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Simultaneous bimaxillary alveolar ridge augmentation by a single free fibular transfer: a case report
Journal of Cranio-Maxillofacial Surgery (2002) 30, 46–53 r 2002 European Association for Cranio-Maxillofacial Surgery. Published by Elsevier Science Ltd. All rights reserved. doi:10.1054/jcms.2001.0270, available online at http://www.idealibrary.com on
Simultaneous bimaxillary alveolar ridge augmentation by a single free fibular transfer: a case report P. F. Nocini,1 G. De Santis,2 A. Bedogni,1 L. Chiarini3 1
Section of Maxillofacial Surgery and Odontostomatology, Department of Biomedical and Morphological Sciences (Head: Prof. Pier Francesco Nocini, MD), University Hospital of Verona, Italy; 2Unit of Plastic and Reconstructive Surgery, Department of Surgery and Emergencies (Head: Giorgio De Santis, MD), University Hospital of Modena and Reggio Emilia, Italy; 3Department of Surgery and Emergencies, Section of Dentistry (Head: Prof. Ugo Consolo, MD), University Hospital of Modena and Reggio Emilia, Italy SUMMARY. Class VI atrophy according to Cawood still represents a major challenge in pre-prosthetic surgery. Reconstruction of mandibular and maxillary bony defects using microvascular techniques is safe and reliable. The fibula, due to its morphological properties, is ideal for alveolar ridge augmentation and its donor site morbidity is the lowest among vascularized bone flaps. In this paper, we report the first case, to our knowledge, of extreme atrophy of both jaws, successfully treated by simultaneous bony augmentation of the maxillary and mandibular alveolar ridges with just one free fibula flap. Pre-operative planning, surgical technique and prosthetic restoration are discussed in detail. r 2002 European Association for Cranio-Maxillofacial Surgery. Published by Elsevier Science Ltd. All rights reserved.
rehabilitation (Van der Berg et al., 1998; Foster et al., 1999). It is therefore very important to ensure stable and vital bone support for successful rehabilitation. Microsurgical reconstruction of jaw resections is safe and reliable, with a success rate 495% (Schusterman et al., 1994; Urken et al., 1998). Iliac crest, scapula, fibula and radius are considered to be the most suitable donor areas for the treatment of composite defects of the facial skeleton (Taylor 1982; Swartz et al., 1986; Soutar and Widdowson 1986; Hidalgo, 1989). Among these, the fibula with its dimensions, unique morphology and its acceptable donor site morbidity, is an excellent source of vascularized bone for mandibular or maxillary reconstruction (Nakayama et al., 1994; Munoz Guerra et al., 2001). The more vascularized bone is needed, such as in subtotal mandibular resections or combined defects of maxilla and mandible, the more the fibula is favoured due to its length, enabling a one-stage bony reconstruction (Shpitzer et al., 1997; Cordeiro et al., 1999). However, with the exception of Sadove and Powell (1993), who reported on a bimaxillary reconstruction for a gunshot wound, the use of a fibular flap for both jaws simultaneously has not been investigated thoroughly yet. Due to the high, long term success rate of prosthetic restorations with implants (more than 90%), immediate or delayed implant placement in vascularized bone is becoming increasingly popular in most centres (Zlotolow et al., 1992; Gurlek et al., 1996; Roumanas et al., 1997; Wei et al., 1997; Chiapasco et al., 2000). Several donor sites have been described for this purpose, including iliac, scapular and fibular bone, but only a few series are reported in the literature (Ka¨rcher et al., 1986; Ba¨hr, 1996; Nocini et al., 2000; De Santis et al., 1999; Stricker et al., 1999; Bedogni et al., 1999). In this paper, we report
INTRODUCTION Jaw atrophy is common and it has been classified into six classes of increasing severity by Cawood and Howell (1991). The major advances in implantology and pre-prosthetic surgery during the last few years have greatly contributed to the improvement of oral function and cosmetics in edentulous patients requiring long lasting prosthetic rehabilitation. Nevertheless, class VI atrophy according to Cawood and Howell, still represents a major challenge. It is characterized by a complete resorption of the alveolar ridges, with involvement of the skeletal bases and progressive loss of vascularization. Restoration of masticatory function requires three distinct surgical steps: reconstruction of bone, placement of implants and alterations involving the soft tissue. Threedimensional bony reconstruction of the alveolar crests represents the framework for implant rehabilitation. Both bone volume and quality affect longterm implant survival (Schliephake et al., 1997; Esposito et al., 1998a, b; Papageorge et al., 1999). The choice between transplantation of non-vascularized or vascularized autogenous bone for alveolar ridge reconstruction should always be related to the degree and the extent of the atrophy. The more severe the atrophy, the poorer the microcirculation to the recipient residual basal bone will be. Thus, extreme jaw atrophy represents poor biological conditions for non-vascularized autologous bone transplants. Furthermore, implant insertion into unstable bone tissue may preclude long-term survival of prosthetic Presented at the 48th National Congress of the Italian Society of Plastic, Reconstructive and Aesthetic Surgery, Perugia, Italy, 25–30 September 1999. 46
Bimaxillary 47
the first case, to our knowledge, of extreme atrophy of both jaws, successfully treated by simultaneous bony augmentation of both the entire maxillary and mandibular alveolar ridges with just one free fibula transplant. CASE REPORT A 48-year-old diabetic and hypothyroid woman came to our department because of functional impairment during mastication. She was edentulous and had worn upper and lower mucosal borne prostheses since the age of 24. Food intake had been limited to a soft diet for the last 2 years. The patient complained that her social life was being affected, and so asked for a fixed prosthesis. At clinical examination, severe
resorption of both superior and inferior alveolar ridges was noted with complete obliteration of the vestibular fornices. Loss of attachment of the facial muscles originating from the dentoalveolar portion of both jaws was responsible for an aged face and a reduced range of expressions. Radiographs and alginate impressions were taken (Fig. 1). Maxillo-mandibular relationships and centric occlusion were recorded and reproduced on a SAM articulator with the aid of a facebow. A class VI atrophy (according to Cawood) was diagnosed, in both the maxilla and the mandible. Three-dimensional jaw relationships were completely altered, resulting in a marked mandibular pseudoprognathism. In order to restore both the vertical and sagittal bone losses, according to prosthetic criteria and not
Fig. 1 – 48 yr old female pre-operative. (A, B) Frontal and lateral view: a typical ageing face with reduction of vertical height and lips retrusion. (C) Orthopantomogram, extreme resorption of both alveolar ridges. (D) Lateral cephalogram: severe mandibular pseudoprognathism.
48 Journal of Cranio-Maxillofacial Surgery
to anatomical ones, a great amount of dense bone would have been necessary to restore both the dentoalveolar ridges. In addition, the spatial position of the grafted bone would have been crucial in correcting skeletal discrepancies and in effecting the final prosthetic restoration. The bone blocks would have had limited contact against the vestibular side of the maxilla and the residual lingual crest of the mandible. Limited bony contact and vascular supply to the recipient site would have adversely affected the integration of non-vascularized bone grafts. For these reasons, a vascularized fibula flap was planned for bimaxillary alveolar ridge augmentation. Pre-operatively the patient underwent a CT scan of the head and neck and colour-Doppler ultrasonography of both external carotid arteries and their branches. The lower extremities were also investigated by colour-Doppler ultrasound of the tibial and peroneal vessels as well as with a CT scan of the fibula, aimed at assessing its bony volume and morphology. Surgical intervention Recipient site preparation. A crestal incision was performed from the left to the right retromandibular space, sparing the mental foramina. The mandibular body was exposed fully. The superior alveolar crest was also fully exposed likewise from right to left tuberosities and the maxilla stripped as far as the infra-orbital nerves. The palatal surface was only partially exposed, preserving the greater palatine arteries. The mucosal layer covering the left buccinator muscle was incised, and a submucosal groove extending from the tuberosity down to the mandible was made. The right facial vessels were exposed in the neck via a 3-cm submandibular incision, taking care not to damage the cervical branch of the facial nerve. A 3-cm vertical tunnel was dissected starting from the submandibular incision, going deeply to the superficial cervical fascia, and reaching the right retromolar area anterior to the insertion of the masseter muscle.
from the medial third of the fibula leaving the periosteal layer intact (Fig. 2, Schemes 1 and 2). The three most distal segments, each 2 cm long, were shaped as a maxillary arch. The maxillary segments and the mandibular segments were then fixed to each other with microplates (Scheme 3).
Fibular transplantation Once the flap were transferred to the oral cavity, mini-plates were used to fix the proximal segments of the fibula to the symphysis of the mandible, while the three distal segments were fixed to the paranasal buttresses by using two mini-plates. The vascular bundle of the fibula was placed along the vestibular side of the new mandibular arch and the palatal aspect of the new maxillary arch (Fig. 3, Scheme 4). The pedicle was connected to the right facial vessels end-to-end through the oro-cervical tunnel, using 9/0 nylon sutures. The muscle cuff of the fibular flap was left partially exposed in the mouth in order to allow free granulation and mucosal colonization to take place. Loose interrupted sutures secured the vestibular and lingual muco-periosteal flaps to the muscle cuff at the maxillary and mandibular levels. No inter-maxillary fixation was applied. The muscle cuff allowed direct monitoring of the flap viability in the first few post-operative days.
Flap dissection and side shaping Bone from the fibula was harvested using a tourniquet and a lateral approach to the anterior compartment of the leg, as described by O’Brien and Morrison (1987). A 23-cm bone flap with a 3-mm muscle cuff from the flexor hallucis longus and soleus muscles was harvested. The flap was then tailored to create both the mandibular and maxillary alveolar ridges, vascularized by the same pedicle. Based on the preoperative evaluation, six osteotomies of the fibula were performed preserving the periosteal and vascular integrity. Seven bone segments were obtained by this procedure. The three most proximal segments, each 2.5 cm long, were shaped to reconstruct the mandibular ridge. A 4.5-cm segment was removed
Fig. 2 – Shaping the fibula. (A) Six osteotomies preserving the periosteal and vascular continuity; a 4.5 cm bone block was removed from the periosteum. (B) Three segments were fixed to each other with microplates.
Bimaxillary 49
Scheme 1 – Seven bone segments obtained.
Scheme 2 – One segment (4.5 cm long) taken from the periosteal layer.
Scheme 4 – Flap insetting. Fixation of the three proximal bone segments to the mandible, 1801 counter clockwise rotation applied to the vascular bundle, and the three distal segments brought into position for fixation to the maxilla.
Scheme 3 – Intersegmental fixation of the new mandibular alveolar process achieved with one straight microplate on the lingual side. Two labial L-shaped microplates were used to fix the three distal segments to be transplanted to the maxilla.
Fig. 4 – Alveolar ridges restored with normalization of previous skeletal relationship.
Fig. 3 – Post-operative radiograph (10th post-operative day).
The post-operative course was uneventful. Within a few weeks epithelialization and contraction of the muscle cuff produced a stable soft-tissue covering for the bone, and allowed for a partial preservation of the vestibular fornices. Normalization of the skeletal relationships was achieved (Fig. 4). Six months after surgery, all fixation plates were removed and 10
implant fixtures (Sustain, Lifecore, 3.4-mm diameter 10–13 mm length) were inserted bicortically, six into the maxilla and four into the mandible, with the aid of acrylic surgical stents. Three months later, at the time of the abutment connection, vestibuloplasties were performed using thin split-thickness skin grafts taken from the buttocks. In this way, keratinized epithelium around the fixtures was obtained. A metallic, spark-eroded bar was connected to the 6 maxillary fixtures and a removable superstructure was fixed to the bar with hinged plate attachments. An Ackerman bar was connected to the 4 mandibular implants and a retained overdenture made carrying acrylic resin teeth was applied to it (Fig. 5).
50 Journal of Cranio-Maxillofacial Surgery
Facial rejuvenation was achieved (Fig. 6), and the patient was very satisfied with the aesthetic and functional results. She is now able to take solid food without restrictions. Radiologically there was no evidence of peri-implant bone loss after 12 months of masticatory load (Fig.7). DISCUSSION Until now autologous bone grafting in combination with endosseous implant placement is the preferred method for the treatment of severe atrophy of alveolar bone (Tolman, 1995; Kramer et al., 1999; Joos and Kleinheinz, 2000). Conventional non-vascularized bone transplants suffice in most cases. However, their use is not advisable in severe conditions, when the residual basal bone is poorly vascularized and/or mechanically unstable (Fonseca, 1986; Motoki and Mulliken, 1990; Phillips and Rahn 1990; Marx, 1994; Ba¨hr, 1996; Binger and Hell, 1999). Stabilization of bone grafts by means of rigid fixation is mandatory in order to promote bony union (La Trenta et al., 1989). The lack of these factors leads to rapid resorption of non-vascularized bone grafts. Even in cases of complete bony union, a resorption rate of more than 30% has been described (Verhoeven et al., 1997). In contrast to this, the use of vascularized bone flaps offers advantages e.g. transplanting living bone cells due to the re-established vascular supply (Gold-
berg et al., 1987, 1990; Hoffman et al., 1991). Microplates are sufficient to stabilize the bone segments to each other, leaving a minimal impact on their periosteal supply, whilst mini-plates are preferable to fix them to the recipient site (Haller, 1998; Strackee et al., 2001). Resorption of vascularized bone flaps is minimal (Disa et al., 1999) especially when compared to non-vascularized bone grafts (Gosain et al., 1999). When both jaws have undergone extreme resorption, up to 20–25 cm of bone is necessary to fill the defect, and the fibula is the only flap, which can provide such a quantity of bone and is ideal for placement of implants (Frodel et al., 1993; Matsuura et al, 1999; Bedogni et al., 2000). Fixtures inserted bicortically into the fibula show excellent osseointegration due to the large bone-implant interface (Sumi et al., 2001). The fibular donor site morbidity is minimal compared to that with iliac or scapular flaps (Anthony et al., 1995; Disa and Cordeiro, 2000). In this case, we performed six osteotomies and used six bone segments nourished by the same pedicle. Blood perfusion was ensured by intact periosteal circulation. It has been shown that it is possible to perform multiple osteotomies (of as little as 1 cm) without compromising the viability of the bone blocks (Ba¨hr, 1998). To achieve this, careful dissection of the bone flap performed supraperiosteally, and maintainance of periosteal continuity is essential. Implant surgery was performed as a second-step, 6 months after bony augmentation, when the bone remodelling had been completed. Delayed implanta-
Fig. 5 – Final prosthetic rehabilitation. (A) Metallic spark-eroded bar connected to the 6 fixtures in the maxilla. (B) Implant-retained Ackermann bar to the mandible. (C) Final denture.
Bimaxillary 51
Fig. 6 – Clinical result. (A, B) Post-operative frontal and lateral views.
retained dentures (Clepper, 1999; Zitmann and Marinello, 1999). We prefer to use fixed/removable prostheses whenever possible, especially for the maxilla. However, when the implants are limited to the anterior region it is not advisable to use fixed/removable prostheses and so we opt for an implant-retained overdenture, as in this case. CONCLUSION
Fig. 7 – Post-operative orthopantomogram at completion.
tion is preferable when dealing with bone grafts, because of greater bone-implant surface contact (Gurlek et al., 1996; Keller et al., 1998; Lundgren et al., 1999; Werkmeister et al., 1999; Nocini et al., 2000). Peri-implant soft-tissue improvement using thin split skin grafts, was performed at the time of abutment connection, to create keratinized tissue, surrounding the implants. The decision to use any particular types of prostheses is determined by the number of implants and by the patient’s expectations (Bosse and Taylor, 1998). A minimum of six implants was felt necessary in the upper and four in the lower jaw for implant-
This case shows that bimaxillary alveolar ridge augmentation with a single free fibular transfer is feasible. The fibula provides a large amount of wellvascularized bone. Its geometry and dimensions suit that of the mandibular and maxillary alveolar ridges. The bicortical structure provides a good, long-term implant site due to the great bone–implant interface. However, it must be noted that this procedure is only suitable for very specific cases. It requires accurate planning and a multidisciplinary team, including surgeons with microsurgical experience and an experienced prosthodontist.
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Alberto Bedogni, MD Department of Biomedical and Morphological Sciences Section of Maxillofacial Surgery University Hospital of Verona P.le Ludovico A. Scuro, 10 37134 Verona, Italy Tel.: +39 45 8074912 Fax: +39 45 8202142 Paper received 7 August 2000 Accepted 6 November 2001
Simultaneous bimaxillary alveolar ridge augmentation by a single free fibular transfer: a case report P. F. Nocini,1 G. De Santis,2 A. Bedogni,1 L. Chiarini3 1
Section of Maxillofacial Surgery and Odontostomatology, Department of Biomedical and Morphological Sciences (Head: Prof. Pier Francesco Nocini, MD), University Hospital of Verona, Italy; 2Unit of Plastic and Reconstructive Surgery, Department of Surgery and Emergencies (Head: Giorgio De Santis, MD), University Hospital of Modena and Reggio Emilia, Italy; 3Department of Surgery and Emergencies, Section of Dentistry (Head: Prof. Ugo Consolo, MD), University Hospital of Modena and Reggio Emilia, Italy SUMMARY. Class VI atrophy according to Cawood still represents a major challenge in pre-prosthetic surgery. Reconstruction of mandibular and maxillary bony defects using microvascular techniques is safe and reliable. The fibula, due to its morphological properties, is ideal for alveolar ridge augmentation and its donor site morbidity is the lowest among vascularized bone flaps. In this paper, we report the first case, to our knowledge, of extreme atrophy of both jaws, successfully treated by simultaneous bony augmentation of the maxillary and mandibular alveolar ridges with just one free fibula flap. Pre-operative planning, surgical technique and prosthetic restoration are discussed in detail. r 2002 European Association for Cranio-Maxillofacial Surgery. Published by Elsevier Science Ltd. All rights reserved.
rehabilitation (Van der Berg et al., 1998; Foster et al., 1999). It is therefore very important to ensure stable and vital bone support for successful rehabilitation. Microsurgical reconstruction of jaw resections is safe and reliable, with a success rate 495% (Schusterman et al., 1994; Urken et al., 1998). Iliac crest, scapula, fibula and radius are considered to be the most suitable donor areas for the treatment of composite defects of the facial skeleton (Taylor 1982; Swartz et al., 1986; Soutar and Widdowson 1986; Hidalgo, 1989). Among these, the fibula with its dimensions, unique morphology and its acceptable donor site morbidity, is an excellent source of vascularized bone for mandibular or maxillary reconstruction (Nakayama et al., 1994; Munoz Guerra et al., 2001). The more vascularized bone is needed, such as in subtotal mandibular resections or combined defects of maxilla and mandible, the more the fibula is favoured due to its length, enabling a one-stage bony reconstruction (Shpitzer et al., 1997; Cordeiro et al., 1999). However, with the exception of Sadove and Powell (1993), who reported on a bimaxillary reconstruction for a gunshot wound, the use of a fibular flap for both jaws simultaneously has not been investigated thoroughly yet. Due to the high, long term success rate of prosthetic restorations with implants (more than 90%), immediate or delayed implant placement in vascularized bone is becoming increasingly popular in most centres (Zlotolow et al., 1992; Gurlek et al., 1996; Roumanas et al., 1997; Wei et al., 1997; Chiapasco et al., 2000). Several donor sites have been described for this purpose, including iliac, scapular and fibular bone, but only a few series are reported in the literature (Ka¨rcher et al., 1986; Ba¨hr, 1996; Nocini et al., 2000; De Santis et al., 1999; Stricker et al., 1999; Bedogni et al., 1999). In this paper, we report
INTRODUCTION Jaw atrophy is common and it has been classified into six classes of increasing severity by Cawood and Howell (1991). The major advances in implantology and pre-prosthetic surgery during the last few years have greatly contributed to the improvement of oral function and cosmetics in edentulous patients requiring long lasting prosthetic rehabilitation. Nevertheless, class VI atrophy according to Cawood and Howell, still represents a major challenge. It is characterized by a complete resorption of the alveolar ridges, with involvement of the skeletal bases and progressive loss of vascularization. Restoration of masticatory function requires three distinct surgical steps: reconstruction of bone, placement of implants and alterations involving the soft tissue. Threedimensional bony reconstruction of the alveolar crests represents the framework for implant rehabilitation. Both bone volume and quality affect longterm implant survival (Schliephake et al., 1997; Esposito et al., 1998a, b; Papageorge et al., 1999). The choice between transplantation of non-vascularized or vascularized autogenous bone for alveolar ridge reconstruction should always be related to the degree and the extent of the atrophy. The more severe the atrophy, the poorer the microcirculation to the recipient residual basal bone will be. Thus, extreme jaw atrophy represents poor biological conditions for non-vascularized autologous bone transplants. Furthermore, implant insertion into unstable bone tissue may preclude long-term survival of prosthetic Presented at the 48th National Congress of the Italian Society of Plastic, Reconstructive and Aesthetic Surgery, Perugia, Italy, 25–30 September 1999. 46
Bimaxillary 47
the first case, to our knowledge, of extreme atrophy of both jaws, successfully treated by simultaneous bony augmentation of both the entire maxillary and mandibular alveolar ridges with just one free fibula transplant. CASE REPORT A 48-year-old diabetic and hypothyroid woman came to our department because of functional impairment during mastication. She was edentulous and had worn upper and lower mucosal borne prostheses since the age of 24. Food intake had been limited to a soft diet for the last 2 years. The patient complained that her social life was being affected, and so asked for a fixed prosthesis. At clinical examination, severe
resorption of both superior and inferior alveolar ridges was noted with complete obliteration of the vestibular fornices. Loss of attachment of the facial muscles originating from the dentoalveolar portion of both jaws was responsible for an aged face and a reduced range of expressions. Radiographs and alginate impressions were taken (Fig. 1). Maxillo-mandibular relationships and centric occlusion were recorded and reproduced on a SAM articulator with the aid of a facebow. A class VI atrophy (according to Cawood) was diagnosed, in both the maxilla and the mandible. Three-dimensional jaw relationships were completely altered, resulting in a marked mandibular pseudoprognathism. In order to restore both the vertical and sagittal bone losses, according to prosthetic criteria and not
Fig. 1 – 48 yr old female pre-operative. (A, B) Frontal and lateral view: a typical ageing face with reduction of vertical height and lips retrusion. (C) Orthopantomogram, extreme resorption of both alveolar ridges. (D) Lateral cephalogram: severe mandibular pseudoprognathism.
48 Journal of Cranio-Maxillofacial Surgery
to anatomical ones, a great amount of dense bone would have been necessary to restore both the dentoalveolar ridges. In addition, the spatial position of the grafted bone would have been crucial in correcting skeletal discrepancies and in effecting the final prosthetic restoration. The bone blocks would have had limited contact against the vestibular side of the maxilla and the residual lingual crest of the mandible. Limited bony contact and vascular supply to the recipient site would have adversely affected the integration of non-vascularized bone grafts. For these reasons, a vascularized fibula flap was planned for bimaxillary alveolar ridge augmentation. Pre-operatively the patient underwent a CT scan of the head and neck and colour-Doppler ultrasonography of both external carotid arteries and their branches. The lower extremities were also investigated by colour-Doppler ultrasound of the tibial and peroneal vessels as well as with a CT scan of the fibula, aimed at assessing its bony volume and morphology. Surgical intervention Recipient site preparation. A crestal incision was performed from the left to the right retromandibular space, sparing the mental foramina. The mandibular body was exposed fully. The superior alveolar crest was also fully exposed likewise from right to left tuberosities and the maxilla stripped as far as the infra-orbital nerves. The palatal surface was only partially exposed, preserving the greater palatine arteries. The mucosal layer covering the left buccinator muscle was incised, and a submucosal groove extending from the tuberosity down to the mandible was made. The right facial vessels were exposed in the neck via a 3-cm submandibular incision, taking care not to damage the cervical branch of the facial nerve. A 3-cm vertical tunnel was dissected starting from the submandibular incision, going deeply to the superficial cervical fascia, and reaching the right retromolar area anterior to the insertion of the masseter muscle.
from the medial third of the fibula leaving the periosteal layer intact (Fig. 2, Schemes 1 and 2). The three most distal segments, each 2 cm long, were shaped as a maxillary arch. The maxillary segments and the mandibular segments were then fixed to each other with microplates (Scheme 3).
Fibular transplantation Once the flap were transferred to the oral cavity, mini-plates were used to fix the proximal segments of the fibula to the symphysis of the mandible, while the three distal segments were fixed to the paranasal buttresses by using two mini-plates. The vascular bundle of the fibula was placed along the vestibular side of the new mandibular arch and the palatal aspect of the new maxillary arch (Fig. 3, Scheme 4). The pedicle was connected to the right facial vessels end-to-end through the oro-cervical tunnel, using 9/0 nylon sutures. The muscle cuff of the fibular flap was left partially exposed in the mouth in order to allow free granulation and mucosal colonization to take place. Loose interrupted sutures secured the vestibular and lingual muco-periosteal flaps to the muscle cuff at the maxillary and mandibular levels. No inter-maxillary fixation was applied. The muscle cuff allowed direct monitoring of the flap viability in the first few post-operative days.
Flap dissection and side shaping Bone from the fibula was harvested using a tourniquet and a lateral approach to the anterior compartment of the leg, as described by O’Brien and Morrison (1987). A 23-cm bone flap with a 3-mm muscle cuff from the flexor hallucis longus and soleus muscles was harvested. The flap was then tailored to create both the mandibular and maxillary alveolar ridges, vascularized by the same pedicle. Based on the preoperative evaluation, six osteotomies of the fibula were performed preserving the periosteal and vascular integrity. Seven bone segments were obtained by this procedure. The three most proximal segments, each 2.5 cm long, were shaped to reconstruct the mandibular ridge. A 4.5-cm segment was removed
Fig. 2 – Shaping the fibula. (A) Six osteotomies preserving the periosteal and vascular continuity; a 4.5 cm bone block was removed from the periosteum. (B) Three segments were fixed to each other with microplates.
Bimaxillary 49
Scheme 1 – Seven bone segments obtained.
Scheme 2 – One segment (4.5 cm long) taken from the periosteal layer.
Scheme 4 – Flap insetting. Fixation of the three proximal bone segments to the mandible, 1801 counter clockwise rotation applied to the vascular bundle, and the three distal segments brought into position for fixation to the maxilla.
Scheme 3 – Intersegmental fixation of the new mandibular alveolar process achieved with one straight microplate on the lingual side. Two labial L-shaped microplates were used to fix the three distal segments to be transplanted to the maxilla.
Fig. 4 – Alveolar ridges restored with normalization of previous skeletal relationship.
Fig. 3 – Post-operative radiograph (10th post-operative day).
The post-operative course was uneventful. Within a few weeks epithelialization and contraction of the muscle cuff produced a stable soft-tissue covering for the bone, and allowed for a partial preservation of the vestibular fornices. Normalization of the skeletal relationships was achieved (Fig. 4). Six months after surgery, all fixation plates were removed and 10
implant fixtures (Sustain, Lifecore, 3.4-mm diameter 10–13 mm length) were inserted bicortically, six into the maxilla and four into the mandible, with the aid of acrylic surgical stents. Three months later, at the time of the abutment connection, vestibuloplasties were performed using thin split-thickness skin grafts taken from the buttocks. In this way, keratinized epithelium around the fixtures was obtained. A metallic, spark-eroded bar was connected to the 6 maxillary fixtures and a removable superstructure was fixed to the bar with hinged plate attachments. An Ackerman bar was connected to the 4 mandibular implants and a retained overdenture made carrying acrylic resin teeth was applied to it (Fig. 5).
50 Journal of Cranio-Maxillofacial Surgery
Facial rejuvenation was achieved (Fig. 6), and the patient was very satisfied with the aesthetic and functional results. She is now able to take solid food without restrictions. Radiologically there was no evidence of peri-implant bone loss after 12 months of masticatory load (Fig.7). DISCUSSION Until now autologous bone grafting in combination with endosseous implant placement is the preferred method for the treatment of severe atrophy of alveolar bone (Tolman, 1995; Kramer et al., 1999; Joos and Kleinheinz, 2000). Conventional non-vascularized bone transplants suffice in most cases. However, their use is not advisable in severe conditions, when the residual basal bone is poorly vascularized and/or mechanically unstable (Fonseca, 1986; Motoki and Mulliken, 1990; Phillips and Rahn 1990; Marx, 1994; Ba¨hr, 1996; Binger and Hell, 1999). Stabilization of bone grafts by means of rigid fixation is mandatory in order to promote bony union (La Trenta et al., 1989). The lack of these factors leads to rapid resorption of non-vascularized bone grafts. Even in cases of complete bony union, a resorption rate of more than 30% has been described (Verhoeven et al., 1997). In contrast to this, the use of vascularized bone flaps offers advantages e.g. transplanting living bone cells due to the re-established vascular supply (Gold-
berg et al., 1987, 1990; Hoffman et al., 1991). Microplates are sufficient to stabilize the bone segments to each other, leaving a minimal impact on their periosteal supply, whilst mini-plates are preferable to fix them to the recipient site (Haller, 1998; Strackee et al., 2001). Resorption of vascularized bone flaps is minimal (Disa et al., 1999) especially when compared to non-vascularized bone grafts (Gosain et al., 1999). When both jaws have undergone extreme resorption, up to 20–25 cm of bone is necessary to fill the defect, and the fibula is the only flap, which can provide such a quantity of bone and is ideal for placement of implants (Frodel et al., 1993; Matsuura et al, 1999; Bedogni et al., 2000). Fixtures inserted bicortically into the fibula show excellent osseointegration due to the large bone-implant interface (Sumi et al., 2001). The fibular donor site morbidity is minimal compared to that with iliac or scapular flaps (Anthony et al., 1995; Disa and Cordeiro, 2000). In this case, we performed six osteotomies and used six bone segments nourished by the same pedicle. Blood perfusion was ensured by intact periosteal circulation. It has been shown that it is possible to perform multiple osteotomies (of as little as 1 cm) without compromising the viability of the bone blocks (Ba¨hr, 1998). To achieve this, careful dissection of the bone flap performed supraperiosteally, and maintainance of periosteal continuity is essential. Implant surgery was performed as a second-step, 6 months after bony augmentation, when the bone remodelling had been completed. Delayed implanta-
Fig. 5 – Final prosthetic rehabilitation. (A) Metallic spark-eroded bar connected to the 6 fixtures in the maxilla. (B) Implant-retained Ackermann bar to the mandible. (C) Final denture.
Bimaxillary 51
Fig. 6 – Clinical result. (A, B) Post-operative frontal and lateral views.
retained dentures (Clepper, 1999; Zitmann and Marinello, 1999). We prefer to use fixed/removable prostheses whenever possible, especially for the maxilla. However, when the implants are limited to the anterior region it is not advisable to use fixed/removable prostheses and so we opt for an implant-retained overdenture, as in this case. CONCLUSION
Fig. 7 – Post-operative orthopantomogram at completion.
tion is preferable when dealing with bone grafts, because of greater bone-implant surface contact (Gurlek et al., 1996; Keller et al., 1998; Lundgren et al., 1999; Werkmeister et al., 1999; Nocini et al., 2000). Peri-implant soft-tissue improvement using thin split skin grafts, was performed at the time of abutment connection, to create keratinized tissue, surrounding the implants. The decision to use any particular types of prostheses is determined by the number of implants and by the patient’s expectations (Bosse and Taylor, 1998). A minimum of six implants was felt necessary in the upper and four in the lower jaw for implant-
This case shows that bimaxillary alveolar ridge augmentation with a single free fibular transfer is feasible. The fibula provides a large amount of wellvascularized bone. Its geometry and dimensions suit that of the mandibular and maxillary alveolar ridges. The bicortical structure provides a good, long-term implant site due to the great bone–implant interface. However, it must be noted that this procedure is only suitable for very specific cases. It requires accurate planning and a multidisciplinary team, including surgeons with microsurgical experience and an experienced prosthodontist.
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Alberto Bedogni, MD Department of Biomedical and Morphological Sciences Section of Maxillofacial Surgery University Hospital of Verona P.le Ludovico A. Scuro, 10 37134 Verona, Italy Tel.: +39 45 8074912 Fax: +39 45 8202142 Paper received 7 August 2000 Accepted 6 November 2001