Interpositional bone grafting and Le Fort I osteotomy for reconstruction of the atrophic edentulous maxilla: A two-stage technique

This study presents the results from ten consecutive patients who, because of insufficient bone volume for conventional implant placement in the maxilla, were treated with an interpositional bone graft and Le Fort I osteotomy. The endosteal implants were placed six months after the osteotomy. A total of 60 screw-shaped titanium implants (Brånemark^®) were placed, of which three failed to integrate during the six-month healing period. No further implants were lost during the follow-up period, ranging from 15 to 39 months after placement of the implants. All patients received fixed bridges and all have continued to function efficiently.     

Tomographic evaluation of iliac crest bone grafting and the use of immediate temporary implants to the atrophic maxilla

Sixteen consecutive patients with atrophic maxillae, who had been referred for bone augmentation using iliac bone grafting before the placement of dental implants, received a full clinical examination and underwent a CT scan before and after surgery. Linear vertical and horizontal measurements were made before and 6 months after surgery. Differences in mean bone gain or loss for each area were compared between a group that received an immediate total provisional prosthesis on temporary immediate implants (test group, 12 patients) and a control group (four patients). Both groups showed significant horizontal bone gain in all regions and vertical bone augmentation in the posterior regions. The test group showed no significant difference for bone gain compared to the control group, but half the test group had problems during treatment. Bone augmentation of the atrophic maxilla with iliac crest bone grafting resulted in sufficient vertical and horizontal bone augmentation to install six or eight implants in all patients and successfully rehabilitate them. The results suggest that the use of total provisional prostheses on temporary immediate implants meets the aesthetic demands required, but should be used with care and in special cases.     

Reconstruction of an atrophic maxilla: comparison of two methods

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

Donor site morbidity in two different approaches to anterior iliac crest bone harvesting

Background: Bone grafting is a surgical technique for the reconstruction of the atrophic edentulous maxilla prior to treatment with endosseous implants. The anterior iliac crest is a commonly used donor site. Purpose: The aim of this study was to evaluate the donor site morbidity and complications when harvesting corticocan‐cellous bone from the medial table of the anterior iliac crest and compare this with results when bone was harvested from the lateral and superior table of the anterior iliac crest. In addition, the outcome of the oral rehabilitation was evaluated by means of a quality‐of‐life questionnaire. Material and Methods: The study was composed of 70 consecutively treated patients with a mean age of 56 years. The patients were retrospectively evaluated with regard to postoperative donor site morbidity and complications at the donor site. Results: For the donor site morbidity, 74% of the patients were free of pain within 3 weeks, whereas 26% of the patients had a prolonged period of pain lasting from a few weeks to several months. For 11% of the patients, there was still some pain or discomfort 2 years after the grafting surgery. For gait disturbance the figures were similar:79% had no problems after 3 weeks. For the eight patients who still had some pain after 2 years, which was considered permanent, three also had gait disturbance. There was a total of three major complications (4%), one iliac wing fracture and two neurologic injuries. Conclusion: When harvesting a large amount of unicortical corticocancellous bone blocks from the the superolateral site of the iliac crest with a “peel off’ technique, morbidity and complication rates do not differ significantly compared with those of the traditional anterior medial approach. Oral rehabilitation with maxillary reconstruction with bone grafts from the iliac crest and endosseous implants significantly improved oral function, facial appearance, and recreation/social activities and resulted in an overall improvement in quality of life in formerly edentulous patients.     

Reconstruction of the atrophic edentulous maxilla with free iliac crest grafts and implants: a 3-year report of a prospective clinical study

Purpose: The purpose of this study was to perform a longitudinal follow-up study of implant stability in grafted maxillae with the aid of clinical, radiological, and resonance frequency analysis (RFA) parameters. Materials and Methods: The atrophic edentulous maxillae in 29 patients were reconstructed with free iliac crest grafts using onlay/inlay or interpositional grafting techniques. The endpoint of the resorption pattern in the maxilla determined the grafting technique used. Endosteal implants were placed after 6 months of bone-graft healing. Implant stability was measured four times using RFA: when the implants were placed, after 6 to 8 months of healing, after 6 months and 3 years of bridge loading. Individual checkups were performed at the two later RFA registrations after removal of the supraconstructions (Procera® Implant Bridge, Nobel Biocare AB, Göteborg, Sweden). Radiological follow up of marginal bone level was performed annually. Results: Twenty-five patients remained for the follow-up period. A total of 192 implants were placed and with a survival rate of 90% at the 3-year follow up. Women and an implant position with a class 6 resorption prior to reconstruction were factors with significant increased risk for implant failure (multivariate logistic regression). Twelve of the 20 failed implants were lost before loading (early failures). The change in the marginal bone level was 0.3 ± 0.3 mm between baseline (bridge delivery) and the 3-year follow up. The implant stability quotient (ISQ) value for all implants differed significantly between abutment connection (60.2 ± 7.3) and after 6 months of bridge loading (62.5 ± 5.5) (Wilcoxon signed ranks test for paired data, p=.05) but were nonsignificant between 6 months of bridge loading and 3 years of bridge loading (61.8 ± 5.5). There was a significant difference between successful and failed implants when the ISQ values were compared for individual implants at placement (Mann-Whitney U test, p=.004). All 25 patients were provided with fixed implant bridges at the time of the 3-year follow up. Conclusion: This clinical follow up using radiological examinations and RFA measurements indicates a predictable and stable long-term result for patients with atrophic edentulous maxillae reconstructed with autogenous bone and with delayed placement of endosteal implants. The ISQ value at the time of placement can probably serve as an indicator of level of risk for implant failure.     

Reconstruction of the anterior maxilla with platelet gel,autogenous bone,and titanium mesh: a case report

Background: Reconstruction of defects in the anterior part of the maxilla to enable implant placement is a challenging treatment. Recent studies have suggested that the use of autogenous platelet gel may contribute to improved healing of bone grafts. Purpose: A case is presented in which particulated autogenous bone, platelet gel, and a titanium mesh were used for alveolar bone reconstruction of the anterior maxilla prior to implant placement. Materials and Methods: Corticocancellous bone from the iliac crest was mixed with a preparation of autogenous platelet gel (platelet‐rich plasma, thrombin, and calcium chloride) and placed against a titanium mesh fixed to the bone of the palate in a patient with severe resorption of the anterior maxilla. After 4.5 months of healing the mesh was removed and titanium implants were placed. A prolonged healing period of 8 months was allowed before healing abutments were placed and a fixed dental bridge was fabricated. Results: Healing was uneventful, and the anterior maxilla had increased in height and width during the initial healing. All implants became integrated and have been supporting a fixed dental bridge for over 3 years with no dramatic dimensional changes of the graft. Conclusions: This case demonstrates that particulated autogenous bone and platelet gel may be used for reconstruction of the anterior maxilla. Autogenous growth factors in the gel possibly contributed to the positive outcome. Controlled clinical studies are needed to evaluate the effect of using platelet‐rich plasma.     

翼上颌区种植体联合前部种植体修复萎缩上颌无牙颌的临床回顾研究

目的 评估翼上颌区种植体联合前部种植体修复后部萎缩的上颌无牙颌的短期临床效果及患者的满意度.方法 回顾性研究筛选25例行前部和翼上颌区种植体支持的上颌固定修复并随访1年以上的上颌无牙颌患者作为研究对象,观察种植体存留率、种植体周软组织状态(包括探诊深度,改良龈沟出血指数,菌斑指数)、边缘骨吸收以及患者的满意度.结果 前...     

Bone grafting and insertion of dental implants followed by Le Fort advancement for correction of severely atrophic maxilla in young patients

The atrophic maxilla often results in lateral, anteroposterior and vertical disproportion of the maxillary arches. This paper presents the case of a 40-year-old male with a severely atrophic maxilla who underwent oral rehabilitation. He was treated with onlay and inlay iliac bone grafts followed by vestibuloplasty and dental implant placement 170 days after initial bone grafting. The dental implants were uncovered after 4 months of healing. The patient also underwent orthognathic surgery for correction of the maxillary basal bone and to improve implant positioning. At the 48-month follow-up there were no complications.     

Early loading of endosseous implants in the augmented maxilla: a 1-year prospective study

In 10 patients, 68 endosseous implants were inserted in the augmented edentulous maxilla using a one-stage implant placement technique. Three months before implant insertion, the width and height of the alveolar crest were augmented with autologous bone grafts from the iliac crest. In all cases, the resulting bone volume was sufficient for implant insertion. According to an early loading protocol, the implant-supported overdenture was fabricated 2 months after insertion of the implants. Evaluation was performed according to a standardised protocol immediately and 1 year after fabrication of the prosthetic construction. The protocol included assessment of both clinical (bleeding score, pocket depth, implant mobility) and radiographic (marginal bone level on standardised radiographs) parameters. Three implants in two patients in the upper jaw were lost (survival rate: 95.6%). The peri-implant tissues had a healthy appearance and bone loss was minimal. Overall, the patients were very satisfied with the prosthetic construction. From this preliminary study, it is concluded that in selected cases, early loading of implants may develop into a predictable treatment modality after augmentation of the maxilla.     

Immediate occlusal loading and tilted implants for the rehabilitation of the atrophic edentulous maxilla: 1-year interim results of a multicenter prospective study

OBJECTIVES: The aims of this prospective study were to assess the treatment outcome of immediately loaded full-arch fixed bridges anchored to both tilted and axially placed implants for the rehabilitation of fully edentulous maxillae and to compare the outcome of axial vs. tilted implants. MATERIAL AND METHODS: Forty-one patients with edentulous maxillae were included in the study. Each patient received a full-arch fixed bridge supported by four axial implants and two distal tilted implants. Loading was applied within 48 h from surgery. Patients were scheduled for follow-up at 6 months, 1 year and annually up to 5 years. Radiographic evaluation of marginal bone-level change was performed at 1 year. RESULTS: One patient died 4 months after surgery. Thirty patients were followed for a minimum of 1 year (range 3-42 months, mean 22.1 months). Three failures were recorded at 1-year follow-up (two axial implants and one tilted). Two more implants (one tilted and one axially placed) were lost within 18 months of loading. The 1-year implant survival rate was 98.8% for both axial and tilted implants. Prosthesis success rate was 100% at 1 year. Marginal bone loss around axial and tilted implants at 12-month evaluation was similar, being, respectively, 0.9+/-0.4 (standard deviation) mm and 0.8+/-0.5 mm. CONCLUSIONS: The present preliminary data suggest that immediate loading associated with tilted implants could be considered to be a viable treatment modality for the atrophic maxilla and that there does not seem to be a different clinical outcome between tilted and axial implants.     

上颌窦开窗植骨种植修复的远期效果评价

目的:探讨上颌窦开窗植骨种植修复在上颌后牙区骨量不足患者中的临床应用效果。方法:2002年1月—2006年11月,使用上颌窦开窗植骨种植修复上颌后牙缺失40例,其中3例行双侧手术。男29例,女11例,平均年龄51.4岁(28～66岁)。共植入84颗种植体。采用埋入式愈合方式。种植体平均愈合11.8个月(8～19个月)后行永久修复。随访期为62.3个月(47～84个月)。结果:植入的84颗种植体在愈合和随访期内均未发生松动脱落,留存率达100%。4侧上颌窦黏膜在手术过程中发生穿破,但未发生上颌窦炎等并发症。随访期X线片显示种植体颈部骨吸收平均值为(0.63±0.33)mm。结论:上颌窦开窗植骨种植修复技术安全可行,是解决上颌后牙区骨高度不足区种植修复难题的有效方法。     

Iliac crest autogenous bone graft versus alloplastic graft and guided bone regeneration in the reconstruction of atrophic maxillae: a 5-year retrospective study on cost-effectiveness and clinical outcome

Background: Reconstruction of the atrophic maxillae with autogenous bone graft and jawbone‐anchored bridges is a well‐proven technique. However, the morbidity associated with the concept should not be neglected. Furthermore, the costs for such treatment, including general anesthesia and hospital stay, are significant. Little data are found in the literature with regard to a cost‐benefit approach to various treatment alternates. Purpose: The aim of this retrospective study was to compare from a health‐economical and clinical perspective the reconstruction of the atrophic maxillae prior to oral implant treatment either with autogenous bone grafts harvested from the iliac crest or the use of demineralized freeze‐dried bone (DFDB) in combination with a thermoplastic carrier (Regeneration Technologies Inc., Alachua, FL, USA) and guided bone regeneration (GBR). Materials and Methods: A total of 26 patients (13 + 13) were selected and matched with regard to indication, sex, and age. The study was performed 5 years after the completion of the treatment. Implant survival, morbidity, and complications were analyzed. Furthermore, a detailed analysis of the total cost for the respective treatment modality was performed, including material, costs for staff, sick leave, etc. Results: The study revealed no statistical difference with regard to implant survival for the respective groups. The average total cost, per patient, for the DFDB group was 22.5% of the total cost for a patient treated with autogenous bone grafting procedures. Conclusions: The study concluded that reconstruction of atrophic maxillae with a bone substitute material (DFDB) in combination with GBR can be performed with an equal treatment outcome and with less resources and a significant reduced cost in selected cases compared with autogenous bone grafts from the iliac crest.     

Implant-supported fixed prostheses in the edentulous maxilla. A 2-year clinical and radiological follow-up of treatment with non-submerged ITI implants

OBJECTIVES: To evaluate the survival rate of non-submerged solid-screw ITI dental implants with a rough (titanium plasma sprayed, TPS) surface in the edentulous maxilla after 1 and 2 years of loading. MATERIAL AND METHOD: Twenty-five patients (mean age 64 years) with edentulous upper jaws received five-seven implants and, after a mean healing time of 6.9 months, screw-retained implant-supported fixed prostheses. A total of 146 ITI solid screw TPS implants were inserted. The diameter of 56% of the implants was smaller (3.3 mm) than the standard (4.1 mm) and the diameter of the rest (44%) was standard. The bone quantity of the majority of the patients was low and the bone quality poor. Clinical parameters were registered at baseline and at two annual follow-ups. Radiological examinations and assessments were also made at these times. RESULTS: Mean marginal bone level at baseline was measured at a point 4.52 mm (range 1.45-7.70, SD 1.2) apical of the reference point. Mean bone loss from baseline to 1 year of loading was 0.24 mm (SD 0.9, P=0.002) and from 1 year to 2 years of loading 0.15 mm (SD 0.4, P<0.001). Five implants failed, four of which were early failures prior to loading. One implant failed shortly after bridge installation. The cumulative survival rate was 96.6% after 1 and 2 years. CONCLUSION: ITI TPS solid-screw implants in combination with fixed prostheses had successful survival rates and were found to be a viable treatment alternative in the edentulous maxilla.     

Implant-supported fixed prostheses in the edentulous maxilla: 8-year prospective results

Objective: The purpose of this prospective study was to evaluate the long‐term survival and success rates of implants and screw‐retained, full‐arch prostheses placed in edentulous maxillae over 8 years of function. Materials and methods: A total of 106 Astra Tech implants were placed in the maxillae of 17 edentulous patients in a one‐stage surgical approach. After a healing period of 6 months, the patients received fixed screw‐retained bridges. Follow‐up visits, including clinical and radiographic examinations, were performed after 6 months and at yearly intervals. Implant survival, implant success, and marginal bone‐level changes were defined as the primary outcome variables. The secondary aims were to report periodontal pathogens at 5 years' follow‐up and patients' satisfaction at the 8‐year follow‐up. Results: The overall observation time was 8 years. One patient died during the study and one implant failed during the healing period, yielding an 8‐year cumulative implant survival rate of 99%. The prosthetic survival rate was 100%. The mean crestal bone loss amounted to 0.3 ± 0.72 mm. Patients' subjective evaluations demonstrated an overall high level of satisfaction. In all cases, except for one, microbiologic probing of the peri‐implant sulcus after 5 years showed no higher incidence of periodontal pathogens. Conclusions: Screw‐retained, full‐arch restorations on six implants in an edentulous maxilla are a predictable and highly successful treatment concept as observed throughout this study with an observation period of 8 years of function, in particular with respect to low crestal bone loss and high patient satisfaction. To cite this article:
Mertens C, Steveling HG. Implant‐supported fixed prostheses in the edentulous maxilla: 8‐year prospective results.
Clin. Oral Impl. Res. 22 , 2011; 464–472
doi: 10.1111/j.1600‐0501.2010.02028.x     

A prospective clinical study on titanium implants in the zygomatic arch for prosthetic rehabilitation of the atrophic edentulous maxilla with a follow-up of 6 months to 5 years

Background Prosthetic rehabilitation with implant‐supported prostheses in the atrophic edentulous maxilla often requires a bone augmentation procedure to enable implant placement and integration. However, a rigid anchorage can also be achieved by using so‐called zygomatic implants placed in the zygomatic arch in combination with regular implants placed in residual bone. Purpose The aim of the present study was to report on the clinical outcome of using zygomatic and regular implants for prosthetic rehabilitation of the severely atrophic edentulous maxilla. Materials and Methods Sixty‐nine consecutive patients with severe maxillary atrophy were, during a 5‐year period, treated with a total of 69 fixed full‐arch prostheses anchored on 435 implants. Of these, 131 were zygomatic implants and 304 were regular implants. Fifty‐seven bridges were screw‐retained and 12 were cemented. The screw‐retained bridges were removed at the examination appointments and each implant was tested for mobility. In addition, the zygomatic implants were subjected to Periotest^® (Siemens AG, Bensheim, Germany) measurements. The patients had at the time of this report been followed for at least 6 months up to 5 years in loading. Results Two regular implants failed during the study period giving a cumulative survival rate of 99.0%. None of the zygomatic implants was removed. All patients received and maintained a fixed full‐arch bridge during the study. Periotest measurements of zygomatic implants showed a decreased Periotest values value with time, indictating an increased stability. Three patients presented with sinusitis 14–27 months postoperatively, which could be resolved with antibiotics. Loosening of the zygomatic implant gold screws was recorded in nine patients. Fracture of one gold screw as well as the prosthesis occurred twice in one patient. Fracture of anterior prosthetic teeth was experienced in four patients. Conclusions The results from the present study show that the use of zygomatic and regular implants represents a predictable alternative to bone grafting in the rehabilitation of the atrophic edentulous maxilla.     

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

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