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This study describes a protocol for the direct manufacturing of a customized titanium mesh using CAD-CAM procedures and rapid prototyping to augment maxillary bone and minimize surgery when severe atrophy or post-oncological deformities are present. Titanium mesh and particulate autogenous plus bovine demineralised bone were planned for patient rehabilitation. Bone augmentation planning was performed using the pre-op CT data set in relation to the prosthetic demands, minimizing the bone volume to augment at the minimum necessary for implants. The containment mesh design was used to prototype the 0.6 mm thickness customized titanium mesh, by direct metal laser sintering. The levels of regenerated bone were calculated using the post-op CT data set, through comparison with the pre-op CT data set. The mean vertical height difference of the crestal bone was 2.57 mm, while the mean buccal-palatal dimension of thickness difference was 3.41 mm. All planned implants were positioned after an 8 month healing period using two-step implant surgery, and finally restored with a partial fixed prosthesis. We present a viable and reproducible method to determine the correct bone augmentation prior to implant placement and CAD-CAM to produce a customized direct laser-sintered titanium mesh that can be used for bone regeneration.

This study evaluated the outcomes of computer-aided design-computer-aided machining (CAD-CAM)-customized titanium mesh used for prosthetically guided bone augmentation related to the occlusion-driven implant position, to the vertical bone volume gain of the mandible and maxilla, and to complications, such as mesh exposure. Nine patients scheduled for bone augmentation of atrophic sites were treated with custom titanium mesh and particulate bone grafts with autologous bone and anorganic bovine bone in a 1:1 ratio prior to implant surgery. The bone volume needed to augment was virtually projected based on implant position, width, and length, and the mesh design was programmed for the necessary retaining screws. After 6 to 8 months, bone augmentations of 1.72 to 4.1 mm (mean: 3.83 mm) for the mandibular arch and 2.14 to 6.88 mm (mean: 3.95 mm) for the maxilla were registered on cone-beam computerized tomography. Mesh premature (within 4 to 6 weeks) exposure was observed in 3 cases and delayed (after 4 to 6 weeks) in 3 other cases. One titanium mesh was removed before the programmed time but in all augmented sites was possible implant insertion. No complication occurred during prosthetic follow-up. Using CAD-CAM technology for prosthetically guided bone augmentation showed important postoperative morbidity of mesh exposure (66%). Because of this high prevalence of mesh exposure and the potential infection that could affect the expected bone augmentation, this study suggests a cautious approach to this procedure when designing the titanium mesh, to avoid flap tension that may cause mucosal rupture.

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This paper describes a new protocol for mandibular reconstruction. Computer-aided design/computer-aided manufacturing (CAD/CAM) technology was used to manufacture custom-made cutting guides for tumor ablation and reconstructive plates to support fibula free flaps. CT scan data from a patient with an odontogenic keratocyst on the left mandibular ramus were elaborated to produce a virtual surgical plan of mandibular osteotomy in safe tissue for complete ramus resection. The CAD/CAM procedure was used to construct a customized surgical device composed of a cutting guide and a titanium reconstructive bone plate. The cutting guide allowed the surgeon to precisely transfer the virtual planned osteotomy into the surgical environment. The bone plate, including a custom-made anatomical condylar prosthesis, was designed using the outer surface of the healthy side of the mandible to obtain an ideal contour and avoid the bone deformities present on the side affected by the tumor. Operation time was reduced in the demolition and reconstruction phases. Functional and aesthetic outcomes allowed patients to immediately recover their usual appearance and functionality. This new protocol for mandibular reconstruction using CAD/CAM to construct custom-made guides and plates may represent a viable way to reproduce the patient's anatomical contour, give the surgeon better procedural control, and reduce operation time.

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