Introduction

Advancements in dental implant technology have been documented and corroborated by their well-established, long-term success rates.1,2  The successful use of dental implants for replacing missing dentition requires adequate available bone in the treatment-planning phase. In clinical scenarios with substantial alveolar bone resorption, multiple surgical techniques for regenerating osseous defects have been suggested in the dental literature.3,4  For osseous wound space maintenance, titanium mesh (TiMe) for guided bone regeneration (GBR) has been used with desirable outcomes.4,5 

TiMe has been successfully used for GBR,510  sinus augmentation,11  correction of cleft palate,9,12  and simultaneously with implant placement.13,14  Moreover, TiMe has been used successfully with different types of graft materials.1519  This includes autogenous bone graft,15,16  xenograft,15  allograft,17  hydroxyapatite,18  and bone morphogenetic proteins.16,19  Several advantages of TiMe have been reported in the literature, such as material-related rigidity and biocompatibility, which provide the best dimensional containment (height and width) of the bone graft material.4,20 

Systematic reviews,25  clinical studies,815,18,21  and clinical case reports7,19,2225  have reported several complications with TiMe. TiMe exposure was reported to be the most common complication.25,825  TiMe exposure has been reported with different rates in the literature ranging from 5% up to 50%.4,810,13,21,2630  The mean exposure rate was found to be 20.7%.4  The average reported bone regeneration with TiMe was 4.91 mm (2.56–8.6 mm) vertically and 4.36 mm (3.75–5.65 mm) horizontally.4 

The cause-and-effect relationship between TiMe exposure and bone loss has been reported in clinical studies.4,8,11,21,29  To overcome this complication, exposure is treated with the topical application of chlorhexidine gel to avoid surgical site suprainfection.4  In a more aggressive TiMe exposure, shown in 20% of clinical situations, the removal of TiMe is found to be necessary.4  Early exposure of the TiMe at 3 to 4 weeks has been shown to increase the chance of membrane removal.4,27  Proper TiMe planning and simulation of the GBR surgery on a model prior to preforming the surgery may reduce the chance of such exposures. This model planning may allow visualization of where to place the TiMe, where to place the bone screws/tacks, and a custom-formed TiMe.

The purpose of this clinical technique report is to introduce a time-efficient TiMe positioning jig from a digitally planned virtually regenerated ridge and a 3-dimensional (3D)–printed surgical model. A 3D surgical model was created virtually from a cone-beam computerized tomography (CBCT) scan. Missing teeth were arranged based on available prosthetic space, required bone volume (horizontally and vertically) was created digitally, and the new alveolar bone architecture was printed. The surgical procedure was performed as a mock surgery on the printed 3D surgical model, and the design of the TiMe with the location of the bone tacks/screws was preserved. The new 3D surgical model with the simulated surgery was used to fabricate a TiMe positioning jig with all required dimensions.

Technique Report

Patient history

A 56-year-old female patient presented to the Center for Implant Dentistry at Loma Linda University to address her chief complaint of replacing her missing teeth. The patient lost teeth Nos. 6–9 due to a traumatic injury, which left a large bony defect. The patient's dental history revealed 2 previous unsuccessful bone-grafting procedures using a resorbable membrane. The patient explained there was no second surgery to remove any hardware postaugmentation. The referring office did not have information on the technique/materials used, as it was done elsewhere. Review of the patient's medical history did not reveal any contraindication to oral surgical procedures.

Intraoral examination revealed a severe horizontal and vertical bone defect and thin buccal soft tissue at the area of teeth Nos. 6–9 (Figure 1). CBCT (NewTom Go, NewTom, Verona, Italy) revealed horizontal and vertical bone defect, confirming our clinical impression (Figure 2). After discussing various treatment options, the decision was made to perform a GBR to restore the bony defect, followed by the placement of root form endosseous implants and restoration with an implant-supported fixed partial denture. Considering the size and morphology of the defect, TiMe was to be used to maintain the bone graft to restore the osseous defect.

Figures 1–6

Figure 1. Preoperative frontal intraoral view. Figure 2. Three-dimensional (3D) reconstruction frontal view obtained from patient's cone-beam computerized tomography scan. Figure 3. 3D virtual frontal view of defect. Figure 4. 3D virtual frontal view of virtual teeth wax patterns over defect. Figure 5. (a) Frontal view of planned 3D virtual ridge augmentation in relation to teeth wax patterns. (b) Occlusal view of planned 3D virtual ridge augmentation in relation to teeth wax patterns. Figure 6. (a) Frontal view of final planned 3D virtual ridge augmentation. (b) Occlusal view of final planned 3D virtual ridge augmentation.

Figures 1–6

Figure 1. Preoperative frontal intraoral view. Figure 2. Three-dimensional (3D) reconstruction frontal view obtained from patient's cone-beam computerized tomography scan. Figure 3. 3D virtual frontal view of defect. Figure 4. 3D virtual frontal view of virtual teeth wax patterns over defect. Figure 5. (a) Frontal view of planned 3D virtual ridge augmentation in relation to teeth wax patterns. (b) Occlusal view of planned 3D virtual ridge augmentation in relation to teeth wax patterns. Figure 6. (a) Frontal view of final planned 3D virtual ridge augmentation. (b) Occlusal view of final planned 3D virtual ridge augmentation.

Virtual GBR and 3D model fabrication

Maxillary and mandibular irreversible hydrocolloid impressions (Jeltrate Plus, Dentsply International Inc, York, Penn) were made and study casts were fabricated. The study casts were mounted on a Panadent articulator (Magnetic Model PCH Articulator, Panadent, Colton, Calif). A diagnostic wax pattern was made and scanned with a 3Shape D900 lab scanner (3Shape, Copenhagen, Denmark). The stereo lithography files for both the maxillary CBCT (InVivo5, Anatomage, San Jose, Calif) and scanned diagnostic wax up (Dental System Premium, 3Shape) were imported to Geomagic Studio 2012 software (Geomagic, Morrisville, NC; Figure 3). Both of the obtained 3D virtual models were superimposed (Figure 4). This created a virtual 3D model showing the bony defect and desired prosthetic outcome. A virtual GBR was made using Meshmixer 3D sculpting and modeling software (Autodesk, San Rafael, Calif), in which the bone defect was modified to the desired alveolar ridge dimensions virtually, using the final prosthetic outcome as a guide (Figures 5 and 6). The obtained digital 3D model with the virtual GBR (3D-GBR model) was then 3D printed (Formlabs, Somerville, Mass; Figure 7). A prefabricated TiMe (Titanium Augmentation Micro Mesh, ACE Surgical Supply, Inc, Brockton, Mass) was modified, adjusted, and adapted to the 3D-GBR model. Following adaptation of the TiMe to the model, 4 bone tacks were placed corresponding to the future surgical position to fixate the TiMe to the 3D-GBR model (Figure 8). A positioning jig for the TiMe was fabricated using a polyolefine material (MG21, Molten Medical Inc, Tokyo, Japan) with a vacuum former (Pro-form, Dental Resources, Inc, Delano, Minn; Figure 9). The positioning jig was then removed and trimmed to the desired extensions. The TiMe was retrieved and autoclaved (Figure 10).

Figures 7–9

Figure 7. (a) Frontal view of 3D-printed maxillary model with final planned virtual ridge augmentation. (b) Occlusal view of 3D printed maxillary model with final planned virtual ridge augmentation. Figure 8. Frontal view showing titanium mesh form and positioned with fixation screws on 3D-printed model. Figure 9. Different views of positioning thermoplastic jig fabricated on formed titanium mesh over 3D-printed model. (a) Occlusal view. (b) Frontal view. (c) Palatal view.

Figures 7–9

Figure 7. (a) Frontal view of 3D-printed maxillary model with final planned virtual ridge augmentation. (b) Occlusal view of 3D printed maxillary model with final planned virtual ridge augmentation. Figure 8. Frontal view showing titanium mesh form and positioned with fixation screws on 3D-printed model. Figure 9. Different views of positioning thermoplastic jig fabricated on formed titanium mesh over 3D-printed model. (a) Occlusal view. (b) Frontal view. (c) Palatal view.

Figures 10 and 11

Figure 10. Different views of the thermoplastic positioning jig. (a) Frontal view of the positioning jig alone. (b) Palatal view of the positioning jig with titanium mesh in place. (c) Frontal view of the positioning jig with titanium mesh in place. Note how stable the titanium mesh is and how well retained by the positioning jig. Figure 11. (a) Intraoperative frontal view of bony defect. (b) Intraoperative occlusal view of bony defect.

Figures 10 and 11

Figure 10. Different views of the thermoplastic positioning jig. (a) Frontal view of the positioning jig alone. (b) Palatal view of the positioning jig with titanium mesh in place. (c) Frontal view of the positioning jig with titanium mesh in place. Note how stable the titanium mesh is and how well retained by the positioning jig. Figure 11. (a) Intraoperative frontal view of bony defect. (b) Intraoperative occlusal view of bony defect.

Surgery

Donor Site

Under local anesthesia, a crestal incision was made distal to tooth No. 31, which followed the direction of the ramus with a sulcular incision buccal to Nos. 30 and 31. A full-thickness buccal flap was reflected. Autogenus bone was harvested from the ramus with the use of a bone-collecting scraping device (Safescraper Twist META, Reggio Emilia, Italy). Approximately 1.5 mL of cortical bone graft shavings was harvested. The flap was reapproximated and sutured using a polyglactin 5.0 suture (Vicryl sutures, Ethicon Inc, Guaynabo, Puerto Rico).

Recipient Site and Guided TiMe GBR

Local anesthesia was administered labially and palatally to the area of teeth Nos. 5–13. A crestal incision was made from the area of teeth Nos. 6–9, with buccal and palatal sulcular incisions around Nos. 4–13 and 2 distal vertical incisions at the area of teeth Nos. 4 and 13. Full-thickness labial and palatal flaps were reflected (Figure 11). The content of the nasopalatine canal was removed using Lucas surgical curettes (Hu-Friedy, Chicago, Ill) and thoroughly irrigated. The buccal bone of the defect was decorticated to induce bleeding and promote the incorporation of the graft. The harvested bone graft was mixed with inorganic bovine mineral (Bio-Oss, Osteohealth Co, Shirley, NY). The bone mixture was further mixed with the patient's consternated blood fibrin. The nasopalatine canal was filled with the bone graft mixture. The positioning jig was tried in with the TiMe (Figure 12a). Bone graft was then loaded on the intaglio surface of the TiMe extraorally while it was held with the positioning jig (Figure 12b and c). The TiMe was placed in the defective site intraorally in the same planned position with the use of the positioning jig (Figure 12d and e). Two bone screws were placed buccally and 2 palatally to fixate and secure the TiMe in place. The poisoning jig was then removed, and more bone graft was condensed underneath the TiMe. Periosteal fenestration was performed along the labial-buccal flap to enable primary closure. Three platelet-rich fibrin membranes (Figure 13a) were placed over the TiMe to accelerate wound healing and minimize the early exposure of the TiMe.20  The vertical incisions were sutured with chromic gut suture (Johnson & Johnson, Somerville, NJ), and the crestal incisions were sutured with expanded polytetrafluoroethylene monofilament suture (Gore-Tex, W. L. Gore and Associates Inc, Flagstaff, Ariz) and polyglactin (Vicryl sutures, Ethicon Inc; Figure. 13b).

Figures 12 and 13

Figure 12. (a) Frontal view of the positioning jig with the titanium mesh in place for try-in intraoperatively. (b) Bone graft being loaded onto titanium mesh. (c) Titanium mesh placed on the positioning jig to be transferred to the patient's mouth. (d) Frontal view of the positioning jig retaining the titanium mesh and bone graft on bony defect. Note that the titanium mesh was very stable and being held to place fixation screws. (e) Occlusal view following fixation of titanium mesh and positioning jig in place prior to its removal. Figure 13. (a) Platelet-rich fibrin membrane placed over titanium mesh. (b) Final suturing of operative area.

Figures 12 and 13

Figure 12. (a) Frontal view of the positioning jig with the titanium mesh in place for try-in intraoperatively. (b) Bone graft being loaded onto titanium mesh. (c) Titanium mesh placed on the positioning jig to be transferred to the patient's mouth. (d) Frontal view of the positioning jig retaining the titanium mesh and bone graft on bony defect. Note that the titanium mesh was very stable and being held to place fixation screws. (e) Occlusal view following fixation of titanium mesh and positioning jig in place prior to its removal. Figure 13. (a) Platelet-rich fibrin membrane placed over titanium mesh. (b) Final suturing of operative area.

Discussion

The use of a TiMe has been reported in the literature as having effective results with both horizontal and vertical bone grafting.4,20  The advantage of nonresorbable rigid devices is their ability to retain a desired shape and volume throughout the entire healing period.28  TiMe's biological and mechanical properties have been rigorously tested in oral and maxillofacial surgeries.47  The most reported complication of TiMe use is exposure of the membrane during the healing period.25,825  One of the causes of this exposure is irritation of the soft tissue, which can be caused by sharp contours of the TiMe.31  These sharp contours are caused by the required cutting and bending needed to create a well-adapted TiMe. Other causes include not being able to obtain tension-free closure, difficult suturing technique, incompliant patient, and infection.24 

It has been advocated that TiMe be premolded prior to surgery.31  With the evolution of computer-aided design and computer-aided manufacturing (CAD-CAM) technology, it has become possible to design and 3D print bone models.32  In this technique article, we proposed digitally designing the desired ridge augmentation. This allows a specific size and volume of augmentation to be designed based on the prosthetically planned tooth positions. With this information, the size of the GBR can be oversized to compensate for any graft consolidation and/or resorption. Using these 3D-printed models, TiMe can be precut and adapted to the model to reduce surgical time. The lack of rigidity of the mesh prior to stabilization to the bone can be an issue when placing the mesh. If the mesh is not properly placed, the preestablished contours may not be favorable for healing and may lead to membrane exposure. Therefore, to ensure ideal placement and further reduce surgical time, the proposed placement jig can be used.

A previously published article discussing a technique to fabricate a CAD-CAM TiMe proposed the following benefits: reduced intervention time, reduced volume to augment, and improved strength of the mesh.32  With the use of this proposed technique, the same benefits can be attained without the increased cost of custom laser sintering of a TiMe. While the strength of the mesh may not reach the strength of the custom laser-sintered TiMe, the ability to preform and accurately place the mesh should increase its potential strength.

Future advancements of this technique could include the fabrication of a 3D-printed positioning jig as well as a combination of a custom laser-sintered TiMe with a 3D-printed positioning jig. Further use of this technique is required prior to realization of its full benefits; however, the proposed technique shows many positive features.

Conclusions

Digitally designing the GBR based on the final prosthetic outcome can allow the clinician to precisely augment a defect. The ability to 3D print a model also allows the clinician to perform a model-based surgery to preform the TiMe and fabricate a positioning jig to aid in placement and stabilization of the membrane. Although this technique does not affect the final outcome of the augmentation procedure; it can greatly reduce surgical time and potential errors in forming the membrane chairside as well as positioning it intraorally.

Abbreviations

    Abbreviations
     
  • 3D

    3-dimensional

  •  
  • CAD-CAM

    computer-aided design and computer-aided manufacturing

  •  
  • CBCT

    cone-beam computerized tomography

  •  
  • GBR

    guided bone regeneration

  •  
  • TiMe

    titanium mesh

Note

The authors report no conflicts of interest related to this study.

References

References
1
Milinkovic
I,
Cordaro
L.
Are there specific indications for the different alveolar bone augmentation procedures for implant placement? A systematic review
.
Int J Oral Maxillofac Surg
.
2014
;
43
:
606
625
.
2
Clementini
M,
Morlupi
A,
Canullo
L,
Agrestini
C,
Barlattani
A.
Success rate of dental implants inserted in horizontal and vertical guided bone regenerated areas: a systematic review
.
Int J Oral Maxillofac Surg
.
2012
;
41
:
847
852
.
3
Polo
MR,
Poli
PP,
Rancitelli
D,
Beretta
M,
Maiorana
C.
Alveolar ridge reconstruction with titanium meshes: a systematic review of the literature
.
Med Oral Patol Oral Cir Bucal
.
2014
;
19
:
639
646
.
4
Rakhmatia
YD,
Ayukawa
Y,
Furuhashi
A,
Koyano
K.
Current barrier membranes: titanium mesh and other membranes for guided bone regeneration in dental application
.
J Prosthodont Res
.
2013
;
57
:
3
14
.
5
Boyne
PJ,
Cole
MD,
Stringer
D,
Shafqat
JP.
A technique for osseous restoration of deficient edentulous maxillary ridges
.
J Oral Maxillofac Surg
.
1985
;
43
:
87
91
.
6
Lozada
J,
Proussaefs
P.
Clinical, radiographic, and histologic evaluation of maxillary bone reconstruction by using a titanium mesh and autogenous iliac graft: a case report
.
J Oral Implantol
.
2002
;
28
:
9
14
.
7
Proussaefs
P,
Lozada
J.
Use of titanium mesh for staged localized alveolar ridge augmentation: clinical and histologic-histomorphometric evaluation
.
J Oral Implantol
.
2006
;
32
:
237
347
.
8
Roccuzzo
M,
Ramieri
GG,
Bunino
M,
Berronr
S.
Alveolar bone graft for patients with cleft lip/palate using bone particles and titanium mesh: a quantitative study
.
Clin Oral Implant Res
.
2007
;
18
:
286
294
.
9
Her
S,
Kang
T,
Fien
MJ.
Titanium mesh as an alternative to a membrane for ridge augmentation
.
J Oral Maxillofac Surg
.
2012
;
70
:
803
810
.
10
Papadogeorgakis
N,
Prokopidi
ME,
Kourtis
S.
The use of titanium mesh in sinus augmentation
.
Implant Dent
.
2010
;
19
:
109
114
.
11
Matsui
Y,
Obta
M,
Obno
K,
Nagumo
M.
Alveolar bone graft for patients with cleft lip/palate using bone particles and titanium mesh: a quantitative study
.
J Oral Maxillofac Surg
.
2006
;
64
:
1540
1546
.
12
von Arx
VT,
Kurt
B.
Implant placement and simultaneous ridge augmentation using autogenous bone and a micro titanium mesh: a prospective clinical study with 20 implants
.
Clin Oral Implant Res
.
1999
;
10
:
24
33
.
13
von Arx
VT,
Kurt
B.
Implant placement and simultaneous peri-implant bone grafting using a micro titanium mesh for graft stabilization
.
Int J Periodontics Restorative Dent
.
1998
;
18
:
117
127
.
14
Proussaefs
P,
Lozada
J,
Kleinman
A,
Rohrer
MD,
McMillan
PJ.
The use of titanium mesh in conjunction with autogenous bone graft and inorganic bovine bone mineral (Bio-Oss) for localized alveolar ridge augmentation: a human study
.
Int J Periodontics Restorative Dent
.
2003
;
23
:
185
195
.
15
de Freitas
RM,
Susin
C,
Spin-Neto
R,
et al.
Horizontal ridge augmentation of the atrophic anterior maxilla using rhBMP-2/ACS or autogenous bone grafts: a proof-of-concept randomized clinical trial
.
J Clin Periodontol
.
2013
;
40
:
968
976
.
16
Misch
CM,
Jensen
OT,
Pikos
MA,
Malmquist
JP.
Vertical bone augmentation using recombinant bone morphogenetic protein, mineralized bone allograft, and titanium mesh: a retrospective cone beam computed tomography study
.
Int J Oral Maxillofac Implants
.
2015
;
30
:
202
207
.
17
Ducic
Y.
Titanium mesh and hydroxyapatite cement cranioplasty: a report of 20 cases
.
J Oral Maxillofac Surg
.
2002
;
60
:
272
276
.
18
Misch
CM.
Bone augmentation of the atrophic posterior mandible for dental implants using rhBMP-2 and titanium mesh: clinical technique and early results
.
Int J Periodontics Restorative Dent
.
2011
;
31
:
581
589
.
19
Louis
PJ.
Vertical ridge augmentation using titanium mesh
.
Oral Maxillofac Surg Clin North Am
.
2010
;
22
:
353
368
.
20
Torres
J,
Tamimi
F,
Alkhraisat
MH,
et al.
Platelet-rich plasma may prevent titanium-mesh exposure in alveolar ridge augmentation with anorganic bovine bone
.
J Clin Periodontol
.
2010
;
37
:
943
951
.
21
Artzi
Z,
Dayan
D,
Alpern
Y,
Nemcovsky
CE.
Vertical ridge augmentation using xenogenic material supported by a configured titanium mesh: clinicohistopathologic and histochemical study
.
Int J Oral Maxillofac Implants
.
2003
;
18
:
440
446
.
22
Chan
HL,
Benavides
E,
Tsai
CY,
Wang
HL.
A titanium mesh and particulate allograft for vertical ridge augmentation in the posterior mandible: a pilot study
.
Int J Periodontics Restorative Dent
.
2015
;
35
:
515
522
.
23
De Angelis
N,
De Lorenzi
M,
Benedicenti
S.
Surgical combined approach for alveolar ridge augmentation with titanium mesh and rhPDGF-BB: a 3-year clinical case series
.
Int J Periodontics Restorative Dent
.
2015
;
35
:
231
237
.
24
Funato
A,
Ishikawa
T,
Kitajima
H,
Yamada
M,
Moroi
H.
A novel combined surgical approach to vertical alveolar ridge augmentation with titanium mesh, resorbable membrane, and rhPDGF-BB: a retrospective consecutive case series
.
Int J Periodontics Restorative Dent
.
2013
;
33
:
437
445
.
25
Pieri
F,
Corinaldesi
G,
Fini
M,
Aldini
NN,
Giardino
R,
Marchetti
C.
Alveolar ridge augmentation with titanium mesh and a combination of autogenous bone and anorganic bovine bone: a 2-year prospective study
.
J Periodontol
.
2008
;
79
:
2093
2103
.
26
Corinaldesi
G,
Pieri
F,
Sapigni
L,
Marchetti
C.
Evaluation of survival and success rates of dental implants placed at the time of or after alveolar ridge augmentation with an autogenous mandibular bone graft and titanium mesh: a 3- to 8-year retrospective study
.
Int J Oral Maxillofac Implants
.
2009
;
24
:
1119
1128
.
27
Roccuzzo
M,
Ramieri
G,
Spada
MC,
Bianchi
SD,
Berrone
S.
Vertical alveolar ridge augmentation by means of a titanium mesh and autogenous bone grafts
.
Clin Oral Implants Res
.
2004
;
15
:
73
81
.
28
von Arx
T,
Hardt
N,
Wallkamm
B.
The TIME technique: a new method for localized alveolar ridge augmentation prior to placement of dental implants
.
Int J Oral Maxillofac Implants
.
1996
;
11
:
387
394
.
29
Louis
PJ,
Gutta
R,
Said-Al-Naief
N,
Bartolucci
AA.
Reconstruction of the maxilla and mandible with particulate bone graft and titanium mesh for implant placement
.
J Oral Maxillofac Surg
.
2008
;
66
:
235
245
.
30
Watzinger
F,
Luksch
J,
Millesi
W,
et al.
Guided bone regeneration with titanium membranes: a clinical study
.
Br J Oral Maxillofac Surg
.
2000
;
38
:
312
315
.
31
Rengier
F,
Mehndiratta
A,
von Tengg-Kobligk
H,
et al.
3D printing based on imaging data: review of medical applications
.
Int J Comput Assist Radiol Surg
.
2010
;
5
:
335
341
.
32
Ciocca
L,
Fantini
M,
De Crescenzio
F,
Corinaldesi
G,
Scotti
R.
Direct metal laser sintering (DMLS) of a customized titanium mesh for prosthetically guided bone regeneration of atrophic maxillary arches
.
Med Biol Eng Comput
.
2011
;
49
:
1347
1352
.