing to reconsider a revised version, based on the review comments. We cannot of course promise publication at that time. Should you decide to revise the manuscript for further consideration here, your revisions should address the specific points made by each reviewer. Please highlight any changes you make in the manuscript itself. You should also send along a cover letter, indicating your response to the review comments and the changes you have made in the manuscript. If you choose to revise your submission, your revision is due by 11/10/2013. To submit a revision, go to http://aaid-joi.edmgr.com/ and log in as an Author. You will see a menu item call Submission Needing Revision. You will find your submission record there. Yours sincerely, Jim Rutkowski, DMD, PhD Editor-in-Chief Journal of Oral Implantology Reviewers' comments: Reviewer #1: 1. Is the title of the manuscript clear, concise, and descriptive? If not, please suggest an appropriate title? YES 2. Does the abstract accurately summarize the content of the investigation? YES 3. Can the Abstract stand alone? YES 4. Does the abstract provide a succinct and accurate summary of the manuscript? YES 5. Has the author completed a comprehensive and critical discussion of recent literature? YES 6. Has the author stated a clear and concise purpose for his/her manuscript? YES 7. Are the procedures described in enough detail to permit a reader to understand them? YES 8. Are the data presented appropriately? 9. Does the case report section contain only pertinent information describing the patient's condition and treatment? YES 10. Does the case report section begin with a description of how the patient presented for treatment, the patient's chief complaint, and history? YES 11. Are all diagnostic procedures, treatment, and results of treatment adequately described? YES 12. If a technique is described in the manuscript, is it accurately described? YES 13. Are the study limitations described? NO. I SUGGEST THE AUTHORS DESCRIBE THE ADO TECHNIQUE IN THE CASE REPORT 14. Has the author acknowledged important alternative points of view? YES 15. Is the interpretation of data consistent with results? YES 16. Are the results compared with other relevant and similar investigations? YES 17. Do the author's conclusions and generalizations logically follow from the text? YES 18. Are the conclusions reflective of the data and data analysis? YES 19. Are the conclusions succinct? YES 20. Are the references current and pertinent? YES 21. Are the references adequate in number? YES 22. Are the references accurately cited? YES 23. Are tables and figures adequately described with legends? YES 24. Should any or all of the illustrations be printed in color? YES Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation
25. Are there tables or figures that should be eliminated? NO 26. Should some sections of the manuscript be expanded, condensed, or omitted? YES. I SUGEST THAT THE AUTHORS GIVE MORE DETAIL ABOUT ADO TECHNIQUE AND BONE GRAFT TECHNIQUE 27. Does the manuscript present original material? YES
The article is well written and the case is well documented. I suggest that the authors give more emphasis on describing surgical procedures, because I believe that within the category that the paper is, it would be of much value this information. In my opinion, few patches are required.
August 14, 2013 James Rutkowski Editor-in-Chief Journal of Oral Implantology Dear Dr: Please find attached the revised version of the manuscript entitled “Clinical, histological and cellular evaluation of vertico-lateral maxillary reconstruction associating alveolar osteogenic distraction and fresh-frozen bone allograft” - Ms. No. AAID-JOI-D-1300102. As requested by reviewer, we have included a detailed description of ADO and bone graft techniques that are highlighted in the Ms. We believe that this revised version address the reviewer suggestion and hope that the Ms will now be deemed acceptable for publication in the Journal of Oral Implantology. Sincerely, Samuel Porfírio Xavier *Correspondence to: Professor Samuel Porfírio Xavier Department of Oral and Maxillofacial Surgery and Periodontology School of Dentistry of Ribeirao Preto, University of Sao Paulo Av. do Cafe, s/n – 14040-904 – Ribeirao Preto, SP, Brazil Phone: + 55 16 3602-4053 Fax: + 55 16 3602-4788 E-mail: [email protected]
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Rebuttal Letter (for revisions) Click here to download Rebuttal Letter (for revisions): Rebuttal Letter JOI.doc
Article File
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1
CLINICAL,
2
VERTICO-LATERAL MAXILLARY RECONSTRUCTION ASSOCIATING
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ALVEOLAR OSTEOGENIC DISTRACTION AND FRESH-FROZEN BONE
4
ALLOGRAFT
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Emanuela Prado Ferraz1; Adalberto Luiz Rosa1, Paulo Tambasco de Oliveira2, Thiago
6
de Santana Santos1, Danilo Maeda Reino1, Cássio Barros Pontes3, Samuel Porfírio
7
Xavier1*
8
1
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Dentistry of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, SP, Brazil
HISTOLOGICAL
AND
CELLULAR
EVALUATION
Department of Oral and Maxillofacial Surgery and Periodontology, School of
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2
11
Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, SP, Brazil
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3
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Paulo, Ribeirao Preto, SP, Brazil
Department of Morphology, Stomatology and Basic Pathology, School of Dentistry of
Department of Prosthodontics, School of Dentistry of Ribeirao Preto, University of Sao
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OF
Short Title: Evaluation of vertico-lateral maxillary reconstruction after 5 years
16 17
*Correspondence to:
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Samuel Porfirio Xavier
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Department of Oral and Maxillofacial Surgery and Periodontology
20
School of Dentistry of Ribeirao Preto, University of Sao Paulo
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Av. do Cafe, s/n – 14040-904 – Ribeirao Preto, SP, Brazil
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Phone: + 55 16 3602-4053
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Fax: + 55 16 3602-4788
24 25
E-mail: [email protected]
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Abstract
27
Despite advances in bone reconstruction and rehabilitation techniques, treatment of
28
partially edentulous patients with atrophic anterior maxilla remains a challenge.
29
Alveolar osteogenic distraction (AOD) and allografts have been used as an alternative
30
to autografts, avoiding the use of a donor area and minimizing morbidities. The aim of
31
this case lette is to report a reconstruction of maxillary defect by these techniques using
32
clinical, histological and cellular parameters. A 42-year-old female patient presented an
33
“U-shaped” maxillary bone defect that was repaired by AOD to gain bone height
34
followed by fresh-frozen human bone allograft (FFBA) to gain thickness. The
35
reconstructed area was rehabilitated by implant-supported prosthesis. At 5-year follow-
36
up, clinical and radiographic evaluations were carried out and biopsies from
37
reconstructed area and autogenous bone were taken for histological and cellular
38
evaluations. The rehabilitation was well succeeded from the clinical point-of-view.
39
Histological analysis showed bone formation in close contact with residual FFBA.
40
Cultures of cells harvested from allograft and autogenous sites displayed similar
41
proliferation rate, alkaline phosphatase activity and extracellular matrix mineralization.
42
These findings indicate that AOD and FFBA may represent a reliable strategy to
43
reconstruct maxillary defects for a successful clinical rehabilitation.
44 45
Keywords:
46
reconstruction; dental implants
47 48
osteogenic
distraction;
fresh-frozen
bone
allograft;
maxillary
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49
Introduction
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The rehabilitation of edentulous anterior maxillary defects with implant-
51
supported prosthesis remains a challenge, since loss of teeth can lead to extensive
52
vertical and horizontal bone resorption, compromising the aesthetical and functional
53
results(1,2,3).
54
Vertical alveolar defects higher than 5 mm are the most difficult to restore with
55
high incidence of failure mainly due to either resorption or dehiscence. Several
56
modalities of treatment have been proposed, such as autografts from distinct donor sites,
57
allografts, xenografts, osteogenic distraction and titanium meshes among others(4).
58
Although autografts are considered the gold standard based on their osseoinduction,
59
osseoconduction and osteogenesis properties, some disadvantages like morbidity, time
60
consuming and cost should be taken onto consideration before selecting this technique(3).
61
In this context, alveolar osteogenic distraction (AOD) is a good alternative to gain both
62
bone and soft tissue augmentation(4) and fresh-frozen bone allograft (FFBA) has been
63
successfully grafted to reconstruct bone defects in oral implantology(5). Beyond the
64
unlimited availability, FFBA avoids the morbidity commonly associated with autograft
65
harvesting(6).
66
The selection of treatment should be based on adequate quality and amount of
67
hard and soft tissues to get a suitable rehabilitation(7). U-shaped defects, usually present
68
in the anterior maxilla area, are characterized by lack of structures that prevents initial
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soft tissue closure over a large bone graft(2). Considering that a tension-free closure
70
must be performed to prevent incision breakdown on a large onlay bone graft(8,9,10),
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strategies to increase the soft tissue drape over a bone defect include free grafts, tissue
72
expanders, and the use of gradual distraction of the residual bone(2,10).
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73
The purpose of this letter is to report a case presenting clinical, histological and
74
cellular evidences to support the combination of AOD and cortico-cancellous FFBA as
75
a good alternative for reconstructing a vertico-lateral maxillary defect, allowing
76
implant-supported rehabilitation.
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Case Report
78
A 42-year-old patient had been referred to the Department of Oral and
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Maxillofacial Surgery of the School of Dentistry of Ribeirão Preto, University of São
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Paulo, for implant-supported rehabilitation. Clinical and radiographic evaluation
81
revealed a 9-mm U-shaped bone defect in the left anterior maxilla (Figure 1 A-B). The
82
proposed treatment was AOD to increase bone height and soft tissue availability
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followed by FFBA to improve lateral dimension. All surgical procedures were
84
performed under local anesthesia with the patient agreement based on signed informed
85
consent. Surgical AOD technique consisted of a horizontal incision and a full thickness
86
mucoperiosteal flap (Figure 1C). Horizontal and vertical osteotomies were created with
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a sagittal saw and the crest segment was gently mobilized. The osteogenic distractor
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(OD - Conexão, São Paulo, SP, Brazil) device was fixed in the original position with
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monocortical screws (1.5 mm in diameter and 5 mm in length), activated to check the
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osteotomies (Figure 1 D) and deactivated to the initial position. After one-week latency
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period, the OD device was activated at a ratio of 0.5 mm/day to obtain both vertical
92
bone and soft tissue augmentation until obtaining a suitable crest level (Figure 1 E-H).
93
After the consolidation period of four months, a crest incision and two vertical incisions
94
allowed to raise a full thickness mucoperiosteal flap. The OD device was removed and
95
the recipient bed was prepared by decortication holes using a 1-mm drill (Figure 2 A).
96
A cortico-cancellous FFBA (Musculoskeletal Tissue Bank of Marilia Hospital, Unioss,
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97
Marília, SP, Brazil) was shaped to get passive adaptation and fixed with non-
98
compressive two bicortical titanium screws (Synthes, West Chester, PA, USA, 1.5 mm
99
in diameter and 12 mm in length) with the cancellous portion facing the recipient bed
100
(Figure 2 B). FFBA allowed a width gain of 5 mm resulting in a reconstructed alveolar
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ridge with 8 mm in width. Through a periosteal releasing incision the wound was
102
passively closed with 5.0 nylon sutures (Figure 2 C). Six months later (Figure 2 D),
103
fixation screws were removed and two dental implants (Nobel Biocare, Yorba Linda,
104
CA, USA) were installed (Figure 3 A-B) and kept unloaded during six months previous
105
to prosthetic rehabilitation. At 5-year follow-up, clinical and radiographic evaluation
106
evidenced that the prosthetic rehabilitation was very satisfactory in terms of functional,
107
periodontal and aesthetic parameters (Figure 3 C-F). At this time-point, bone biopsies
108
from grafted area and maxillary tuberosity (autogenous bone: AB) were taken and
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processed for histological and cellular analysis. Light microscopy of block biopsies
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revealed trabeculae of cancellous bone intermingled with a vascularized, fibrous
111
connective tissue. The bone trabeculae were composed of areas of lamellar bone with
112
empty osteocytic lacunae surrounded by either a viable lamellar bone or bundle bone,
113
with Sharpey’s fibers (Figure 4 A-B). Osteoblastic cells from grafted and AB sites were
114
harvested by enzymatic digestion and cultured as described elsewhere(11). Cell
115
proliferation,
116
mineralization were evaluated to compare cultures derived from both sites. The data
117
were compared by ANOVA followed by Tukey test or t-test when appropriated and the
118
level of significance was set at p0.05. Cell proliferation was not affected by cell source
119
(p=0.710), but was affected by time (p=0.001) and by the interaction cell source vs.
120
time (p=0.001; Figure 5A). The culture growth peaked at day 10 for cells from both
alkaline
phosphatase
(ALP)
activity
and
extracellular
matrix
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sites. ALP activity was not affected by either cell source (p=0.964) or time (p=0.505
122
Figure 5B). Extracellular matrix mineralization evaluated at day 17 was similar
123
(p=0.223) in cultures derived from both sites (Figure 5C).
124 125
Discussion
126
Adequate bone volume in the anterior maxilla is essential for a proper aesthetic
127
and functional implant-supported oral rehabilitation. Vertico-lateral ridge augmentation
128
remains a challenging situation in reconstruction of maxillary defects, particularly due
129
to the combination of bony defect with the lack of soft tissue(4). Here, we presented a
130
case report in which a vertico-lateral defect had been successfully managed by
131
combining AOD and FFBA.
132
AOD is a biologic process originally applied in orthopedic procedures by which
133
new bone is generated through incremental lengthening of osseous segments(12). One of
134
the advantages of this technique is the promotion of concomitant increase of bone and
135
soft tissues avoiding donor site morbity(13). Preclinical studies reported mandibular
136
vertical augmentation as large as 9 mm, with histological evidences of new bone
137
formation at both sides of the distraction gap and maintenance of crest levels after load
138
application(14,15). Furthermore, there is clinical evidence that implants placed into
139
autogenous grafted or AOD reconstructed areas present the same success rate(13).
140
FFBA has been successfully used for horizontal and vertical improvement in
141
ridge augmentation that allowed implant placement(16). The good osseoconductive
142
capacity of allografts allowing new bone formation adjacent to residual graft after 6
143
months is in agreement with our histological findings at 5-years post-grafting(17). This
144
case report supports previous conclusions that allografts are biocompatible and
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145
osseocondutive, allowing new bone formation after anterior maxilla augmentation and
146
implant placement(18).
147
In addition to clinical and histological evidences, here we present data of
148
cultured osteoblastic cells harvested from graft compared with those from AB. In
149
general, graft and autogenous-derived cells were capable of proliferation with
150
increasing cell growth along the culture progression. Both cultures presented the same
151
level of ALP activity and production of extracellular matrix mineralization suggesting
152
they displayed similar osteoblastic phenotype expression. At least in part it could be
153
attributed to the homolog origin of this graft as different bovine bones have been
154
showed to impair osteoblastic phenotype expression(19,20). These cellular analyses
155
strengthen clinical and histological outcomes showing the suitable biocompatibility and
156
osseoconductive properties of FFBA.
157 158
Conclusion
159
This case report showed that the association of osteogenic distraction and allograft
160
represent a feasible strategy to repair anterior maxillary defects for successful
161
rehabilitation.
162 163
References
164
1. MacAfee KA. Reconstruction of the trauma patient. In: Fonseca RJ, Davis WH,
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editors. Reconstructive Preprosthetic Oral and Maxillofacial Surgery. 2 ed.
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Philadelphia: Saunders; 1995. p. 959-976.
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2. Block MS, Baughman DG. Reconstruction of severe anterior maxillary defects using
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distraction osteogenesis, bone grafts, and implants. J Oral Maxillofac Surg.2005;63:
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291-297.
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3. Goh BT, Lee S, Tideman H, Stoelinga PJ. Mandibular reconstruction in adults: a
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review. Int J Oral Maxillofac Surg. 2008;37:597-605.
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4. Louis PJ. Vertical ridge augmentation using titanium mesh.Oral Maxillofac Surg Clin
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North Am. 2010;22:353-368.
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5. Stacchi C, Orsini G, Di Iorio D, Breschi L, Di Lenarda R. Clinical, histologic, and
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histomorphometric analyses of regenerated bone in maxillary sinus augmentation using
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fresh frozen human bone allografts. J Periodontol. 2008;79:1789-1796.
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6. Chiapasco M, Romero E. La riabilitazione implantoprotesica nei casi complessi.
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Milano: UTET; 2002.
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7. Jovanovic SA, Paul SJ, Nishimura RD. Anterior implant-supported reconstructions: a
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surgical challenge. Pract Periodontics Aesthet Dent. 1999;11:551-558.
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8. Politi M, Robiony M. Localized alveolar sandwich osteotomy for vertical
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augmentation of the anterior maxilla. J Oral Maxillofac Surg. 1999;57:1380-1382.
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9. Ribeiro C, Bittencourt TC, Ferreira CF, Assis NM. An alternative approach for
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augmenting the anterior maxilla using autogenous free gingival bone graft for implant
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retained prosthesis. J Oral Implantol 2012. doi:10.1563/AAID-JOI-D-12-00016.1
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10. Kaner, D. Friedmann A Kaner D, Friedmann A. Soft tissue expansion with self-
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filling osmotic tissue expanders before vertical ridge augmentation: a proof of principle
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study. J Clin Periodontol. 2011; 38:95-101.
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11. Rosa AL, Beloti MM. Development of the osteoblast phenotype of serial cell
200
subcultures from human bone marrow. Braz Dent J. 2005;16:225-230.
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12. Castro-Núñez J, González MD. Maxillary reconstruction with bone transport
203
distraction and implants after partial maxillectomy. J Oral Maxillofac Surg.
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2013;71:137-42.
205 206
13. Elo JA, Herford AS, Boyne PJ: Implant success in distracted bone versus
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autogenous bone-grafted sites. J Oral Implantol. 2009;35:181-184.
208 209
14. Block M, Chang A, Crawford C. Mandibular alveolar ridge augmentation in the dog
210
using distraction osteogenesis. J Oral Maxillofac Surg. 1996;54:309-314.
211 212
15. Block M, Almerico B, Crawford C, Gardiner D, Chang A. Bone response to
213
functioning implants in dog mandibular alveolar ridges augmented with distraction
214
osteogenesis. Int J Oral Maxillofac Implants. 1998;13:342-351.
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16. Nissan J, Mardinger O, Calderon S, Romanos GE, Chaushu G. Cancellous bone
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block allografts for the augmentation of the anterior atrophic maxilla. Clinical Implant
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Dentistry &Related Research. 2011;13:104-111.
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17. Buffoli B, Boninsegna R, Rezzani R, Poli PP, Santoro F, Rodella LF.
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Histomorphometrical Evaluation of Fresh Frozen Bone Allografts for Alveolar Bone
222
Reconstruction: Preliminary Cases Comparing Femoral Head with Iliac Crest Grafts.
223
Clin Implant Dent Relat Res. 2013. doi: 10.1111/cid.12028.
224 225
18. Borgonovo AE, Tommasi F, Panigalli A, Bianchi AC, Boninsegna R, Santoro F.
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Use of fresh frozen bone graft in rehabilitation of maxillar atrophy. Minerva Stomatol.
227
2012;61:141-54.
228 229
19. Beloti MM, Martins W Jr, Xavier SP, Rosa AL. In vitro osteogenesis induced by
230
cells derived from sites submitted to sinus grafting with anorganic bovine bone. Clin
231
Oral Implants Res. 2008;19:48-54.
232 233
20. de Melo WM, de Oliveira FS, Marcantonio E Jr, Beloti MM, de Oliveira PT, Rosa
234
AL. Autogenous bone combined with anorganic bovine bone for maxillary sinus
235
augmentation: analysis of the osteogenic potential of cells derived from the donor and
236
the grafted sites. Clin Oral Implants Res. 2013. doi: 10.1111/clr.12100.
237 238
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239
Figure Legends
240
Figure 1 Clinical (A) and radiographic (B) aspects of vertico-lateral defect. Surgical
241
exposure of the defect prior to osteotomies (C) and osteogenic distractor placement.
242
Distractor activated and in position (D). Clinical aspect after 4 months prior to remove
243
the distractor (E). Amount of vertical bone improvement (F). Clinical (G) and CT scan
244
(H) aspects of residual lateral defect.
245 246
Figure 2 Clinical aspect of residual lateral defect (A). Fresh-frozen bone allograft
247
(FFBA) settled with positional screws (B) and sutures (C). Clinical aspect 1 month after
248
the grafting procedure exhibiting lateral volume improvement (D).
249 250
Figure 3 Clinical aspect of graft after 6 months (A) and implants in position (B).
251
Prosthetic rehabilitation restoring function and aesthetics (C-D). Periapical radiograph
252
after 5 years (E). CT scan (coronal view) evidencing the profile maintenance 5 years
253
after the grafting procedure (F).
254 255
Figure 4 Histological findings 5 years after grafting procedure. The presence of
256
acellular areas (bone block) surrounded by new bone is noticed. Scale bar for A=50 µm,
257
B=100 µm.
258 259
Figure 5 Proliferation at days 3, 7 and 10 of cells derived from autogenous bone (AB)
260
and fresh-frozen bone allograft (FFBA) (A); ALP activity at 7, 10 and 14 days of cells
261
derived from AB and FFBA (B); extracellular matrix mineralization at day 17 of cells
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262
derived from AB and FFBA (C). Bars with the same letter are not statistically
263
significant different (p>0.05).
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