Use of polyglactin 9 10 knitted mesh tubing to stabilize particulate hydroxyapatite in alveolar ridge augmentation A prelliminary report J. S. Brown, FDSRCS, FRCS,” A. Martin,b and R. P. Ward-Booth, MB, ChB, FDSRCS, FRCS,” Sunderland, SUNDERLAND
DISTRICT
GENERAL
England
HOSPITAL
A univelrsal problem with the use of hydroxyapatite (HA) particles has been the tendency for these particles to migrate beyond planned boundaries. This is a preliminary report on the use of polyglactin 910 knitted mesh (Vicryl) tubing containing HA particles in ridge-augmentation procedures, assessing the technique and the containment of HA particles. The technique is described and experience with six cases is presented. This study found no clinical or radiographic evidence of particle migration after normal function had been resumed. In one case the graft failed to become firmly incorporated with the bone and the whole graft migrated anteriorly on the mandible but still provided improved function for the patient. The technique facilitates the placement of HA particles and would be particularly useful if open mucosal flap techniques were being used for ridge augmentation. The use of Vicryl tubing for HA augmentation procedures prevents the migration of particles and allows an ea.sier and more accurate placement of the grafts. (ORAL SURC ORAL MED ORAL PATHOL 1992;73:19-22)
T
he use of h:ydroxyapatite (HA) particles to augment edentulous jaws has become an accepted lmethod of treatment.*-s It has been shown that this nonresorbable material will allow fibrous and bony tissue to become incorporated4 and may prevent resorption of bone, although long-term studies are not yet available. A universal problem has been the tendency for the particulate material to disperse beyond planned boundaries.2, 5 The migration of particles can result in mental paresthesia’ or loss of ridge form and height. As a result, various different techniques, including suturing methods, surgical stems and splints, open mucosal flap procedures, and tissue expansion, have been reported.5-10 Animal studies show that IIA particles can be successfully contained without extrusion with the use of polyglycolic acid mesh and collagen tubesI l3 With the development of Vicryl tubing, it
aRegistrar, Oral and Maxillofacial Surgery, Sunderland District General Hospital. b Dental student, Edinburgh Dental Hospital and School. CConsultant, Oral and Maxillofacial Surgery, Sunderland District General Hospital. 7/12/30252
seemed reasonable to use this material to prevent dispersion of HA particles in patients requiring ridge augmentation. METHOD
The new material supplied for this technique was polyglactin 910 knitted mesh tubing 12 mm in diameter and 15 cm long (Fig. 1). Any form of HA particle would be suitable for this technique but Alveograf was used in the patients reported. The Vicryl tubing can be tailored to the length required and one end closed with a Vicryl suture. The tubing is then filled with HA particles from a preloaded 1.2 ml. syringe, (Fig. 2). Under antibiotic cover a small incision is made at one end of the area of the jaw to be augmented and a subperiosteal tunnel is created with suitable periosteal elevators. It is advisable to make a small incision at the other end of the prepared tunnel so that the tubing can be fed into position by means of a small clip passed through the opening to hold one end of the implant, which can then be delivered gently to the desired position. No splint was placed in the immediate postoperative period. The patients were followed up regularly. Three months after the proce19
23
Brown, Martin,
and W6zrd-Boo~~a
Fig.
1. A length of polyglactin ryl) with the HA particles.
910 knitted mesh (Vic-
~&de I. Cases treated with polyglactin
Polyglactin 910 knitted mesh (Vichyi) containing the HA particles before insertion.
910 knitted mesh (Vicryl)
Site Case
Aice
Sex
1
61
2 3 4 5 6
61 73 67 62 22
M F F F F F
ofmft Anterior
Anterior Anterior Anterior Anterior Anterior
mandible mandible mandible maxilla maxilla maxilla
Further surgery
Sulcus deepening Further HA -
dure, when the implants were ;irm to Talpation, the denture was relined appropriately and normal function began. Subsequent follow-ups, including clinical and radiographic assessment of the grafts, have been performed at 6-month intervals.
The results of this study are shown in Table I. No evidence of HA particle migration was found. In one patient (case 3) the whole graft migrated on the anterior part of the mandible (Fig. 3). This may indicate a premature introduction of function in view of the need for the Vicryl to be resorbed before a firm graft to bone interface can form. In case 2 left mental paraesthesia developed after further HA particles were placed without a Vicryl tube in an additional surgical procedure. One case of postoperative infection (case 3) was cured with a course of antibiotics with minimal graft loss. Five of the six patients had improved ridge form and function. lscusslo This preliminary report on the use of Vicryl tubing demonstrates the potential advantages of the tech-
to contam HA particles Mental paresthesia
j ’
Follow-up hoi
-
18
+
18 16 19 12 9
-
-
Particle migration
-t -
nique. Initial resuits show the potential of this material in the successful containment of HA particles. The results were encouraging, and early experience has given some indications of when this technique may be particularly useful. The use of a resorbable tube to retain HA particles is not indicated in all situations. The accepted method for placing HA particles is to create a subperiostea! !tinnel into which the material can be placed.lw3 Desjardins has pointed out that placing hydroxyapatite beyond the attached gingiva may limit its use for denture support and increase the chance of dispersion of particles.2 HA particles can easily be placed with a low risk of dispersion between a prominent ridge and the external oblique ridge or in Cawood’s Class VI mandible when there is a depression in the ridge form that forms a natural gutter.14 A resorbable tube is very useful, however, when mucosal Raps are being raised to increase the augmentation,“: I3 to restore alveolar height under a bridge, or in Cawood’s Class IV (knife edge) or Class V (flat) ridges. ie The technique was found particularly useful in case 6 (Fig. 4) when resorption of the ridge above a bridge appliance resulted in an unnatural space between the teeth and the ridge. When a simple mucoperiosteal tunnel is
Polyglactin 910 knitted mesh tubing
Volume 73 Number 1
Fig. 3. Case 3. Preoperative and postoperative photographs showing the position of the graft.
raised, the material can be placed in the ideal position with less chance of migration. The mesh would also be useful in retaining particles if HA particles are being used for augmentation in the nasomaxillary and zygomatic areas of the facial skeleton. Animal studies have been carried out to ass,essthe resorption of the Vicryl mesh and show it to behave in a manner very similar to Vicryl suture material, (Hargraves J, Ethicon Ltd, personal communication, 1988) usually being resorbed within 49 to 70 days. We know of no animal studies on the use of Vicryl mesh and particulate: HA. Silverberg et a1.,13 however, looked at the use of polyglycolic acid mesh (Dexon) to contain the p,articles in rat tibias and reportled that severe displacement of the particles was prevented and that greater hydroxyapatite augmentation was possible. l3 Dexon is resorbed in a manner similar to Vicryl, and studies on the mesh have shown this material to be completely resorbed within 8.5days. In this study there was no bony ingrowth, whether tlhe HA particles were placed alone or within the Dexon mesh. The question as, to whether the mesh prevents bony ingrowth remains unanswered. Shen and Gongloff12 showed that collagen tube containers successfully re-
21
Fig. 4. Case 6. Preoperative and postoperative radiographs showing the ridge before and after augmentation. This patient had a unilateral cleft lip and palate that had been treated with an alveolar bone graft before Le Fort 1 osteotomy.
tained HA particles in nonfunctional parts of the jaws of rats. The surgical technique used to place the Vicryl tubes is simple, and in the cases reported there were few intraoperative problems. The tube is stable once in position, although in one of the patients with a severely atrophic mandible, the graft drifted anteriorly in function. In cases where the ridge is very flat, it may be beneficial to combine the Vicryl tubing with a mattress-suturing technique suggested by Propper. These sutures are passed between the bone and the graft and, while lateral migration may be minimized, the incorporation of fibrous and bony tissue into the graft may be reduced. Experience with Vicryl tubing and HA augmentation has shown that the technique has few complications, facilitates the placement of HA granules, and successfully prevents their migration. REFERENCES 1.
Kent JN, Finger IM, Quinn JH, GuerraLR. Hydroxyapatite alveolarridge reconstruction:clinical experiences,complica-
tions, and technical modifications. J &al Maxiilofac
2.
3. 4.
5.
6.
7.
8.
9.
Surg 1986;44:37-49. Desjardins RF. Hydroxyapatite for alveolar ridge augmentation. Indications and problems. J Pro&et Dent 1985;54:37483. Frame JN. Hydroxyapatite as a biomaterial for alveolar ridge augmentation. Int J Oral Maxillofac Surg 1987;16:642-55. Jarcho M, Kay JF, Gumaer KI, Doremus RH, Drobeck HB. Tissue, cellular, and subcellular events at a bone-ceramic hydroxyapatite interface. J Bioeng 1977;1:79-92. Bach DE, Downs RH, Muller JT, Nespeca 9.4. Hydroxyapatite mandibular augmentation techniques: a review and splint modification. J Prosthet Dent 1988;59:64-8. Propper RH. A technique for controlled placement of hydroxyapatite over the atrophic mandibular ridge. J Oral Maxillofac Surg 1985;43:469-70. Barret GD. Surgical stent fabrication for hydroxyapatite augmentation of the edentulous ridge. .I Prostbet Dent 1985: 54:215-20. Barson ER, Kent JN. Hydroxyapatite reconstruction of alveolar ridge deficiency with an open mucosal flap technique. OKAL SUKG ORAL MED ORAL PATHOL L985:59:113-9. Lew D, Clark R, Shabazian T. Use of a soft ‘tissue expander in alveolar ridge augmentation: a preliminary report. J Oral Maxillofac Surg 1986;44:516-9.
!O. Pham H. Use of an open splint in ridge augmentation with hydroxyapatite. J Oral Maxillofac Surg 1986;44:80-1. !I. Peterson LJ. Late complications following residual ridge reconstruction with porous hydroxyapatite blocks. J Oral Maxillofac Surg 1986;44:20-1. 12. Shen K, Gongloff RR. An effective means of controlling particulate hydroxyapatite implants. J Prosthet Dent 1986;56:6513. Silverberg M, Singh M, Sreekanth S, Gans BJ. Use of glycolic mesh to confine particulate hydroxyapaiite for mentation of bone in the rat. J Oral Maxillofac 1986;44:877-86. 14. Gawood JI, Howell RA. A classification of the edentulous Int J Oral Maxillofac Surg 198&;17:232-6. Reprint
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J.S. Brown, FDSRCS, FRCS Oral and Maxillofacial Surgery Sunderland District General Hospital Kay11 Rd Sunderland, SR4 7TP, Scotland
polyaugSurg jaws.