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In Situ Bone Regeneration inOral
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andMaxillofacial Surgery: Definition,
Indications, andManufacturing
Considerations
HeliaSadatHaeriBoroojeni, NiushaGharehdaghi,
SaharMoghaddasi, andArashKhojasteh
1 Introduction
In situ regeneration involves utilizing regenerative and reparative aptitude of host
body to effectively recruit endogenous host cells and induce inltrated cells toward
specic 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 exvivo cell manipulations are eliminated, the in situ approach offers a potential
for efcient bone regeneration, time- and resource-wise [4]. In this light, in situ
bone regeneration, necessitating macro- and micro-specics 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- specic
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
143
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intends to deliver bone substitute materials within a predesigned three-dimensional
(3D) space-preserving structure. Creation of patient-specic 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 5mm
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 1–2mm
thickness has been inspected under the titanium mesh [5, 12].
Aside from titanium PSI, Mounir etal. used polyether-ether-ketone (PEEK) PSI
and autologous and xenograft to augment maxillary atrophic ridges. Their results
demonstrated sufcient in situ bone regeneration and comparable bone gain rates
with commercial bendable titanium meshes [14].
ab
cd
ef
In Situ Bone Regeneration in Oral and Maxillofacial Surgery: Denition, Indications…
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145
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 etal., 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
etal. 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)
g
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