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Managing Titanium Mesh Exposure With Partial Removal ofthe Exposed Site: A Case Series StudyAladdin J. Al-Ardah, DDS, MS1*Abdulaziz AlHelal, BDS, MS2

Periklis Proussaefs, DDS, MS1

Bader AlBader, BDS3

Abdulakareem A. Al humaidan, BDS, MSD3

Jaime Lozada, DMD1

INTRODUCTION

Dental implants have become a successful treatment

modality for the totally1 or partially2 edentulous

patient. Bone augmentation techniques have been

introduced for clinical situations in which there is

inadequate bone volume to successfully place dental im-

plants.3–5 Titanium mesh (TiMe) is a device for guided bone

regeneration that has been used with the most desirable

outcome in osseous wound space maintenance.5,6

TiMe has been used successfully in alveolar ridge augmen-

tation,7–11 sinus augmentation,12 treatment of cleft palate,10,13

and in situations with simultaneous placement of dental

implants.14,15 Several authors have used the TiMe in conjunc-

tion with a variety of graft materials. Autogenous bone

graft,16,17 xenograft,16 allograft,18 hydroxyapatite,19 and bone

morphogenetic proteins17,20 have been used successfully with

TiMe for alveolar ridge augmentation procedures. The rationale

of using a TiMe as a barrier during alveolar ridge augmentation

is its rigidity and biocompatibility that provide dimensional

stability and isolation to the graft particles.5,21

Systematic reviews,3–6 clinical studies,9–16,19,22 and clinical

case reports/series8,20,23–26 have reported that exposure of the

TiMe is the most commonly occurring complication. There is a

wide range of frequency of exposure that has been reported in

the literature, ranging from 5%14 up to 50%27 (Table 1). Average

bone regeneration with TiMe was 4.91 mm (2.56–8.6 mm)

vertically and 4.36 mm (3.75–5.65 mm) horizontally.5

Clinical studies have suggested that a certain amount of

bone loss might be associated with exposure of the TiMe.*

The proposed treatment of an exposed TiMe involves topical

application (brushing) of chlorhexidine gel to reduce the

possibilities of infection of the surgical site.5 However, in 20%

of clinical situations in which exposure of the TiMe occurred,

the decision was made to surgically remove the TiMe.5

Surgical removal of the TiMe was associated with an early 3-

to 4-week exposure.5,36 Some authors proposed the use of a

resorbable29 or nonresorbable27 membrane and/or platelet-

rich plasma22 combined with TiMe in an attempt to reduce the

frequency of exposure. However, to the authors’ best

knowledge, there has been no published article in the

literature reporting that exposure of the TiMe resulted in

bone loss significant enough to prevent placement of dental

implants3–5 or in subsequent loss of dental implants placed in

the augmented sites.5

The purpose of this clinical series report is to introduce a

new treatment modality for treating the exposed TiMe. The

technique involved removing the exposed portion of the TiMe

while leaving the rest of the TiMe in place until bone graft

healing and maturation occurs. Removing the portion of the

TiMe that has been exposed might allow the soft tissue to

migrate over the exposed graft material without disrupting

bone healing. The purpose of this treatment approach is to

reduce the amount of trauma and maintain the advantages of

the TiMe as a space maintenance device.

CLINICAL REPORTS

A total of 4 patients were treated at the Center for

Prosthodontics and Implant Dentistry at Loma Linda University

by the same surgeon (A.A.) between 2015 and 2017. Patients

were referred by their restorative doctor to have a staged

alveolar ridge augmentation procedure performed along with

subsequent implant placement. All included patients had

received at least 2 previous failed alveolar ridge augmentations

at the pertaining site. All patients received a cone beam

computed tomography (CBCT) before alveolar ridge augmen-

tation procedures and another CBCT after bone maturation and

healing before proceeding with implant surgery. A removable

Essix interim provisional was placed in all clinical situations after

ridge augmentation was completed. The interim prosthesis was

supported by the adjacent teeth and trimmed to have no

contact with the soft tissue to avoid interference with tissue

healing. All patients were prescribed antibiotics after ridge

augmentation procedure (amoxicillin 500 mg every 8 hours for

8 days) and instructed to rinse twice a day with 0.12%

chlorhexidine gluconate.

1 Advanced Education Program in Implant Dentistry, School of Dentistry,Loma Linda University, Loma Linda, Calif.2 Department of Prosthetic Dental Sciences, College of Dentistry, KingSaud University, Riyadh, Saudi Arabia.3 College of Dentistry, Imam Abdulrahman Bin Faisal University,Dammam, Saudi Arabia.

* Corresponding author, e-mail: [email protected]

DOI: 10.1563/aaid-joi-D-17-00169

* References 5,9,12,22,27–32,34,37,39,43.

482 Vol. XLIII / No. Six / 2017

CASE LETTER

Case 1

A 50-year-old female patient was referred for localized alveolar

ridge augmentation at the area of teeth Nos. 9 and 10 (Figure

1). A preoperative cone beam confirmed the lack of sufficient

bone volume for implant placement in that area. After

discussing various treatment options, the decision was made

to treat the partial edentulism with bone grafting and

subsequent implant placement (Table 2).

After a crestal incision was performed, full-thickness labial

and palatal flaps were reflected. The buccal flap was extended

beyond the mucogingival junction to facilitate primary closure.

In addition, the recipient site was perforated to induce bleeding

and promote the incorporation of the graft.40 A 50/50% mix of

cortical 1.0–2.0 mm amd 0.25–1 mm particulate bone allograft

(Puros, Zimmer Biomet, Carslbad, Calif) was used. The TiMe was

trimmed to fit the edentulous area, while contact of the mesh

with the adjacent teeth was avoided.16 The graft was loaded on

the TiMe (Titanium Augmentation Micro Mesh, ACE Surgical

Supply Co, Brockton, Mass) and placed at the recipient site.

Periosteal fenestration41,42 was performed along the labial flap

to enable primary closure. The mesh was secured in place with

fixation screws (truSCREW, ACE Surgical Supply Co). A

resorbable bilayered collagen membrane (Bio-gide, Geistlich

Parma AG, Wolhusen, Switzerland) was used over the TiMe, and

the flap was then sutured.

Exposure of the TiMe was observed during the fourth week

after the initial alveolar ridge augmentation procedure. The

exposure occurred at the palatal aspect of the edentulous area.

The exposure was measured with a periodontal probe to be 4 3

4 mm. The portion of the exposed TiMe was removed using

carbide burs (Nos. 557 and 8 carbide bur, Brasseler Dental

Instrumentation, Savannah, Ga) and scissors at the 12th week

after the initial grafting procedure and 8 weeks after the

exposure was noted (Table 2). The remaining portion of the

mesh was left submerged until 6.5 months after grafting.

Full-thickness labial and palatal flaps were reflected, and

the mesh was removed. The graft appeared well integrated.

There was some minimal amount of granulation tissue at the

area. Postoperative CBCT was performed after mesh removal to

evaluate bone availability for implant placement. A comparison

of the preoperative and postoperative CBCTs revealed 4.1 mm

of horizontal and 4.5 mm of vertical ridge augmentation. The

flaps were then sutured, and the patient was scheduled for

subsequent implant surgery. The obtained bone volume was

adequate for implant placement.

FIGURE 1. Showing case 1. (a) Facial view of defect at time of surgery. (b) Occlusal view of defective alveolar ridge following full-thicknessflap reflection. (c) Occlusal view of titanium mesh (TiMe) in position following fixation. (d) Occlusal view of palatal TiMe exposure. (e)Occlusal view at time of partial removal of exposed TiMe. (f) Occlusal view showing healing after partial removal of exposed TiMe. (g)Occlusal view of regenerated alveolar ridge at time of implant placement.

Journal of Oral Implantology 483

Al-Ardah et al

Case 2

A 47-year-old male patient was referred for localized alveolar

ridge augmentation at the area of tooth No. 8 (Figure 2). A

preoperative CBCT confirmed the lack of sufficient bone

volume (Table 2). Surgical technique and bone graft material

were identical to that described in case 1, with the exception of

replacing the resorbable bilayered collagen membrane (Bio-

gide, Geistlich Biomaterials) with a platelet-rich fibrin (PRF)

membrane over the TiMe.

Exposure of the TiMe was observed during the first week

after the initial grafting procedure. The exposure occurred at

the crestal aspect of the edentulous area and extended toward

the labial aspect. The exposure was measured to be 6 3 10 mm.

The portion of the exposed TiMe was removed the 10th week

after the initial grafting procedure. The remaining portion of

the mesh was left submerged until 6.5 months after grafting.

During the surgical removal of the TiMe, the graft appeared

well integrated. Similarly to case 1, there was some minimal

amount of granulation tissue at the area. A comparison of the

TABLE 1

TiMe exposure in a total of 29 articles*

Article Type of Edentulism

Number of

Patients/Sites Type of Bone

von Arx et al27 Partially edentulous 20/20 Autogenous

von Arx et al15 Partially edentulous 18/18 Autogenous

Malchiodi et al28 Edentulous ridge max. 25/25 Particulated autogenous

Leghissa et al29 Partially edentulous 10/10 Blood clot only

von Arx et al14 Partially edentulous 15/19 Particulated autogenous

Assenza et al30 Partially edentulous 22/22 Blood clot only

Mariorana et al31 5 edentulous,

9 partially edentulous

14/23 Autogenous þ DBBM (50:50 ration)

Artzi et al23 Partially edentulous 10/10 DBBM

Degidi et al32 Partially edentulous 18/18 Autogenous

Proussaefs et al16 Partially edentulous 7/7 Autogenous þ DBBM (50:50 ratio)

Roccuzzo et al33 Partially edentulous 18/18 Autogenous

Proussaefs et al9 Partially edentulous 17/17 Autogenous þ DBBM (50:50 ratio)

Molly et al34 5 edentulous,


11/11 Blood clot

Matsui et al13 Partially edentulous 15/15 Autogenous

Roccuzzo et al10 Partially edentulous 12/12 Autogenous

Pieri et al35 Partially edentulous 16/19 Autogenous þ DBBM (70:30 ratio)

Louis et al21 16 edentulous,


44/45 Autogenous þ hydroxyapatite (75:25 ratio)

Corinaldesi et al36 Partially edentulous 24/27 Autogenous

Torres et al22 Partially edentulous

15:mesh and 15:mesh with PRP

30/43 DBBM

Mish et al20 Partially edentulous 5/5 Acellular collagen sponge (rhBMP-2)

Her et al11 Partially edentulous 26/27 Various bone graft material with different patients

Miyamoto et al37 Partially edentulous 41/50 Autogenous

de Freitas et al17 Partially edentulous 24/24 Autogenous VS rhBMP-2

Funato et al26 Partially edentulous 19/19 Human platelet-derived growth factor BB (rhPDGF-BB)

mixed with DBBM and autogenous

Poli et al38 Edentulous 13/13 Autogenous þ DBBM (50:50 ratio)

Chan et al24 Partially edentulous 5/5 Allograft

De Angelis et al25 Partially edentulous 2/2 Human platelet-derived growth factor BB (rhPDGF-BB)

mixed with DBBM

Uehara et al39 Partially edentulous 21/30 Autogenous mixed with hydroxyapatite (50:50 ratio)

Misch et al18 Partially edentulous 15/15 Allograft and rHBMP-2

* CT indicates computed tomography; CBCT, cone beam computed tomography; DBBM, deproteinized anorganic bovine bone; H, horizontal; max., maxilla;

mand., mandible; PA, periapical radiograph; PRP, platelet-rich plasma; rHBMP-2, recombinant human bone morphogenic protein–2; TiMe, titanium mesh; V,

vertical.


Partial Removal of the Exposed Site to Manage Titanium Mesh Exposure

preoperative and postoperative CBCTs revealed 7.8 mm of

horizontal and 4.6 mm of vertical ridge augmentation. The

obtained bone volume was sufficient for implant placement.

Case 3

A 44-year-old female patient was referred for bone grafting at

the area of teeth Nos. 9–11 (Figure 3). All surgical procedures

for TiMe placement and removal were identical to that

described in case 1, except that fresh frozen allograft was used

(Osteocell Plus, ACE Surgical Co), a resorbable thick spongious

scaffold collagen membrane (Mucograft, Geistlich Pharma AG)

instead of the resorbable bilayered collagen membrane, and

TiMe used was Ridge-Form Mesh (OsteoMed, Addison, Tex;

Table 2).

Exposure of the mesh occurred the sixth week after initial

surgery. The exposed portion was removed 4 weeks later. The

exposure area of the TiMe was measured to be 11 3 4 mm, and

it was located along the crest of the edentulous area. The

remaining portion of the TiMe was left submerged and

surgically removed 6.5 months after the initial bone-grafting

procedure.

During the surgical procedure for removing the TiMe, the

graft appeared well integrated. Similarly to previous cases,

there was some minimal amount of granulation tissue present.

TABLE 1

Extended

Follow-up Period—

Removal, mo

Percentage

of Exposure Bone Gain Outcome and Mean of Evaluation

4.7 50

5.2 0 Measuring bone graft at reentry; 25 were type A and 2 as type B by Misch ridge morphology

classification

8 4 Edentuolus ridge expansion with TiMe and implant placement; evaluation with histology and

measuring at reentry H ¼ 5.65 mm

5 0 Following extraction, placement of implant and grafting; evaluation with histology and PA

radiographs

6.6 5.26 Grafting around implants; evaluation at reentry V ¼ 5.8 mm

4 for mand.,

6 for max.

18.18 Grafting around implants; evaluation at reentry with histology and PA radiographs

5 14.28 Used for maxillary sinus when indicated; evaluated with histology

9 20 Reentry for histopathology and histochemistry; V ¼ 5.2 mm

4 for mand.,

6 for max.

0 Placement of implant and mesh; evaluated at reentry for histology

6–9 57.14 Evaluated with CT (V ¼ 2.86 mm, H ¼ 3,71), laboratory evaluation (stone casts): (volumetric ¼1.07 mL/mean V ¼ 2.57 mm, H ¼ 3.86 mm) and histology

4–6 22.2 Evaluated with CT with V ¼ 4.8 mm

5–13 35.3 Evaluated with CT (V ¼ 2.56 mm, H ¼ 3,75), laboratory evaluation (stone casts)—volumetric ¼0.73 cc, mean V ¼ 2.59 mm, H ¼ 3.88 mm), histologic and histomorphomertric evaluation

9–17 63.63 2 with very early and 5 late exposure

1–21 N Evaluated with CT (average H ¼ 4.4 mm and H ¼ 4.6 mm)

4–6 33.3 Evaluation at reentry by periodontal probe; V ¼ 5.7 mm

8–9 6.25 Exposure treated with absorbable collagen membrane; evaluation with CT (V ¼ 3.71 and

H ¼ 4.16)

6.9 52.7 Evaluated at reentry; mean of V ¼ 13.7 mm and histology

8–9 14.8

6 13.95 Evaluated at reentry histology and CT; no mesh exposure with PRP

6 0

6 26 No significant difference between type of graft and TiMe exposure

6 36% within a week,

resuturing

Evaluated with CBCT scans; mean bone gain with horizontal and vertical defect was

H ¼ 3.7 mm and V ¼ 5.4); for horizontal defect, H ¼ 3.9 mm

6 12.5 Evaluated at reentry and CT; no significant difference between the 2 groups (H ¼ 3.2,

VS 3.7 mm)

5.26 TiMe was covered with resorbable collagen membrane; evaluated at reentry and histology;

V gain ¼ 8.6 mm

6 7.69 Evaluated at reentry and panoramic radiograph with software

5 0 Evaluated with CBCT scan and histomorphometric examination; mean vertical gain ¼ 3.4 mm

0 Evaluated at reentry with histology

3–7 70% (they mentioned

criteria for risk of

exposure and infection)

Not reported

6 0 Evaluated with the use of CBCT; bone gain V ¼ 8.53 mm


Al-Ardah et al

Radiographic analysis revealed 4.6 mm of horizontal and 7.0

mm of vertical ridge augmentation.

Case 4

A 27-year-old male patient was referred for ridge augmentation

at the area of tooth No. 9 (Figure 4). Surgical procedures were

performed as described in case 1, except that a PRF membrane

was used also over the resorbable bilayered collagen mem-

brane (Bio-gide, Geistlich Biomaterials). Cancellous particulate

bone allograft (Puros, Zimmer Biomet) was used as the graft

material.

Exposure of the TiMe was observed during the third week

after the initial surgery. The exposure occurred at the palatal

aspect of the edentulous area. The exposure was measured to

be 5 3 3 mm. The portion of the exposed TiMe was removed

the fifth week after the initial grafting procedure (Table 2). The

FIGURE 2. Showing case 2. (a) Facial view of defect at time of surgery. (b) Occlusal view of defective alveolar ridge following full-thicknessflap reflection. (c) Occlusal view of titanium mesh (TiMe) in position following fixation. (d) Facial view of TiMe exposure at the crest of theridge with facial extension. (e) Occlusal view of TiMe exposure. (f) Facial view at time of partial removal of exposed TiMe. (g) Occlusal viewat time of partial removal of exposed TiMe. (h) Occlusal view showing healing after partial removal of exposed TiMe. (i) Occlusal view ofregenerated alveolar ridge at time of implant placement.

TABLE 2

Patient and defect data pre- and postgrafting providing location and size of titanium mesh exposure and end result following thedescribed clinical protocol

Patient Age Gender Bone Graft Material

Defect

Location

Week of

Exposure

After Grafting

Location

of Exposure

1 50 F Allograft cortical 1–2 mm bone (puros) 9, 10 4th Palatal

2 47 M Allograft cortical 1–2 mm bone (puros) 8 1st Crestal with labial extension

3 44 F Fresh frozen allograft (osteocell) 9, 10, 11 6th Crestal

4 27 M Allograft cortical cancellous 1–2 mm bone (puros) 9 3rd Palatal

* Measured from pre- and postgrafting cone beam computed tomography after titanium mesh removal.



remaining portion of the mesh was left submerged until 6

months after grafting.

Upon surgical removal of the TiMe, the graft appeared well

integrated while the presence of granulation tissue at the area

was consistent as with previous cases. Radiographic measure-

ments revealed 5.4 mm of horizontal and 3.1 mm of vertical

ridge augmentation. The obtained bone volume was adequate

for implant placement.

DISCUSSION

The significance of the current case series report is that it

provides a suggested treatment modality for addressing a

frequent complication associated with utilization of the TiMe as

a barrier for localized alveolar ridge augmentation. The current

report indicated an average 4.8 mm of vertical alveolar ridge

augmentation and 5.5 mm of horizontal augmentation. The

obtained augmentation is consistent with the typical alveolar

FIGURE 3. Showing case 3. (a) Facial view of defect at time of surgery. (b) Occlusal view of defective alveolar ridge following full-thicknessflap reflection. (c) Occlusal view of TiMe in position following fixation. (d) Occlusal view of TiMe exposure at crest of ridge. (e) Occlusal viewat time of partial removal of exposed TiMe. (f) Occlusal view showing healing after partial removal of exposed TiMe. (g) Occlusal view ofregenerated alveolar ridge at time of implant placement.

TABLE 2

Extended

Exposure

Size, mm

Week of

Removal of

Exposed

Titanium Mesh

Total

Healing

Period

Achieved

Horizontal (H)

Augmentation, mm*

Achieved

Vertical (V)

Augmentation, mm*

Clinical

Appearance of

Graft Material

Additional Bone

Graft Placed With

Implant Surgery

4 3 4 12th 6.5 months 4.1 4.5 Well integrated No



5 3 3 5th 6 months 5.4 3.1 Well integrated No


Al-Ardah et al

ridge augmentation that has been reported in the literature.5

Racia-dal Polo et al5 in a systemic review indicated that

utilization of a TiMe as a barrier resulted in 4.91 mm of vertical

ridge augmentation and 4.36 mm of horizontal augmentation.

It should be noted that comparing various studies should be

performed with caution because different graft materials and

different techniques have been implemented in the published

literature. However, despite the divergence of grafting mate-

rials and techniques, the preliminary findings indicate that

removing the exposed portion of the mesh and allowing the

remaining portion to be submerged may not compromise the

final clinical outcome.

An interesting finding in this case series study was that all

of the patients with TiMe exposure had received at least 2 failed

alveolar ridge augmentations previously. In addition, each

patient had received a different surgical technique in terms of

the type of membrane used to cover the TiMe. In cases 2 and 4,

a PRF membrane was used. Cases 1 and 3 were without a PRF

membrane and yet all had TiMe exposure. The PRF membrane

failed to prevent TiMe exposure with the presented cases.

There could be a cause-and-effect relationship between

multiple-site entry and future TiMe exposure. It would be of

great interest to explore this theory with a future study that has

a broader sample size.

There is a controversy in the literature regarding the effect

of TiMe exposure on bone volume. While several authors have

reported no effect of the exposure on the volume of bone

grafting,10,23,36 others have reported that bone loss occurs

when the TiMe is exposed.9,11,14,16,27,35 Despite the reported

loss of bone volume, when this occurred, the obtained bone

volume was sufficient to place implants.11,14,35 However, von

Arx at el27 experienced a clinical situation in which the

exposure of the TiMe resulted in significant bone loss that

precluded placement of implants. The effect of the size of the

exposure, the timing of the exposure after the initial ridge

augmentation procedure, and the type of graft material on the

final clinical outcome are elements that need to be studied.

There is a scarcity in the literature regarding the quality of

the obtained osseous tissue when exposure of the TiMe occurs.

Proussaefs et al16 published a case series report in which

histologic specimens were obtained and analyzed from alveolar

ridges where a localized alveolar ridge augmentation procedure

was performed by using a TiMe as a barrier. In their study, in

which histomorphometric analysis was performed, the exposed

sites had lesser bone formation while a bigger portion of

connective tissue was present at the augmented sites associated

with mesh exposure. It might be suggested that in addition to

the reduced bone volume, exposure of the mesh may result in

FIGURE 4. Showing case 4. (a) Facial view of defect at time of surgery. (b) Occlusal view of defective alveolar ridge following full-thicknessflap reflection. (c) Occlusal view of titanium mesh (TiMe) in position following fixation. (d) Occlusal view of TiMe palatal exposure. (e)Occlusal view at time of partial removal of exposed TiMe. (f) Occlusal view showing healing after partial removal of exposed TiMe. (g)Occlusal view of regenerated alveolar ridge at time of implant placement.



decreased quality of the augmented alveolus. While further

research is needed to validate this hypothesis, the preliminary

results of the current case series report indicate that treating the

complication of TiMe exposure by removing the exposed

portion of the mesh may result in bone-grafting results similar

to clinical situations in which the mesh had not been exposed.

In the current case series, the remaining portion of the TiMe

was removed 1 to 2 months before placement of the implants.

Removal of the mesh was performed as a separate surgical

procedure. Boyne et al7 observed the presence of a newly formed

connective layer along with granulation tissue under the mesh

(‘‘pseudo periosteum’’). The presence of abundant granulation

tissue underneath the mesh may indicate placement of implants

at a later stage.7,9,16 The clinical significance of this connective and

granulation tissue layer is unknown. Proussaefs et al43 suggested

that the micromovement of the titanium barrier could induce the

formation of this layer of connective and granulation tissue. While

this suggestion has not been validated, removing the portion of

the exposed mesh may result in lesser TiMe micromovement and

lesser amount of granulation tissue formation.

The limitations of the current cases series report are the

limited number of patients and the lack of long-term follow-up.

In addition, histologic analysis of the augmented alveolus

would have offered valuable information regarding the quality

of the augmented alveolus.

In summary, the proposed removal of the exposed portion

of the TiMe might offer results similar to results associated with

nonexposed sites. Further clinical research and increased

patient volume are needed before applying this technique on

a routine basis.

CONCLUSION

Removing the exposed portion of the TiMe did not have a

negative effect clinically on the integration of the grafted bone

and the bone volume available for implant placement.

Furthermore, it allowed for easier hygiene maintenance by

the patient at the grafted site. Further research is needed

before definitive conclusions can be made.

ABBREVIATIONS

CBCT: cone beam computed tomography

DBBM: deproteinized anorganic bovine bone

PRF: platelet-rich fibrin

rHBMP-2: recombinant human bone morphogenic protein–2

TiMe: titanium mesh

NOTE

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

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