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In Situ Bone Regeneration inOral
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andMaxillofacial Surgery: Definition, Indications, andManufacturing Considerations
HeliaSadatHaeriBoroojeni, NiushaGharehdaghi, SaharMoghaddasi, andArashKhojasteh
1 Introduction
In situ regeneration involves utilizing regenerative and reparative aptitude of host body to effectively recruit endogenous host cells and induce inltrated cells toward specic lineages at the defect site [1]. This approach has evolved to compromise the challenging aspects of cell-based regenerative therapeutic approaches. Among which, inquiry of reliable cell sources, donor site biopsies, extensive cell expansion stages, and heterogeneity of isolated tissue-derived stem/progenitor cells resulting in demanding standardization procedures, can be mentioned [2, 3]. As preimplanta­tion exvivo cell manipulations are eliminated, the in situ approach offers a potential for efcient bone regeneration, time- and resource-wise [4]. In this light, in situ bone regeneration, necessitating macro- and micro-specics restoring of bone tissue environment, consists of two integral areas: (a) providing and maintaining a pro­tected healing space for cells to recruit and lead the regeneration orchestra and (b) optimizing host’s regenerative capacities using biochemical cues.
Integration of computer-aided designing and computer-assisted manufacturing (CAD-CAM) systems with maxillofacial surgeries has enhanced regenerative approaches. From preoperative defect modeling to manufacturing of patient- specic implants (PSI) for bone regeneration, consolidation of CAD-CAM systems with multiple surgical stages has advanced bone regeneration techniques. Among regen­erative approaches conducted by CAM-CAM-based PSIs, in situ bone regeneration
H. S. H. Boroojeni · N. Gharehdaghi · S. Moghaddasi Department of Oral and Maxillofacial Surgery, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
A. Khojasteh (*) Department of Oral and Maxillofacial Surgery, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
Department of Health and Medical Sciences, University of Antwerp, Antwerp, Belgium
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 A. Khojasteh et al. (eds.), Emerging Technologies in Oral and Maxillofacial Surgery, https://doi.org/10.1007/978-981-19-8602-4_9
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intends to deliver bone substitute materials within a predesigned three-dimensional (3D) space-preserving structure. Creation of patient-specic containment compart­ments (i.e., meshes, shell, lattices, plates, membranes, chambers, compartments, etc.) enables establishment of a protected healing space upon implantation. While PSIs preserve a space, host body regenerative and reparative capacities direct regen­eration toward desired tissue lineages to meet the preplanned dimensional topogra­phies of implant. Moreover, the underlying graft material is sheltered and a stable space for directed regeneration is provided.
H. S. H. Boroojeni et al.
2 Protected Healing Space
Preserving a protected healing space for regeneration is among the prerequisites of in situ bone regeneration. Many studies have aimed to perform in situ bone regen­eration for reconstruction of both jaws and maxillofacial bone defects. Although numerous bone substitute materials and their combinations have been employed alongside PSIs, the working concept remains identical.
2.1 Clinical Applications
2.1.1 Ridge Augmentation
Titanium PSIs have been clinically lled with different bone substitute composi­tions that can be categorized as freeze-dried bone allograft (FDBA), combined autologous and xenograft particulates, and combined autologous graft and alloplas­tic material.
Application of packed a titanium PSI with a mixture of FDBA, enamel matrix derivatives, and plasma-rich plasma (PRP) for ridge augmentation revealed a 5mm horizontal at 8 months [5].
Using autologous and xenograft-packed titanium PSI, esthetic zones and atrophic ridges have been aimed to be augmented. The most common xenograft material for this purpose has been demineralized bovine bone mineral (DBBM) [6–13] (Figs.1, and 2). Histological evaluations of tissue surrounding the titanium PSI have revealed mucosal characteristics on one side of PSI and osseous mineralized characteristics on the other. The mineralized bone tissue depicted organized structures and cellular pop­ulations of mostly blast-like cells in medullary regions. The medullary regions of min­eralized bone tissue contained new capillaries in focal buds. Remodeling fronts characterized by large osteoid tissue and abundant amounts of osteoblasts and osteo­clasts were also present [9]. At times, overgrowth of regenerated bone tissue beyond titanium PSI has been reported. Most implant placements in the in situ regenerated cases of ridge augmentation have reported to be not only uneventful but with a 100% survival rate [8, 13]. Moreover, formation of pseudo- periosteum tissue of 1–2mm thickness has been inspected under the titanium mesh [5, 12].
Aside from titanium PSI, Mounir etal. used polyether-ether-ketone (PEEK) PSI and autologous and xenograft to augment maxillary atrophic ridges. Their results demonstrated sufcient in situ bone regeneration and comparable bone gain rates with commercial bendable titanium meshes [14].
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ef
In Situ Bone Regeneration in Oral and Maxillofacial Surgery: Denition, Indications…
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Fig. 1 Surgical phases of Ti PSI for in situ bone regeneration: preoperative clinical view of the surgical site (a), preoperative osseous status of the surgical site (b), block graft harvested from the mandibular ramus (c), mesh loaded with particulate bone (d), xated mesh (e); closure (f) [7]
2.1.2 Reconstruction
Maxillary Bone Defects
Satisfactory reconstruction and recontouring procedures have been conducted for Brown’s class II and III of maxillary defects and orbital oor over prolonged fol­low- up [15, 16]. Following reconstruction of orbital oor, no incidence of diplopia, enophthalmos, or optic nerve damage consequent to PSI insertion was inspected. Globe projection and orbital volume remained symmetric in both eyes [16].
According to Shan etal., maxillary reconstruction with the use of titanium PSI and bular ap grafting is less yielding and has a lower reproducibility rate, com­pared to mandible [17].
Mandibular Bone Defects
All clinical applications of mandibular reconstruction using in situ bone regeneration involved autologous bone grafting and placement of titanium PSIs. Antunez- Conde etal. employed autologous grafting and Ti PSI for reconstruction of segmental man­dibular defects. Successful repair and, at times, overcorrection of bone volume were achieved with in situ bone regeneration. They reported an increase in bone-to-bone
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H. S. H. Boroojeni et al.
a b
e
f
h
Fig. 2 In situ bone regeneration for mandibular ridge augmentation: CAD of PSI (a), fabricated Ti PSI (b), PSI tting (c), xated Ti PSI lled with bone substitute material (d), panoramic view of xated Ti PSI (e), PSI view upon surgical reentry (f), regenerated bone (g), post-implant placement (h) (Courtesy of Dr. Khojasteh)
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