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The case for bone graft reconstruction including sinus grafting and distraction osteogenesis for the atrophic edentulous maxilla
CLINICAL CONTROVERSIES IN ORAL AND MAXILLOFACIAL SURGERY: PART TWO J Oral Maxillofac Surg 62:1423-1428, 2004
The Case for Bone Graft Reconstruction Including Sinus Grafting and Distraction Osteogenesis for the Atrophic Edentulous Maxilla Ole T. Jensen, DDS, MS,* Aldo Leopardi, DDS, MS,† and Louisa Gallegos, DDS, MSD‡ The 2 basic criteria for restoration of the edentulous maxilla are adequate bone mass and orthoalveolar form. These goals can be achieved by augmentation of the available substrate using prescribed techniques such as vertical and lateral augmentation of the alveolus, sinus floor bone grafting, and jaw bone repositioning.1-4 When the available substrate is too deficient for implant placement, 1 or more of these options can be used to improve load-bearing capacity for implants. The use of vertical alveolar grafting for augmentation without the placement of dental implants remains suspect as a viable long-term strategy for bone mass maintenance.5,6 Optimal restoration of the edentulous alveolus suggests the concept of orthoalveolar form. Orthoalveolar form is defined as idealized alveolar bone positioned in Class I relation axially aligned with the opposing arch. When orthoalveolar form is achieved, implant prosthetic horizontal cantilever is minimized and crown/implant ratios are favorable. Restorations are short, “gum set,” and axially placed over implants.7 Resorption of the atrophic maxilla often results in a disparity of the arches mediolaterally and anterior-posteriorly. The resorbed maxilla decreases in bone mass in all directions. The basal maxilla presents up and back in its cephalometric projection and is often in “cross-bite” in its alveolar position as it relates to the lower arch. This means that despite vertical and lateral grafting, the interarch position *Private Practice, Denver, CO. †Private Practice, Greenwood Village, CO. ‡Private Practice, Denver, CO. Address correspondence and reprint requests to Dr Jensen: 303 Josephine St, Suite 303, Denver, CO 80206; e-mail: [email protected] © 2004 American Association of Oral and Maxillofacial Surgeons
0278-2391/04/6211-0096$30.00/0 doi:10.1016/j.joms.2004.06.037
of the maxilla, as it relates to a dentate mandible, is still Class III. Therefore, orthoalveolar form is largely unachievable in the resorbed retrodisplaced maxilla with bone graft reconstruction alone. Distraction osteogenesis is required to finalize the jaw into a more favorable position. This subjects the patient to a second surgical procedure, which may not be warranted given the ability for prosthetics to make up for surgical inadequacy.8,9 The problems with improper orthoalveolar form have largely been ignored in favor of concentrating on the task of increasing available bone stock.10,11 In the Cawood classification of edentulous atrophy, the Class IV maxilla requires augmentation bone grafting for implants to be performed. Specific sites within the maxilla vary. In the posterior, sinus grafting is needed when there is 4 mm or less of vertical bone or there will be insufficient support for implant osseointegration.12,13 In advanced maxillary atrophy, although there may be vertical height available anteriorly, a width deficiency will need to be addressed. Both vertical and horizontal bone deficiencies are usually present in the second bicuspid and first molar positions.14 When there is significant loss of vertical alveolar height, interocclusal space is usually increased, complicating the reconstruction. Despite this, there may not be enough interarch room in the posterior to vertically augment the crest without performing a sinus graft. The net effect is that vertical alveolar augmentation is often deferred or combined with sinus bone grafting to place implants in the posterior maxilla.15,16 Of the various augmentation procedures presently in use, certainly the most volumetrically stable bone graft in the jaws is the sinus bone graft. Sinus grafts, using a variety of materials and techniques, have shown an 80% to 90% success rate at integrating dental implants of at least 10 mm in length.17 The use of bone grafting to gain width for
1423
1424
FIGURE 1. The preoperative clinical photo shows the patient with the upper denture removed and complete absence of maxillary alveolar projection. Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
implants by various approaches is also 80% to 90% effective.18 In experienced hands, onlay block grafts or alveolar split grafts have been shown to be highly effective.19,20 Vertical augmentation by Le Fort I down graft has been reported to be stable enough for implant placement in a high percentage of cases.21 Finally, the orthopedic movement of the edentulous jaw or segments into prescribed locations by distraction osteogenesis has been found to be reliable.22,23 Two cases are presented here to illustrate the desired prosthetic restoration by first obtaining increased bone mass and improved orthoalveolar form.
Case 1 A 57-year-old patient with severe Class V atrophy with marked retrodisplacement of the maxilla and minimal vertical projection presented for iliac bone graft reconstruction and implants. Figure 1 illustrates the extreme maxillary retrognathic position
MAXILLARY DISTRACTION AND SINUS GRAFTING
FIGURE 3. The bone graft technique used for the maxilla was Le Fort I down fracture preserving the sinus and nasal membranes followed by sinus and nasal floor grafting with overlay corticocancellous grafting around the arch. Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
preoperatively. Figure 2 shows pretreatment and post-treatment cephalographs. Figure 3 shows the surgically advanced maxilla with sinus grafts placed, then overlayed with corticocancellous struts. Note the subnasal grafting for gaining alveolar vertical dimension. Figure 4 shows that despite a 5 mm advancement of the maxilla and additional onlay grafting, the maxilla is still in Class III relation. The maxilla does have adequate bone mass to integrate implants. Four years later the bone levels and implant integration remain stable. Available bone in the first molar and bicuspids areas was 1 mm in height preoperatively, but 12 to 15 mm 4 years later. Eight implants had been placed into consolidated autograft 6 months after the initial grafting (Fig 5). The final restoration occurred 6 months after that for a total of 12 months healing
FIGURE 2. The preoperative maxillary position on cephalograph shows a 15 mm retrognathic position. A cephalograph taken 4 years posttreatment indicates Class III implant placement for the cantilevered prosthesis.
FIGURE 4. The combined maxillary advancement and augmentation gained about 10 mm of anterior projection, still short of Class I relation.
Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
JENSEN, LEOPARDI, AND GALLEGOS
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FIGURE 5. Implant placement 6 months after bone graft reconstruction. Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
before the final restoration. Six implants were 15 mm in length. The 2 anterior implants were 8.5 mm long. Late-term bone loss around the implant has been minimal. Note the prosthetic stages leading up to the final prosthesis (Figs 6-8). The final acrylic fused to gold fixed prosthesis is cantilevered for approximately 7 mm to obtain lip support.
Case 2 In the second case, a 36-year-old woman presents with a maxilla in Class III relation opposing a complete lower natural dentition (Fig 9). The patient
FIGURE 7. Completed acrylic fused to a gold fixed partial denture. Note the horizontal cantilever of 5 to 8 mm around the arch. Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
desired a fixed prosthesis for the upper jaw. Sinus and lateral grafting alone might not eliminate the need for a fixed hybrid prosthesis with horizontal cantilevers. A Le Fort I downfracture with sinus membrane elevation combined with placement of distraction devices laterally was performed to bring the maxilla down and forward. No grafting was performed in the osteotomy site (Fig 10). The vector of the distraction was established beforehand using a steriolithic model (Fig 11). After a 1-week latency period, the distraction was completed in 7 days for a total 7 mm anterior movement and a 4 mm inferior movement (Fig 12). Six months later, 8 implants were placed using a guide stent. Gingival sculpting was performed for aesthetic reasons anteriorly (Fig 13). A temporary
FIGURE 6. Articulated master working conical abutment cast at correct vertical dimension of occlusion demonstrates relative maxillary retrognathic as well as increased interarch space posteriorly.
FIGURE 8. The completed acrylic fused to gold implant borne fixed partial denture provides prosthetic lip support to gain aesthetics.
Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
1426
MAXILLARY DISTRACTION AND SINUS GRAFTING
FIGURE 11. A steriolithic model shows a down and forward vector for maxillary distraction. Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
Discussion
FIGURE 9. A 36-year-old patient presents with an 18-year history of maxillary edentulism restored with a full upper denture opposing lower natural dentition. Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
prosthesis rested on the gingiva with axial implant angles in Class I relation (Fig 14). The final porcelain fused to gold restoration was placed 6 months later (Figs 15, 16).
Reconstruction of jaw bone structure with bone grafting or distraction osteogenesis is the treatment option of choice when there is insufficient bone mass for a desired implant restoration. However, the morbidity, cost, and time required for augmentation of insufficient jaw substrate must be weighed against the benefits of alternative approaches including nonsurgical treatment. The problem with moderately severe maxillary resorption is that bone grafting of some type is almost always required to obtain sufficient load-bearing bone for dental implants. Surgeons must ask themselves what amount of surgery is sufficient for the task at
FIGURE 10. A Le Fort I down fracture combined with sinus membrane elevation and iliac grafting to the sinus floor.
FIGURE 12. After a 1-week latency period, the distraction was completed in 7 days for a 7 mm advancement and 4 mm vertical enhancement.
Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
1427
JENSEN, LEOPARDI, AND GALLEGOS
FIGURE 13. Implants were placed percutaneous in the posterior according to a guide stent. Anteriorly gingival sculpting was performed to prepare for pontics in the simultaneously placed temporary bridge. Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
hand. And what is too little? Reconstructive procedures should be tailored to the requirements of the case and not limited to treatment protocols based on ideal conditions. A treatment strategy that attempts to minimize the risk of failure of the reconstruction is perhaps more conservative in the long term, even though more surgery may be required initially. Alternatives to the sinus graft, such as the zygomaticus implant, must be weighed against the highly successful track record of the sinus graft procedure and is not without comparable cost or potential morbidity. Other alternative treatments such as the subperiosteal implant, vestibuloplasty, or hard tissue grafting without implant placement have not been shown to have consistent long-term results.
FIGURE 15. A final porcelain bonded to metal restoration is cemented onto 8 osseointegrated implants. Note the “gum set” appearance of the final restoration. Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
Reconstructive surgery by inveni guod deficiens* focuses treatment to the defect site, in this case, by replacing missing teeth and associated bone with tooth/root analogues. The case for bone graft reconstruction in association with dental implants is sound, especially as it relates to the sinus graft. Treatment of the atrophic maxilla, as illustrated here by 2 case examples, shows the well-established finding that jaw bone structure can be dependably augmented or manipulated for implant therapy.
*recover what is missing.
FIGURE 14. The temporary prosthesis is left in place for 6 months.
FIGURE 16. Final restoration.
Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
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References 1. Shirota T, Ohno K, Motohashi M, et al: Histologic and microradiologic comparison of block and particulate cancellous bone and marrow grafts in reconstructed mandibles being considered for dental implant placement. J Oral Maxillofac Surg 54:15, 1996 2. Wheeler SL, Holmes RE, Calhoun CJ: Six-year clinical and histologic study of sinus-lift grafts. Int J Oral Maxillofac Implants 11:26, 1996 3. Tinti C, Parma-Benefenati S: Vertical ridge augmentation: Surgical protocol and retrospective evaluation of 48 consecutively inserted implants. Int J Periodont Restor Dent 18:434, 1998 4. Keller EE: The maxillary interpositional composite graft, in Worthington P, Brånemark P-I (eds): Advanced Osseointegration Surgery: Application in the Maxillofacial Region. Chicago, IL, Quintessence, 1992, pp 162-174 5. Baker RD, Terry BC, Connole PW: Long term results of alveolar ridge augmentation. J Oral Surg 37:486, 1979 6. Davis WH, Delo RI, Ward B, et al: Long term ridge augmentation with rib graft. J Maxillofac Surg 3:103, 1975 7. Jensen OT, Ueda M, Laster Z, et al: Distraction osteogenesis. Selected Readings Oral Maxillofac Surg 10(4):1, 2002 8. Zitzmann NU, Marinello CP: Treatment plan for restoring the edentulous maxilla with implant-supported restorations: Removable overdentures versus fixed implant partial denture design. J Prosthet Dent 82:188, 1999 9. Jemt T, Lekholm U: Implant treatment in edentulous maxillae: A 5-year follow-up report on patients with different degrees of jaw resorption. Int J Oral Maxillofac Implants 10:303, 1995 10. Keller EE, Tolman DE, Eckert S: Maxillary antral-nasal inlay autogenous bone graft reconstruction of compromised maxilla: A 12-year retrospective study. Int J Oral Maxillofac Implants 14:707, 1999 11. Misch CM, Jensen OT, Cockrell R: Autogenous free bone graft harvesting for sinus floor and alveolar reconstruction, in Jensen OT (ed): The Sinus Bone Graft. Chicago, IL, Quintessence, 1999, pp 117-121
MAXILLARY DISTRACTION AND SINUS GRAFTING 12. Cawood JI, Howell RA: A classification of the edentulous jaws. Int J Oral Maxillofac Surg 17:232, 1988 13. Kent JN, Block MS: Simultaneous maxillary sinus floor bone grafting and placement of hydroxylapatite coated implants. J Oral Maxillofac Surg 47:238, 1989 14. Nystrom E, Kahnberg K-E, Gunne J: Bone grafts and Brånemark implants in the treatment of the severely resorbed maxilla: A two year longitudinal study. Int J Oral Maxillofac Implants 8:45, 1993 15. Jensen OT: Guided bone graft augmentation, in Buser D, Dahlin C, Shenk R (eds): Guided Bone Graft Regeneration in Implant Dentistry. Chicago, IL, Quintessence, 1994, pp 235-264 16. Collins TA: Onlay bone grafting in combination with Brånemark implants. Oral Maxillofac Surg Clin North Am 3:893, 1991 17. Jensen OT, Shulman LB, Block MS, et al: Report of the Sinus Consensus Conference of 1996. Int J Oral Maxillofac Implants 13:11, 1998 (suppl) 18. Scipioni, Bruschi GB, Calesini G: The edentulous ridge expansion technique: A five-year study. Int J Periodont Restor Dent 14:451, 1994 19. Misch CM, Misch CE: The repair of localized severe ridge defects for implant placement using mandibular bone grafts. Implant Dent 4:261, 1995 20. Keller EE, Tolman DE, Eckert S: Surgical-prosthodontic reconstruction of advanced maxillary bone compromise with autogenous onlay block bone grafts and osseointegrated endosseous implants: A 12-year study of 32 consecutive patients. Int J Oral Maxillofac Implants 14:197, 1999 21. Jensen OT: Combined sinus grafting and Le Fort I procedures, in Jensen OT (ed): The Sinus Bone Graft. Chicago, IL, Quintessence Publishing, 1999, pp 191-200 22. Stucki-McCormick SU, Moses JJ, Robinson R, et al: Alveolar distraction devices, in Jensen OT (ed): Alveolar Distraction Osteogenesis. Chicago, IL, Quintessence Publishing, 2002, pp 41-57 23. Soares MM: Alveolar distraction in the class V and VI edentulous mandible. Alveolar distraction in the Class V and VI edentulous mandible, in Jensen OT (ed): Alveolar Distraction Osteogenesis. Chicago, IL, Quintessence Publishing, 2002, pp 77-88
The Case for Bone Graft Reconstruction Including Sinus Grafting and Distraction Osteogenesis for the Atrophic Edentulous Maxilla Ole T. Jensen, DDS, MS,* Aldo Leopardi, DDS, MS,† and Louisa Gallegos, DDS, MSD‡ The 2 basic criteria for restoration of the edentulous maxilla are adequate bone mass and orthoalveolar form. These goals can be achieved by augmentation of the available substrate using prescribed techniques such as vertical and lateral augmentation of the alveolus, sinus floor bone grafting, and jaw bone repositioning.1-4 When the available substrate is too deficient for implant placement, 1 or more of these options can be used to improve load-bearing capacity for implants. The use of vertical alveolar grafting for augmentation without the placement of dental implants remains suspect as a viable long-term strategy for bone mass maintenance.5,6 Optimal restoration of the edentulous alveolus suggests the concept of orthoalveolar form. Orthoalveolar form is defined as idealized alveolar bone positioned in Class I relation axially aligned with the opposing arch. When orthoalveolar form is achieved, implant prosthetic horizontal cantilever is minimized and crown/implant ratios are favorable. Restorations are short, “gum set,” and axially placed over implants.7 Resorption of the atrophic maxilla often results in a disparity of the arches mediolaterally and anterior-posteriorly. The resorbed maxilla decreases in bone mass in all directions. The basal maxilla presents up and back in its cephalometric projection and is often in “cross-bite” in its alveolar position as it relates to the lower arch. This means that despite vertical and lateral grafting, the interarch position *Private Practice, Denver, CO. †Private Practice, Greenwood Village, CO. ‡Private Practice, Denver, CO. Address correspondence and reprint requests to Dr Jensen: 303 Josephine St, Suite 303, Denver, CO 80206; e-mail: [email protected] © 2004 American Association of Oral and Maxillofacial Surgeons
0278-2391/04/6211-0096$30.00/0 doi:10.1016/j.joms.2004.06.037
of the maxilla, as it relates to a dentate mandible, is still Class III. Therefore, orthoalveolar form is largely unachievable in the resorbed retrodisplaced maxilla with bone graft reconstruction alone. Distraction osteogenesis is required to finalize the jaw into a more favorable position. This subjects the patient to a second surgical procedure, which may not be warranted given the ability for prosthetics to make up for surgical inadequacy.8,9 The problems with improper orthoalveolar form have largely been ignored in favor of concentrating on the task of increasing available bone stock.10,11 In the Cawood classification of edentulous atrophy, the Class IV maxilla requires augmentation bone grafting for implants to be performed. Specific sites within the maxilla vary. In the posterior, sinus grafting is needed when there is 4 mm or less of vertical bone or there will be insufficient support for implant osseointegration.12,13 In advanced maxillary atrophy, although there may be vertical height available anteriorly, a width deficiency will need to be addressed. Both vertical and horizontal bone deficiencies are usually present in the second bicuspid and first molar positions.14 When there is significant loss of vertical alveolar height, interocclusal space is usually increased, complicating the reconstruction. Despite this, there may not be enough interarch room in the posterior to vertically augment the crest without performing a sinus graft. The net effect is that vertical alveolar augmentation is often deferred or combined with sinus bone grafting to place implants in the posterior maxilla.15,16 Of the various augmentation procedures presently in use, certainly the most volumetrically stable bone graft in the jaws is the sinus bone graft. Sinus grafts, using a variety of materials and techniques, have shown an 80% to 90% success rate at integrating dental implants of at least 10 mm in length.17 The use of bone grafting to gain width for
1423
1424
FIGURE 1. The preoperative clinical photo shows the patient with the upper denture removed and complete absence of maxillary alveolar projection. Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
implants by various approaches is also 80% to 90% effective.18 In experienced hands, onlay block grafts or alveolar split grafts have been shown to be highly effective.19,20 Vertical augmentation by Le Fort I down graft has been reported to be stable enough for implant placement in a high percentage of cases.21 Finally, the orthopedic movement of the edentulous jaw or segments into prescribed locations by distraction osteogenesis has been found to be reliable.22,23 Two cases are presented here to illustrate the desired prosthetic restoration by first obtaining increased bone mass and improved orthoalveolar form.
Case 1 A 57-year-old patient with severe Class V atrophy with marked retrodisplacement of the maxilla and minimal vertical projection presented for iliac bone graft reconstruction and implants. Figure 1 illustrates the extreme maxillary retrognathic position
MAXILLARY DISTRACTION AND SINUS GRAFTING
FIGURE 3. The bone graft technique used for the maxilla was Le Fort I down fracture preserving the sinus and nasal membranes followed by sinus and nasal floor grafting with overlay corticocancellous grafting around the arch. Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
preoperatively. Figure 2 shows pretreatment and post-treatment cephalographs. Figure 3 shows the surgically advanced maxilla with sinus grafts placed, then overlayed with corticocancellous struts. Note the subnasal grafting for gaining alveolar vertical dimension. Figure 4 shows that despite a 5 mm advancement of the maxilla and additional onlay grafting, the maxilla is still in Class III relation. The maxilla does have adequate bone mass to integrate implants. Four years later the bone levels and implant integration remain stable. Available bone in the first molar and bicuspids areas was 1 mm in height preoperatively, but 12 to 15 mm 4 years later. Eight implants had been placed into consolidated autograft 6 months after the initial grafting (Fig 5). The final restoration occurred 6 months after that for a total of 12 months healing
FIGURE 2. The preoperative maxillary position on cephalograph shows a 15 mm retrognathic position. A cephalograph taken 4 years posttreatment indicates Class III implant placement for the cantilevered prosthesis.
FIGURE 4. The combined maxillary advancement and augmentation gained about 10 mm of anterior projection, still short of Class I relation.
Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
JENSEN, LEOPARDI, AND GALLEGOS
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FIGURE 5. Implant placement 6 months after bone graft reconstruction. Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
before the final restoration. Six implants were 15 mm in length. The 2 anterior implants were 8.5 mm long. Late-term bone loss around the implant has been minimal. Note the prosthetic stages leading up to the final prosthesis (Figs 6-8). The final acrylic fused to gold fixed prosthesis is cantilevered for approximately 7 mm to obtain lip support.
Case 2 In the second case, a 36-year-old woman presents with a maxilla in Class III relation opposing a complete lower natural dentition (Fig 9). The patient
FIGURE 7. Completed acrylic fused to a gold fixed partial denture. Note the horizontal cantilever of 5 to 8 mm around the arch. Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
desired a fixed prosthesis for the upper jaw. Sinus and lateral grafting alone might not eliminate the need for a fixed hybrid prosthesis with horizontal cantilevers. A Le Fort I downfracture with sinus membrane elevation combined with placement of distraction devices laterally was performed to bring the maxilla down and forward. No grafting was performed in the osteotomy site (Fig 10). The vector of the distraction was established beforehand using a steriolithic model (Fig 11). After a 1-week latency period, the distraction was completed in 7 days for a total 7 mm anterior movement and a 4 mm inferior movement (Fig 12). Six months later, 8 implants were placed using a guide stent. Gingival sculpting was performed for aesthetic reasons anteriorly (Fig 13). A temporary
FIGURE 6. Articulated master working conical abutment cast at correct vertical dimension of occlusion demonstrates relative maxillary retrognathic as well as increased interarch space posteriorly.
FIGURE 8. The completed acrylic fused to gold implant borne fixed partial denture provides prosthetic lip support to gain aesthetics.
Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
1426
MAXILLARY DISTRACTION AND SINUS GRAFTING
FIGURE 11. A steriolithic model shows a down and forward vector for maxillary distraction. Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
Discussion
FIGURE 9. A 36-year-old patient presents with an 18-year history of maxillary edentulism restored with a full upper denture opposing lower natural dentition. Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
prosthesis rested on the gingiva with axial implant angles in Class I relation (Fig 14). The final porcelain fused to gold restoration was placed 6 months later (Figs 15, 16).
Reconstruction of jaw bone structure with bone grafting or distraction osteogenesis is the treatment option of choice when there is insufficient bone mass for a desired implant restoration. However, the morbidity, cost, and time required for augmentation of insufficient jaw substrate must be weighed against the benefits of alternative approaches including nonsurgical treatment. The problem with moderately severe maxillary resorption is that bone grafting of some type is almost always required to obtain sufficient load-bearing bone for dental implants. Surgeons must ask themselves what amount of surgery is sufficient for the task at
FIGURE 10. A Le Fort I down fracture combined with sinus membrane elevation and iliac grafting to the sinus floor.
FIGURE 12. After a 1-week latency period, the distraction was completed in 7 days for a 7 mm advancement and 4 mm vertical enhancement.
Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
1427
JENSEN, LEOPARDI, AND GALLEGOS
FIGURE 13. Implants were placed percutaneous in the posterior according to a guide stent. Anteriorly gingival sculpting was performed to prepare for pontics in the simultaneously placed temporary bridge. Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
hand. And what is too little? Reconstructive procedures should be tailored to the requirements of the case and not limited to treatment protocols based on ideal conditions. A treatment strategy that attempts to minimize the risk of failure of the reconstruction is perhaps more conservative in the long term, even though more surgery may be required initially. Alternatives to the sinus graft, such as the zygomaticus implant, must be weighed against the highly successful track record of the sinus graft procedure and is not without comparable cost or potential morbidity. Other alternative treatments such as the subperiosteal implant, vestibuloplasty, or hard tissue grafting without implant placement have not been shown to have consistent long-term results.
FIGURE 15. A final porcelain bonded to metal restoration is cemented onto 8 osseointegrated implants. Note the “gum set” appearance of the final restoration. Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
Reconstructive surgery by inveni guod deficiens* focuses treatment to the defect site, in this case, by replacing missing teeth and associated bone with tooth/root analogues. The case for bone graft reconstruction in association with dental implants is sound, especially as it relates to the sinus graft. Treatment of the atrophic maxilla, as illustrated here by 2 case examples, shows the well-established finding that jaw bone structure can be dependably augmented or manipulated for implant therapy.
*recover what is missing.
FIGURE 14. The temporary prosthesis is left in place for 6 months.
FIGURE 16. Final restoration.
Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
Jensen, Leopardi, and Gallegos. Maxillary Distraction and Sinus Grafting. J Oral Maxillofac Surg 2004.
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References 1. Shirota T, Ohno K, Motohashi M, et al: Histologic and microradiologic comparison of block and particulate cancellous bone and marrow grafts in reconstructed mandibles being considered for dental implant placement. J Oral Maxillofac Surg 54:15, 1996 2. Wheeler SL, Holmes RE, Calhoun CJ: Six-year clinical and histologic study of sinus-lift grafts. Int J Oral Maxillofac Implants 11:26, 1996 3. Tinti C, Parma-Benefenati S: Vertical ridge augmentation: Surgical protocol and retrospective evaluation of 48 consecutively inserted implants. Int J Periodont Restor Dent 18:434, 1998 4. Keller EE: The maxillary interpositional composite graft, in Worthington P, Brånemark P-I (eds): Advanced Osseointegration Surgery: Application in the Maxillofacial Region. Chicago, IL, Quintessence, 1992, pp 162-174 5. Baker RD, Terry BC, Connole PW: Long term results of alveolar ridge augmentation. J Oral Surg 37:486, 1979 6. Davis WH, Delo RI, Ward B, et al: Long term ridge augmentation with rib graft. J Maxillofac Surg 3:103, 1975 7. Jensen OT, Ueda M, Laster Z, et al: Distraction osteogenesis. Selected Readings Oral Maxillofac Surg 10(4):1, 2002 8. Zitzmann NU, Marinello CP: Treatment plan for restoring the edentulous maxilla with implant-supported restorations: Removable overdentures versus fixed implant partial denture design. J Prosthet Dent 82:188, 1999 9. Jemt T, Lekholm U: Implant treatment in edentulous maxillae: A 5-year follow-up report on patients with different degrees of jaw resorption. Int J Oral Maxillofac Implants 10:303, 1995 10. Keller EE, Tolman DE, Eckert S: Maxillary antral-nasal inlay autogenous bone graft reconstruction of compromised maxilla: A 12-year retrospective study. Int J Oral Maxillofac Implants 14:707, 1999 11. Misch CM, Jensen OT, Cockrell R: Autogenous free bone graft harvesting for sinus floor and alveolar reconstruction, in Jensen OT (ed): The Sinus Bone Graft. Chicago, IL, Quintessence, 1999, pp 117-121
MAXILLARY DISTRACTION AND SINUS GRAFTING 12. Cawood JI, Howell RA: A classification of the edentulous jaws. Int J Oral Maxillofac Surg 17:232, 1988 13. Kent JN, Block MS: Simultaneous maxillary sinus floor bone grafting and placement of hydroxylapatite coated implants. J Oral Maxillofac Surg 47:238, 1989 14. Nystrom E, Kahnberg K-E, Gunne J: Bone grafts and Brånemark implants in the treatment of the severely resorbed maxilla: A two year longitudinal study. Int J Oral Maxillofac Implants 8:45, 1993 15. Jensen OT: Guided bone graft augmentation, in Buser D, Dahlin C, Shenk R (eds): Guided Bone Graft Regeneration in Implant Dentistry. Chicago, IL, Quintessence, 1994, pp 235-264 16. Collins TA: Onlay bone grafting in combination with Brånemark implants. Oral Maxillofac Surg Clin North Am 3:893, 1991 17. Jensen OT, Shulman LB, Block MS, et al: Report of the Sinus Consensus Conference of 1996. Int J Oral Maxillofac Implants 13:11, 1998 (suppl) 18. Scipioni, Bruschi GB, Calesini G: The edentulous ridge expansion technique: A five-year study. Int J Periodont Restor Dent 14:451, 1994 19. Misch CM, Misch CE: The repair of localized severe ridge defects for implant placement using mandibular bone grafts. Implant Dent 4:261, 1995 20. Keller EE, Tolman DE, Eckert S: Surgical-prosthodontic reconstruction of advanced maxillary bone compromise with autogenous onlay block bone grafts and osseointegrated endosseous implants: A 12-year study of 32 consecutive patients. Int J Oral Maxillofac Implants 14:197, 1999 21. Jensen OT: Combined sinus grafting and Le Fort I procedures, in Jensen OT (ed): The Sinus Bone Graft. Chicago, IL, Quintessence Publishing, 1999, pp 191-200 22. Stucki-McCormick SU, Moses JJ, Robinson R, et al: Alveolar distraction devices, in Jensen OT (ed): Alveolar Distraction Osteogenesis. Chicago, IL, Quintessence Publishing, 2002, pp 41-57 23. Soares MM: Alveolar distraction in the class V and VI edentulous mandible. Alveolar distraction in the Class V and VI edentulous mandible, in Jensen OT (ed): Alveolar Distraction Osteogenesis. Chicago, IL, Quintessence Publishing, 2002, pp 77-88