YBJOM-4264; No. of Pages 5
ARTICLE IN PRESS Available online at www.sciencedirect.com
British Journal of Oral and Maxillofacial Surgery xxx (2014) xxx–xxx
Leading article
Osteoplastic reconstruction of severely resorbed maxilla by stack plasty: combining sinus augmentation with lateral and vertical onlay bone grafting Christian Schaudy ∗ , Kurt Vinzenz Department for Oral and Maxillofacial Surgery, Evangelisches Krankenhaus Vienna, Hans Sachs-Gasse 10-12, 1180 Vienna, Austria Accepted 26 April 2014
Abstract Progressive loss of the alveolus with aging leads to defects in the buccolingual and vertical dimensions. Maxillomandibular spatial discrepancies and deficits in sagittal facial projection develop at the same time as deficiencies of the periodontal unit, alveolar bone, and attached gingiva increase, depending on the extent of the atrophy. To restore the anatomy, a sinus lift should be combined with lateral and vertical bony augmentation in an osteoplastic procedure. To achieve this, “block over block” replacement with bone from the iliac crest allows precise functional and aesthetic restoration of the alveolus and the nasomaxillary region by combining inlay, interpositional, and onlay grafting. To our knowledge, preprosthetic osteoplastic reconstruction with stacked bone grafts has not previously been documented with a large number of patients. We report the results of this procedure in 62 patients with severe maxillary atrophy. © 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Sinus augmentation; Stackplasty; Onlay grafting; Maxillary atrophy; Osteoplastic oral and maxillofacial surgery
Introduction Restorative orofacial surgery using like-with-like tissues to achieve both functional and aesthetic rehabilitation is the gold standard for plastic and reconstructive surgery, including oral implantology. In reconstructive surgery in patients with oral and maxillofacial defects such as cleft palate, evaluation of the amount of tissue to be replaced (such as the periodontal unit, alveolar bone, and attached gingiva) governs which procedure is required to restore the normal anatomy. This evaluation must take into account increases in the degree of disfigurement with the extent of the defect or atrophy.1 Block grafts, together with prelaminated and complex prefabricated bone blocks, are used in osteoplastic ∗
Corresponding author. Fax: +43 1 40422-2008. E-mail address: [email protected] (C. Schaudy).
reconstruction for the range of conditions that involve the loss of alveolar bone.2–4 The use of the block grafting technique described in this paper relies on the availability of sufficient attached masticatory gingiva for the functional and aesthetic periointegration of correctly-positioned implants that are anchored in a restored alveolus.5–7 Alveolar restoration with stacked bone grafts has not to our knowledge been reported previously for a large number of patients.8–12 We therefore present the results of this preprosthetic osteoplastic reconstruction technique after loss of the maxillary alveolar ridge.
Material and methods The surgical technique described here is an osteoplastic approach that can be used for all indications that require
http://dx.doi.org/10.1016/j.bjoms.2014.04.018 0266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Schaudy C, Vinzenz K. Osteoplastic reconstruction of severely resorbed maxilla by stack plasty: combining sinus augmentation with lateral and vertical onlay bone grafting. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.04.018
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ARTICLE IN PRESS
C. Schaudy, K. Vinzenz / British Journal of Oral and Maxillofacial Surgery xxx (2014) xxx–xxx
manipulation of images through a graphics workstation and appropriate software packages, as it uses saved CT sections. In this manner, facial defects can be anatomically correlated with the donor region.2,4 The system was used to calculate the size and shape of the transplants required. Prosthetic variables were correlated with 3-dimensional views of the skull, and the positions of the implants were calculated. Stereolithographic models together with casts and a SAM Articulator were also used for operative planning in patients with extensive defects.2,4 To measure the degree of bony resorption, another CT scan was taken 2 weeks after reconstruction, and a third before insertion of the implants 6 months later.15 Fig. 1. Original 3-dimensional computed tomographic scan of Case 1 (after successful reconstruction to improve lateral augmentation), mirroring the position of the implants (red circles) from the right side to the area of reconstruction. The black outline on the left side illustrates the initial position of the maxilla. Note that implants in their correct position would not have sufficient bone in the lateral dimension.
maxillary reconstruction. It needs adaptation only to the anatomical location according to the extent of the atrophy. Based on precise occlusion-defined positioning of implants, bicortical anchorage of implants, and periointegration with masticatory attached gingiva, functional and aesthetic rehabilitation can be achieved after implant dentistry.3,13 Patients Only healthy (in terms of bone metabolism and infectious disease) non-smokers who had not had radiotherapy were included in this study. The defect area had to have a class V or VI atrophy according to the Cawood and Howell classification.14 A computed tomographic (CT) scan was used preoperatively to confirm these in each patient. Over five years, 62 patients (21 male and 41 female, mean (SD 5.8) age at operation 56.9 years, were included in the study. The operation for treatment of loss of the alveolus in the maxilla and the anterior nasomaxillary complex is described in 3 case reports that illustrate typical clinical presentations. For a precise description of the technique the original CT scans of Case 1 are used in all illustrations.
Surgical technique The technique is a consistent method that can be adapted to the precise anatomical site according to the degree of atrophy. It takes into consideration the fact that maxillary disfigurement and the gradual loss of the attached gingiva increases in parallel with the extent of atrophy. Fig. 4 shows operations on the maxillary and nasomaxillary region as a 2-stage procedure. First, we did an osteoplastic reconstruction of the alveolar process of the maxilla; the implants were inserted 6 months later with bicortical anchorage of bone. Corticocancellous bone grafts from the anterior iliac crest were harvested in the desired dimension using a trapdoor technique (lateral antrostomy originally described by Tatum) and fixed by micro-osteosynthesis (KLS Martin, Tuttlingen, Germany) in the maxillary region (Fig. 4).8,15–18 After the mucoperiostium had been raised, we used a standard procedure to raise the sinus floor. The mucosa was completely reflected from the floor of the antrum and the medial sinus wall to create sufficient space for the bone graft. Reconstruction was achieved with several blocks. The sinus inlay procedure was combined with vertical and lateral augmentation. The first block was placed with the bony cortex facing upwards to provide two-point compact anchorage of bone for the implants. Cancellous bone blocks and chips served as interpositional grafts. Insertion of implants
Diagnosis, planning, and control CT scans were combined with stereolithographic models and casts according to a stepwise plan. This approach has been published previously for use in reconstruction with prefabricated composite grafts.4 After we had calculated the positions of the implants according to the extent of atrophy (Fig. 1), we planned the operation (Fig. 3). CT data were acquired using a Siemens Somatom Plus 4 and HiQ system (Siemens AG, Erlangen, Germany) in high resolution mode. Sections were 1–2 mm thick. Initial planning required a high speed image processing system (ARRI Voxel Flinger) with completely interactive 2-dimensional and 3-dimensional visualisation. This system allows interactive
After a healing period of at least 6 months, dental implants were installed in the reconstructed alveolus. All implants were placed by the same surgeon and included both Mark III and Mark IV TiU-Brånemark implants (Nobel Biocare, Gothenburg, Sweden). Before they were loaded, the implants were allowed to heal for 5 months.
Results Two hundred and twenty-one implants (mean (SD 0.8) 3.6 implants/patient) were inserted in newly assembled alveolar crests. Six patients had mild problems with wound healing
Please cite this article in press as: Schaudy C, Vinzenz K. Osteoplastic reconstruction of severely resorbed maxilla by stack plasty: combining sinus augmentation with lateral and vertical onlay bone grafting. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.04.018
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Fig. 2. On the basis of the original computed tomographic data for Case 1, this figure shows the possible surgical options. Label (3) indicates the transversally correct (mirrored) position of the implant as described in Fig. 1. Label (4) corresponds to the vertical dimension of atrophy. Conventional sinus lift technique. Because a sinus lift increases only the vertical aspect of the bone supply, the lateral dimension (2) is ignored and therefore the implant is inserted in a transversally incorrect position (1). Together with the missing restoration of the vertical atrophy of the alveolar crest (4), this results in a deficiency sum vector (5) that leads to inappropriate biomechanical stress on the loaded implant.
that were treated conservatively. Another six patients reported temporary paraesthesia or hypoaesthesia shortly after operation. Within the follow-up time of at least 16 months (mean (SD 21.4) 31.9 months), 11 implants were lost as a result of peri-implantitis and partial loss of the graft. However, these implants were successfully replaced at short notice, although the ideal predefined position had to be sacrificed. In one case, the entire graft was lost and retransplantation was required. This was successful after a healing period of 4 months. We achieved a mean increase in the alveolus of 16.5 (range 12-19) mm in height and 6 (range 4-13) mm in width. The degree of bony resorption within the first 6 months after reconstruction ranged from 7% to 9.5% (mean 8.3%) in the vertical and 4% to 12% (mean 7.5%) in the transverse dimension. Case 1 A 27-year-old woman had severe atrophy of the left maxilla after several operations. CT data were used to calculate the position of the implant (Fig. 1). Based on the availability of attached masticatory gingiva, osteoplastic reconstruction of the alveolus by stackplasty was chosen to restore the missing bone according to vector 5 in Fig. 2. The technique and the
3
Fig. 3. With the bony reconstruction orientated at the predefined position of the implant (3), multiple corticospongious bone blocks are used to create a framework that offers a bicortical anchorage for the implants. The remaining cavities are then filled with spongious bone chips.
bone grafts with osteotomy lines are shown in Fig. 4 and Fig. 5, respectively, and aesthetic and functional restoration of the alveolus were achieved (Fig. 6). Case 2 To date, we know of no safe diagnostic method for assessment of whether a safe amount of attached gingiva can be provided; the evaluation of the surgeon in the context of the specific procedure is therefore critical. A 40-year-old woman refused reconstruction using complex prefabricated composite grafts, but was unsatisfied with the results of the stackplasty. The massive losses of alveolar bone, attached gingiva, and bony support were consequences of the extraction of the still-vital canine 13 during the extraction of all teeth in the first quadrant. This procedure was designed to treat pain of unknown cause in this region. A sinus lift had been excluded because of the insufficient amount of bone and, as a result, the patient was transferred to our department for treatment. Although the alveolus was successfully reconstructed with the technique described, an overdenture was necessary because the attached masticatory gingiva was inadequate and the peri-implant mucosa was vulnerable. This resulted in pain, which was associated with difficulties in maintaining oral hygiene. Case 3 A 64-year-old woman had had a sinus lift 15 years previously, which had resulted in the loss of teeth 22 and 23, spatial discrepancy, and the loss of the lateral nasomaxillary bony framework. The pyriform region was involved, with
Please cite this article in press as: Schaudy C, Vinzenz K. Osteoplastic reconstruction of severely resorbed maxilla by stack plasty: combining sinus augmentation with lateral and vertical onlay bone grafting. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.04.018
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Fig. 4. A corticospongious bone block harvested from the inner side of the iliac crest together with at least two spongious half-cone shaped blocks (1+2). While the latter mainly serves as filling material beneath the “cover” plate and the maxillary alveolar crest, the corticospongious block (see Fig. 5) is cut to serve as both lateral (4) and cover (3) plates. These onlay grafts are secured using osteosynthesis that holds the spongious blocks in place. This allows for future insertion of implants in the correct position.
amplification of the nasolabial folds and loss of labial support. To achieve a symmetrical nasomaxillary complex, particularly in the area of the canine fossa, we chose a modified stackplasty that followed the surgical approach for osteoplasty of a tertiary cleft, including lateral augmentation of the alveolus for the correction of the sagittal facial projection of the nasomaxillary complex. The results from the orofacial functional and aesthetic points of view included an aesthetically pleasing implant and perioral restoration, and correction of the skeletal disfigurements in the nasomaxillary region.
Discussion Although there have been many reports on the topic of sinus lifts, reconstruction of the alveolar crests using bone blocks has rarely been described outside case reports,8–12,15,19–22
Fig. 5. Harvested corticospongious bone block from the iliac crest. The superimposed line indicates the osteotomy line to modify the osteoplasty according to the anatomical region and vectors for replacement of missing bone. Indexes (3) and (4) correspond to the diagram in Fig. 4.
probably because osteoplastic facial surgery is part of plastic and reconstructive surgery rather than oral implantology. An interdisciplinary group of plastic and oral and maxillofacial surgeons has improved preprosthetic osteoplastic surgery by using sole bone blocks and prelaminated and complex prefabricated bone blocks with microsurgical techniques in patients with cancer, cleft palate, or cancrum oris.1–4 Precise diagnostic evaluations of the tissue deficiencies and surgical planning are already the basis for treatment of maxillofacial defects, and have now found their way into restorative surgery for atrophy of the alveolar crest.4 Two important aspects need to be considered: the tissue deficit itself and the disfigurement that accompanies the atrophy.1 The problem of the design of a smile and the projection of the midface in patients with larger areas of atrophy has usually been dealt with by overdentures. However, preprosthetic osteoplastic surgery in an adapted form for oral implantology now offers a solution to the correction of spatial
Fig. 6. Mirror image showing the clinical picture after completion of dental restoration. Both vertical and lateral discrepancies were avoided.
Please cite this article in press as: Schaudy C, Vinzenz K. Osteoplastic reconstruction of severely resorbed maxilla by stack plasty: combining sinus augmentation with lateral and vertical onlay bone grafting. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.04.018
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discrepancies. The use of complex prefabricated composite grafts was introduced into oral implantology in 2006.3 The periointegration of dental implants that are in their anatomically correct position requires a minimum amount of attached gingiva.7 As in Case 2, failure to take this into account results in adverse consequences such as difficulties in maintaining oral hygiene, pain, and possible early loss of the implant.23 The development of the surgical concept of “stackplasty” bridges the whole range of osteoplastic operations from sole vertical sinus lifts to like-with-like reconstruction by prefabricated composite grafts. In cases where not enough attached gingiva is available, the technique should be upgraded to prelaminated, or even prefabricated, grafts to provide adequate cover for the transplant itself as well as periointegration for dental implants in their anatomically correct positions.1–4 Using the procedure described in this paper it is possible to meet the requirements of aesthetic implant dentistry and to provide better facial projection. The method integrates perfectly into the range of preprosthetic osteoplastic surgical techniques that have already been published, and closes the gap between implantology and restorative orofacial surgery. Conflict of interest The authors certify to have no affiliations with or involvement in any organization or entity with any financial or non-financial interest in the subject matter or materials discussed in this manuscript.
Ethics statement/confirmation of patient permission Not required.
References 1. Vinzenz K, Holle J, Wuringer E. Reconstruction of the maxilla with prefabricated scapular flaps in noma patients. Plast Reconstr Surg 2008;121:1964–73. 2. Holle J, Vinzenz K, Wuringer E, Kulenkampff KJ, Saidi M. The prefabricated combined scapula flap for bony and soft-tissue reconstruction in maxillofacial defects–a new method. Plast Reconstr Surg 1996;98:542–52. 3. Vinzenz K, Schaudy C, Wuringer E. The iliac prefabricated composite graft for dentoalveolar reconstruction: a clinical procedure. Int J Oral Maxillofac Implants 2006;21:117–23. 4. Vinzenz KG, Holle J, Wuringer E, Kulenkampff KJ, Plenk Jr H. Revascularized composite grafts with inserted implants for reconstructing the maxilla–improved flap design and flap prefabrication. Br J Oral Maxillofac Surg 1998;36:346–52.
5
5. Krekeler G, Schilli W, Diemer J. Should the exit of the artificial abutment tooth be positioned in the region of the attached gingiva? Int J Oral Surg 1985;14:504–8. 6. Artzi Z, Tal H, Moses O, Kozlovsky A. Mucosal considerations for osseointegrated implants. J Prosthet Dent 1993;70: 427–32. 7. Bouri Jr A, Bissada N, Al-Zahrani MS, Faddoul F, Nouneh I. Width of keratinized gingiva and the health status of the supporting tissues around dental implants. Int J Oral Maxillofac Implants 2008;23: 323–6. 8. Raghoebar GM, Vissink A, Reintsema H, Batenburg RH. Bone grafting of the floor of the maxillary sinus for the placement of endosseous implants. Br J Oral Maxillofac Surg 1997;35:119–25. 9. Senel FC, Duran S, Icten O, Izbudak I, Cizmeci F. Assessment of the sinus lift operation by magnetic resonance imaging. Br J Oral Maxillofac Surg 2006;44:511–4. 10. Blomqvist JE, Alberius P, Isaksson S. Sinus inlay bone augmentation: comparison of implant positioning after one- or two-staged procedures. J Oral Maxillofac Surg 1997;55:804–10. 11. Aghaloo TL, Moy PK. Which hard tissue augmentation techniques are the most successful in furnishing bony support for implant placement? Int J Oral Maxillofac Implants 2007;22(Suppl):49–70. Erratum in: Int J Oral Maxillofac Implants 2008; 23:56. 12. Voss P, Sauerbier S, Wiedmann-Al-Ahmad M, et al. Bone regeneration in sinus lifts: comparing tissue-engineered bone and iliac bone. Br J Oral Maxillofac Surg 2010;48:121–6. 13. Schuller-Gotzburg P, Entacher K, Petutschnigg A, Pomwenger W, Watzinger F. Sinus elevation with a cortical bone graft block: a patientspecific three-dimensional finite element study. Int J Oral Maxillofac Implants 2012;27:359–68. 14. Cawood JI, Howell RA. A classification of the edentulous jaws. Int J Oral Maxillofac Surg 1988;17:232–6. 15. Nystrom E, Ahlqvist J, Kahnberg KE, Rosenquist JB. Autogenous onlay bone grafts fixed with screw implants for the treatment of severely resorbed maxillae. Radiographic evaluation of preoperative bone dimensions, postoperative bone loss, and changes in soft-tissue profile. Int J Oral Maxillofac Surg 1996;25:351–9. 16. Tatum Jr H. Maxillary and sinus implant reconstructions. Dent Clin North Am 1986;30:207–29. 17. Boyne PJ, James RA. Grafting of the maxillary sinus floor with autogenous marrow and bone. J Oral Surg 1980;38:613–6. 18. Lin KY, Bartlett SP, Yaremchuk MJ, Fallon M, Grossman RF, Whitaker LA. The effect of rigid fixation on the survival of onlay bone grafts: an experimental study. Plast Reconstr Surg 1990;86:449–56. 19. Woo I, Le BT. Maxillary sinus floor elevation: review of anatomy and two techniques. Implant Dent 2004;13:28–32. 20. Adell R, Lekholm U, Grondahl K, Branemark PI, Lindstrom J, Jacobsson M. Reconstruction of severely resorbed edentulous maxillae using osseointegrated fixtures in immediate autogenous bone grafts. Int J Oral Maxillofac Implants 1990;5:233–46. 21. Isaksson S, Alberius P. Maxillary alveolar ridge augmentation with onlay bone-grafts and immediate endosseous implants. J Craniomaxillofac Surg 1992;20:2–7. 22. Neyt LF, De Clercq CA, Abeloos JV, Mommaerts MY. Reconstruction of the severely resorbed maxilla with a combination of sinus augmentation, onlay bone grafting, and implants. J Oral Maxillofac Surg 1997;55:1397–401. 23. Reinert S, Konig S, Bremerich A, Eufinger H, Krimmel M. Stability of bone grafting and placement of implants in the severely atrophic maxilla. Br J Oral Maxillofac Surg 2003;41:249–55.
Please cite this article in press as: Schaudy C, Vinzenz K. Osteoplastic reconstruction of severely resorbed maxilla by stack plasty: combining sinus augmentation with lateral and vertical onlay bone grafting. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.04.018
ARTICLE IN PRESS Available online at www.sciencedirect.com
British Journal of Oral and Maxillofacial Surgery xxx (2014) xxx–xxx
Leading article
Osteoplastic reconstruction of severely resorbed maxilla by stack plasty: combining sinus augmentation with lateral and vertical onlay bone grafting Christian Schaudy ∗ , Kurt Vinzenz Department for Oral and Maxillofacial Surgery, Evangelisches Krankenhaus Vienna, Hans Sachs-Gasse 10-12, 1180 Vienna, Austria Accepted 26 April 2014
Abstract Progressive loss of the alveolus with aging leads to defects in the buccolingual and vertical dimensions. Maxillomandibular spatial discrepancies and deficits in sagittal facial projection develop at the same time as deficiencies of the periodontal unit, alveolar bone, and attached gingiva increase, depending on the extent of the atrophy. To restore the anatomy, a sinus lift should be combined with lateral and vertical bony augmentation in an osteoplastic procedure. To achieve this, “block over block” replacement with bone from the iliac crest allows precise functional and aesthetic restoration of the alveolus and the nasomaxillary region by combining inlay, interpositional, and onlay grafting. To our knowledge, preprosthetic osteoplastic reconstruction with stacked bone grafts has not previously been documented with a large number of patients. We report the results of this procedure in 62 patients with severe maxillary atrophy. © 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Sinus augmentation; Stackplasty; Onlay grafting; Maxillary atrophy; Osteoplastic oral and maxillofacial surgery
Introduction Restorative orofacial surgery using like-with-like tissues to achieve both functional and aesthetic rehabilitation is the gold standard for plastic and reconstructive surgery, including oral implantology. In reconstructive surgery in patients with oral and maxillofacial defects such as cleft palate, evaluation of the amount of tissue to be replaced (such as the periodontal unit, alveolar bone, and attached gingiva) governs which procedure is required to restore the normal anatomy. This evaluation must take into account increases in the degree of disfigurement with the extent of the defect or atrophy.1 Block grafts, together with prelaminated and complex prefabricated bone blocks, are used in osteoplastic ∗
Corresponding author. Fax: +43 1 40422-2008. E-mail address: [email protected] (C. Schaudy).
reconstruction for the range of conditions that involve the loss of alveolar bone.2–4 The use of the block grafting technique described in this paper relies on the availability of sufficient attached masticatory gingiva for the functional and aesthetic periointegration of correctly-positioned implants that are anchored in a restored alveolus.5–7 Alveolar restoration with stacked bone grafts has not to our knowledge been reported previously for a large number of patients.8–12 We therefore present the results of this preprosthetic osteoplastic reconstruction technique after loss of the maxillary alveolar ridge.
Material and methods The surgical technique described here is an osteoplastic approach that can be used for all indications that require
http://dx.doi.org/10.1016/j.bjoms.2014.04.018 0266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Schaudy C, Vinzenz K. Osteoplastic reconstruction of severely resorbed maxilla by stack plasty: combining sinus augmentation with lateral and vertical onlay bone grafting. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.04.018
YBJOM-4264; No. of Pages 5
2
ARTICLE IN PRESS
C. Schaudy, K. Vinzenz / British Journal of Oral and Maxillofacial Surgery xxx (2014) xxx–xxx
manipulation of images through a graphics workstation and appropriate software packages, as it uses saved CT sections. In this manner, facial defects can be anatomically correlated with the donor region.2,4 The system was used to calculate the size and shape of the transplants required. Prosthetic variables were correlated with 3-dimensional views of the skull, and the positions of the implants were calculated. Stereolithographic models together with casts and a SAM Articulator were also used for operative planning in patients with extensive defects.2,4 To measure the degree of bony resorption, another CT scan was taken 2 weeks after reconstruction, and a third before insertion of the implants 6 months later.15 Fig. 1. Original 3-dimensional computed tomographic scan of Case 1 (after successful reconstruction to improve lateral augmentation), mirroring the position of the implants (red circles) from the right side to the area of reconstruction. The black outline on the left side illustrates the initial position of the maxilla. Note that implants in their correct position would not have sufficient bone in the lateral dimension.
maxillary reconstruction. It needs adaptation only to the anatomical location according to the extent of the atrophy. Based on precise occlusion-defined positioning of implants, bicortical anchorage of implants, and periointegration with masticatory attached gingiva, functional and aesthetic rehabilitation can be achieved after implant dentistry.3,13 Patients Only healthy (in terms of bone metabolism and infectious disease) non-smokers who had not had radiotherapy were included in this study. The defect area had to have a class V or VI atrophy according to the Cawood and Howell classification.14 A computed tomographic (CT) scan was used preoperatively to confirm these in each patient. Over five years, 62 patients (21 male and 41 female, mean (SD 5.8) age at operation 56.9 years, were included in the study. The operation for treatment of loss of the alveolus in the maxilla and the anterior nasomaxillary complex is described in 3 case reports that illustrate typical clinical presentations. For a precise description of the technique the original CT scans of Case 1 are used in all illustrations.
Surgical technique The technique is a consistent method that can be adapted to the precise anatomical site according to the degree of atrophy. It takes into consideration the fact that maxillary disfigurement and the gradual loss of the attached gingiva increases in parallel with the extent of atrophy. Fig. 4 shows operations on the maxillary and nasomaxillary region as a 2-stage procedure. First, we did an osteoplastic reconstruction of the alveolar process of the maxilla; the implants were inserted 6 months later with bicortical anchorage of bone. Corticocancellous bone grafts from the anterior iliac crest were harvested in the desired dimension using a trapdoor technique (lateral antrostomy originally described by Tatum) and fixed by micro-osteosynthesis (KLS Martin, Tuttlingen, Germany) in the maxillary region (Fig. 4).8,15–18 After the mucoperiostium had been raised, we used a standard procedure to raise the sinus floor. The mucosa was completely reflected from the floor of the antrum and the medial sinus wall to create sufficient space for the bone graft. Reconstruction was achieved with several blocks. The sinus inlay procedure was combined with vertical and lateral augmentation. The first block was placed with the bony cortex facing upwards to provide two-point compact anchorage of bone for the implants. Cancellous bone blocks and chips served as interpositional grafts. Insertion of implants
Diagnosis, planning, and control CT scans were combined with stereolithographic models and casts according to a stepwise plan. This approach has been published previously for use in reconstruction with prefabricated composite grafts.4 After we had calculated the positions of the implants according to the extent of atrophy (Fig. 1), we planned the operation (Fig. 3). CT data were acquired using a Siemens Somatom Plus 4 and HiQ system (Siemens AG, Erlangen, Germany) in high resolution mode. Sections were 1–2 mm thick. Initial planning required a high speed image processing system (ARRI Voxel Flinger) with completely interactive 2-dimensional and 3-dimensional visualisation. This system allows interactive
After a healing period of at least 6 months, dental implants were installed in the reconstructed alveolus. All implants were placed by the same surgeon and included both Mark III and Mark IV TiU-Brånemark implants (Nobel Biocare, Gothenburg, Sweden). Before they were loaded, the implants were allowed to heal for 5 months.
Results Two hundred and twenty-one implants (mean (SD 0.8) 3.6 implants/patient) were inserted in newly assembled alveolar crests. Six patients had mild problems with wound healing
Please cite this article in press as: Schaudy C, Vinzenz K. Osteoplastic reconstruction of severely resorbed maxilla by stack plasty: combining sinus augmentation with lateral and vertical onlay bone grafting. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.04.018
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ARTICLE IN PRESS
C. Schaudy, K. Vinzenz / British Journal of Oral and Maxillofacial Surgery xxx (2014) xxx–xxx
Fig. 2. On the basis of the original computed tomographic data for Case 1, this figure shows the possible surgical options. Label (3) indicates the transversally correct (mirrored) position of the implant as described in Fig. 1. Label (4) corresponds to the vertical dimension of atrophy. Conventional sinus lift technique. Because a sinus lift increases only the vertical aspect of the bone supply, the lateral dimension (2) is ignored and therefore the implant is inserted in a transversally incorrect position (1). Together with the missing restoration of the vertical atrophy of the alveolar crest (4), this results in a deficiency sum vector (5) that leads to inappropriate biomechanical stress on the loaded implant.
that were treated conservatively. Another six patients reported temporary paraesthesia or hypoaesthesia shortly after operation. Within the follow-up time of at least 16 months (mean (SD 21.4) 31.9 months), 11 implants were lost as a result of peri-implantitis and partial loss of the graft. However, these implants were successfully replaced at short notice, although the ideal predefined position had to be sacrificed. In one case, the entire graft was lost and retransplantation was required. This was successful after a healing period of 4 months. We achieved a mean increase in the alveolus of 16.5 (range 12-19) mm in height and 6 (range 4-13) mm in width. The degree of bony resorption within the first 6 months after reconstruction ranged from 7% to 9.5% (mean 8.3%) in the vertical and 4% to 12% (mean 7.5%) in the transverse dimension. Case 1 A 27-year-old woman had severe atrophy of the left maxilla after several operations. CT data were used to calculate the position of the implant (Fig. 1). Based on the availability of attached masticatory gingiva, osteoplastic reconstruction of the alveolus by stackplasty was chosen to restore the missing bone according to vector 5 in Fig. 2. The technique and the
3
Fig. 3. With the bony reconstruction orientated at the predefined position of the implant (3), multiple corticospongious bone blocks are used to create a framework that offers a bicortical anchorage for the implants. The remaining cavities are then filled with spongious bone chips.
bone grafts with osteotomy lines are shown in Fig. 4 and Fig. 5, respectively, and aesthetic and functional restoration of the alveolus were achieved (Fig. 6). Case 2 To date, we know of no safe diagnostic method for assessment of whether a safe amount of attached gingiva can be provided; the evaluation of the surgeon in the context of the specific procedure is therefore critical. A 40-year-old woman refused reconstruction using complex prefabricated composite grafts, but was unsatisfied with the results of the stackplasty. The massive losses of alveolar bone, attached gingiva, and bony support were consequences of the extraction of the still-vital canine 13 during the extraction of all teeth in the first quadrant. This procedure was designed to treat pain of unknown cause in this region. A sinus lift had been excluded because of the insufficient amount of bone and, as a result, the patient was transferred to our department for treatment. Although the alveolus was successfully reconstructed with the technique described, an overdenture was necessary because the attached masticatory gingiva was inadequate and the peri-implant mucosa was vulnerable. This resulted in pain, which was associated with difficulties in maintaining oral hygiene. Case 3 A 64-year-old woman had had a sinus lift 15 years previously, which had resulted in the loss of teeth 22 and 23, spatial discrepancy, and the loss of the lateral nasomaxillary bony framework. The pyriform region was involved, with
Please cite this article in press as: Schaudy C, Vinzenz K. Osteoplastic reconstruction of severely resorbed maxilla by stack plasty: combining sinus augmentation with lateral and vertical onlay bone grafting. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.04.018
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Fig. 4. A corticospongious bone block harvested from the inner side of the iliac crest together with at least two spongious half-cone shaped blocks (1+2). While the latter mainly serves as filling material beneath the “cover” plate and the maxillary alveolar crest, the corticospongious block (see Fig. 5) is cut to serve as both lateral (4) and cover (3) plates. These onlay grafts are secured using osteosynthesis that holds the spongious blocks in place. This allows for future insertion of implants in the correct position.
amplification of the nasolabial folds and loss of labial support. To achieve a symmetrical nasomaxillary complex, particularly in the area of the canine fossa, we chose a modified stackplasty that followed the surgical approach for osteoplasty of a tertiary cleft, including lateral augmentation of the alveolus for the correction of the sagittal facial projection of the nasomaxillary complex. The results from the orofacial functional and aesthetic points of view included an aesthetically pleasing implant and perioral restoration, and correction of the skeletal disfigurements in the nasomaxillary region.
Discussion Although there have been many reports on the topic of sinus lifts, reconstruction of the alveolar crests using bone blocks has rarely been described outside case reports,8–12,15,19–22
Fig. 5. Harvested corticospongious bone block from the iliac crest. The superimposed line indicates the osteotomy line to modify the osteoplasty according to the anatomical region and vectors for replacement of missing bone. Indexes (3) and (4) correspond to the diagram in Fig. 4.
probably because osteoplastic facial surgery is part of plastic and reconstructive surgery rather than oral implantology. An interdisciplinary group of plastic and oral and maxillofacial surgeons has improved preprosthetic osteoplastic surgery by using sole bone blocks and prelaminated and complex prefabricated bone blocks with microsurgical techniques in patients with cancer, cleft palate, or cancrum oris.1–4 Precise diagnostic evaluations of the tissue deficiencies and surgical planning are already the basis for treatment of maxillofacial defects, and have now found their way into restorative surgery for atrophy of the alveolar crest.4 Two important aspects need to be considered: the tissue deficit itself and the disfigurement that accompanies the atrophy.1 The problem of the design of a smile and the projection of the midface in patients with larger areas of atrophy has usually been dealt with by overdentures. However, preprosthetic osteoplastic surgery in an adapted form for oral implantology now offers a solution to the correction of spatial
Fig. 6. Mirror image showing the clinical picture after completion of dental restoration. Both vertical and lateral discrepancies were avoided.
Please cite this article in press as: Schaudy C, Vinzenz K. Osteoplastic reconstruction of severely resorbed maxilla by stack plasty: combining sinus augmentation with lateral and vertical onlay bone grafting. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.04.018
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discrepancies. The use of complex prefabricated composite grafts was introduced into oral implantology in 2006.3 The periointegration of dental implants that are in their anatomically correct position requires a minimum amount of attached gingiva.7 As in Case 2, failure to take this into account results in adverse consequences such as difficulties in maintaining oral hygiene, pain, and possible early loss of the implant.23 The development of the surgical concept of “stackplasty” bridges the whole range of osteoplastic operations from sole vertical sinus lifts to like-with-like reconstruction by prefabricated composite grafts. In cases where not enough attached gingiva is available, the technique should be upgraded to prelaminated, or even prefabricated, grafts to provide adequate cover for the transplant itself as well as periointegration for dental implants in their anatomically correct positions.1–4 Using the procedure described in this paper it is possible to meet the requirements of aesthetic implant dentistry and to provide better facial projection. The method integrates perfectly into the range of preprosthetic osteoplastic surgical techniques that have already been published, and closes the gap between implantology and restorative orofacial surgery. Conflict of interest The authors certify to have no affiliations with or involvement in any organization or entity with any financial or non-financial interest in the subject matter or materials discussed in this manuscript.
Ethics statement/confirmation of patient permission Not required.
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