Rehabilitation of patients with severe (Class VI) maxillary resorption using Le Fort I osteotomy, interposed bone grafts and endosteal implants: 1–8 years follow-up on a two-stage procedure

Staged autogenous calvarial bone grafting and dental implants placement in the management of oligodontia: a retrospective study of 20 patients over a 12-year period

Oligodontia demands multidisciplinary management due to its repercussions on dentofacial growth. To place implants to realize implant-borne fixed denture, preimplant surgery may be necessary if bone volumes are insufficient. Our aim was to assess bone increase following autogenic bone grafting and to discuss prosthetic options. Twenty patients followed for oligodontia, who underwent bone grafting, were treated from 2008 to 2019. Transversal and vertical bone levels were measured pre- and postoperatively to assess alveolar ridge augmentation. Mean horizontal grafting increase was 4.60 mm [standard deviation (SD) 0.79 mm], mean sinus lift increase was 9.95 mm (SD 2.35 mm). Mean implants placed per patient was 9, mean implants placed on grafted site was 5 per patient. Overall implant survival rate was 100%. All patients benefited from prosthetic procedures when it was planned to perform implant-borne fixed dentures. Within the framework of a complete treatment plan (involving paediatric dentistry, dentofacial orthopaedics, oral and maxillofacial surgery, and prosthodontics), autologous bone grafting combined or not with orthognathic surgery is fully adapted to patients with oligodontia. It allows reconstruction of favourable bone volumes for placement of implants to realize implant-borne fixed dentures, with high implant survival rates and great improvements to quality of life.

Volumetric osseous changes in the completely edentulous maxilla after sinus grafting and lateral bone augmentation: a systematic review

The aim of this systematic review was to evaluate the volumetric changes associated with different bone grafting techniques in the completely edentulous atrophic maxilla before dental implant placement. A search was performed according to the PRISMA guidelines. A PICO question was formed, and the PubMed, Scopus, Embase, and Cochrane Library databases were searched, covering the period 2000-2018. Relevant data were extracted from the results regarding study population, surgical details, technical information on volumetric data acquirement, and volumetric outcome after bone augmentation procedures before implant placement. Six articles with a combined population of 84 patients were included. All patients had a completely edentulous maxilla, with a crestal horizontal width of <3-4mm or a crestal vertical height of <6-7mm. The iliac bone and ascending ramus were most frequently used as grafts. Five of the six studies reported volumes of sinus inlay graft (SIG) and four reported volumes of lateral bone augmentation (LBA). Radiographic analyses of the augmented areas differed among the studies. Volume loss after bone augmentation procedures ranged from 5% to 50% for SIG and from 5% to 47% for LBA. All surgical augmentation techniques for the edentulous maxilla are prone to resorption; no procedure seemed to be superior, but some interesting observations were made.

Are there specific indications for the different alveolar bone augmentation procedures for implant placement? A systematic review

Bone resorption following tooth loss often interferes with dental implant placement in a desired position, and requires additional bone augmentation procedures. Many techniques have been described to augment and reconstruct alveolar ridge width and height. The aim of this study was to systemically review whether there is evidence to provide indications for the various bone augmentation procedures based on defect dimension and type. An electronic search of the Medline database and Cochrane library, complemented by a manual search, was performed. Inclusion criteria for partial edentulism were: clinical trials on bone augmentation procedures in preparation or at the time of implant placement, reporting preoperative and postoperative dimensions of the ridge. For edentulous patients, studies were included when providing the data on ridge and defect description, or the amount of augmentation achieved. The search yielded 53 publications for partially edentulous patients and 15 publications for edentulous patients. The literature provides evidence that dehiscence and fenestrations can be treated successfully with guided bone regeneration (GBR) at the time of implant placement (mean implant survival rate (MISR) 92.2%, mean complication rate (MCR) 4.99%). In partially edentulous ridges, when a horizontal defect is present, procedures such as staged GBR (MISR 100%, MCR 11.9%), bone block grafts (MISR 98.4%, MCR 6.3%), and ridge expansion/splitting (MISR 97.4%, MCR 6.8%) have proved to be effective. Vertical defects can be treated with simultaneous and staged GBR (MISR 98.9%, MCR 13.1% and MISR 100%, MCR 6.95%, respectively), bone block grafts (MISR 96.3%, MCR 8.1%), and distraction osteogenesis (MISR 98.2%, MCR 22.4%). In edentulous patients, there is evidence that bone block grafts can be used (MISR 87.75%), and that Le Fort I osteotomies can be applied (MISR 87.9%), but associated with a high complication rate. The objective of extracting specific indications for each procedure could not be fully achieved due to the heterogeneity of the studies available. Further studies on bone augmentation procedures should report precise preoperative and postoperative measurements to enable a more exact analysis of the augmentation procedure, as well as to provide the clinician with the rationale for choosing the most indicated surgical approach.

Simultaneous sinus lifting and alveolar distraction of a severely atrophic posterior maxilla for oral rehabilitation with dental implants

We retrospectively reviewed a new preimplantation regenerative augmentation technique for a severely atrophic posterior maxilla using sinus lifting with simultaneous alveolar distraction, together with long-term oral rehabilitation with implants. We also analyzed the regenerated bone histomorphologically. This study included 25 maxillary sinus sites in 17 patients. The technique consisted of alveolar osteotomy combined with simultaneous sinus lifting. After sufficient sinus lifting, a track-type vertical alveolar distractor was placed. Following a latent period, patient self-distraction was started. After the required augmentation was achieved, the distractor was left in place to allow consolidation. The distractor was then removed, and osseointegrated implants (average of 3.2 implants per sinus site, 80 implants) were placed. Bone for histomorphometric analysis was sampled from six patients and compared with samples collected after sinus lifting alone as controls (n = 4). A sufficient alveolus was regenerated, and all patients achieved stable oral rehabilitation. The implant survival rate was 96.3% (77/80) after an average postloading followup of 47.5 months. Good bone regeneration was observed in a morphological study, with no significant difference in the rate of bone formation compared with control samples. This new regenerative technique could be a useful option for a severely atrophic maxilla requiring implant rehabilitation.

Severe maxillary atrophy treatment with Le Fort I, allografts, and implant-supported prosthetic rehabilitation

PURPOSE

Recently, several authors have described that autologous and fresh-frozen bones are effective materials to correct jaw bone defects before endosseous implant positioning. The aim of this study was to report a multistep oral rehabilitation of severe atrophic maxilla by means of Le Fort I osteotomy for maxillary downward and forward repositioning, allografts, implant insertion, and prosthetic loading.

METHODS

Patients with severe maxillary atrophy underwent Le Fort I osteotomy associated to fresh-frozen interpositional bone allografts. At 7 months after reconstructive procedure, 2 biopsies for each patient have been taken, and in the same surgical procedure, endosseous implants were placed. Five months afterward, abutments were connected for the final prosthodontic restauration. Each patient was evaluated at 1-year follow-up after prosthetic loading.

RESULTS

At 1-year follow-up after functional prosthetic loading, no infection of the allografts or implant failure has been reported. Clinical and radiologic follow-up showed no sign of bone resorption in all the osteotomic sites and in the grafted areas. Histological analysis showed evidence of allograft osteointegration and healing.

CONCLUSIONS

Multistep oral rehabilitation of severe atrophic maxilla with Le Fort and interpositional bone allografts represents a reliable surgical technique. According to this clinical, radiologic, and histologic reports, interpositional fresh-frozen bone allograft seems to be a valuable material for grafting jaw as it is cheaper than other materials and is safe, and it avoids donor site, decreasing the morbidity of the treatment

Long-term outcome of dental implants placed in revascularized fibula free flaps used for the reconstruction of maxillo-mandibular defects due to extreme atrophy

PURPOSE

the objectives of this study were to evaluate (a) the clinical outcome of revascularized fibula flaps used for the reconstruction of extremely atrophic jaws and (b) the survival rates of dental implants placed in the reconstructed areas.

MATERIALS AND METHODS

between 1999 and 2004, 12 patients presenting with extreme atrophy of the edentulous jaws were reconstructed with fibula free flaps. Five to 12 months after the reconstructive procedure, 75 titanium dental implants were placed in the reconstructed areas, while prosthetic rehabilitation was started 4-6 months afterward. The mean follow-up of patients after the start of prosthetic loading was 77 months (range: 48-116).

RESULTS

an uneventful healing of the bone transplants occurred in all patients. One out of the 75 dental implants placed was not loaded due to prosthetic reasons. No dental implants failed to integrate before prosthetic loading, while three were removed during the follow-up period. Despite the high survival rate of dental implants (95.8%), a relevant number of them presented relevant peri-implant bone-level loss, ranging from 1 to 7 mm for maxillary dental implants and from 1 to 4.5 mm for mandibular dental implants.

CONCLUSION

although no failures of the bone transplants occurred and a high long-term survival rate of dental implants were observed, this study showed that fibula free flaps do not guarantee dimensional stability of peri-implant bone, despite the immediate blood supply delivered by the vascular pedicle. The peri-implant bone resorption was higher when compared with the one related to dental implants placed in native bone.

Reconstruction of an atrophic maxilla: comparison of two methods

We have evaluated the survival of dental implants in extremely atrophic edentulous maxillas after autogenous bone grafting. We compared two techniques: the Le Fort I down-grafting procedure and conventional raising of the sinus floor with onlay bone grafting. Twenty-seven consecutive patients had their atrophic maxillas reconstructed, 10 of whom were treated with a Le Fort I osteotomy with down-grafting and interpositioning of bone, and 17 by raising the sinus floor and onlay grafts. All implants were placed 5-6 months after grafting. There was no difference in the survival of implants between the two groups. The choice of grafting technique will therefore be based primarily on the interarch relations and the need for soft tissue support.

Le Fort I osteotomy with interpositional graft and immediate loading of delayed modified SLActive surface dental implants for rehabilitation of extremely atrophied maxilla: a case report

PURPOSE

To describe a successful clinical case of immediate prosthetic loading of modified sandblasting and acid-etching surface ITI dental implants inserted in a grafted maxilla after Le Fort I osteotomy.

MATERIALS AND METHODS

A 59-year-old man with a severely atrophied maxilla was treated with Le Fort I osteotomy and interpositional iliac bone graft. Thirteen weeks later, 7 modified sandblasted and acid-etched surface ITI dental implants were inserted with immediate application of a screw-fixed prosthetic acrylic device kept in functional loading for 3 months until a definitive fixed prosthesis was inserted.

RESULTS

After 20-month follow-up there has been no implant failure, with minimal bone loss and healthy peri-implant soft tissues; the patient is functionally and esthetically satisfied.

CONCLUSIONS

Immediate loading of implants placed after Le Fort I osteotomy and interpositional iliac bone grafting could be an applicable protocol to rehabilitate extremely atrophied edentulous maxillas.

Le Fort I osteotomy, bilateral sinus lift, and inlay bone-grafting for reconstruction in the severely atrophic maxilla: a new vision of the sandwich technique, using bone scrapers and piezosurgery

Severe atrophy of the edentulous maxilla and progressive pneumatisation of the maxillary sinus can compromise the insertion of dental implants. In this context, ideal implant positioning is limited by inadequate height, width, and quality of the bone. Le Fort I osteotomy and interpositional bone graft is an excellent treatment concept for the dental rehabilitation of patients with atrophied maxilla and reversed intermaxillary relationship. In this report, we indicate the transcendent aspect of elevation and preservation of maxillary sinus and nasal mucosa, modifying the sandwich technique by the useful of bone scrapers and piezosurgery. The procedure is described including a 1-stage approach using cortico-cancellous bone blocks through which implants are placed. In the extremely atrophied alveolar process of the maxilla, this technique provides the desired gain of bone, allows for the ideal placement of dental implants, and improves any discrepancy between the upper and lower arches.

Maxillary reconstruction to enable implant insertion: a retrospective study of 181 patients

Background

The purpose of the present study was to evaluate different types of maxillary pre-prosthetic surgery using autogenous bone graft and suggest a guideline for maxillary reconstruction to place implant.

Methods

181 patients (125 females and 56 males), age range from 16 to 76 years old, were operated at the Maxillo-Facial Service of the Lille's 2 Universitary Hospital Center (Chairman Pr Joël Ferri). Different techniques were used, but always with autogenous bone grafting. 21 patients underwent a Lefort 1 procedure, 139 underwent sinus graft with or without vestibular onlay graft and 21 underwent onlay graft. This surgical procedure was made to allow the insertion of 685 implants.

Results

The patients were evaluated by clinical and radiological assessment. In the cases of Lefort 1, the rate of successful osteointegration was higher when the implants were placed in the second part of a two stages procedure: 92%, against 81% for one stage. In cases of sinus lift procedure, the rate of implant success was 98%. The infection rate was 3.5%. There was no significant resorption and the type of prosthesis used was a denture retained by a bar or fixed bridge. In cases of onlay graft, the implant insertion success was 97% and there was no infection. The amount of resorption was more significant in the pre-maxilla than in the other areas and the type of prosthesis used was fixed dentures.

Conclusion

These observations demonstrate that: the aetiology of the bone defect indicate the type and number of the surgical procedures to re-established good jaws relationship and give the bone conditions to implant insertion successful.

Clinical Relevance

A guideline for surgical decision in the maxillary reconstruction for oral rehabilitation by implants may help to prevent failures of osseous resorption disorders and to foresee the investment of the bone in quality and necessary quantity.

The value of a diagnostic setup for full fixed maxillary implant prosthetics

The concept of prosthesis-directed implant-supported restoration is well accepted. The implementation of this principle for patients requesting full fixed implant-supported maxillary prosthetics has not been thoroughly described. We present a technique for the evaluation and preprosthetic surgical management of patients who are edentulous in the maxilla and wish to have fixed implant-supported crown and bridge prosthetics.

Implant Reconstruction of the Bone- Grafted Maxilla: Review of the Literature and Presentation of 8 Cases

PURPOSE

This study prospectively investigates the long-term success of iliac crest bone grafting and the secondary placement of osseointegrated implants in reconstructing maxillae with severely reduced bone mass.

MATERIALS AND METHODS

Eight consecutive patients (7 women, 1 man), aged 18 to 69 (mean, 49.6), were treated by augmentation of their maxillae with corticocancellous autogenous iliac bone blocks. Forty-one Branemark implants of 7 to 15 mm in length and 3.75 mm in diameter were placed after a minimum delay of 6 months. Bone healing, maintenance of bone height, and implant stability were measured by clinical examination and radiographic control.

RESULTS

One patient was lost to follow-up at 24 months after delivery of the prosthesis and one was lost at 75 months. The average duration of follow-up after loading of the implants was 90.5 months, and the longest was 154 months. Thirty-four of 41 (83%) of the implants survived to the end of the observation period. Four of 6 implants that failed were 7 mm in length and the other 2 were 10 mm in length. One 10-mm implant was "slept" because of poor positioning. All prostheses survived. There was one significant gingival infection that resulted in loss of 1.5 mm of bone after which the implant remained stable. None of the other implants were associated with crestal bone loss of more than 0.5 mm for the duration of this study.

CONCLUSIONS

Delayed placement of osseointegrated implants in maxillae augmented by iliac bone grafts is predictable and successful in the long term.

Rehabilitation of the severely atrophied maxilla by horseshoe Le Fort I osteotomy (HLFO)

OBJECTIVE

The purpose of this study was to determine the long-term outcome of the horseshoe Le Fort I osteotomy (HLFO) as a preprosthetic operation technique for implant insertion in the extremely atrophied maxilla.

STUDY DESIGN

36 patients (8 male, 28 female, average age 57.6 years) underwent HLFO combined with iliac crest bone grafting. They were divided into 2 groups: group A with 12 patients who simultaneously received 100 implants; group B with 24 patients where 176 implants were inserted in 18 patients in a second-stage procedure. Clinical and radiographic outcome with regard to implant osseointegration, alveolar bone height in the canine and molar regions, peri-implant bone loss and satisfaction of patients (esthetics, masticatory function, overall treatment) were investigated in all cases.

RESULTS

The overall 2-year failure-free fraction of implants was 95.5%; the 5-year failure-free fraction was 89.3%. In the 1-step group the 2-year and 5-year failure-free fractions were 95.9% and 86.9%, respectively, in the 2-step group 95.0% and 91.3% (log rank test P=.57). A total of 27 implants were lost during the entire follow-up: 14 in 6 patients of the 1-stage and 13 in 9 patients of the 2-stage group. The mean loss of alveolar bone after augmentation in the canine and molar regions was almost equal in both groups (overall means for the 2 regions 3.67 +/- 2.77 and 4.42 +/- 2.72 mm, respectively). The relationship between the jaws and thereby the esthetic profile could be improved in all cases. All patients were satisfied with the dental rehabilitation and the achieved new esthetic appearance.

CONCLUSIONS

HLFO combined with iliac bone grafting is a feasible preprosthetic technique prior to implant insertion in cases of severe atrophy of the maxillary alveolar ridge, leading to satisfying implant survival and rehabilitation of function.

10-year follow-up of onlay bone grafts and implants in severely resorbed maxillae

Thirty patients with extremely resorbed maxillae had reconstructive bone grafts from the ala iliaca and endosseous implants in a one-stage procedure. The first ten patients constituted a development group and the following 20 patients a routine group. The marginal bone level and implants success rate was evaluated in a prospective long-term follow-up for a minimum of 10 years (10-13 years). Clinical and radiographic examinations were performed at 6 months and then annually up to 5 years. The final examinations were performed at the 10-year follow-up. The bridges were removed at every clinical examination. Marginal bone loss was seen up to the 3-year examination, where it averaged 4.6 mm in the routine group. Between the 3- and 10-year follow-up no significant change was registered. The initial bone loss was probably due to the design of the 3.6 mm conical unthreaded marginal part of the implant. The implant success rate was 83.1% in the routine group. Failures mostly occurred during the first 2 years (14 out of 20). A substantial amount of bone can be gained in patients with extremely resorbed maxillae, when treated with bone graft according to the procedure described in this study.

Stability of bone grafting and placement of implants in the severely atrophic maxilla

A severely atrophic maxilla can be restored by bone grafts to allow the insertion of implants. We present 30 consecutive patients treated with autogenous inlay and onlay bone grafts from the iliac crest to the floor of the maxillary sinus and the alveolar crest. A total of 200 implants were inserted 4-6 months after bone grafting. A mean vertical increase in bone thickness of 14mm was achieved. After a mean bone loss of 1.3mm during the first year after bone grafting only minimal resorption was observed during the second and third year. Seven implants failed to integrate and a further four implants were lost during follow-up.

Assessment of the value of anorganic bone additives in sinus floor augmentation: a review of clinical reports

In order to objectively assess the value of anorganic bone additives in sinus floor augmentation, a review of the English literature till May 2002 was carried out. The studies or parts of studies had to include at the least two patients, with a follow-up of at least 3 months, whilst histomorphometric data ought to be available of biopsies taken from the core of the graft. Only 12 studies fulfilled these criteria. Firm conclusions could not be drawn because there were substantial differences in histomorphometric techniques, healing periods and ratio autogenous bone anorganic additives, but it seemed that autogenous bone without anorganic additives resulted in the highest amount of bone after a 4-6 months healing period, while hydroxyapatite and bovine bone mineral, used as a bone substitute, gave the lowest amount of bone. No correlation between bone volume and time of graft healing could be found. The consequences, however, for implant placement and survival are at present, not fully understood. A plea is made for systematic prospective clinical and experimental studies to assess the various bone additives and ratios of autogenous bone to bone additives in composite grafts analysed with an adequate histomorphometric technique. Part of this study was presented at the 15th ICOMS, Durban, South Africa, 19-24 May 2001.