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ET AL
Guided Bone Regeneration Using Autogenous Tooth Bone Graft in Implant Therapy: Case Series Young-Kyun Kim, DDS, PhD,* Su-Gwan Kim, DDS, PhD,† Ji-Hyun Bae, DDS, PhD,‡ In-Woong Um, DDS, PhD,§ Ji-Su Oh, DDS, PhD,k and Kyung-In Jeong, DDS, MSD¶
one dehiscence or fenestration is developed in many implant treatment cases, and guided bone regeneration (GBR) using bone graft materials is becoming a common procedure. The most ideal materials for GBR are autogenous bone. Nevertheless, the main limitation to autogenous bone grafts is the inability to harvest large amounts of tissue. Also, complications in the donor area are abundant, and resorption after graft is substantial. Therefore, the bone substitutes include allogenic, xenogeneic, and alloplastic materials that have been developed and used in clinics. However, in terms of bone healing, it is true that these are inferior to autogenous bone. From 1993, Kim et al1–6 have been engaged in the development of materials using human teeth and have conducted experimental studies and published several papers. Based on
B
*Professor, Department of Oral and Maxillofacial Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea. †Professor, Department of Oral and Maxillofacial Surgery, School of Dentistry, Chosun University, Gwangju, Republic of Korea. ‡Assistant Professor, Department of Conservative Dentistry, Seoul National University Bundang Hospital, Seongnam, Republic of Korea. §CTO, R&D Director, Korea Tooth Bank, Republic of Korea. kAssistant Professor, Department of Oral and Maxillofacial Surgery, School of Dentistry, Chosun University, Gwangju, Republic of Korea. ¶Fellow, Department of Oral and Maxillofacial Surgery, School of Dentistry, Chosun University, Gwangju, Republic of Korea.
Reprint requests and correspondence to: Su-Gwan Kim, DDS, PhD, Department of Oral and Maxillofacial Surgery, School of Dentistry, Chosun University, 375, SeoSukDong, DongGu, Gwangju 501-759, Republic of Korea, Phone: 82-62-220-3819, Fax: 82-62-228-7316, E-mail: [email protected] ISSN 1056-6163/14/02302-138 Implant Dentistry Volume 23 Number 2 Copyright © 2014 by Lippincott Williams & Wilkins DOI: 10.1097/ID.0000000000000046
Recently, techniques have been reported that involve the preparation of extracted teeth from patients used as particulated bone graft materials for bone graft purposes. For implant placement and bone graft, autogenous teeth bone graft materials were used in 15 patients, and clinically
excellent results were obtained. In histological examination, favorable bony healing by osteoconduction was observed. (Implant Dent 2014; 23:138–143) Key Words: bone graft, dental implant, tooth bone
these results, studies have been conducted to develop and evaluate new materials with bone regeneration capacity similar to autogenous bones that could overcome shortcomings of allogenic bones, xenogeneic bones, and synthetic bones. Recently, bone graft materials using extracted autogenous teeth were developed successfully.7 We performed GBR using autogenous tooth bone graft materials (AutoBT; Korea Tooth Bank Co., Seoul, Korea) in 15 patients, and good outcomes were obtained. Here, we report the cases together with histological findings.
simultaneously. In 7 patients, membranes were not used, but the other 8 patients received resorbable collagen membranes. Regarding autogenous tooth bone graft materials, blocks were used in 1 patient, and powder materials were used in the other patients. No patient received additional bone graft materials. The mean primary stability of the placed implants was 72 implant stability quotient (ISQ), and the mean secondary stability was 81 ISQ. Regarding postsurgical complications, wound dehiscence developed in 3 cases. Among them, 2 cases achieved favorable secondary healing and showed almost no crestal bone loss, but 2 implants in 1 case had crestal bone loss of 3.6 and 2.5 mm. One case developed a postsurgical hematoma that resolved uneventfully. The follow-up period after completion of the upper prosthesis was 7 to 45 months, average 31 months. All implants maintained normal function (Table 1).
CASE SERIES Implant placement and GBR were performed on 15 patients ranging in age from 27 to 68 years (mean age, 49.9 years). Eight patients were male and 7 were female. Four patients were being medically treated for cardiac disease, hypertension, thyroid disease, or diabetes mellitus, which were well controlled in all patients. Twenty-three implants were placed in the maxillary and mandibular molars. In 2 implants of 2 patients, sinus lifting was performed
Case 1 (#15)
A 33-year-old female patient presented because of pain in the left mandibular 1st molar and gingival
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Table 1. Case Summary of Guided Bone Regeneration Case
Age (y)
1 2
Sex
Area
Surgery
Type
Membrane
Comp
39 45
F M
SL No
Powder Powder
No Yes
No No
3 4 5 6
45 27 62 40
M F M M
No No SL No
Powder Powder Block Powder
Yes No No Yes
No No No WD, BL
7 8 9 10
47 61 57 52
F F M M
No No No No
Powder Powder Powder Powder
Yes No No No
No No No No
11 12 13
49 68 63
F M M
No No No
Powder Powder Powder
Yes Yes No
Hematoma WD No
14 15
61 33
F F
17 35 36 37 47 36 16 36 37 37 36 24 46 47 36 46 36 37 26 27 46 36 37
No No
Powder Powder
Yes Yes
WD No
Mean
49.9
Primary Stability
Secondary Stability
Follow-up Period (mo)
Bone Loss
57 57 74 78 76 85 72 64 68 32 85 88 80 79 44 53 78 80 75 71 85 81 91 72
78 86 88 86 80 88 75 73 80 86 85 67 86 90 69 70 88 82 78 77 78 86 85 81
31 43
0 0 0 0.5 0 0.2 1 3.6 2.5 0 0 0 0.7 0.3 0 0.2 0.5 0.2 0.8 0 0 0.4 0 0.47
42 38 41 12 42 42 26 14 7 8 45
27 41 31
SL indicates sinus lifting; WD, wound dehiscence.
Fig. 1. Panoramic radiograph taken at the initial examination. Left mandibular 1st molar was extracted and fabricated into AutoBT powder.
Fig. 2. Photograph of the oral cavity after implant placement. Periimplant bone defects are observed.
Fig. 3. Image after grafting AutoBT powder to periimplant bone defects. BioGide membrane was covered.
Fig. 5. Second surgery was performed, and excellent bony healing was observed.
Fig. 4. Periapical radiograph 2 weeks after implant placement.
Fig. 6. Panoramic radiograph 41 months after final prosthetic delivery.
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Case 2 (#14)
Fig. 7. Implant was placed.
Fig. 8. AutoBT powder was grafted around the periimplant bone defect.
Fig. 9. Wound dehiscence was developed 1 week after operation.
Fig. 10. Periapical radiograph 1 week after implant placement. Good secondary healing was achieved, and the loss of bone graft material was minimal after 1 month.
Fig. 11. Periapical radiograph 1 month after final prosthetic delivery.
Fig. 12. Periapical radiograph 27 months after the final prosthetic delivery. The periimplant bone level remained relatively stable.
swelling. Because of severe caries in the lower cantilever prosthesis, subsequent implant placement after tooth extraction was planned. The upper prosthesis was removed and the 1st molar was extracted, after which autogenous tooth bone graft powder (AutoBT) was prepared. Two weeks after extraction, the flap was lifted, and 2 implants (Osstem GS III; Osstem Implant Co., Busan, Korea) were placed. The primary stability measured by an Osstell Mentor (Integration Diagnostics AB, Göteberg, Sweden) was #36 (81), #37 (91) ISQ value. After placement, the AutoBT powder was grafted to the periimplant bone defect area, which was covered with resorbable collagen membranes (BioGide; Geistlich Pharma AG, Wolhausen, Switzerland), after which the wound was sutured. Three months later, the implants were exposed by a secondary surgery, and excellent bone healing was observed. The upper prosthesis treatment was completed successfully. Up to 41 months after prosthetic loading, the implants remained stable (Figs. 1–6).
A 61-year-old female patient presented because of pain in the right mandibular 1st molar. On clinical and radiological examination, mobility and a periapical radiolucent lesion were observed. Thus, extraction and subsequent implant placement were planned. The 1st molar was extracted and powder type AutoBT was prepared. One month after extraction, an implant (Implantium Superline; Dentium, Seoul, Korea) was placed and AutoBT powder was grafted to the periimplant defects area, which was covered with resorbable collagen membranes (BioArm; ACE Surgical Supply Co., Brockton, MA), after which the wound was sutured. The stitches were removed 1 week postoperatively. As wound dehiscence developed, the cover screws were partially exposed. To prevent secondary infection, the patient was instructed to use an antibiotic and chlorhexidine rinse. One month after implant placement, a healing abutment was connected. Eight weeks after implant placement, a final prosthesis was loaded. Despite the development of wound dehiscence, secondary infection was absent, and a large amount of AutoBT powder remained. Twentyseven months after final prosthesis loading, the implant remained stable (Figs. 7–12). Fabrication Process of Autogenous Tooth Bone Graft Materials
Extracted teeth were immersed in 70% ethyl alcohol and transported to a company specializing in the treatments (Korea Tooth Bank Co.). At the company, soft tissues, calculus, and foreign materials (eg, prosthesis and endodontic filling materials attached to the tooth) were removed, crowns were severed, and the root portions were crushed. The particle size was prepared in different 2 sizes, as requested by the dentists. For GBR, they were prepared as 0.5 to 1 mm particles, and for sinus bone graft and ridge augmentation, they were prepared as 1 to 2 mm particles. The crushed tooth particles were added to distilled water and a hydrogen peroxide solution, and the residual foreign materials were removed by washing with ultrasonography. The washed
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formed bones, and well-vascularized dense fibrous tissues were observed. Newly formed bone infiltrated into the resorbed site of the graft material (Fig. 14).
DISCUSSION
Fig. 13. The 2-month tissue sample. Dentin graft materials and newly formed immature woven bones were fused directly, and newly formed immature woven bones were surrounded by well-vascularized loose fibrous tissues (hematoxylin-eosin stain, 3100).
Fig. 14. The 4-month tissue sample. Immature woven bone formation around the graft material and abundant vascularized fibrous tissues were observed. Newly formed bone infiltrated into the resorbed site of the graft material (hematoxylin-eosin stain, 3200).
tooth particles were dehydrated with an ethyl alcohol solution and defatted subsequently with an ethyl ether solution. Subsequently, they were partially demineralized, and after a lyophilization process, the teeth were sterilized with ethylene oxide gas. The products were then packaged and transported to the requested dental clinics. Histological Findings
Tissue samples were harvested during the second surgery 2 and 4 months after the AutoBT graft in patients. The bone graft area could be identified macroscopically, and using a #15 surgical blade, a wedge incisional biopsy was performed. The specimens were fixed in 10% formalin for 24 hours and decalcified in Calci-Clear Rapid (National Diagnostics, Atlanta, GA)
for 12 hours. The tissues were rinsed in running water, treated with a Hypercentre XP tissue processor (Shandon, Cheshire, United Kingdom), embedded in paraffin, cut to a thickness of 4 to 5 mm, and stained with hematoxylin and eosin. The prepared specimens were observed using light microscopy. After 2 months, tissue samples showed several inflammatory cells and hemorrhage findings. The finding of the direct union with new bones by osteoconduction was shown, and loose fibrous tissue and bone were infiltrated into the resorbed site of the graft material. Most of the new bone formation was limited around the dentin graft materials. Well-vascularized loose fibrous tissues surrounded newly formed woven bone (Fig. 13). In the 4-month samples, graft materials were directly fused with newly
Regarding the reconstruction of hard tissue defects, several studies8,9 support that autogenous bone grafts are the most ideal implant. The advantages of using this autogenous bone include its increased capacity for bone formation, osteoconduction, and osteoinduction. It does not induce immunologic rejection, and it heals rapidly. Nonetheless, the biggest shortcomings are that the harvest amount is limited and that harvesting bone induces a secondary defect. Allogenic bone and xenogeneic bone were developed as the substitutes for autogenous bone but have the risk of inducing immunologic rejection or infection and contamination. However, some investigators favor synthetic bone secondary to a decreased risk of infection compared to the xeno- and allogenic options. It is evident that it has only osteoconduction capacity, and bone healing capacity is low in comparison with autogenous bone or allogenic bone.10–14 Hassan et al15 placed implants immediately after tooth extraction, performed GBR using autogenous bone and synthetic bone, and conducted clinical comparative studies. They observed that, after 12 months, the autogenous bone graft group showed good outcomes of the pocket depth in the vicinity of implants, clinical attachment level, and the resorption of the alveolar bone. Clinically, they also reported that autogenous bone graft showed noticeably better results than synthetic bone graft. Lee et al16 conducted animal experiments investigating the bone dehiscence defect area restored with autogenous bone powder collected during the implant drilling procedure and xenogeneic bone. The results showed that in the experimental group, who were treated with autogenous bone powder, the boneimplant contact rate was higher, and the results of good bone formation were obtained. This result supports the usefulness of autogenous bone for the treatment of bone dehiscence defect areas.
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GUIDED BONE REGENERATION
Kim et al7 reported that AutoBT underwent gradual resorption and was replaced by new bone of excellent quality through osteoinduction and osteoconduction. The AutoBT contains both inorganic and organic materials, and the major component of the inorganic material contains 4 types of calcium phosphate (hydroxyapatite, tricalcium phosphate, amorphous calcium phosphate, and octacalcium phosphate). The chemical composition of teeth is very similar to that of bone. In the enamel, the total inorganic content is 95%, the organic content is 0.6%, and water makes up 4%. However, in the dentin, the inorganic content is 70% to 75%, the organic content is 20%, and water makes up 10%; in alveolar bone, the inorganic, organic, and water contents are 65%, 25%, and 10%, respectively.17 Lee and Kim18 evaluated the postoperative safety of AutoBT. In 37 patients (23 men and 14 women), bone graft using AutoBT after tooth extraction was performed from October 2008 to December 2009. Postsurgical complications pertinent to bone graft materials were examined by reviewing radiographs and medical records. In 8 implants of 7 patients, hematoma and wound dehiscence developed, all of which were treated successfully by conservative treatments. All cases who developed wound dehiscence achieved favorable secondary healing and none developed infection. In addition, by clinical and radiological evaluation, the residue of a substantial amount of the exposed AutoBT was detected. Jeong et al19 performed the clinical study of graft materials using autogenous teeth in maxillary sinus augmentation. In cases using autogenous tooth bone graft alone, or together with other graft material, the implant survival rate was 96.15%. On histomorphologic examination, autogenous tooth bone graft materials showed gradual resorption and new bone formation through osteoconduction and osteoinduction. It has been reported that the tooth contains bone morphogenetic proteins and thus has osteoinductive potential.20–22 Yagihashi et al23 have reported that demineralized dentin matrix could act as a scaffold for the repair of articular cartilage defects. In addition, it was mentioned that demineralized bone matrix could maintain an acceptable
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ET AL
osteogenic capacity even after storage at room temperature for more than 10 years. Ike and Uris24 have reported that dentin root matrix could be recycled as a carrier of recombinant human bone morphogenetic proteins. Autogenous tooth bone graft materials that we used are tissues of patients themselves, with all foreign materials attached to the tooth removed and treated via lyophilization and sterilization processes. They did not induce immune reactions, and the organic components within the tooth were preserved well. Thus, we anticipated good healing after the bone graft. In our case series, excellent healing from GBR using AutoBT was observed on clinical, radiological, and histological evaluation. During the average 31-month follow-up period after final prosthesis loading, the crestal bone level in the vicinity of the implants remained stable in all patients except one, who developed wound dehiscence. However, 2 patients who developed wound dehiscence achieved favorable secondary healing almost without graft material loss. In 2 and 4-month tissue samples, good bone healing was observed. From 2 months, newly formed bone and wellvascularized loose fibrous tissues were observed. Eventually, favorable bone healing by osteoconduction and resorption of graft material was observed.
CONCLUSIONS Our case study was somewhat limited by the relatively small number of subjects. Nevertheless, given that studies reporting the clinical application of autogenous tooth bone graft materials are very rare, this study is clinically valuable. Prospective clinical studies investigating sinus bone grafts, ridge augmentation, and currently used socket preservation are required.
DISCLOSURE The authors claim to have no financial interest, directly or indirectly, in any entity that is commercially related to the products mentioned in this article.
REFERENCES 1. Kim YK, Yeo HH, Ryu CH, et al. An experimental study on the tissue reaction
of tooth ash implanted in mandible body of the mature dog. J Korean Maxillofac Plast Reconstr Surg. 1993;15:129–136. 2. Kim YK, Yeo HH, Cho JO. The experimental study of implantation combined with tooth ash and plaster of paris in the rats: Comparison according to the mixing ratio. J Korean Maxillofac Plast Reconstr Surg. 1996;18:26–32. 3. Kim YK. The development of new biomaterial for restoration of hard tissue defects. J Korean Dent Assoc. 1998;36:289–295. 4. Kim SG, Yeo HH, Kim YK. Grafting of large defects of the jaws with a particulate dentin-plaster of paris combination. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999;88:22–25. 5. Kim SG, Kim HK, Lim SC. Combined implantation of particulate dentin, plaster of paris, and a bone xenograft (Bio-Oss) for bone regeneration in rats. J Craniomaxillofac Surg. 2001;29:282–288. 6. Kim SG, Chung CH, Kim YK, et al. Use of particulate dentin-plaster of Paris combination with/without platelet-rich plasma in the treatment of bone defects around implants. Int J Oral Maxillofac Implants. 2002;17:86–94. 7. Kim YK, Kim SG, Byeon JH, et al. Development of a novel bone grafting material using autogenous teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;109:496–503. 8. Kim YK, Hwang JW, Lee HJ, et al. Use of the coronoid process as a donor site for sinus augmentation: A case report. Int J Oral Maxillofac Implants. 2009;24:1149–1152. 9. Chiapasco M, Casentini P, Zaniboni M. Bone augmentation procedures in implant dentistry. Int J Oral Maxillofac Implants. 2009;24:237–259. 10. Kim YK, Kim SG, Lee BG. Bone graft and implant. Vol. 1. Bone biology and bone graft material. Narae Publishing Inc. 2007;24–75. 11. Misch CE, Dietsh F. Bone-grafting materials in implant dentistry. Implant Dent. 1993;2:158–167. 12. Lane JM. Bone graft substitutes. West J Med. 1995;163:565–566. 13. Morelli T, Neiva R, Wang HL. Human histology of allogeneic block grafts for alveolar ridge augmentation: Case report. Int J Periodontics Restorative Dent. 2009;29:649–656. 14. Proussaefs P. Clinical and histologic evaluation of the use of mandibular tori as donor site for mandibular block autografts: Report of three cases. Int J Periodontics Restorative Dent. 2006;26:43–51. 15. Hassan KS, Kassim A, Al Ogaly AU. A comparative evaluation of immediate dental implant with autogenous versus synthetic guided bone regeneration. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106:e8–e15.
IMPLANT DENTISTRY / VOLUME 23, NUMBER 2 2014 16. Lee SH, Yoon HJ, Park MK, et al. Guided bone regeneration with the combined use of resorbable membranes and autogenous drilling dust or xenografts for the treatment of dehiscence-type defects around implants: An experimental study in dogs. Int J Oral Maxillofac Implants. 2008; 23:1089–1094. 17. Min BM. Oral Biochemistry. Narae Publishing Inc. 2007;8:64. 18. Lee JY, Kim YK. Retrospective cohort study of autogenous tooth bone graft. Oral Biol Res. 2012;36:39–43.
19. Jeong KI, Kim SG, Kim YK, et al. Clinical study of graft materials using autogenous teeth in maxillary sinus augmentation. Implant Dent. 2011;20:471– 475. 20. Inoue T, Deporter DA, Melcher AH. Induction of cartilage and bone by dentin demineralized in citric acid. J Period Res. 1986;21:243–255. 21. Bessho K, Tanaka N, Matsumoto J, et al. Human dentin-matrix-derived bone morphogenetic protein. J Dent Res. 1991; 70:171–175.
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22. Bessho K, Tagawa T, Murata M. Purification of rabbit bone morphogenetic protein derived from bone, dentin, and wound tissue after tooth extraction. J Oral Maxillofac Surg. 1990;48:162–169. 23. Yagihashi K, Miyazawa K, Togari K. Demineralized dentin matrix acts as a scaffold for repair of articular cartilage defects. Calcif Tissue Int. 2009;84:210–220. 24. Ike M, Urist MR. Recycled dentin root matrix for a carrier of recombinant human bone morphogenetic protein. J Oral Implantol. 1998;24;124–132.
GUIDED BONE REGENERATION
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ET AL
Guided Bone Regeneration Using Autogenous Tooth Bone Graft in Implant Therapy: Case Series Young-Kyun Kim, DDS, PhD,* Su-Gwan Kim, DDS, PhD,† Ji-Hyun Bae, DDS, PhD,‡ In-Woong Um, DDS, PhD,§ Ji-Su Oh, DDS, PhD,k and Kyung-In Jeong, DDS, MSD¶
one dehiscence or fenestration is developed in many implant treatment cases, and guided bone regeneration (GBR) using bone graft materials is becoming a common procedure. The most ideal materials for GBR are autogenous bone. Nevertheless, the main limitation to autogenous bone grafts is the inability to harvest large amounts of tissue. Also, complications in the donor area are abundant, and resorption after graft is substantial. Therefore, the bone substitutes include allogenic, xenogeneic, and alloplastic materials that have been developed and used in clinics. However, in terms of bone healing, it is true that these are inferior to autogenous bone. From 1993, Kim et al1–6 have been engaged in the development of materials using human teeth and have conducted experimental studies and published several papers. Based on
B
*Professor, Department of Oral and Maxillofacial Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea. †Professor, Department of Oral and Maxillofacial Surgery, School of Dentistry, Chosun University, Gwangju, Republic of Korea. ‡Assistant Professor, Department of Conservative Dentistry, Seoul National University Bundang Hospital, Seongnam, Republic of Korea. §CTO, R&D Director, Korea Tooth Bank, Republic of Korea. kAssistant Professor, Department of Oral and Maxillofacial Surgery, School of Dentistry, Chosun University, Gwangju, Republic of Korea. ¶Fellow, Department of Oral and Maxillofacial Surgery, School of Dentistry, Chosun University, Gwangju, Republic of Korea.
Reprint requests and correspondence to: Su-Gwan Kim, DDS, PhD, Department of Oral and Maxillofacial Surgery, School of Dentistry, Chosun University, 375, SeoSukDong, DongGu, Gwangju 501-759, Republic of Korea, Phone: 82-62-220-3819, Fax: 82-62-228-7316, E-mail: [email protected] ISSN 1056-6163/14/02302-138 Implant Dentistry Volume 23 Number 2 Copyright © 2014 by Lippincott Williams & Wilkins DOI: 10.1097/ID.0000000000000046
Recently, techniques have been reported that involve the preparation of extracted teeth from patients used as particulated bone graft materials for bone graft purposes. For implant placement and bone graft, autogenous teeth bone graft materials were used in 15 patients, and clinically
excellent results were obtained. In histological examination, favorable bony healing by osteoconduction was observed. (Implant Dent 2014; 23:138–143) Key Words: bone graft, dental implant, tooth bone
these results, studies have been conducted to develop and evaluate new materials with bone regeneration capacity similar to autogenous bones that could overcome shortcomings of allogenic bones, xenogeneic bones, and synthetic bones. Recently, bone graft materials using extracted autogenous teeth were developed successfully.7 We performed GBR using autogenous tooth bone graft materials (AutoBT; Korea Tooth Bank Co., Seoul, Korea) in 15 patients, and good outcomes were obtained. Here, we report the cases together with histological findings.
simultaneously. In 7 patients, membranes were not used, but the other 8 patients received resorbable collagen membranes. Regarding autogenous tooth bone graft materials, blocks were used in 1 patient, and powder materials were used in the other patients. No patient received additional bone graft materials. The mean primary stability of the placed implants was 72 implant stability quotient (ISQ), and the mean secondary stability was 81 ISQ. Regarding postsurgical complications, wound dehiscence developed in 3 cases. Among them, 2 cases achieved favorable secondary healing and showed almost no crestal bone loss, but 2 implants in 1 case had crestal bone loss of 3.6 and 2.5 mm. One case developed a postsurgical hematoma that resolved uneventfully. The follow-up period after completion of the upper prosthesis was 7 to 45 months, average 31 months. All implants maintained normal function (Table 1).
CASE SERIES Implant placement and GBR were performed on 15 patients ranging in age from 27 to 68 years (mean age, 49.9 years). Eight patients were male and 7 were female. Four patients were being medically treated for cardiac disease, hypertension, thyroid disease, or diabetes mellitus, which were well controlled in all patients. Twenty-three implants were placed in the maxillary and mandibular molars. In 2 implants of 2 patients, sinus lifting was performed
Case 1 (#15)
A 33-year-old female patient presented because of pain in the left mandibular 1st molar and gingival
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Table 1. Case Summary of Guided Bone Regeneration Case
Age (y)
1 2
Sex
Area
Surgery
Type
Membrane
Comp
39 45
F M
SL No
Powder Powder
No Yes
No No
3 4 5 6
45 27 62 40
M F M M
No No SL No
Powder Powder Block Powder
Yes No No Yes
No No No WD, BL
7 8 9 10
47 61 57 52
F F M M
No No No No
Powder Powder Powder Powder
Yes No No No
No No No No
11 12 13
49 68 63
F M M
No No No
Powder Powder Powder
Yes Yes No
Hematoma WD No
14 15
61 33
F F
17 35 36 37 47 36 16 36 37 37 36 24 46 47 36 46 36 37 26 27 46 36 37
No No
Powder Powder
Yes Yes
WD No
Mean
49.9
Primary Stability
Secondary Stability
Follow-up Period (mo)
Bone Loss
57 57 74 78 76 85 72 64 68 32 85 88 80 79 44 53 78 80 75 71 85 81 91 72
78 86 88 86 80 88 75 73 80 86 85 67 86 90 69 70 88 82 78 77 78 86 85 81
31 43
0 0 0 0.5 0 0.2 1 3.6 2.5 0 0 0 0.7 0.3 0 0.2 0.5 0.2 0.8 0 0 0.4 0 0.47
42 38 41 12 42 42 26 14 7 8 45
27 41 31
SL indicates sinus lifting; WD, wound dehiscence.
Fig. 1. Panoramic radiograph taken at the initial examination. Left mandibular 1st molar was extracted and fabricated into AutoBT powder.
Fig. 2. Photograph of the oral cavity after implant placement. Periimplant bone defects are observed.
Fig. 3. Image after grafting AutoBT powder to periimplant bone defects. BioGide membrane was covered.
Fig. 5. Second surgery was performed, and excellent bony healing was observed.
Fig. 4. Periapical radiograph 2 weeks after implant placement.
Fig. 6. Panoramic radiograph 41 months after final prosthetic delivery.
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Case 2 (#14)
Fig. 7. Implant was placed.
Fig. 8. AutoBT powder was grafted around the periimplant bone defect.
Fig. 9. Wound dehiscence was developed 1 week after operation.
Fig. 10. Periapical radiograph 1 week after implant placement. Good secondary healing was achieved, and the loss of bone graft material was minimal after 1 month.
Fig. 11. Periapical radiograph 1 month after final prosthetic delivery.
Fig. 12. Periapical radiograph 27 months after the final prosthetic delivery. The periimplant bone level remained relatively stable.
swelling. Because of severe caries in the lower cantilever prosthesis, subsequent implant placement after tooth extraction was planned. The upper prosthesis was removed and the 1st molar was extracted, after which autogenous tooth bone graft powder (AutoBT) was prepared. Two weeks after extraction, the flap was lifted, and 2 implants (Osstem GS III; Osstem Implant Co., Busan, Korea) were placed. The primary stability measured by an Osstell Mentor (Integration Diagnostics AB, Göteberg, Sweden) was #36 (81), #37 (91) ISQ value. After placement, the AutoBT powder was grafted to the periimplant bone defect area, which was covered with resorbable collagen membranes (BioGide; Geistlich Pharma AG, Wolhausen, Switzerland), after which the wound was sutured. Three months later, the implants were exposed by a secondary surgery, and excellent bone healing was observed. The upper prosthesis treatment was completed successfully. Up to 41 months after prosthetic loading, the implants remained stable (Figs. 1–6).
A 61-year-old female patient presented because of pain in the right mandibular 1st molar. On clinical and radiological examination, mobility and a periapical radiolucent lesion were observed. Thus, extraction and subsequent implant placement were planned. The 1st molar was extracted and powder type AutoBT was prepared. One month after extraction, an implant (Implantium Superline; Dentium, Seoul, Korea) was placed and AutoBT powder was grafted to the periimplant defects area, which was covered with resorbable collagen membranes (BioArm; ACE Surgical Supply Co., Brockton, MA), after which the wound was sutured. The stitches were removed 1 week postoperatively. As wound dehiscence developed, the cover screws were partially exposed. To prevent secondary infection, the patient was instructed to use an antibiotic and chlorhexidine rinse. One month after implant placement, a healing abutment was connected. Eight weeks after implant placement, a final prosthesis was loaded. Despite the development of wound dehiscence, secondary infection was absent, and a large amount of AutoBT powder remained. Twentyseven months after final prosthesis loading, the implant remained stable (Figs. 7–12). Fabrication Process of Autogenous Tooth Bone Graft Materials
Extracted teeth were immersed in 70% ethyl alcohol and transported to a company specializing in the treatments (Korea Tooth Bank Co.). At the company, soft tissues, calculus, and foreign materials (eg, prosthesis and endodontic filling materials attached to the tooth) were removed, crowns were severed, and the root portions were crushed. The particle size was prepared in different 2 sizes, as requested by the dentists. For GBR, they were prepared as 0.5 to 1 mm particles, and for sinus bone graft and ridge augmentation, they were prepared as 1 to 2 mm particles. The crushed tooth particles were added to distilled water and a hydrogen peroxide solution, and the residual foreign materials were removed by washing with ultrasonography. The washed
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formed bones, and well-vascularized dense fibrous tissues were observed. Newly formed bone infiltrated into the resorbed site of the graft material (Fig. 14).
DISCUSSION
Fig. 13. The 2-month tissue sample. Dentin graft materials and newly formed immature woven bones were fused directly, and newly formed immature woven bones were surrounded by well-vascularized loose fibrous tissues (hematoxylin-eosin stain, 3100).
Fig. 14. The 4-month tissue sample. Immature woven bone formation around the graft material and abundant vascularized fibrous tissues were observed. Newly formed bone infiltrated into the resorbed site of the graft material (hematoxylin-eosin stain, 3200).
tooth particles were dehydrated with an ethyl alcohol solution and defatted subsequently with an ethyl ether solution. Subsequently, they were partially demineralized, and after a lyophilization process, the teeth were sterilized with ethylene oxide gas. The products were then packaged and transported to the requested dental clinics. Histological Findings
Tissue samples were harvested during the second surgery 2 and 4 months after the AutoBT graft in patients. The bone graft area could be identified macroscopically, and using a #15 surgical blade, a wedge incisional biopsy was performed. The specimens were fixed in 10% formalin for 24 hours and decalcified in Calci-Clear Rapid (National Diagnostics, Atlanta, GA)
for 12 hours. The tissues were rinsed in running water, treated with a Hypercentre XP tissue processor (Shandon, Cheshire, United Kingdom), embedded in paraffin, cut to a thickness of 4 to 5 mm, and stained with hematoxylin and eosin. The prepared specimens were observed using light microscopy. After 2 months, tissue samples showed several inflammatory cells and hemorrhage findings. The finding of the direct union with new bones by osteoconduction was shown, and loose fibrous tissue and bone were infiltrated into the resorbed site of the graft material. Most of the new bone formation was limited around the dentin graft materials. Well-vascularized loose fibrous tissues surrounded newly formed woven bone (Fig. 13). In the 4-month samples, graft materials were directly fused with newly
Regarding the reconstruction of hard tissue defects, several studies8,9 support that autogenous bone grafts are the most ideal implant. The advantages of using this autogenous bone include its increased capacity for bone formation, osteoconduction, and osteoinduction. It does not induce immunologic rejection, and it heals rapidly. Nonetheless, the biggest shortcomings are that the harvest amount is limited and that harvesting bone induces a secondary defect. Allogenic bone and xenogeneic bone were developed as the substitutes for autogenous bone but have the risk of inducing immunologic rejection or infection and contamination. However, some investigators favor synthetic bone secondary to a decreased risk of infection compared to the xeno- and allogenic options. It is evident that it has only osteoconduction capacity, and bone healing capacity is low in comparison with autogenous bone or allogenic bone.10–14 Hassan et al15 placed implants immediately after tooth extraction, performed GBR using autogenous bone and synthetic bone, and conducted clinical comparative studies. They observed that, after 12 months, the autogenous bone graft group showed good outcomes of the pocket depth in the vicinity of implants, clinical attachment level, and the resorption of the alveolar bone. Clinically, they also reported that autogenous bone graft showed noticeably better results than synthetic bone graft. Lee et al16 conducted animal experiments investigating the bone dehiscence defect area restored with autogenous bone powder collected during the implant drilling procedure and xenogeneic bone. The results showed that in the experimental group, who were treated with autogenous bone powder, the boneimplant contact rate was higher, and the results of good bone formation were obtained. This result supports the usefulness of autogenous bone for the treatment of bone dehiscence defect areas.
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GUIDED BONE REGENERATION
Kim et al7 reported that AutoBT underwent gradual resorption and was replaced by new bone of excellent quality through osteoinduction and osteoconduction. The AutoBT contains both inorganic and organic materials, and the major component of the inorganic material contains 4 types of calcium phosphate (hydroxyapatite, tricalcium phosphate, amorphous calcium phosphate, and octacalcium phosphate). The chemical composition of teeth is very similar to that of bone. In the enamel, the total inorganic content is 95%, the organic content is 0.6%, and water makes up 4%. However, in the dentin, the inorganic content is 70% to 75%, the organic content is 20%, and water makes up 10%; in alveolar bone, the inorganic, organic, and water contents are 65%, 25%, and 10%, respectively.17 Lee and Kim18 evaluated the postoperative safety of AutoBT. In 37 patients (23 men and 14 women), bone graft using AutoBT after tooth extraction was performed from October 2008 to December 2009. Postsurgical complications pertinent to bone graft materials were examined by reviewing radiographs and medical records. In 8 implants of 7 patients, hematoma and wound dehiscence developed, all of which were treated successfully by conservative treatments. All cases who developed wound dehiscence achieved favorable secondary healing and none developed infection. In addition, by clinical and radiological evaluation, the residue of a substantial amount of the exposed AutoBT was detected. Jeong et al19 performed the clinical study of graft materials using autogenous teeth in maxillary sinus augmentation. In cases using autogenous tooth bone graft alone, or together with other graft material, the implant survival rate was 96.15%. On histomorphologic examination, autogenous tooth bone graft materials showed gradual resorption and new bone formation through osteoconduction and osteoinduction. It has been reported that the tooth contains bone morphogenetic proteins and thus has osteoinductive potential.20–22 Yagihashi et al23 have reported that demineralized dentin matrix could act as a scaffold for the repair of articular cartilage defects. In addition, it was mentioned that demineralized bone matrix could maintain an acceptable
KIM
ET AL
osteogenic capacity even after storage at room temperature for more than 10 years. Ike and Uris24 have reported that dentin root matrix could be recycled as a carrier of recombinant human bone morphogenetic proteins. Autogenous tooth bone graft materials that we used are tissues of patients themselves, with all foreign materials attached to the tooth removed and treated via lyophilization and sterilization processes. They did not induce immune reactions, and the organic components within the tooth were preserved well. Thus, we anticipated good healing after the bone graft. In our case series, excellent healing from GBR using AutoBT was observed on clinical, radiological, and histological evaluation. During the average 31-month follow-up period after final prosthesis loading, the crestal bone level in the vicinity of the implants remained stable in all patients except one, who developed wound dehiscence. However, 2 patients who developed wound dehiscence achieved favorable secondary healing almost without graft material loss. In 2 and 4-month tissue samples, good bone healing was observed. From 2 months, newly formed bone and wellvascularized loose fibrous tissues were observed. Eventually, favorable bone healing by osteoconduction and resorption of graft material was observed.
CONCLUSIONS Our case study was somewhat limited by the relatively small number of subjects. Nevertheless, given that studies reporting the clinical application of autogenous tooth bone graft materials are very rare, this study is clinically valuable. Prospective clinical studies investigating sinus bone grafts, ridge augmentation, and currently used socket preservation are required.
DISCLOSURE The authors claim to have no financial interest, directly or indirectly, in any entity that is commercially related to the products mentioned in this article.
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