Mechanical Characterization of 3D-Printed Individualized Ti-Mesh (Membrane) for Alveolar Bone Defects

Enhancing Guided Bone Regeneration with a Novel Carp Collagen Scaffold: Principles and Applications

Bone defects resulting from trauma, surgery, and congenital, infectious, or oncological diseases are a functional and aesthetic burden for patients. Bone regeneration is a demanding procedure, involving a spectrum of molecular processes and requiring the use of various scaffolds and substances, often yielding an unsatisfactory result. Recently, the new collagen sponge and its structural derivatives manufactured from European carp (Cyprinus carpio) were introduced and patented. Due to its fish origin, the novel scaffold poses no risk of allergic reactions or transfer of zoonoses and additionally shows superior biocompatibility, mechanical stability, adjustable degradation rate, and porosity. In this review, we focus on the basic principles of bone regeneration and describe the characteristics of an "ideal" bone scaffold focusing on guided bone regeneration. Moreover, we suggest several possible applications of this novel material in bone regeneration processes, thus opening new horizons for further research.

Influence of Different Porosities of Titanium Meshes on Bone Neoformation: Pre-Clinical Animal Study with Microtomographic and Histomorphometric Evaluation

The aim of this study was to evaluate the influence of different types of porosity of titanium meshes on the bone neoformation process in critical defects surgically created in rat calvaria, by means of microtomographic and histomorphometric analyses. Defects of 5 mm in diameter were created in the calvaria of 36 rats, and the animals were randomly treated and divided into the following groups (6 animals per group): NCOG (negative control, only blood clot), TEMG (Polytetrafluoroethylene-PTFE-membrane), SPTMG (small pore titanium mesh), SPMMG (small pore mesh + PTFE), LPTMG (large pore titanium mesh), and LPMMG (large pore mesh + PTFE). After 60 days, the animals were sacrificed, and the bone tissue formed was evaluated with micro-CT and histomorphometry. The data were compared using an ANOVA followed by the Tukey post-test (p ≤ 0.05). The microtomographic results showed that the SPTMG group presented the highest numerical value for bone volume/total volume (22.24 ± 8.97), with statistically significant differences for all the other groups except LPTMG. Considering the histomorphometric evaluation, groups with only porous titanium meshes showed higher values compared to the groups that used the PTFE membrane and the negative control. The SPTMG group presented higher values in the parameters of area (0.44 mm2 ± 0.06), extension (1.19 mm2 ± 0.12), and percentage (7.56 ± 1.45%) of neoformed bone. It was concluded that titanium mesh with smaller pores showed better results and that the association of PTFE membranes with titanium meshes did not improve the outcomes, suggesting a correlation between mesh porosity and underlying bone repair.

Finite element analysis of stress in oral mucosa and titanium mesh interface

BACKGROUND

The stiffness of titanium mesh is a double-blade sword to repair larger alveolar ridges defect with excellent space maintenance ability, while invade the surrounding soft tissue and lead to higher mesh exposure rates. Understanding the mechanical of oral mucosa/titanium mesh/bone interface is clinically meaningful. In this study, the above relationship was analyzed by finite elements and verified by setting different keratinized tissue width in oral mucosa.

METHODS

Two three-dimensional finite element models were constructed with 5 mm keratinized tissue in labial mucosa (KM cases) and 0 mm keratinized tissue in labial mucosa (LM cases). Each model was composed of titanium mesh, titanium screws, graft materials, bone, teeth and oral mucosa. After that, a vertical (30 N) loadings were applied from both alveolar ridges direction and labial mucosa direction to stimulate the force from masticatory system. The displacements and von Mises stress of each element at the interfaces were analyzed.

RESULTS

Little displacements were found for titanium mesh, titanium screws, graft materials, bone and teeth in both LM and KM cases under different loading conditions. The maximum von Mises stress was found around the lingual titanium screw insertion place for those elements in all cases. The keratinized tissue decreased the displacement of oral mucosa, decreased the maximum von Mises stress generated by an alveolar ridges direction load, while increased those stress from labial mucosa direction load. Only the von Mises stress of the KM cases was all lower than the tensile strength of the oral mucosa.

CONCLUSION

The mucosa was vulnerable under the increasing stress generated by the force from masticatory system. The adequate buccal keratinized mucosa width are critical factors in reducing the stress beyond the titanium mesh, which might reduce the titanium exposure rate.

High porosity 3D printed titanium mesh allows better bone regeneration

BACKGROUND

Most patients with insufficient bone mass suffer from severe horizontal or vertical bone defects in oral implant surgery. The purpose of this study was to compare the bone regeneration effects of titanium meshes with different porosity in the treatment of bone defects.

METHODS

Nine beagle dogs were equally divided into three groups based on execution time. Three months after the extraction of the first to fourth premolars of the mandible, three bone defects were randomly made in the mandible. Bone particles and three kinds of three-dimensional (3D) printed titanium nets with different porosities (low porosity group (LP), 55%; medium porosity group (MP), 62%; and high porosity group (HP), 68%) were replanted in situ. The beagles were killed 4, 8, and 12 weeks after surgery. Formalin-fixed specimens were embedded in acrylic resin. The specimens were stained with micro-CT, basic fuchsin staining, and toluidine blue staining.

RESULTS

Micro-CT analysis showed that the trabecular thickness, trabecular number, and bone volume fraction of the HP group were higher than those of the other two groups. Moreover, the trabecular separation of the HP group decreased slightly and was lower than that of the MP and LP groups. Histological staining analysis showed that the trabecular number in the HP group was higher than in the other two groups at 8 and 12 weeks, and the bone volume fraction of the HP was higher than that in the other two groups at 12 weeks. Moreover, the trabecular thickness of the MP was higher than that of the LP group at 12 weeks and the trabecular separation was lower in the HP group at 4 and 8 weeks. The differences were statistically significant (p < 0.05).

CONCLUSION

A 3D printed titanium mesh with HP in a certain range may have more advantages than a titanium mesh with LP in repairing large bone defects.

Polyetherketoneketone Mesh for Alveolar Bone Augmentation: Geometric Parameter Design and Finite Element Analysis

Objective

To evaluate the mechanical properties of porous polyetherketoneketone (PEKK) meshes with different thicknesses, pore sizes, and porosities through finite element analysis to provide an optimal PEKK design for alveolar bone augmentation in the posterior mandibular region.

Methods

A three-dimensional evaluation model of severe alveolar bone defects in the mandibular posterior was constructed based on cone beam computerized tomography (CBCT) data. Then, PEKK meshes with different structural designs were obtained. Two key parameters were set with different values: five levels of thickness (0.2 mm, 0.3 mm, 0.4 mm, 0.5 mm, and 0.6 mm) and three levels of pore size (1 mm, 2 mm, and 3 mm) with a corresponding porosity of 19.18%-42.67%. A 100 N physiological force was simultaneously loaded by finite element analysis (FEA), and the deformation and stress data were outputted for further analysis.

Results

The deformation and stress of the PEKK meshes are negatively correlated with the changes in thickness and positively correlated with the changes in pore size. The FEA results show that the maximum deformation, equivalent stress, and maximum principal stress of the PEKK meshes are 0.168 mm-0.478 mm, 49.243 MPa-124.890 MPa, and 31.549 MPa-104.200 MPa, respectively. The PEKK mesh group with a thickness of 0.2 mm, pore size of 3 mm, and porosity of 42.67% is in danger of plastic deformation or even fracture during use.

Conclusion

According to the FEA results, the PEKK meshes with larger thicknesses and smaller pore sizes and porosities behave better. In consideration of reducing soft tissue stimulation and promoting bone regeneration, an ultrathin porous PEKK mesh with a pore size of no more than 3 mm, porosity of no more than 42.67%, and thickness of 0.2 mm can be used clinically to meet the mechanical performance requirements of the guided bone regeneration (GBR) structure.

The effect of bone defect size on the 3D accuracy of alveolar bone augmentation performed with additively manufactured patient-specific titanium mesh

OBJECTIVE

Additively manufactured (3D-printed) titanium meshes have been adopted in the dental field as non-resorbable membranes for guided bone regeneration (GBR) surgery. However, according to previous studies, inaccuracies between planned and created bone volume and contour are common, and many reasons have been speculated to affect its accuracy. The size of the alveolar bone defect can significantly increase patient-specific titanium mesh design and surgical difficulty. Therefore, this study aimed to analyze and investigate the effect of bone defect size on the 3D accuracy of alveolar bone augmentation performed with additively manufactured patient-specific titanium meshes.

METHODS

Twenty 3D-printed patient-specific titanium mesh GBR surgery cases were enrolled, in which 10 cases were minor bone defect/augmentation (the planned bone augmentation surface area is less than or equal to 150 mm² or one tooth missing or two adjacent front-teeth/premolars missing) and another 10 cases were significant bone defect/augmentation (the planned bone augmentation surface area is greater than 150 mm² or missing adjacent teeth are more than two (i.e. ≥ three teeth) or missing adjacent molars are ≥ two teeth). 3D digital reconstruction/superposition technology was employed to investigate the bone augmentation accuracy of 3D-printed patient-specific titanium meshes.

RESULTS

There was no significant difference in the 3D deviation distance of bone augmentation between the minor bone defect/augmentation group and the major one. The contour lines of planned-CAD models in two groups were basically consistent with the contour lines after GBR surgery, and both covered the preoperative contour lines. Moreover, the exposure rate of titanium mesh in the minor bone defect/augmentation group was slightly lower than the major one.

CONCLUSION

It can be concluded that the size of the bone defect has no significant effect on the 3D accuracy of alveolar bone augmentation performed with the additively manufactured patient-specific titanium mesh.

Barrier Membranes for Guided Bone Regeneration (GBR): A Focus on Recent Advances in Collagen Membranes

Guided bone regeneration (GBR) has become a clinically standard modality for the treatment of localized jawbone defects. Barrier membranes play an important role in this process by preventing soft tissue invasion outgoing from the mucosa and creating an underlying space to support bone growth. Different membrane types provide different biological mechanisms due to their different origins, preparation methods and structures. Among them, collagen membranes have attracted great interest due to their excellent biological properties and desired bone regeneration results to non-absorbable membranes even without a second surgery for removal. This work provides a comparative summary of common barrier membranes used in GBR, focusing on recent advances in collagen membranes and their biological mechanisms. In conclusion, the review article highlights the biological and regenerative properties of currently available barrier membranes with a particular focus on bioresorbable collagen-based materials. In addition, the advantages and disadvantages of these biomaterials are highlighted, and possible improvements for future material developments are summarized.

3D Printed and Bioprinted Membranes and Scaffolds for the Periodontal Tissue Regeneration: A Narrative Review

Numerous technologies and materials were developed with the aim of repairing and reconstructing the tissue loss in patients with periodontitis. Periodontal guided bone regeneration (GBR) and guided tissue regeneration (GTR) involves the use of a membrane which prevents epithelial cell migration, and helps to maintain the space, creating a protected area in which tissue regeneration is favored. Over the time, manufacturing procedures of such barrier membranes followed important improvements. Three-dimensional (3D) printing technology has led to major innovations in periodontal regeneration methods, using technologies such as inkjet printing, light-assisted 3D printing or micro-extrusion. Besides the 3D printing of monophasic and multi-phasic scaffolds, bioprinting and tissue engineering have emerged as innovative technologies which can change the way we see GTR and GBR.

Photocrosslinkable Col/PCL/Mg composite membrane providing spatiotemporal maintenance and positive osteogenetic effects during guided bone regeneration

Guided bone regeneration membranes have been effectively applied in oral implantology to repair bone defects. However, typical resorbable membranes composed of collagen (Col) have insufficient mechanical properties and high degradation rate, while non-resorbable membranes need secondary surgery. Herein, we designed a photocrosslinkable collagen/polycaprolactone methacryloyl/magnesium (Col/PCLMA/Mg) composite membrane that provided spatiotemporal support effect after photocrosslinking. Magnesium particles were added to the PCLMA solution and Col/PCLMA and Col/PCLMA/Mg membranes were developed; Col membranes and PCL membranes were used as controls. After photocrosslinking, an interpenetrating polymer network was observed by scanning electron microscopy (SEM) in Col/PCL and Col/PCL/Mg membranes. The elastic modulus, swelling behavior, cytotoxicity, cell attachment, and cell proliferation of the membranes were evaluated. Degradation behavior in vivo and in vitro was monitored according to mass change and by SEM. The membranes were implanted into calvarial bone defects of rats for 8 weeks. The Col/PCL and Col/PCL/Mg membranes displayed much higher elastic modulus (p < 0.05), and a lower swelling rate (p < 0.05), than Col membranes, and there were no differences in cell biocompatibility among groups (p > 0.05). The Col/PCL and Col/PCL/Mg membranes had lower degradation rates than the Col membranes, both in vivo and in vitro (p < 0.05). The Col/PCL/Mg groups showed enhanced osteogenic capability compared with the Col groups at week 8 (p < 0.05). The Col/PCL/Mg composite membrane represents a new strategy to display space maintenance and enhance osteogenic potential, which meets clinical needs.

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Photocrosslinked Col/PCL and Col/PCL/Mg membranes displayed good mechanical support to provide space for bone regeneration.

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Col/PCL and Col/PCL/Mg membranes had suitable degradation rates for the maintenance duration of bone regeneration.

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Photocrosslinked Col/PCL/Mg membranes enhanced osteogenesis and expedited the formation of high-quality bone on week 8.

Customized Barrier Membrane (Titanium Alloy, Poly Ether-Ether Ketone and Unsintered Hydroxyapatite/Poly-l-Lactide) for Guided Bone Regeneration

Sufficient bone volume is indispensable to achieve functional and aesthetic results in the fields of oral oncology, trauma, and implantology. Currently, guided bone regeneration (GBR) is widely used in reconstructing the alveolar ridge and repairing bone defects owing to its low technical sensitivity and considerable osteogenic effect. However, traditional barrier membranes such as collagen membranes or commercial titanium mesh cannot meet clinical requirements, such as lack of space-preserving ability, or may lead to more complications. With the development of digitalization and three-dimensional printing technology, the above problems can be addressed by employing customized barrier membranes to achieve space maintenance, precise predictability of bone graft, and optimization of patient-specific strategies. The article reviews the processes and advantages of three-dimensional computer-assisted surgery with GBR in maxillofacial reconstruction and alveolar bone augmentation; the properties of materials used in fabricating customized bone regeneration sheets; the promising bone regeneration potency of customized barrier membranes in clinical applications; and up-to-date achievements. This review aims to present a reference on the clinical aspects and future applications of customized barrier membranes.

Advances in Barrier Membranes for Guided Bone Regeneration Techniques

Guided bone regeneration (GBR) is a widely used technique for alveolar bone augmentation. Among all the principal elements, barrier membrane is recognized as the key to the success of GBR. Ideal barrier membrane should have satisfactory biological and mechanical properties. According to their composition, barrier membranes can be divided into polymer membranes and non-polymer membranes. Polymer barrier membranes have become a research hotspot not only because they can control the physical and chemical characteristics of the membranes by regulating the synthesis conditions but also because their prices are relatively low. Still now the bone augment effect of barrier membrane used in clinical practice is more dependent on the body’s own growth potential and the osteogenic effect is difficult to predict. Therefore, scholars have carried out many researches to explore new barrier membranes in order to improve the success rate of bone enhancement. The aim of this study is to collect and compare recent studies on optimizing barrier membranes. The characteristics and research progress of different types of barrier membranes were also discussed in detail.

Assessment of Customized Alveolar Bone Augmentation Using Titanium Scaffolds vs Polyetheretherketone (PEEK) Scaffolds: A Comparative Study Based on 3D Printing Technology

Customized alveolar bone augmentation provides sufficient and precisely regenerated bone tissue for subsequent dental implant placement. Although some clinical cases have confirmed the successful use of the patient-specific polyetheretherketone (PEEK) scaffolds, the biomechanical property and osteogenic performance of the patient-specific PEEK scaffolds remain unclear. The objectives of this study were (1) to evaluate the space maintenance capacity and osteogenic performance of the patient-specific PEEK scaffolds for customized alveolar bone augmentation and (2) to compare the biomechanical properties of three-dimensionally printed titanium scaffolds and PEEK scaffolds. Both titanium scaffolds and PEEK scaffolds were designed and manufactured via additive manufacturing technology combined with computer-aided design (CAD). In three-point bending tests, the bending strength of the PEEK scaffold was about 1/3 that of the titanium scaffold. Accordingly, the equivalent strain value of the internal bone graft beneath the PEEK scaffold was about 3 times that beneath the titanium scaffold in finite element analysis, but the maximum deformations of both scaffolds were less than 0.05 mm. Meanwhile, in in vivo experiments, it is demonstrated that both scaffolds have similar space maintenance capacity and bone ingrowth efficiency. In conclusion, patient-specific PEEK scaffolds showed significantly lower biomechanical strength but comparable space maintenance and osteogenic properties to the titanium counterpart. Compared with traditional guided bone regeneration (GBR) surgery, both patient-specific PEEK and titanium scaffolds can achieve excellent osteogenic space maintenance ability. This study provides a preliminary basis for the clinical translation of the nonmetallic barrier membrane in customized alveolar bone augmentation.

Finding the Perfect Membrane: Current Knowledge on Barrier Membranes in Regenerative Procedures: A Descriptive Review

Guided tissue regeneration (GTR) and guided bone regeneration (GBR) became common procedures in the corrective phase of periodontal treatment. In order to obtain good quality tissue neo-formation, most techniques require the use of a membrane that will act as a barrier, having as a main purpose the blocking of cell invasion from the gingival epithelium and connective tissue into the newly formed bone structure. Different techniques and materials have been developed, aiming to obtain the perfect barrier membrane. The membranes can be divided according to the biodegradability of the base material into absorbable membranes and non-absorbable membranes. The use of absorbable membranes is extremely widespread due to their advantages, but in clinical situations of significant tissue loss, the use of non-absorbable membranes is often still preferred. This descriptive review presents a synthesis of the types of barrier membranes available and their characteristics, as well as future trends in the development of barrier membranes along with some allergological aspects of membrane use.

Finding the Perfect Membrane: Current Knowledge on Barrier Membranes in Regenerative Procedures: A Descriptive Review

Guided tissue regeneration (GTR) and guided bone regeneration (GBR) became common procedures in the corrective phase of periodontal treatment. In order to obtain good quality tissue neo-formation, most techniques require the use of a membrane that will act as a barrier, having as a main purpose the blocking of cell invasion from the gingival epithelium and connective tissue into the newly formed bone structure. Different techniques and materials have been developed, aiming to obtain the perfect barrier membrane. The membranes can be divided according to the biodegradability of the base material into absorbable membranes and non-absorbable membranes. The use of absorbable membranes is extremely widespread due to their advantages, but in clinical situations of significant tissue loss, the use of non-absorbable membranes is often still preferred. This descriptive review presents a synthesis of the types of barrier membranes available and their characteristics, as well as future trends in the development of barrier membranes along with some allergological aspects of membrane use.

Research on the dimensional accuracy of customized bone augmentation combined with 3D-printing individualized titanium mesh: A retrospective case series study

BACKGROUND

Few studies have focused on the dimensional accuracy of customized bone grafting by means of guided bone regeneration (GBR) with 3D-Printed Individual Titanium Mesh (3D-PITM).

PURPOSE

Digital technologies were applied to evaluate the dimensional accuracy of customized bone augmentation with 3D-PITM with a two-stage technique.

MATERIALS AND METHODS

Sixteen patients were included in this study. The CBCT data of post-GBR (immediate post-GBR) and post-implantation (immediate post-implant placement) were 3D reconstructed and compared with the pre-surgical planned bone augmentation. The dimensional differences were evaluated by superimposition using the Materialize 3-matic software.

RESULTS

The superimposition analysis showed that the maximum deviations of contour between were 3.4 mm, and the average differences of the augmentation contour were 0.5 ± 0.4 and 0.6 ± 0.5 mm respectively. The planned volume of bone regeneration was approximately equal to the amount of regenerated bone present 6 to 9 months after the surgical procedure. On average, the vertical gain in bone height was about 0.5 mm less than planned. And, the horizontal bone gain on the straight buccal of the dental implants and 2 to 4 mm apical of the platform fell also about a 0.5 mm short on average. Statistically significant differences were observed between the augmented volume of virtual and post-GBR, and the horizontal bone gain of post-implantation on the level of 4 mm apical to the implant platform (P < .05).

CONCLUSIONS

The dimensional accuracy of customized bone augmentation with the 3D-PITM approach needs further improvement and compared to other surgical approaches of bone augmentation.

Surface Comparison of Three Different Commercial Custom-Made Titanium Meshes Produced by SLM for Dental Applications

The use of individualized titanium meshes has been referred to in scientific literature since 2011. There are many advantages to its use, however, the main complications are related to early or late exposures. As some aspects such as its surface properties have been pointed out to influence the soft tissue response, this study was designed to compare the surface characteristics of three commercially available individualized titanium meshes between them and according to the manufacturer’s specifications. The results from the scanning electron microscopy, energy-dispersive X-ray spectroscopy, X-ray diffraction and the contact profilometry measurements were analyzed and cross-checked. It was discovered that, the BoneEasy’s post-processing superficial treatment was more refined, as it delivers the mesh with the lowest Ra value, 0.61 ± 0.14 µm, due to the applied electropolishing. On the other hand, the Yxoss CBR^® mesh from ReOss^® was sandblasted, presenting an extremely rough surface with a Ra of 6.59 ± 0.76 µm.