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logo 19 • CAMLOG Partner Magazine • December 2018 22 The average vertical augmentation height for customized titanium meshes was given in the literature with a mean of 6.5 ± 1.7 mm [7]. A systematic review [24] indicates a mean of 3.7 ± 1.4 mm with regard to prefabricated meshes. The present case with a vertical augmentation of approx. 9 mm therefore clearly represents a limit as to what is surgically possible. From a conservative point of view, the pronounced vertical defect would have required a two-stage procedure. In the present case, the implant was inserted using an “adjusting screw“ and a “modified tentpole technique“ [25], which had a stabilizing effect on the augmentation. The limiting factor in such a pronounced augmentation is primarily the soft tissue management [7]. The development of dehiscences is the most common complication in the use of titanium meshes. In this case, the necessary gain in soft tissue was achieved by pure periosteal slitting and tunneling into the vestibule. If necessary, a free connective tissue graft could have been used simultaneously with the first intervention. The creation of a fixed gingival area around the implant was decisive. Subsequent peri-implant hygiene and thus long-term prognosis of the implant-prosthetic restoration were therefore to be improved. In general, vertical augmentation is liable to lead to complications [26]. In this case, the insertion of an additional occlusal collagen membrane inhibited competitive wound healing and thus the ingrowth of soft tissue cells. This may have contributed to sufficient revascularization of the augmentation material and to the longterm success. The bone level also proved to be stable after a 2-year follow-up and the peri-implant conditions were free of irritation. Further research on the topic of customized bone regeneration in connection with implantations is desirable. Long-term and follow-up studies would be of particular interest. Topics for titanium meshes in the future will be different surface coatings to avoid dehiscences [27], resorbable materials and the ideal thickness of the mesh [28]. Conclusion Many implantations would not be possible without the use of bone augmentation. Three-dimensional defects remain a challenge in everyday implant surgery. In this case report it was shown that a complex defect could be reconstructed by using a patient-specific titanium mesh. Using the digital surgical workflow, the clinician was involved in the design process, the implantation was planned virtually and the intervention time was shortened as a result. [1] Pobloth AM, Checa S, Razi H, Petersen A, Weaver JC, Schmidt-Bleek K, et al. Mechanobiologically optimized 3D titanium-mesh scaffolds enhance bone regeneration in critical segmental defects in sheep. Sci Transl Med. 2018;10(423). [2] Yan R, Luo D, Huang H, Li R, Yu N, Liu C, et al. Electron beam melting in the fabrication of three-dimensional mesh titanium mandibular prosthesis scaffold. Sci Rep. 2018;8(1):750. [3] Moura RV, Kojima AN, Saraceni CHC, Bassolli L, Balducci I, Ozcan M, et al. Evaluation of the Accuracy of Conventional and Digital Impression Techniques for Implant Restorations. J Prosthodont. 2018. [4] Tomita Y, Uechi J, Konno M, Sasamoto S, Iijima M, Mizoguchi I. Accuracy of digital models generated by conventional impression/plaster-model methods and intraoral scanning. Dent Mater J. 2018. [5] Sumida T, Otawa N, Kamata YU, Kamakura S, Mtsushita T, Kitagaki H, et al. Custom-made titanium devices as membranes for bone augmentation in implant treatment: Clinical application and the comparison with conventional titanium mesh. J Craniomaxillofac Surg. 2015;43(10):2183-8. [6] Shan XF, Chen HM, Liang J, Huang JW, Cai ZG. Surgical Reconstruction of Maxillary and Mandibular Defects Using a Printed Titanium Mesh. J Oral Maxillofac Surg. 2015;73(7):1437 e1-9. [7] Sagheb K, Schiegnitz E, Moergel M, Walter C, Al-Nawas B, Wagner W. Clinical outcome of alveolar ridge augmentation with individualized CAD-CAM-produced titanium mesh. Int J Implant Dent. 2017;3(1):36. [8] Ciocca L, Fantini M, De Crescenzio F, Corinaldesi G, Scotti R. CAD-CAM prosthetically guided bone regeneration using preformed titanium mesh for the reconstruction of atrophic maxillary arches. Comput Methods Biomech Biomed Engin. 2013;16(1):26-32. [9] Roccuzzo M, Ramieri G, Bunino M, Berrone S. Autogenous bone graft alone or associated with titanium mesh for vertical alveolar ridge augmentation: a controlled clinical trial. Clin Oral Implants Res. 2007;18(3):286-94. [10] Jung GU, Jeon JY, Hwang KG, Park CJ. Preliminary evaluation of a three-dimensional, customized, and preformed titanium mesh in peri-implant alveolar bone regeneration. J Korean Assoc Oral Maxillofac Surg. 2014;40(4):181-7. [11] Penarrocha MA, Vina JA, Maestre L, Penarrocha-Oltra D. Bilateral vertical ridge augmentation with block grafts and guided bone regeneration in the posterior mandible: a case report. J Oral Implantol. 2012;38 Spec No:533-7. [12] Keestra JA, Barry O, Jong L, Wahl G. Long-term effects of vertical bone augmentation: a systematic review. J Appl Oral Sci. 2016;24(1):3-17. [13] Chappuis V, Cavusoglu Y, Buser D, von Arx T. Lateral Ridge Augmentation Using Autogenous Block Grafts and Guided Bone Regeneration: A 10-Year Prospective Case Series Study. Clin Implant Dent Relat Res. 2017;19(1):85-96. [14] Friberg B. Bone augmentation for single tooth implants: A review of the literature. Eur J Oral Implantol. 2016;9(2):123-34. [15] Sbordone L, Toti P, Menchini-Fabris G, Sbordone C, Guidetti F. Implant survival in maxillary and mandibular osseous onlay grafts and native bone: a 3-year clinical and computerized tomographic follow-up. Int J Oral Maxillofac Implants. 2009;24(4):695-703. [16] Boyne PJ. Restoration of osseous defects in maxillofacial casualities. J Am Dent Assoc. 1969;78(4):767-76. [17] Rasia-dal Polo M, 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(6):e639-46. [18] Lizio G, Mazzone N, Corinaldesi G, Marchetti C. Reconstruction of Extended and Morphologically Varied Alveolar Ridge Defects with the Titanium Mesh Technique: Clinical and Dental Implants Outcomes. Int J Periodontics Restorative Dent. 2016;36(5):689-97. [19] Pellegrino G, Lizio G, Corinaldesi G, Marchetti C. Titanium Mesh Technique in Rehabilitation of Totally Edentulous Atrophic Maxillae: A Retrospective Case Series. J Periodontol. 2016;87(5):519-28. [20] Zita Gomes R, Paraud Freixas A, Han CH, Bechara S, Tawil I. Alveolar Ridge Reconstruction with Titanium Meshes and Simultaneous Implant Placement: A Retrospective, Multicenter Clinical Study. Biomed Res Int. 2016;2016:5126838. [21] Seiler M, Kaemmerer PW, Peetz M, Hartmann AG. Customized Titanium Lattice Structure in Three-Dimensional Alveolar Defect: An Initial Case Letter. J Oral Implantol. 2018. [22] Galindo-Moreno P, Fernandez-Jimenez A, O’Valle F, Silvestre FJ, Sanchez-Fernandez E, Monje A, et al. Marginal bone loss in implants placed in grafted maxillary sinus. Clin Implant Dent Relat Res. 2015;17(2):373-83. [23] Reininger D, Cobo-Vazquez C, Monteserin-Matesanz M, Lopez-Quiles J. Complications in the use of the mandibular body, ramus and symphysis as donor sites in bone graft surgery. A systematic review. Med Oral Patol Oral Cir Bucal. 2016;21(2):e241-9. [24] Troeltzsch M, Troeltzsch M, Kauffmann P, Gruber R, Brockmeyer P, Moser N, et al. Clinical efficacy of grafting materials in alveolar ridge augmentation: A systematic review. J Craniomaxillofac Surg. 2016;44(10):1618-29. [25] Daga D, Mehrotra D, Mohammad S, Singh G, Natu SM. Tentpole technique for bone regeneration in vertically deficient alveolar ridges: A review. J Oral Biol Craniofac Res. 2015;5(2):92-7. [26] Esposito M, Grusovin MG, Felice P, Karatzopoulos G, Worthington HV, Coulthard P. The efficacy of horizontal and vertical bone augmentation procedures for dental implants – a Cochrane systematic review. Eur J Oral Implantol. 2009;2(3):167-84. [27] Nguyen TT, Bae TS, Yang DH, Park MS, Yoon SJ. Effects of Titanium Mesh Surfaces-Coated with Hydroxyapatite/betaTricalcium Phosphate Nanotubes on Acetabular Bone Defects in Rabbits. Int J Mol Sci. 2017;18(7). [28] Rakhmatia YD, Ayukawa Y, Jinno Y, Furuhashi A, Koyano K. Micro-computed tomography analysis of early stage bone healing using micro-porous titanium mesh for guided bone regeneration: preliminary experiment in a canine model. Odontology. 2017;105(4):408-17. LITERATURE CASE STUDY