Functional Rehabilitation of the Atrophic Mandible and Maxilla with Fibula Flaps and Implant-Supported Prosthesis

Challenges during implant-assisted prosthetic rehabilitation in fibula reconstructed jaws and its management: a scoping review protocol

Introduction

Oral cancer is the sixth most prevalent cancer type worldwide. Patients are placed in a crippling predicament due to the functional and psychosocial difficulties brought on by the illness and its treatments. Both surgeons and maxillofacial prosthodontists may encounter challenges with reconstruction and therapy following cancer treatment. Over 20 years, the fibula has remained the mainstay of reconstructions for head and neck cancer. Maxillary and mandibular jaws with fibula reconstructions can use fixed or removable prosthetic rehabilitation solutions. The proposed scoping review aims to ascertain the volume and nature of evidence concerning the difficulties and corrective measures in the prosthetic rehabilitation of fibula-reconstructed head and neck cancer cases. The findings will aid in improving the prosthetic treatment care for the affected population.

Materials and Methods

The Joanna Briggs Institute (JBI) scoping review protocol will be followed in developing and reporting the scoping review methodology. Methods to identify the relevant literature will involve the systematic search of databases like PubMed, Scopus, Google Scholar, Cochrane Library, and gray literature sources for pertinent articles on the subject. Only papers published in English literature will be considered for the review, and the data collection period is limited to the past 20 years. The screening process will utilize defined inclusion/exclusion criteria for Title/Abstract and Full-text screening by two independent reviewers in covidence, and a third reviewer will resolve any conflicts. The data extracted will include specific details about the participants, concept, population, study methods, challenges encountered during prosthetic rehabilitation, and their management. Inductive thematic analysis and descriptive statistics will be applied where appropriate. The narrative synthesis of the evidence will be accomplished through data extraction in a tabular format, and the results will be presented as a narrative summary.

Clinical outcomes and periodontal conditions of dental implants placed in free fibula flaps (FFF): a retrospective study with a mean follow-up of 6 years

OBJECTIVES

Up-to-date literature regarding long-term success of implant rehabilitations after microvascular reconstructions with free fibula flap (FFF) is still very scarce. This study aimed to evaluate clinical outcomes, especially related to oral hygiene conditions, of patients rehabilitated with this technique.

MATERIALS AND METHODS

A total of 25 patients who underwent maxillofacial reconstructive surgery with FFF were retrospectively evaluated for soft tissues conditions, oral hygiene habits, and implant survival and success, assessed with a mean follow-up of 6 (range 2-15) years after loading.

RESULTS

Fourteen patients received full-arch fixed prostheses and 11 removable bar-supported overdentures. At the follow-up evaluation, 52% of prostheses did not allow proper accessibility for oral hygiene. Overall prosthetic survival was 100%, and implant survival and success were respectively 93.6% and 72%. Prevalence of peri-implantitis was 29% at implant level and that at patient level 96%.

CONCLUSIONS

Six-year clinical outcomes of this study reveal that poor oral hygiene practices and compliance by patients who underwent maxillofacial reconstruction with FFF are significantly associated with peri-implant disease.

CLINICAL RELEVANCE

Findings of the present study underline the need by clinicians for a careful assessment, in reference to a specific implant therapy, of patient's prosthetic accessibility for oral hygiene procedures.

The Implant-borne Articulation Splint in Fibula Free Flap Mandibular Reconstruction: A Technical Note

Computer-aided design and computer-aided manufacturing and digitally simulated surgeries have revolutionized maxillomandibular reconstruction. In particular, this technology has increased the accuracy and facilitated the process of dental implantation in fibula free flaps. Despite the efficacy of virtual planning, there is a minor degree of translational difference between digital and intraoperative measurements, which may affect the precision of implant and fibula orientations. This is especially concerning during the last stage of fibula insetting, where the graft segments have the potential to roll, yaw, or pitch. The objective of this study is to describe an advanced prosthodontic technique that ensures the fibula grafts and implants remain in a restorable position during final insetting. We describe the technique and workflow of the implant-borne articulation splint through a case presentation and demonstrate results at 4 months postoperative and postradiotherapy. Given the degree of investment placed in virtual planning, free flap reconstruction, and endosteal implants, a technique that ensures optimal restorability of each implant is pivotal. Larger studies are still required to fully elucidate the cost-effectiveness and long-term results of the implant-borne articulation splint.

Bone Tissue Engineering (BTE) of the Craniofacial Skeleton, Part I: Evolution and Optimization of 3D-Printed Scaffolds for Repair of Defects

Bone tissue regeneration is a complex process that proceeds along the well-established wound healing pathway of hemostasis, inflammation, proliferation, and remodeling. Recently, tissue engineering efforts have focused on the application of biological and technological principles for the development of soft and hard tissue substitutes. Aim is directed towards boosting pathways of the healing process to restore form and function of tissue deficits. Continued development of synthetic scaffolds, cell therapies, and signaling biomolecules seeks to minimize the need for autografting. Despite being the current gold standard treatment, it is limited by donor sites' size and shape, as well as donor site morbidity. Since the advent of computer-aided design/computer-aided manufacturing (CAD/CAM) and additive manufacturing (AM) techniques (3D printing), bioengineering has expanded markedly while continuing to present innovative approaches to oral and craniofacial skeletal reconstruction. Prime examples include customizable, high-strength, load bearing, bioactive ceramic scaffolds. Porous macro- and micro-architecture along with the surface topography of 3D printed scaffolds favors osteoconduction and vascular in-growth, as well as the incorporation of stem and/or other osteoprogenitor cells and growth factors. This includes platelet concentrates (PCs), bone morphogenetic proteins (BMPs), and some pharmacological agents, such as dipyridamole (DIPY), an adenosine A 2A receptor indirect agonist that enhances osteogenic and osteoinductive capacity, thus improving bone formation. This two-part review commences by presenting current biological and engineering principles of bone regeneration utilized to produce 3D-printed ceramic scaffolds with the goal to create a viable alternative to autografts for craniofacial skeleton reconstruction. Part II comprehensively examines recent preclinical data to elucidate the potential clinical translation of such 3D-printed ceramic scaffolds.

Complications related to zygomatic implants placement: A retrospective evaluation with 5 years follow-up

This retrospective study assessed zygoma implants in patients treated for upper maxilla extreme atrophy, trauma, cleft palate, or failed reconstruction. The implants were placed using Quad (4 zygoma implants) or mixed (zygoma and conventional implants in premaxilla) surgical technique, with intra-sinus or extra-sinus approach, followed by immediate or deferred loading. Clinical and radiographic evaluations were carried out at 5-year follow-up from loading. Implant survival, symptoms and signs of sinusitis, radiological alterations in terms of mucosal thickening or obliteration of the maxillary sinuses, oroantral communications, and peri-implant soft tissues were examined. A total of 42 patients, with 116 zygoma implants, were included in the study. The cumulative survival rate was 97.41%. One zygomatic bone fracture was assessed. Eight patients reported sinusitis, and two showed oro-antral communications. A comparison between mean pre- and post-operative Lund-Mackay scores showed a statistically significant increase of sino-nasal disease in the post-operative scores (p = 0.0019). Mucositis and gingival recession was observed in 21 and 8 implants respectively. Average recession was 2.52 ± 2.35 mm. According to our results, placement of zygoma implants has proved to be a predictable procedure, with a lower rate of severe complications compared to other treatment options in extreme upper jaw atrophy.

Extended and unusual indications in jaw reconstruction with the fibula flap: An overview based on our 30-year experience

Since the introduction of fibula flap as a reconstructive technique, an evolution of indications has been observed. Our first report of a traumatic mandibular reconstruction using fibula flap was in 1992. The vast majority of indications for surgery, are: malignant tumors, benign neoplasms, osteoradionecrosis and traumas. Nevertheless, extended indications have been described such as the treatment of dentoalveolar defect without bone discontinuity or reconstruction of maxilla defect up to type III (A and B), according to Cordeiro's classification. Unusual indications include cleft palate malformations with bone discontinuity less than 6 cm. Moreover, a particular attention should be focus on fibula flap harvest with more innovative technologies than traditional use of monopolar or bipolar and their advantages in pre and postoperative management.

Free fibula flap for reconstruction of the severely atrophic mandible: a retrospective study

The purpose of this retrospective study was to assess the feasibility of using a free fibula flap (FFF) for reconstruction of the alveolar region of the severely atrophic mandible, by determining bone stability after dental implant insertion and prosthetic rehabilitation in a series of eight female patients aged 36-65 years. Dental implant insertion was performed 3-4 months after reconstruction. Prosthetic loading was performed 3-4 months after implant insertion. The height of the reconstructed mandible after surgery was 21.20±1.87mm, with an increase of 8.80±1.71mm from the preoperative height. The height of the FFF immediately after reconstruction was 11.24±1.10mm; this showed a vertical loss of 0.99±0.52mm (8.79%) and maintenance of 91.21% of the initial height at a mean 14 months post-reconstruction. Applying the Wical and Swoope formula to estimate the original mandibular body height, it was found that the difference between this calculated height (21.17±3.76mm) and the reconstructed height (21.20±1.87mm) was only 0.03±3.17mm (0.14%). An overall insignificant decrease of 0.46±1.14 cm³ in FFF volume had occurred at 3-4 months after dental implant functional loading, while in two cases an increase in volume was found (1.22cm³ and 1.71cm³). The good and stable results obtained show that the FFF may be used to reconstruct the whole mandibular alveolar region, with the best possible outcomes.

Factors Affecting Dental Rehabilitation Following Jaw Reconstruction With Free-Fibular Graft In Patients With Head and Neck Cancer

Existing anatomic factors play a significant role in affecting the possibility of dental rehabilitation in head and neck cancer patients undergoing free-fibular graft reconstruction. An observational, cross-sectional study was initiated to evaluate factors affecting dental rehabilitation following free-fibular graft jaw reconstruction in head and neck cancer patients.Patients who had undergone jaw reconstruction with free-fibular graft, requiring dental rehabilitation were recruited. Irradiated, reconstructed patients who had completed at least 1 year since the last dose of radiotherapy and nonradiated patients who had completed 6 months since reconstruction were recruited. Patients who had undergone soft-tissue reconstruction or free-fibular graft in non-condyle sparing resections were excluded. Patient's demographic data, disease and treatment-related data were obtained. An intra-oral examination was carried out to evaluate anatomic variables affecting dental rehabilitation. Descriptive statistical analyses were carried out to study demographic data. Logistic regression analysis was carried out using Pearson χ test and Fisher exact test. Estimates of regression coefficient and their standard errors with 95% confidence interval were calculated.Total of 138 patients were enrolled and considered for prosthetic rehabilitation. A review of the frequency-based data revealed that 30% (n = 41) patients were considered suitable for prosthetic rehabilitation. On multivariate logistic regression analysis, morbidity of radiotherapy (P = 0.01), interference to placement of implants by reconstruction plates and screws (P = 0.023), unfavorable diagnostic maxilla-mandibular relationship (P = 0.011), and obliterated vestibule (P = 0.001) were statistically established (P < 0.05) as the most significant reasons for not carrying out dental rehabilitation in patients who had undergone free-fibular graft reconstruction.

Osseous Changes Over Time in Free Fibular Flap Reconstruction

OBJECTIVES/HYPOTHESIS

Evaluate bone resorption in free fibular grafts and document resorption behavior as compared to dentulous and edentulous autochthonous mandibular bone.

STUDY DESIGN

Retrospective Chart review.

METHODS

Postoperative computed tomography images were used to evaluate fibular graft resorption rates and corresponding sites of the dentulous or edentulous mandible. Bone height, width, and cortical thickness were measured.

RESULTS

Eighteen patients underwent fibula free flap reconstruction following resection of a primary head and neck cancer. Mandibular defects were classified using Jewer's classification. The average interval loss of osseous height was 0.23 ± 0.09 mm/yr for fibula flap, 0.55 ± 0.13 mm/yr for dentulous native mandible, and 0.98 ± 0.41 mm/yr in edentulous native mandible. Change in osseous width was 0.19 ± 0.08 mm/yr, 0.55 ± 0.33 mm/yr, and 0.73 ± 0.15 mm/yr, respectively. Rate of superior cortical resorption was 0.33 ± 0.34 mm/yr, 0.35 ± 0.13 mm/yr, and 0.53 ± 0.11 mm/yr in fibula flap, dentulous, and edentulous mandible, respectively. Inferior cortical resorption rates were quantified as 0.30 ± 0.11 mm/yr, 0.35 ± 0.08 mm/yr, and 0.51 ± 0.08 mm/yr.

CONCLUSIONS

Fibula free flap reconstruction of the mandible provides excellent functional results and allows for stable outcomes. Bone resorption is significantly lower in fibular graft compared with both edentulous and dentulous mandible. Edentulous bone displays significantly increased rates of atrophy in comparison to the dentulous mandible. This may have implications with regard to long-term viability of both the fibular flap and native mandible. The role of dental restoration on overall osseous stability warrants further research.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:1113-1116, 2019.

Management of High-energy Avulsive Ballistic Facial Injury: A Review of the Literature and Algorithmic Approach

Background:

High-energy avulsive ballistic facial injuries pose one of the most significant reconstructive challenges. We conducted a systematic review of the literature to evaluate management trends and outcomes for the treatment of devastating ballistic facial trauma. Furthermore, we describe the senior author’s early and definitive staged reconstructive approach to these challenging patients.

Methods:

A Medline search was conducted to include studies that described timing of treatment, interventions, complications, and/or aesthetic outcomes.

Results:

Initial query revealed 41 articles, of which 17 articles met inclusion criteria. A single comparative study revealed that early versus delayed management resulted in a decreased incidence of soft-tissue contracture, required fewer total procedures, and resulted in shorter hospitalizations (level 3 evidence). Seven of the 9 studies (78%) that advocated delayed reconstruction were from the Middle East, whereas 5 of the 6 studies (83%) advocating immediate or early definitive reconstruction were from the United States. No study compared debridement timing directly in a head-to-head fashion, nor described flap selection based on defect characteristics.

Conclusions:

Existing literature suggests that early and aggressive intervention improves outcomes following avulsive ballistic injuries. Further comparative studies are needed; however, although evidence is limited, the senior author presents a 3-stage reconstructive algorithm advocating early and definitive reconstruction with aesthetic free tissue transfer in an attempt to optimize reconstructive outcomes of these complex injuries.

Success of dental implants in vascularised fibular osteoseptocutaneous flaps used as onlay grafts after marginal mandibulectomy

We have evaluated the survival of dental implants placed in vascularised fibular flap onlay grafts placed over marginal mandibulectomies and the effects on marginal bone loss of different types of soft tissue around implants under functional loading. From 2001-2009 we studied a total of 11 patients (1 woman and10 men), three of whom had had ameloblastoma and eight who had had squamous cell carcinomas resected. A total of 38 dental implants were placed either at the time of transfer of the vascularised fibular ostoseptocutaneous flaps (nine patients with 30 implants) or secondarily (two patients with eight implants). Four patients were given palatal mucosal grafts to replace intraoral skin flaps around the dental implants (n=13), and the other seven had the skin flaps around the dental implants thinned (n=25) at the second stage of implantation of the osteointegrated teeth. All vascularised fibular osteoseptocutaneous flaps were successfully transferred, and all implants survived a mean (range) of 73 (33-113) months after occlusal functional loading. The mean (SD) marginal bone loss was 0.5 (0.3) mm on both mesial and distal sides in patients who had palatal mucosal grafts, but 1.8 (1.6) mm, and 1.7 (1.5) mm, respectively, on the mesial and distal sides in the patients who had had thinning of their skin flaps. This difference is significant (p=0.008) with less resorption of bone in the group who had palatal mucosal grafts. Palatal mucosa around the implants helps to reduce resorption of bone after functional loading of implants.

[Anterior mandibular bone augmentation techniques. Literature review]

INTRODUCTION

Mandibular edentation may lead to major symphyseal resorption making the placement of dental implants impossible. In this situation, bone augmentation techniques are available. The goal of our study was to make a review of the literature of the different techniques in use.

METHOD

A bibliographic research was conducted on the Medline, Ovid and Cochrane Library databases with the following keywords: anterior mandible, bone grafting, mandibular symphysis reconstruction. We selected only articles written in English, published from January 1975 to August 2014 and expressly dealing with anterior mandibular bone augmentation techniques.

RESULTS

Sixty-nine articles were analyzed. Eight bone augmentation techniques were reported. Bone grafting using iliac or calvarial bone and immediate or delayed implantation was the most popular technique. The main complications were infection, exposure or resorption of the graft, and chin and lip hypo- or anesthesia. The other reported techniques (osteotomies, distraction osteogenesis, transmandibular implants, mandibular reconstruction plates, fibula free flaps) were more confidential or had specific indications. There was no indication for biomaterials excepted if combined with autologous bone.

Pre-augmentation soft tissue expansion: an overview

OBJECTIVES

The aim of this study was to explore the development of soft tissue expanders, their different types and their potential applications prior to bone augmentation and implant placement.

MATERIAL AND METHODS

A review of pertinent literature was performed using PubMed to comprehend the dynamics of soft tissue expanders and determine the current position of their pre-augmentation applications.

RESULTS

There is promising, albeit preliminary information regarding the benefits of pre-augmentation soft tissue expansion. Findings cannot be generalised due to relatively small sample size.

CONCLUSIONS

Further clinical trials with larger sample sizes and long-term follow-up are needed before soft tissue expanders can be confidently applied in everyday clinical practice.

Oral Rehabilitation of Adult Edentulous Siblings Severely Lacking Alveolar Bone Due to Ectodermal Dysplasia: A Report of 2 Clinical Cases and a Literature Review

The oral conditions of adult edentulous patients with ectodermal dysplasia (ED) often lead to decreased physical and psychological health, and the negative effects can become as extreme as social and psychological isolation. However, restoring oral function of adult edentulous patients with ED using zygomatic implants (ZIs) or conventional implants (CIs) remains challenging for dentists because of the severe atrophy of these patients' alveolar ridges. This report describes 2 cases of adult edentulous siblings with ED; they exhibited severe alveolar bone atrophy and were treated with ZIs and CIs as bases to augment the bone in their anterior jaws. For these patients, bone augmentation was completed with an autogenous fibular graft. Although there was mild evidence of bone graft resorption in the maxilla, the bone augmentation procedures were successful in the 2 patients. Effective osseointegration of the implants was obtained. After placement, the functional and esthetic results of the oral rehabilitation were acceptable. More importantly, restoration of the patients' oral function enhanced their self-confidence and self-esteem. Therefore, restoring oral function in adult patients with ED and edentulous jaws using ZIs and CIs as the bases for bone augmentation is an effective approach.

[Anterior mandibular bone grafts by sub-mental approach]

INTRODUCTION

Some cases of totally edentulous mandibles are associated with extreme osseous resorption which do not allow the placement of dental implants, even in the symphysis area. We present a bone graft technique performed by mean of a submental approach.

TECHNICAL NOTE

The reconstruction is performed under general anesthesia by mean of calvarial bone bone grafts affixed on the superior face and occasionally on the inferior face of the mandibular symphysis, between the mental foramens. The approach is a conventional sub-mental approach that exposes the entire symphysal region. Four patients (aged 61 to 81) have been operated according to this technic. There was no postoperative complication. Mean bone increase was 9.3mm. Nineteen implants were inserted (4.75 implants per patient). No implant have been lost. The scare was inconspicuous.

DISCUSSION

This technique is indicated for cases with extreme bone resorption. It allows the reconstruction of the mandibular symphysis, without an intraoral approach and thus with minimized risk of bone graft exposure. Postoperative courses are uneventful. This technique is therefore indicated for elderly patients who complain about ill-fitting dentures.

Intra-arch elastics technique: a novel method for controlling the abutment/soft tissue interface during implant reconstruction of the orofacial region

In the past 30 years, composite microvascular free tissue transfer has become a popular and highly successful option for the reconstruction of defects in the head and neck region. However, inherent shortcomings exist with free tissue transfer in that the imported tissue often fails to adequately replicate the characteristics of the native tissues. This can lead to difficulties when attempting reconstruction from a surgical and prosthetic standpoint. Endosseous implants are often required to adequately retain prostheses, and management of the peri-implant soft tissues represents a critical challenge for the oral and maxillofacial surgeon. This report describes a novel technique for controlling the implant-abutment-soft tissue interface and the advantages of this technique as it pertains to orofacial reconstruction.

Long-term follow-up of severely resorbed mandibles reconstructed using tent pole technique without platelet-rich plasma

PURPOSE

To investigate the results of edentulous patients with severely resorbed mandibles who were treated with a modified tent pole procedure.

PATIENTS AND METHODS

Twenty-two edentulous patients (3 men, 19 women; mean age, 62 yr; range, 51 to 72 yr) with a history of conservative prosthodontic treatment failures were included this study. Using a transcutaneous submental approach, 4 endosseous dental implants were placed in the anterior mandible of each patient and covered with autogenous bone grafts harvested from the posterior iliac crest without the addition of platelet-rich plasma. Follow-up ranged from 3 to 9 years.

RESULTS

The postoperative course of the patients was uneventful, without any surgical infections. At 3 months postoperatively, the density of the grafted bone appeared to closely resemble that of the surrounding alveolar bone on panoramic radiographs. The average alveolar augmentation was 6.3 mm (standard deviation, 1.59 mm; range, 4 to 10 mm) and long-term follow-up showed no bone resorption around the endosseous implants.

CONCLUSIONS

The modified tent pole technique without the addition of platelet-rich plasma is a safe and effective method to reconstruct the severely resorbed mandible.

Dental implant placement after mandibular reconstruction by microvascular free fibula flap: current knowledge and remaining questions

Mandibular reconstruction by microvascular free fibula flap has dramatically improved the quality of life of patients treated by interruptive surgery. A simple prosthesis can be used for dental rehabilitation but in many cases, these prostheses remain nonfunctional. The use of osseointegrated implants restores both function and aesthetics. The technique for implantation in fibula flap is very similar to the technique in native mandible but access to the bone is the most difficult step of the surgery. The success rate for osteointegration ranges from 86% to 99% but the success rate of the prosthesis is much lower. This difference could be explained by the vertical discrepancy between the graft and the remaining mandible, which leads to an unfavourable implant-crown ratio. The quality of soft tissues is also a limiting factor for the prosthesis, and hypertrophy often appears after the placement of the abutments. The type of the prosthesis (fixed or removable) should also be discussed. Occlusal considerations should be highlighted as occlusion remains abnormal in many cases. Three-dimensional imaging might help in the planning of these complex reconstructions. A close collaboration between the maxillo-facial surgeon, the oral surgeon and the prosthodontist is necessary to obtain good results.

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.

Horizontal maxillary osteotomy with interpositional fibula flap

Horizontal maxillary osteotomy with an interpositional fibula flap for maxillary deficiency offers several advantages over conventional techniques for maxillary reconstruction. Maxillary deficiencies in all 3 planes, vertical, anterior-posterior, and transverse, can be corrected with a long-term stable construct while simultaneously restoring bony and soft tissue deficiencies. We conducted a retrospective review of patients with maxillary hypoplasia who underwent Horizontal maxillary osteotomy with interpositional osteoseptocutaneous fibula flaps. Compared with nonvascularized bone grafts, vascularized bone flaps undergo less resorption and can be used in poorly vascularized, mechanically unstable, irradiated, or scarred wound beds.

Navigated implantation after microsurgical bone transfer using intraoperatively acquired cone-beam computed tomography data sets

The use of a combination of intraoperative cone-beam computed tomography (CBCT) and a navigation system via a spinal software platform for the navigated implantation of oral implants after microsurgical bone transfer is described. Intraoperative data sets were generated using Arcadis Orbic 3D (Siemens, Medical Solutions, Erlangen, Germany) and immediately transferred to the VectorVision(2) navigation system (BrainLAB, Feldkirchen, Germany) via the NaviLink interface. In two patients who underwent microsurgical bone transfer for midfacial reconstruction, implants were placed using intraoperatively acquired CBCT data sets for planning and navigated insertion. In both cases, successful realization of the planned implant sites was achieved by the guidance of the drill, leading to rehabilitation of both patients. CBCT data generated by mobile systems are sufficient for the planning of implant position, and can be used for navigated insertion using tools originally developed for spinal surgery.

Forced eruption and implant treatment in posterior maxilla: A clinical report

Periodontal disease can result in bone defects that surround periodontally compromised teeth. After the loss of those teeth, remaining defects may compromise successful treatment with dental implants. Forced eruption, induced by applying light orthodontic forces in the coronal direction, provides enhancement of the implant recipient site by enabling the extraction of the periodontally hopeless teeth. This report describes the use of forced eruption to promote the formation of new bone and soft tissue in the resorbed maxillary posterior region, followed by placement of an implant-supported fixed partial denture.

Atrophy of Free Fibular Grafts after Mandibular Reconstruction

BACKGROUND

In free fibular flap surgery, the graft's low vertical height and tendency to resorb over time have been considered potential drawbacks. This study investigated (1) short- and long-term bone resorption in free fibular grafts; (2) resorption behavior of fibular grafts versus dentulous and edentulous autochthonous mandibular bone; and (3) factors that potentially influence long-term bone atrophy, such as site of reconstruction, presence of osseointegrated dental implants, patient age, and adjuvant radiation therapy.

METHODS

Between 1992 and 2004, 113 patients received free fibular grafts. Fifty-four of these patients were examined retrospectively. Postoperative Panorex examinations assessed loss of bone height per month. Standardized miniplate measurements served as a reference to prevent errors caused by projection on magnification.

RESULTS

Follow-up ranged from 6 months to 12 years. According to Jewer's classification, the following defect types were found: L, 23 (42.6 percent); H, five (9.3 percent); C, two (3.7 percent); LC, 12 (22.2 percent); HC, nine (16.7 percent); and LCL, three (5.6 percent). Radiographic analysis revealed a monthly atrophy of 0.04 +/- 0.08 mm (mean +/- SD) for fibular bone, 0.14 +/- 0.11 mm for dentulous mandibula, and 0.20 +/- 0.17 mm for edentulous mandibula. The difference in bone loss between fibula and edentulous or dentulous bone was significant (Friedman's test and Wilcoxon paired-sample test, p < 0.0001 and p = 0.02, respectively). Investigated factors had no significant influence on bone resorption rate.

CONCLUSIONS

Fibular grafts show short- and long-term stability. Their rate of atrophy is significantly lower than that of edentulous or dentulous mandibular bone. Thus, implants can be inserted into this bone graft just as successfully as they are inserted into adjacent mandibular bone when the same bone height is present.

Lambeau libre de péroné en double barre : intérêt du montage dans les reconstructions mandibulaires pour une réhabilitation prothétique sur implants (5 cas)

INTRODUCTION

As major loss of mandibular bone stock requires a vascularized transfer, fibula free flap reconstruction is considered to be the best free flap for its length and reliability. Its main advantage is to accept dental implants. Single or double-barrel reconstruction can be performed. Double-barrel reconstruction is generally preferred because the bone superposition offers enough height to allow dental implants.

MATERIAL AND METHODS

We reviewed five selected cases of double-barrel fibula free flap adaptive mandibular reconstruction performed among a series of 11 oral rehabilitations with planned dental implants, focusing on the technical aspects.

RESULTS

Today, dental rehabilitation has been achieved in three double-barrel fibula flaps. Details are reported concerning the implant step.

DISCUSSION

In this perspective, we discuss the choice of the reconstructive technique in order to obtain adequate bone height. Early in our experience and for different reasons discussed in the text, we used a single barrel fibula flap. This technique provided sufficient height in some cases, but had to be completed by bone grafts in few patients. Our experience illustrates the usefulness of the double barrel technique which provide definitive bone height sufficient for dental implants. The double-barreled technique should be considered as the best solution.

The application of alveolar distraction osteogenesis following nonresorbable hydroxyapatite grafting in the anterior maxilla: A clinical report

Distraction osteogenesis is a method of increasing bone length through the application of slow, controlled force on bone segments where periosteum and medullary blood supply are maintained. Recently, the procedure has been adapted to alveolar augmentation prior to prosthodontic rehabilitation. This report describes the use of alveolar distraction in the anterior maxilla and presents, to the authors' knowledge, the first reported successful application of the technique following nonresorbable hydroxyapatite grafting.