Application of the porous hydroxyapatite bio ceramic 'Stediker' in large cysts of the jaws with subsequent implant prosthesis

A 22-year-old woman seeks dental care for missing lower jaw teeth on the right and a severely damaged lower molar on the left, with a desire to have a metal-ceramic bridge on the right and a metal-ceramic crown on the left. Examination revealed missing 45 and 46, strongly converging to defect 47 and gangrenous root of 37. Radiographs show large radicular cysts of the lower jaw: right, covering the apexes of 47 and 45 and left of 37, bordering the apexes of 36 and 38 teeth. After surgery - extraction of 47, 37 and 38 teeth and cystectomy, we filled the bone defects with the porous hydroxyapatite bio ceramics "Stediker". After the consolidation of the bone defect in the area of the cyst on the right, we placed 2 intraosseous implants, SDV2 system, on which we subsequently made metal-ceramic crowns. X-ray follow-up of the case showed the erasure of the bone defect with an almost close to normal bone picture. Clinically, the patient feels and looks well after 5 years of follow-up. Eat normally. Radiologically, the area where the other cyst was appears to have a structure close to normal bone.

Surgery for large cysts of the jaws is a serious challenge for any dental surgeon. Partsch first in 1892 proposed a method of operating on large jaw cysts. Using the fact that the epithelium of the cyst is identical to that of the oral mucosa, it makes the cystic cavity adjacent to the lip by ejecting the vestibular wall of the cyst and suturing the ends of the lambo to the ends of the cystic sac - this is the so-called Partsch I / cyst method for large cyst surgery. In 1910 he published a second method for the operation of small cysts - the method of Partsch II / cystectomy /. Later in 1951, Nastev, based on these two methods, published his method for the operation of large cysts, which is essentially a cystectomy, and the new one is in the so-called "mattress suture", through which it reduces the volume of the bone defect, which allows it to suture the flap so as to close the cystic cavity.  In other words - to operate on the large cyst as a small cyst.

Later we read in the literature about methods by filling the bone cavity with an autograft, most often taken from the femur or lyophilized spongiosa, in which there is no large clot and stimulate osteogenesis. Often the healing process does not go smoothly, but with inflammation and the graft melts. At the same time, the use of hydroxyapatite to fill periodontal and bone defects began. There are many conflicting opinions about bone metabolism. The formation of new bone in the human body is a complex process associated with the cellular modulation of osteogenic cells - osteoblasts, osteocytes and osteoclasts, which is actually a different condition of the same cell. Due to this, the processes of resorption, osteogenesis and bone reshaping take place. Hydroxyapatite (HA) granules initiate and stimulate this reversible process. Not without significance is the influence of some common factors such as growth hormones, thyroid and parathyroid hormones, vitamin D, prostaglandins. By transmission electron microscopy, we prove that in the first week after the implantation of HA granules in the bone we observe alkaline-phosphatase activity of the osteoblasts, which suggests bone formation. Acid-phosphatase enzyme activity at the same time we observe only in the cytoplasm of osteocytes. The study of this enzyme activity we use to mark the processes of induction of osteogenesis and bone remodeling, which we notice as early as 3 to 4 months after implantation.

In modern methods for surgery of large cysts of the jaws we use calcium hydroxyapatite / HA /. Calcium HA - Ca10 (PO4) 6 (OH) 2 is an inorganic component of the human skeleton and represents 60 - 70% of it. Synthetic forms of calcium HA have a proven biological tolerance and have a number of advantages as a substitute for human bone, as evidenced by their more than 10 years of use in clinical practice.

There are two types of synthetic HA:
1. Solid HA - practically non-absorbable in tissues.
2. Porous HA - there are 3 types: I type: macro porous - with a pore size of 100 to 300 µm - almost non-absorbable, type II: microporous - with a pore size of 1 to 5 µm - slowly absorbed and type III: macro-microporous , which is characterized by the presence of both types of pores. It allows tissue growth and is resorbable, forming new bone in its place. The hydroxyapatite bio ceramic "Stediker" is of the third type and has a structural similarity to the newly formed bone, which explains its cytophilicity.

The hydroxyapatite bio ceramics "Stediker", as well as the implants system SDV2, used in this case, we receive from "Stedikon" Ltd. in glass ampoules, gamma sterilized.

Report

A 22-year-old woman sought dental advice without any subjective complaints in order to make a metal-ceramic bridge of the lower jaw on the right and a metal-ceramic crown of a severely damaged tooth of the lower jaw on the left, as her dentist had not practiced metal-ceramics. She was more concerned with her aesthetic appearance than with the fact that her masticatory function was somewhat disturbed.

Physical examination

Anamnestic - the patient does not report systemic diseases.



Extra oral – we do not observe changes. The opening of the mouth is within the physiological. Intraorally - severely neglected oral hygiene, the presence of tartar and abundant plaque. Multiple caries. Bad breath. The gingiva, however, is calm, pink in color, dense. 45 and 46 teeth are missing, and the strong pathological mobility of 47 teeth and the convergence of its crown to the defect are impressive, due to which the distance between the limiting teeth is small. We found a subtotally destroyed crown of 37 teeth. When probing in the carious cavity there is no pain. Radiographically, orthopantomography (Fig. 1) shows a large cyst in the body of the lower jaw on the right, with an oval shape, the large diameter of which is 28 millimeters, and the small 17 millimeters, covering the apexes of 44 and 47 teeth. Linea albuginea - not observed in places, but no clinical signs of exacerbation.  48 teeth - semi-retined, and 47 and 44 teeth - with visibly intact pulp. On the left of the 37th tooth, we observe a radicular cyst with a regular round shape, with a diameter of 16 millimeters. The dimensions we calculated based on Madjarov's research to increase the size of the image on orthopantomography compared to the actual dimensions. Linea albuginea - absolutely pronounced, and 38 and 28 teeth - semi-retined. During the examination, we found swelling in the vestibule. Palpation - no crepitation. When puncturing in the area of 46 teeth, we extracted abundantly macroscopically "cystic fluid". The same expired during the extraction of 47 teeth, which we did for diagnostic purposes.

Laboratory minimum - within the norm.

Treatment

We planned an operative intervention. 2 days before that we did premedication with Rovamycine every 8 hours for 2 tablets of 0.75 MUI and Supradyn - one effervescent tablet per day. We performed a thorough cleaning of the tartar, cleaned and obstructed the caries of the affected teeth. We performed the operation on the third day. Under wired anesthesia with Baycain - yellow we performed extraction of 37 teeth and cystectomy. Intraoperatively, we extracted 38 teeth for reasons of radicalism, as extirpation of the cyst significantly exposed its medial root. After copious rinsing of the bone cavity with oxygenated water and saline, we filled with 6 grams of porous hydroxyapatite bio ceramic "Stediker", mixing the particles with blood from the surgical wound and Gelaspon. We placed this mixture in the bone defect from the bottom to the surface, without overflow. We sutured the operative wound with a round needle and silk sutures 3/0. We put a gingival bandage on Vocopac. The drug treatment lasted 7 days, and on the seventh day, we removed the bandage and sutures. We treated the surgical wound for another 3 days with Solcoseril. We found leakage of single granules of organic ceramics. To maintain oral hygiene, we recommended gargles with Biodent - Solutio.



After an interval of ten days, we performed a similar surgical intervention on the cyst on the right, with the difference that we filled the bone defect with 8 grams of porous hydroxyapatite bio ceramics "Stediker. Control orthopantomography (Fig. 2 and Fig. 3) showed filling of approximately 3/4 of the volume of the bone defect, which I attribute to the bleeding and pushing of the filling to the surface. In some places, we observed enlightenment, which is probably due to the pieces of Gelaspon.


Four months later, the patient felt well, and on the control, orthopantomography / Fig. 4 / we found a homogeneous shadow, which completely fills the former bone defects. The boundary with the surrounding healthy bone is difficult to detect. According to Froum, histologically, between 8 and 12 months after the implantation of bio ceramics, we already have a new bone formed around the granules. This is also the most favorable time to place intraosseous implants in the restored area, as the bone already provides sufficiently strong support. That is why 4 months later in the area of 45 and 46 teeth we implanted 2 intraosseous implants from the SDV2 system, respectively 11 and 13 mm. During the preparation of the implant bed, bone shavings and several single granules of organic ceramics came out. Control orthopantomography (Fig. 5) showed precise adaptation of the implants in the respective lodges, but with slight convergence of the longitudinal axes. Four months later, we performed a control orthopantomography (Fig. 6), which showed almost complete resorption of the bio ceramics and Osseo integration of the implants.
In the meantime, we depulped and built with canal pin and photo polymer Polofil - molar 42, 43 and 44 teeth due to the strong destruction of their crowns and due to the consideration of inclusion in a block of crowns together with the implants. Orthopantomography showed exact endodontic treatment of these teeth and excellent construction. The next step towards prosthetics was to open the implants and place them over the gingival part. We placed one only on the medial implant, as we could not achieve good parallelism in their placement. On the distal implant, we built a "non-standard" stump, as in the channel of the implant we adjusted and cemented a channel pin and built a stump of photo polymer. By filing, we achieved the necessary parallelism. We made a block - metal-ceramic crowns according to the classic rules. We recommended to the patient strict oral hygiene with chlorhexidine pastes and the use of a specific interdental toothbrush to prevent the formation of plaque around the plinths of the implants. In addition, we recommended follow-up examinations at 6 months.





Almost five years after the end of the treatment, the inexperienced eye could hardly tell that there were cysts here, because the newly formed bone is almost close in its radiological structure to the surrounding healthy one. The implants are integrated and stable. On orthopantomography, we observe about 2 millimeters of resorption of the newly formed bone. The semi-retained 48 tooth grew and arranged very well in the row, adhering to the prosthetic structure / Fig. 7 /. Fig. 8 shows the metal-ceramic construction in the patient's mouth. The physiological rotation of 43 teeth remained. There is no plaque around the plinths of the implants. The periodontium is calm. The patient uses the prosthetic construction perfectly and is satisfied with her aesthetic appearance. We also offered implantation in the area of 37 teeth with subsequent orthopedic restoration of the left lower dentition through a block of metal-ceramic crowns of 36 and 37 teeth, but the patient rejected this proposal for financial reasons.



Comment

Due to the complexity of treatment of such cases, the author of the article recommends a multi-stage method of treatment as well as various measures to ensure the success of this treatment. We must first make sure that the patient does not suffer from systemic diseases that cause impaired bone regeneration. Then we need to rehabilitate the oral cavity to eliminate any type of infection that could jeopardize the survival of the "graft" of organic ceramics and its successful transformation into new bone. For the same reason, it is necessary to create a therapeutic concentration of a broad-spectrum antibiotic in the blood. It takes a period of about 4 months for the resorption of HA bio ceramics and its transformation into bone. We place the implants with even greater strictness with regard to the preparation of the bone bed, due to the lack of an objective criterion for determining the end of the bone modeling.
We start prosthetics in the period between the 8th and 12th month. Due to the lack of experience in our country regarding implantation in artificial bone and subsequent prosthetics, it is preferable to include natural teeth in the prosthetic structure if possible. Finally yet importantly, the good work in a team with dental technicians is extremely important for achieving a long-lasting functional and aesthetic effect of the treatment.

Conclusion

This clinical report recommends the use of porous hydroxyapatite bio ceramic "Stediker" to fill bone defects in the operation of large jaw cysts as an excellent implant material. The treatment approach is multi-stage and long, which requires very good motivation and discipline on the part of the patient. Bio ceramics are absorbed. In its place comes a new bone with a structure close to that of natural. With subsequent surgery, we can successfully place implants. The period from the 8 th to the 12 th month is the most suitable for the production of a prosthetic structure. For an aesthetic and long-lasting healing result, you need a well-coordinated team of dentists - dental technicians.