Journal of Oral Implantology

Prosthetically CAD-CAM guided bone augmentation of atrophic jaws using customized

titanium mesh: preliminary results of an open prospective study.
--Manuscript Draft--

Manuscript Number: aaid-joi-D-17-00125R2

Full Title: Prosthetically CAD-CAM guided bone augmentation of atrophic jaws using customized
titanium mesh: preliminary results of an open prospective study.

Short Title: Bone augmentation of atrophic jaws using customized mesh

Article Type: Clinical Research

Keywords: Bone regeneration, CAD-CAM, atrophic jaws, minimal intervention

Corresponding Author: Leonardo Ciocca, DDS, PhD, Professor of Maxillofacial Prosthodontic

University of Bologna
Bologna, Bo ITALY

Corresponding Author Secondary

Information:

Corresponding Author's Institution: University of Bologna

Corresponding Author's Secondary

Institution:

First Author: Leonardo Ciocca, DDS, PhD, Professor of Maxillofacial Prosthodontic

First Author Secondary Information:

Order of Authors: Leonardo Ciocca, DDS, PhD, Professor of Maxillofacial Prosthodontic

Giuseppe Lizio, Research Fellow

Paolo Baldissara, Aggregate Professor

Alessandro Sambuco, DDS

Roberto Scotti, Full Professor of Prosthodontics

Giuseppe Corinadesi, Aggregate Professor

Order of Authors Secondary Information:

Abstract: This study evaluated the outcomes of CAD-CAM customized titanium mesh used for
prosthetically guided bone augmentation related to the occlusion driven implant
position; to the vertical bone volume gain of mandible and maxilla; and to
complications, like mesh exposure.. Nine patients scheduled for bone augmentation of
atrophic sites were treated with custom titanium mesh and particulate bone grafts with
autologous bone and anorganic bovine bone in a 1:1 ratio prior to implant surgery.
The bone volume needed to augment was virtually projected based on implants
position, width and length, and the mesh design was programmed for the necessary
retaining screws. After 6-8 months, bone augmentations of 1.72 to 4.1 mm (mean: 3,83
mm) for the mandibular arch and 2.14 to 6.88 mm (mean: 3,95 mm) for the maxilla
were registered on cone beam CT. Mesh premature (within 4 to 6 weeks) exposure
was observed in three cases and delayed (after 4 to 6 weeks) in three other cases.
One titanium mesh was removed before the programmed time, but in all augmented
sites was possible implant insertion. No complication occurred during prosthetic follow-
up. CAD-CAM technology used for prosthetically guided bone augmentation showed
important post-operative morbidity of mesh exposure (66%). Due to this high number of
mesh exposure and the potential infection that could affect the expected bone
augmentation, this study suggests a cautious approach to this procedure when
designing the Ti-mesh, to avoid flap tension that may cause mucosal rupture.

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1 Title:

2 Prosthetically CAD-CAM guided bone augmentation of atrophic jaws using customized titanium
3 mesh: preliminary results of an open prospective study.

4 Leonardo Cioccaa, Giuseppe Liziob, Paolo Baldissarac, Alessandro Sambucod, Roberto Scottie, Giuseppe
5 Corinaldesif
6 a
DDS, PhD, Professor of Maxillo-Facial Prosthodontics, Section of Prosthodontics, Department of Biomedical and Neuromotor Science,
7 Alma Mater Studiorum University of Bologna
8 Via S. Vitale 59
9 40125 Bologna Italy
10 Fax: +39 051 225208
11 E-mail: leonardo.ciocca@unibo.it
12
13 b
DDS, PhD, Research Assistant. Section of Oral Surgery, Department of Biomedical and Neuromotor Science, Alma Mater Studiorum
14 University of Bologna
15 Via S. Vitale 59
16 40125 Bologna Italy
17 Fax: +39 051 225208
18 E-mail: giuseppelizio@libero.it
19
20 c
DDS, PhD, Aggregate Professor, Section of Prosthodontics, Department of Biomedical and Neuromotor Science, Alma Mater
21 Studiorum University of Bologna
22 Via S. Vitale 59
23 40125 Bologna Italy
24 Fax: +39 051 225208
25 E-mail: paolo.baldissara@unibo.it
26
27 d
DDS, Private practice, Bologna, Italy
28
29 e
MD, DDS, Professor and Dean of Oral and Maxillo-Facial Rehabilitation, Section of Prosthodontics, Department of Biomedical and
30 Neuromotor Sciences, Alma Mater Studiorum University of Bologna
31 Via S. Vitale 59
32 40125 Bologna Italy
33 Fax: +39 051 225208
34 E-mail: roberto.scotti@unibo.it
35
36 f
DDS, PhD, Aggregate Professor, Section of Oral and Maxillofacial surgery, Department of Biomedical and Neuromotor Science, Alma
37 Mater Studiorum University of Bologna
38 Via S. Vitale 59
39 40125 Bologna – Italy
40 Fax: 0039 051 225208
41 E-mail: giuseppe.corinaldesi@unibo.it
42
43 Correspondence address:
44 Dr. Leonardo Ciocca
45 Via S. Vitale 59
46 40125 Bologna Italy
47 Fax: +39 051 225208 E-mail: leonardo.ciocca@unibo.it
48

49 NO FINANCIAL FUNDING WAS RECEIVED FOR THIS RESEARCH.

50 NO CONFLICT OF INTEREST EXIST FOR ALL AUTHORS.

51 Acknowledgments
52 The authors thank Dr. Andrea Sandi for his valuable work with the CAD and for prototyping the titanium
53 mesh.
54
55 The English in this document has been checked by at least two professional editors, both native speakers of
56 English. For a certificate, please see:
57 http://www.textcheck.com/certificate/2bajxi
58
59 Abstract

60 This study evaluated the outcomes of CAD-CAM customized titanium mesh used for

61 prosthetically guided bone augmentation related to the occlusion driven implant position;

62 to the vertical bone volume gain of mandible and maxilla; and to complications, like mesh

63 exposure.. Nine patients scheduled for bone augmentation of atrophic sites were treated

64 with custom titanium mesh and particulate bone grafts with autologous bone and

65 anorganic bovine bone in a 1:1 ratio prior to implant surgery. The bone volume needed to

66 augment was virtually projected based on implants position, width and length, and the

67 mesh design was programmed for the necessary retaining screws. After 6-8 months, bone

68 augmentations of 1.72 to 4.1 mm (mean: 3,83 mm) for the mandibular arch and 2.14 to

69 6.88 mm (mean: 3,95 mm) for the maxilla were registered on cone beam CT. Mesh

70 premature (within 4 to 6 weeks) exposure was observed in three cases and delayed (after

71 4 to 6 weeks) in three other cases. One titanium mesh was removed before the

72 programmed time, but in all augmented sites was possible implant insertion. No

73 complication occurred during prosthetic follow-up. CAD-CAM technology used for

74 prosthetically guided bone augmentation showed important post-operative morbidity of

75 mesh exposure (66%). Due to this high number of mesh exposure and the potential

76 infection that could affect the expected bone augmentation, this study suggests a cautious

77 approach to this procedure when designing the Ti-mesh, to avoid flap tension that may

78 cause mucosal rupture.

79

80 Keywords:

81 Bone regeneration, CAD-CAM, atrophic jaws, minimal intervention

82

83
 84 Introduction

85 Since the 1990s, several studies have described the use of titanium mesh for regeneration

86 of the atrophic maxilla and mandible bones.1-15 Clinical studies of titanium mesh1-16 have

87 produced important data regarding exposures or removal: the percentage of exposures

88 ranged between 0%14 and 52.7%7, and the number of early removals was between

89 0%1,3,4,6,9-11,13,15,16 and 30.4%7, depending on the protocols used by different surgeons

90 (Table 1). A more recent study17 documented the complete workflow of

91 prosthetically guided bone regeneration (PGBR), describing the step-by-step digital design

92 and rapid prototyping (RP) procedures required to obtain custom-made mesh for minimal

93 intervention surgery. Moreover, Sumida et al.18 compared computer-aided design–

94 computer-aided machining (CAD-CAM) custom-made mesh with conventional mesh for

95 the bone augmentation of atrophic maxillary arches. The operation time and the number

96 of retaining screws were significantly lower than those in the conventional group (both p <

97 0.01); the incidence of mucosal rupture with mesh exposure and the number of infections

98 were not significantly different between groups (p = 0.27 for both variables).

99 This study presents preliminary data on nine patients undergoing bone augmentation of

100 partially or totally atrophic maxillary arches using customized titanium mesh prior to

101 implant surgery. The aims of this pilot study were to evaluate the outcomes of customized

102 titanium mesh loaded with autologous bone chips and anorganic bovine bone (Bio-Oss;

103 Geistlich Pharma, Wolhusen, Switzerland) in a 1:1 ratio and used for prosthetically guided

104 bone augmentation; to calculate the vertical bone volume gain of the mandible and

105 maxilla; and to evaluate complications, such as mesh exposure.

106 Methods and Materials

107 Case selection

108 The study was approved by the S. Orsola Hospital Ethics Committee in May 2013

109 (approval no. 121/2013/O/Disp). Nine healthy patients, six women and three men with a

110 mean age of 50 years (range: 25 to 68 years), with no systemic contraindications for

111 treatment (diabetes mellitus or heavy smoking, > 10 cigarettes a day) were included in this

112 preliminary data analysis.

113

114 Virtual planning

115 Each implant site was evaluated in either the mandible and/or the maxilla by positioning an

116 at least 8-mm long implant (WinSix; Biosafin Srl, Ancona, Italy; Keystone Dental,

117 Burlington, MA, USA) and observing the required bone regeneration, via data obtained

118 with CBCT (NewTom; Cefla, Verona, Italy). Using NobelClinician software (Nobel Biocare,

119 Kloten, Switzerland), each dental element was positioned as a function of the occlusion in

120 relation to the bucco–palatal/lingual position of the opposite masticatory arch, according to

121 the concept of prosthetically guided bone regeneration.(Fig. 1). Because NobelClinician

122 does not include volume calculation for grafting procedures, the two-dimensional (2D)

123 project screenshots (upper, frontal, and lateral views) were imported into the Mimics

124 Innovation Suite software (ver. 17.0; Materialise, Leuven, Belgium) for conversion into

125 three-dimensional (3D) models. The skull of the maxilla and the mandible was

126 reconstructed by setting the same threshold values used in NobelClinician. Then, the plan

127 was exported into general-purpose CAD software (Freeform Modelling Plus, ver. 13.0; 3D

128 Systems, Rock Hill, SC, USA) to design the bone augmentation, guided by the positions of

129 the implants and corresponding containment mesh.

130

131 Design of containment mesh

132 The 1.5-mm safety zone around each implant was virtually modeled to provide the minimal

133 bone width/height of available bone to enhance the clinical safety of the implant
134 procedure. (Fig. 2 a,b) Over this augmented bone volume, we projected an over-

135 contouring of 1.5 mm thickness to compensate for the biological formation of the pseudo-

136 periosteum (connective tissue)21 that typically develops between the titanium mesh and

137 the bone. (Fig. 2c) The mesh was calibrated at a 0.3-mm thickness, and holes in the mesh

138 were calibrated at 1-mm diameter for printing with the direct metal laser sintering (DMLS)

139 technique, by using a rapid-prototyping machine.

140

141 Prototyping of titanium mesh

142 After completing the CAD design, the Standard Tesselation Language (STL) file was 3D-

143 printed using an EOSINT M270 (Electro Optical Systems, Munich, Germany), a DMLS

144 machine. The metal powder used for RP was Titanium Ti64, a pre-alloyed Ti6AIV4 alloy in

145 fine powder form with excellent mechanical properties and corrosion resistance, low

146 specific weight, and high biocompatibility. The thickness of the mesh was reduced up to

147 0.1 mm by laminating the metal after printing without increasing its fragility.

148 Success criteria:

149 1. Ability to insert implants as previously planned on a virtual surgery simulator

150 (according to a planned minimal intervention), and its influence on the final outcome

151 2. Evaluation of the vertical bone gain

152 3. Presence and timing of mesh exposure

153 Clinical procedure

154 The observation period ranged from 6 to 18 months after implant placement. Patients were

155 scheduled to undergo the bone augmentation procedure under general or local

156 anesthesia, depending on whether the autologous bone graft was harvested from the iliac

157 crest or the mandibular ramus. A midcrestal incision was made, maximizing the keratinized

158 mucosa on each side of the incision over the atrophic edentulous ridge. Perforations into

159 the marrow space were produced using a round bur to improve vascularization and
160 incorporation of the graft (Fig. 3a). The mesh was loaded with autologous bone chips

161 (harvested from the mandibular ramus or the iliac crest) and anorganic bovine bone (Bio-

162 Oss; Geistlich Pharma, Wolhusen, Switzerland) in a 1:1 ratio and was fixed with one, or at

163 most two, osteo-synthesis screws (Synthes, West Chester, PA, USA) (Fig. 3b). Releasing

164 incisions of the periosteum along the buccal flap allowed extension of the flap coronally

165 over the mesh to enable passive primary closure. The flap was sutured with Vicryl 4-0

166 (Johnson & Johnson Intl, Ethicon GmbH, Norderstedt, Germany). Postoperatively, patients

167 received antibiotic (amoxicillin and clavulanic acid) and analgesic (ibuprofen) and were

168 instructed to rinse twice daily for 2 weeks (digluconate chlorhexidine, 0.12%).

169 After a 6–8-month healing period, a new CT scan dataset was collected to verify the bone

170 augmentation prior to implant surgery. In all patients, the regenerated bone was sufficient

171 to position the planned implants (n = 26). At the time of implant surgery, the titanium mesh

172 was removed, and the implants were inserted using a two-step technique (submerged

173 implants). After 4-month (maxilla) and 3-month (mandible) healing periods, the implants

174 were uncovered, and prosthetic procedures for construction of the prosthesis were

175 performed (Fig. 4). No implant failure was observed after a 2-year follow-up.

176

177 Data elaboration

178 CT data of post-operative results after implant surgery were used to calculate the bone

179 gain obtained with regenerative therapy. The linear vertical bone augmentation was

180 calculated based on superimposition of the pre-op and post-op CT. A virtual calculation of

181 bone augmentation was performed in relation to each planned implant site (Fig. 5, 6).

182 Table 2 shows all results of the pre/post-op bone augmentation, the incidence and timing

183 of mesh exposure, and its removal time during follow-up.

184
185 Bone augmentation results

186 The vertical bone augmentation was digitally measured in relation to the long axis of each

187 programmed implant site. The single values of the augmentation are presented in Table 2.

188 Results data were not considered as mean values to compare with other studies because

189 of their individual specific planning for minimal bone augmentation. However, the data

190 showed 1.72 mm to 4.1 mm of bone reconstruction in the mandible and 2.14 to 6.88 mm in

191 the maxilla.

192

193 Surgical follow-up

194 Table 2 provides data on the exposure and removal time of the mesh: three of nine

195 patients showed premature exposure of the mesh (2 to 4 weeks), and three of nine

196 patients showed a delayed exposure (10–24 weeks). All meshes except one, which was

197 removed at 3 months with evident discharge of purulent exudate, were removed at 6–8

198 months after surgery. The mesh exposures were examined every 2 months for clinical

199 signs of infection, and the patients were instructed to use a soft toothbrush to apply

200 chlorhexidine digluconate gel 1% (Corsodyl gel; GlaxoSmithKline, Baranzate, Italy) twice a

201 day to the exposed mesh.

202

203 Discussion

204 Several studies have supported the excellent mechanical properties of commercial (non-

205 customized) titanium mesh: sufficient rigidity, plasticity for manual bending, and elasticity

206 for the prevention of flap compression.4,19-22 Ciocca et al.24 described a further problem

207 with commercial mesh. After superimposition of the mesh post-op CT data on the planned

208 volume of bone to restore, they registered a compression of the mesh in the palatal area

209 that was interpreted as possible being due to wearing the prosthesis (full denture) during
210 follow-up for regenerative surgery, or as a probable further deformation due to screw

211 fixation of the mesh in the palate.

212 Other studies reported the results of customized titanium mesh in terms of accuracy when

213 using RP techniques25,26 The CAD-CAM technology used in this study allowed for

214 programming of the ideal position of implants for atrophic maxillary/mandibular total or

215 partial arches, taking into account the occlusal intermaxillary relationship by using CAD

216 software; moreover, this procedure permitted projecting the least bone augmentation

217 required for implant surgery. When designing the mesh, the virtual project must consider,

218 as an over-contouring with respect to the expected bone augmentation, the width (1.2–1.5

219 mm) of the connective tissue that develops between the mesh and the regenerated bone

220 (pseudo-periosteum). Moreover, the time saving afforded by intraoperative mesh cutting,

221 the bending and adaptation, and the post-op site morbidity due to the limited bone harvest

222 (in turn due to the planned augmentation) represent advantages of this protocol.

223 In terms of bone augmentation, two main variables were analyzed: the increase in the

224 vertical bone level, and mesh exposure. For the first variable, the method described by

225 Ciocca et al. (2011)27 was used to calculate the amount of bone (Fig. 6). The premature

226 (within 4–6 weeks) or delayed (after 4–6 weeks) exposure of the mesh did not limit bone

227 augmentation (mean value: 3.83 mm for the mandible and 3.95 mm for the maxilla) for

228 purposes of the implant surgery, as all programmed implants were positioned according to

229 the treatment plan, even after premature mesh exposure. However, in this case series

230 study, the incidence of mesh exposure was important, and consequently there was a

231 possibility of infection that could jeopardize the desired augmentation. In this regard six

232 patients reported mesh exposure (66%), and one needed to remove the mesh early (3

233 months) to prevent infection risks. Although all instances of wound dehiscence were

234 controlled with local antibacterial rinse and gel during the 6–8-month follow-up before
235 mesh removal, the continuous monitoring of these situations is a weakness of this

236 procedure. This rate of mesh exposure might be due to the stiffness of the Ti-mesh, which

237 could cause mechanical irritation to the mucosal flap 24 that may be worsened if a

238 provisional removable prosthesis is used in the edentulous augmented crest during the

239 healing period. Mesh exposure may be also due to the learning curve associated with

240 CAD-CAM mesh projecting: when virtual design of the mesh is performed, the mesiodistal

241 end of the titanium mesh should be separated at least 2 mm from the adjacent tooth, to

242 avoid creating a pathway for the penetration of bacteria. Moreover, the external shape of

243 the mesh should be projected as smoothly as possible to avoid flap tension that can lead

244 to mucosal rupture. However, no flap re-suturing was required, and even if these

245 complications occurred, they did not influence implant treatment, and no implant failure or

246 bone loss was noted during the follow-up or after the prosthetic rehabilitation.

247 A disadvantage of this technique may be the cost of the CAD-CAM process needed to

248 prototype the titanium mesh: in comparison with a standard commercially available mesh,

249 the cost was slightly higher (USD $425), but the surgical advantage of operation time

250 reduction seems to compensate for this problem.

251 No sample sizing or power evaluation was performed in this study due to the limited

252 number of implant sites, which does not permit inferential considerations. Further studies

253 are required to develop new resorbable and sufficiently rigid and smoothed mesh that may

254 be directly printed using modern bio-printing technologies.

255

256 Conclusions

257 This study suggests a cautious approach to this procedure, because the CAD-CAM

258 technology used for prosthetically guided bone augmentation was less successful than

259 expected, especially in terms of post-operative morbidity due to mesh exposure. However,
260 this protocol allowed positioning of all programmed implants according to the treatment

261 plan and simplified the surgery by reducing the number of retaining screws to one, or at

262 most, two.

263

264

265

266

267 ABBREVIATIONS
268 PGBR: prosthetically guided bone regeneration
269 CAD-CAM: computer aided design–computer aided machining
270 CT: computed tomography
271 RP: rapid prototyping
272 USD: United States dollar
273
274
275 References

276 1. Roccuzzo M, Ramieri G, Spada MC, et al. Vertical alveolar ridge augmentation by means of a titanium
277 mesh and autogenous bone grafts. Clin Oral Implants Res 2004;15:73–81.
278
279 2. von Arx T, Hardt N, Wallkamm B. The TIME technique: a new method for localized alveolar ridge
280 augmentation prior to placement of dental implants. Int J Oral Maxillofac Implants 1996;11:387–94.
281
282 3. Proussaefs P, Lozada J. Use of titanium mesh for staged localized alveolar ridge augmentation: clinical
283 and histologic-histomorphometric evaluation. J Oral Implantol 2006;32:237–47.
284
285 4. Her S, Kang T, Fien MJ. Titanium mesh as an alternative to a membrane for ridge augmentation. J Oral
286 Maxillofac Surg 2012;70:803–10.
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288 5. Corinaldesi G, Pieri F, Sapigni L, et al. Evaluation of survival and success rates of dental implants placed
289 at the time of or after alveolar ridge augmentation with an autogenous mandibular bone graft and titanium
290 mesh: a 3- to 8-year retrospective study. Int J Oral Maxillofac Implants 2009;24:1119–28.
291
292 6. Torres J, Tamimi F, Alkhraisat MH, et al. Platelet-rich plasma may prevent titanium-mesh exposure in
293 alveolar ridge augmentation with anorganic bovine bone. J Clin Periodontol 2010;37:943–51.
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295 7. Louis PJ, Gutta R, Said-Al-Naief N, et al. Reconstruction of the maxilla and mandible with particulate bone
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298 8. Roccuzzo M, Ramieri G, Bunino M, et al. Autogenous bone graft alone or associated with titanium mesh
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301 9. Molly L, Quirynen M, Michiels K, et al. Comparison between jaw bone augmentation by means of a stiff
302 occlusive titanium membrane or an autologous hip graft: a retrospective clinical assessment. Clin Oral
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305 10. Artzi Z, Dayan D, Alpern Y, et al. Vertical ridge augmentation using xenogeneic material supported by a
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309 11. Lozada J, Proussaefs P. Clinical radiographic and histologic evaluation of maxillary bone reconstruction
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319 14. Von Arx T, Kurt B. Implant placement and simultaneous ridge augmentation using autogenous bone and
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322 15 Von Arx T, Kurt B. Implant placement and simultaneous peri-implant bone grafting using a microtitanium
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328 17 Ciocca L, Ragazzini S, Fantini M et al. Work flow for the prosthetic rehabilitation of atrophic patients with
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356

357
358 Figure legends
359 Fig. 1 Virtual implant positioning.
360
361 Fig. 2 Mesh design. a: frontal view; b: palatal view; c: calculation of the pseudo-periosteum.
362
363 Fig. 3: a: Evidence of maxillary atrophy especially in width; b: Rapid prototyping of the mesh and surgical
364 application with two screws.
365
366 Fig. 4 Prosthetic procedures. a: Digital impression; b: try-in of the prototyped metal framework; c: Prosthetic
367 rehabilitation.
368
369 Fig. 5 Schematic diagram of the bone augmentation pre-op planning in reference to each implant head.
370
371 Fig. 6 Actual calculation by superimposition of pre- (red) and post-operative (B/W) computed tomography
372 (CT) data.
373
374
375
376
377
378
379
Table Click here to download Table Tables.docx

Tables

Table 1: Summary of clinical studies

Study No. of patients Exposure Removal

1996 von Arx [2] 20 50% 1
1998 von Arx [15] 18 0 0
1998 Malchiodi [16] 25 16.66% 0
1999 von Arx [14] 15 6.66% 1
2001 Maiorana [13] 14 14.28% 0
2001 Assenza [12] 22 18.18% 2
2002 Lozada [11] 1 0 0
2003 Artzi [10] 10 20% 0
2004 Roccuzzo [1] 18 22.22% 0
2006 Proussaefs [3] 17 35.3% 0
2006 Molly [9] 11 29.41% 0
2007 Roccuzzo [8] 23 33.33% 2
2008 Louis [7] 44 52.7% 7
2009 Corinaldesi 24 14.8% 4
2010 Torres [6] 30 28.5% 0
2012 Her [4] 27 26% 0
Table 2: Bone augmentation results and time of exposure and removal.

PATIEN Sex/age Implant Implant lenght Bone Time of Removal

T site (mm) augmentation exposure time
(pre–post, (week) (month)
mm)
#1 F/51 #44 3.3x11.5 2,7 / 8
#45 4x10 4,2
#46 4x10 4,1

#2 F/68 #34 3.8x9.5 4,97 4 6

#35 3.8x8 4
#36 3.8x8 2,76

#3 M/46 #14 3.3x13 2,43 2 7

#15 3.3x15 6,88
#16 4x10 4,34

#4 M/59 #14 3.8x11 5,78 4 8

#12 3.8x13 5,23
#22 3.8x9 5,51
#24 3.8x11 6,15

#5 F/57 #36 3.8x9 5,21 / 8

#37 3.8x9 5,16

#6 M/46 #13 3.8x13 2,39 24 8

#11 3.8x11 1,8
#22 3.8x9 2,14
#23 3.3x11 1,88

#7 F/45 #45 3.3x9 4,68 / 8

#46 3.8x9 3,92

#8 F/25 #35 3.3x11 1,72 10 3

#36 3.3x9 2,64

#9 F/55 #23 3.8x9 4,16 24 6.2

#24 3.3x11 3,74
#25 3.8x9 2,87
Fig.1: Virtual implant positioning Click here to download Figure Fig. 1.jpg
Fig. 2a Mesh design: frontal view Click here to download Figure Fig. 2a.jpg
Fig. 2b Mesh design: palatal view. Click here to download Figure Fig. 2b.jpg
Fig. 2c: Calculation of the pseoudoperiosteum Click here to download Figure Fig. 2c.png
Fig. 3: a: Evidence of maxillary atrophy especially in width. Click here to download Figure Fig. 3a.JPG
Fig. 3: b Rapid prototyping of the mesh and surgical application with two screws. Click here to download Figure Fig. 3b.jpg
Fig. 4 Prosthetic procedures. a: Digital impression Click here to download Figure Fig. 4a.jpg
Fig.4 Prosthetic procedures. b: try-in of the prototyped metal framework Click here to download Figure Fig. 4b.tiff
Fig.4 Prosthetic procedures. c: Prosthetic rehabilitation Click here to download Figure Fig. 4c.JPG
Fig. 5 Schematic diagram of the bone augmentation pre-op planning in reference to Click here to download Figure Fig. 5.png
each implant head
Fig. 6 Actual calculation using the superimposition of pre-op (red) and post-op (B/W) Click here to download Figure Fig. 6.jpg
CT data
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