Prosthetic rehabilitation of a maxillary defect with a bone anchored prosthesis: A clinical report.

Mucormycosis is an opportunistic fungal infection that frequently infects sinuses, brain, or lungs and arises mostly in immunocompromised patients. Although its occurrence in the maxilla is rare, debridement and resection of the infected and necrotic area is often the best treatment but usually results in an extensive maxillary defect. Protocols for prosthetic obturation versus microvascular reconstruction have been established and used effectively in tertiary institutions for patients with such large defects. Aramany Class VI defects involving more than half of the palatal surface can be managed effectively by surgical reconstruction using microvascular free flaps as a platform for supporting bone-anchored prostheses. Providing fixed prostheses may offer advantages over a conventional obturator prosthesis in terms of hygiene, function, and esthetics. Nonetheless, fixed prostheses retained by endosseous implants in patients with reconstructive osteomyocutaneous flaps often require a sequential team approach by the surgeon and prosthodontist. This clinical report describes the reconstruction of a maxilla by using a scapular free flap with subsequent prosthetic rehabilitation in a patient with maxillary sinus infection secondary to mucormycosis.

Three-Dimensional Printing: A Novel Approach to the Creation of Obturator Prostheses Following Palatal Resection for Malignant Palate Tumors.

BACKGROUND: A subgroup of patients who have an oronasal fistula live in areas that have limited access to oral prosthetics. For these individuals, a temporary prosthesis, such as a palatal obturator, may be necessary in order to speak, eat, and breath properly. The creation of an obturator, which requires a highly trained prosthodontist, can take time and can be expensive. Through the current proof-of-concept study, there is an attempt to create a patient-specific palatal obturator through use of free and publicly available software, and a low-cost desktop 3-dimensional printer. The ascribed study may provide a means to increase global access to oral prosthetics if suitable biomaterials are developed. METHODS: Computerized tomography data were acquired from a patient who had an oronasal fistula. Through use of free software, these data were converted into a 3-dimensional image. The image was manipulated in order to isolate the patient's maxilla and was subsequently printed. The palatal obturator models were designed, and reformed, in correspondence with the maxilla model design. A final suitable obturator was determined and printed with 2 differing materials in order to better simulate a patient obturator. RESULTS: Creating a suitable palatal obturator for the specified patient model was possible with a low-cost printer and free software. CONCLUSIONS: With further development in biomaterials, it may be possible to design and create an oral prosthesis through use of low-cost 3-dimensional printing technology and freeware. This can empower individuals to attain good healthcare, even if they live in rural, developing, or underserviced areas.

Influence of maxillary obturator prostheses on facial morphology in patients with unilateral maxillary defects.

STATEMENT OF PROBLEM: Facial asymmetry is prominent with individuals with unilateral bone resorption and can lead to decreased quality of life. PURPOSE: The purpose of this study was to investigate the influence of maxillary obturator prostheses on facial morphology of individuals with unilateral maxillary defects by using 3-dimensional digital stereophotogrammetry. MATERIAL AND METHODS: The facial data of 8 participants with unilateral maxillary defects were acquired with a noncontact 3-dimensional digitizer, both with and without maxillary prostheses. The mid-facial plane was established by overlapping an original facial image with its mirror image. Displacement at 18 measurement points, including 7 bilateral pairs, was compared between the 2 sides, with and without the prostheses. Asymmetry indices of these 7 pairs also were calculated. Multivariate repeated-measures ANOVA was used to determine differences. RESULTS: Displacements of the lateral and inferior points at the ala of the nose were significantly greater on the defect side than on the normal side. The distances between the ideal and defect side points at the superior ala, the upper lip, and the angle of the mouth decreased significantly with the prosthesis. No significant differences were found in asymmetry indices, but the angle of the upper lip line to the mid-sagittal plane increased significantly with the prosthesis. CONCLUSIONS: The 3-dimensional analyzing method developed in this study can be useful in evaluating facial reconstruction with maxillary obturator prostheses with individuals with unilateral maxillary defects. The prostheses affect the region of the nasal ala, the upper lip, and the angles of the mouth.

Satisfaction and quality of life with palatal positioned implants in severely atrophic maxillae versus conventional implants supporting fixed full-arch prostheses.

BACKGROUND: To evaluate satisfaction and quality of life in patients with palatal positioned implants supporting fixed full-arch prostheses to rehabilitate edentulous maxillae with horizontal atrophy and compare them with conventional well-centered implants placed in non-atrophic supporting fixed full-arch prostheses. MATERIAL AND METHOD: A clinical retrospective study was performed of patients that were rehabilitated with full-arch fixed implant-supported maxillary prostheses and had a minimum follow-up of 5 years after implant loading. Patients were divided into 2 groups: patients with class IV maxilla according to Cawood and Howell and treated with palatal positioned implants (test) and with class III maxilla and treated with implants well-centered in the alveolar ridge and completely surrounded by bone (control). Ten-cm visual analogue scales (VAS) (range 1-10) and the OHIP-14 (Oral Health Impact Profile) questionnaire were used respectively to estimate patient satisfaction and quality of life after implant therapy. Statistical analysis was performed applying Mann-Whitney Test using alpha set at 0.05. RESULTS: Mean global and specific satisfaction--except for self-esteem--were superior for the test group than the control group, although differences were not statistically significant. Regarding quality of life, the reported incidence of problems was lower in the test group for all the studied items except for 'problems at work'. However, differences were not statistically significant in any case. CONCLUSION: Despite the limitations of the study (retrospective and nonrandomized design) the results suggest that the prosthesis design needed to rehabilitate palatally positioned implants (more coverage of palate) does not lead to lower satisfaction and quality of life of patients, compared to patients treated with implants placed centered and conventional design prostheses that do not cover the palate.

Prosthetic rehabilitation of a patient with a unilateral cleft palate: a clinical report.

Cleft palate is a congenital disorder characterized by maxillary growth defect and dental anomalies. Its correction requires an interdisciplinary approach, which includes surgical, orthodontic, and prosthetic treatments. This clinical report describes the prosthetic management of a 19-year-old woman with a unilateral cleft palate defect that had not been closed completely with surgical repair. The deficient maxillary residual anterior ridge was restored with a tooth-supported overdenture that improved her facial appearance, speech, and masticatory functions.

Prosthetic rehabilitation of acquired maxillary defects secondary to mucormycosis: clinical cases.

Maxillary necrosis can occur due to bacterial infections such as osteomyelitis, viral infections, such as herpes zoster or fungal infections, such as mucormycosis, aspergillosis etc. Mucormycosis is an opportunistic fungal infection, which mainly infects immunocompromised patients. Once the maxilla is involved, surgical resection and debridement of the necrosed areas can result in extensive maxillary defects. The clinician is to face many a challenge in order to replace not only the missing teeth, but also the lost soft tissues and bone, including hard palate and alveolar ridges. The prosthesis (Obturator) lacks a bony base and the lost structures of the posterior palatal seal area compromise retention of the prosthesis. Furthermore, the post surgical soft tissues are scarred and tense, which exert strong dislodging forces. The present article describes the prosthetic rehabilitation of maxillary necrosis secondary to mucormycosis in two cases, one completely edentulous and the other partially edentulous.

Impact of dental and zygomatic implants on stress distribution in maxillary defects: a 3-dimensional finite element analysis study.

The aim of this study was to evaluate the stress distribution in the bone around dental and zygomatic implants for 4 different implant-supported obturator prostheses designs in a unilaterally maxillary defect using a 3-dimensional finite element stress analysis. A 3-dimensional finite element model of the human unilateral maxillary defect was constructed. Four different implant-supported obturator prostheses were modeled; model 1 with 2 zygomatic implants and 1 dental implant, model 2 with 2 zygomatic implants and 2 dental implants, model 3 with 2 zygomatic implants and 3 dental implants, and model 4 with 1 zygomatic implant and 3 dental implants. Bar attachments were used as superstructure. A 150-N vertical load was applied in 3 different ways, and von Mises stresses in the cortical bone around implants were evaluated. When the models (model 1-3) were compared in terms of number of implants, all of the models showed similar highest stress values under the first loading condition, and these values were less than under model 4 conditions. The highest stress values of models 1-4 under the first loading condition were 8.56, 8.59, 8.32, and 11.55 Mpa, respectively. The same trend was also observed under the other loading conditions. It may be concluded that the use of a zygomatic implant on the nondefective side decreased the highest stress values, and increasing the number of dental implants between the most distal and most mesial implants on the nondefective side did not decrease the highest stress values.

Rehabilitation of the atrophic posterior maxilla with pterygoid implants: a review.

The purpose of this article is to review the literature published and to assess the success of treatment of patients with atrophic posterior maxilla with pterygoid implants. Studies from 1992 to 2009 on patients with atrophic posterior maxilla rehabilitated with pterygoid implants were reviewed. Those reporting clinical series of at least 5 patients with atrophic posterior maxilla (Class IV and V of Cawood and Howell), rehabilitated with pterygoid implants and fixed prosthesis, and with 12 months minimum follow-up were included. In each study the following were assessed: number of patients, number of implants, surgical technique, prosthetic rehabilitation, success rate, bone loss, complications and patient satisfaction. Thirteen articles were included, reporting a total of 1053 pterygoid implants in 676 patients. The weighted average success of pterygoid implants was 90.7%; bone loss evaluated radiographically ranged between 0 and 4.5 mm. No additional complications compared with conventional implants were found, and patient satisfaction level with the prosthesis was high. Pterygoid implants have high success rates, similar bone loss levels to those of conventional implants, minimal complications and good acceptance by patients, being therefore an alternative to treat patients with atrophic posterior maxilla. Two anatomical locations in which implants are placed in the retromolar area can be distinguished: the pterygoid process and the pterygomaxillary region. Implant lengths and angulations vary between these two techniques.

A two-piece sectional interim obturator. A clinical report.

Prosthetic rehabilitation of acquired maxillary defects can be achieved satisfactorily if all facets of treatment planning and design considerations are taken into account before the rehabilitation process. Complications associated with maxillary defects limit treatment protocols to a great extent. The prosthodontist has to identify these problem areas and suitably devise feasible options and incorporate them in the design. In this report, an acquired maxillary defect with unfavorable undercuts in the defect was successfully treated by making a two-piece sectional obturator. The two pieces were connected by the use of double-die pin system. The methodology greatly reduced chairside time and number of visits, and effective obturation was satisfactorily achieved.

Rehabilitation of a maxillary defect secondary to recurrent giant cell granuloma.

This is a presentation of the treatment history of a young woman with a benign lesion resulting in a large maxillary defect. This patient's complex treatment resulted in a full spectrum of rehabilitation modalities. Her story shows alternative treatment options with the ultimate goal of restoring form, function, and quality of life to a patient with an extensive maxillary defect.

Osteotome sinus floor elevation technique without grafting: a 5-year prospective study.

AIM: To evaluate the long-term stability of peri-implant bone formation following implant placement without grafting into resorbed posterior maxillae. MATERIALS AND METHODS: Twenty-five implants of 10 mm were placed in 17 patients to rehabilitate atrophic maxillae by means of an osteotome sinus floor elevation (OSFE) procedure without grafting. Mean residual bone height was 5.4±2.3mm. Bone levels were evaluated at 1, 3 and 5 years using periapical radiographs. RESULTS: All implants fulfilled survival criteria and gained peri-implant bone (mean increase 3.2±1.3mm). Implant protrusion into the sinus decreased from 4.9±1.9mm after surgery to 1.5±0.9mm after 5 years. Mean crestal bone loss amounting to 0.8±0.8mm stabilized over the 5-year observation interval. Twenty implants showed additional peri-implant bone gain following the 1-year control. CONCLUSIONS: Implant rehabilitation of atrophic maxillae may be greatly simplified using implants 10mm and the OSFE technique without grafting. Grafting material is not needed to gain at least 3mm of bone in the atrophic maxilla. The procedure appears predictable with favourable long-term results.

A 12-year retrospective analytic study of the implant survival rate in 177 consecutive maxillary sinus augmentation procedures.

PURPOSE: This retrospective study sought to demonstrate the outcome of maxillary sinus elevation surgery in a series of 177 procedures performed over 12 years and to determine the existence of variables that could independently predict implant survival. MATERIALS AND METHODS: A retrospective descriptive and analytic study of a series of maxillary sinus elevation procedures performed between 1996 and 2007 was undertaken. The sample was composed of patients with severe atrophy of the posterior maxilla who had been rehabilitated with osseointegrated implants placed in grafted maxillary sinuses. Several features of the patients (smoking habit, presence of comorbidities, and previous oral carcinoma) and of the surgical procedure (grafting material, associated procedures, associated materials, simultaneous/delayed implant placement, and complications) related to implant survival or failure were monitored during the follow-up period. Implant survival and the existence of variables that could predict implant survival independently were analyzed statistically. RESULTS: One hundred seventy-seven sinus augmentation procedures were performed in 119 consecutive patients (mean age 50.02 years; SD 11.5). Of the 272 implants placed in sinus-augmented regions, 19 were lost. The mean follow-up period was 60.7 months (SD 36.5). The overall cumulative implant survival rate was 93% after 5 years. The multivariate analysis showed that the presence of complications related to the sinus augmentation procedure (membrane perforation and sinusitis) and peri-implantitis were factors in predicting implant failure. CONCLUSIONS: On the basis of this retrospective analysis, it might be concluded that sinus augmentation is a very versatile procedure. Its efficacy and predictability in terms of implant survival rate is extremely high and independent of the graft material, surgical technique, associated comorbidities, smoking habits, and timing of implant placement. Complications such as membrane perforation, sinusitis, and peri-implantitis appeared to influence implant failure.

Treatment of a severely atrophic maxilla using an immediately loaded, implant-supported fixed prosthesis without the use of bone grafts: a clinical report.

This report describes a clinical approach to using the zygomatic and pterygomaxillary bones to provide additional anchorage for longer implants to support an immediately functional maxillary screw-retained provisional fixed prosthesis. The purpose is to report the problems of patients who have experienced the most severe form of maxillary alveolar resorption and to demonstrate a specific protocol which provides immediately loaded implants without bone grafting.

[Zygoma implants--an option for the treatment of severe atrophy of the maxilla? Case report]. / Zygoma-Implantate. Therapiealternative in der stark atrophierten Maxilla? Ein Fallbericht.

The reconstruction of the severe atrophy of the maxilla using dental implants requires extensive surgical treatments. Sinus lift procedure, ridge augmentation with free bone grafts or free vascularized bone transfers represent the common techniques. With regard to a higher life expectancy the number of patients suffering from limited chewing function based on atrophic bone conditions will increase. In addition to a higher number of failed implants in elderly people ask for other treatment strategies to regain proper oral function with limited surgical effort. This case report presents the failed treatment of maxilla, using disc implants and shows the new maxillary reconstruction using Brånemark-Zygoma implants combined with standard Nobel Replace implants in order to avoid extensive augmentation procedure.

[Does the combination syndrome exist? A case report]. / Existiert das Kombinationssyndrom? Ein Fallbericht.

This case report documents the prosthetic rehabilitation of a patient showing the typical features of combination syndrome. This case documentation gives a general overview of the suspected development and the prevalence of this "syndrome". A treatment option should be shown by the example of a patient from the starting situation until the prosthetic therapy by means of a complete maxillary denture and an implant-supported mandibular overdenture rigidly retained with a milled bar.

Distraction osteogenesis of iliac bone graft as a reconstruction after central giant cell granuloma curettage.

This case report describes a successful aesthetic and functional reconstruction of a patient who had severe maxilla bony deficiency as a result of excision of central giant cell granuloma. Initially, the lesion was curetted plus peripheral ostectomy. The defect was reconstructed with iliac bone graft in a second step, with both surgeries performed under general anesthesia. Six months after second step, later vertical distraction osteogenesis was performed on the grafted maxilla to obtain a satisfactory bony height. Distraction osteogenesis can be a good alternative for the reconstruction of bone deficiencies associated to bone graft; however, it should be not done as first treatment in the severe pathologic jaw defects.

One-year outcome of narrow diameter blasted implants for rehabilitation of maxillas with knife-edge resorption.

OBJECTIVES: This study aimed at assessing the clinical outcome of narrow diameter implants in the treatment of knife-edge edentulous maxillas of adequate bone height but inadequate width (class IV of Cawood and Howell). MATERIAL AND METHODS: Twelve consecutive patients (eight women and four men, mean age 58 years) with class IV atrophic edentulous maxillas were included in the study. Seventy-three microthreaded TiO(2)-blasted implants were placed and the resonance frequency measured. All the implants had a diameter of 3.5 mm. After 6 months of submerged healing, fixed implant-supported prostheses were delivered to the patients and resonance frequency and radiographic examinations performed. After the first year of loading, the implant outcome was again evaluated clinically, radiographically and with resonance frequency analysis. RESULTS: All the implants were followed up to 1 year of loading and their survival rate was 100%. Bone loss after 1 year of loading was (mean+/-SD) 0.30+/-0.13 mm. Stability values were (mean+/-SD) 63+/-5.8 ISQ at placement, 60+/-4.7 ISQ at the abutment connection and 61+/-5 ISQ after 1 year of loading. A significant difference resulted between placement and abutment connection values (P=0.03). CONCLUSIONS: According to the present study, narrow implants may be used to restore edentulous maxillas with atrophies of class IV of Cawood and Howell. When planning the treatment of edentulous maxillas with such a resorption pattern, this possibility has to be considered as an alternative to more demanding grafting techniques.

A new approach to rehabilitate the severely atrophic maxilla using extramaxillary anchored implants in immediate function: a pilot study.

STATEMENT OF PROBLEM: There is a need to simplify implant treatment for complete arch rehabilitation of severely atrophic maxillae, as well as a desire to eliminate grafting and provide quality rehabilitation in terms of esthetics, function, and comfort for the patient. PURPOSE: The purpose of this study was to report on the initial results of rehabilitation of complete edentulous atrophied maxillae using a new surgical approach and a newly designed extra long implant, placed externally to the maxillary bone (implant only accommodated in the maxillary bone) and anchored in the zygomatic bone. MATERIAL AND METHODS: The pilot study included 29 patients (21 women and 8 men), with an age range of 32-75 years (mean=52.4 years), followed between 6 and 18 months, with a mean follow-up time of 1 year. The patients presenting severe atrophy in the maxillae (Cawood and Howell classification C-VI and D-V or D-VI) were rehabilitated either by using 1, 2, or 4 extra long implants (30 to 50 mm in length; Nobel Biocare AB) placed in the zygomatic bone in conjunction with standard implants (24 patients): or 4 extra long implants (5 patients), all placed in immediate function. The criteria used to evaluate implant outcome were: implants function as support for reconstruction; implants stable when individually and manually tested; no signs of infection observed; and good esthetic outcome of the rehabilitation. To evaluate the secondary objective of assessing the stability and health of the soft tissue covering the implants, the mucosal seal efficacy evaluation index (MSEE) was used. This index was modified from the probing depth for standard implants and performed with a 0.25-N calibrated plastic periodontal probe measuring the depth (mm) of the space between the implant and the mucosa. Data were analyzed with descriptive and inferential analyses. RESULTS: The cumulative implant survival rate and prosthetic survival rate at 1 year were 98.5% and 100%, respectively. The mean and median values of the MSEE at 2 months (2.9 mm, 3 mm), 4 months (2.5 mm, 2.8 mm), 6 months (2.9 mm, 2.8 mm), and 1 year (2.8 mm, 2.5 mm) are comparable to the values of probing depths assessed for standard implants. CONCLUSIONS: The results indicate that, within the limitations of this preliminary study, the rehabilitation of maxillae with severe atrophy can be performed using extra long implants placed external to the maxilla and anchored only in the zygomatic bone, and placed in immediate function.

The use of zygomatic implants in severe maxillary atrophy: a systematic and meta-analysis review of randomised clinical trials / El uso de implantes zigomáticos para atrofia maxilar severa: una revisión sistemática y meta-análisis de ensayos clínicos aleatorizados

SUMMARY: Conventional implant treatment cannot always be used to rehabilitate edentulous patients with advanced maxillary atrophic. Zygomatic dental implants have been used over the past 20 years as an alternative treatment solution to bone grafting. The purpose of this meta-analysis is to evaluate the implant and prosthetic survival rate in non-oncologic patients with a severely atrophic maxilla. This review also aims to better understand the rate of peri-operative complications in this cohort of patients. A multi-database (PubMed, MEDLINE, EMBASE, and CINAHAL) focused systematic search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. Any randomised control trials studies involving human participants treated with zygomatic osseous implants were included. After eliminating duplicates, a total of 4 studies met the inclusion criteria for this meta-analysis review. With all the studies included there was a total of 174 patients treated with zygomatic osseous implants. The overall implant success rate was 98.03 %. The prosthetic success rate was 96.4 %. The most frequent peri-operative complication was sinusitis. Based on the limited data available in literature, zygomatic dental implants represent a valid alternative to bone augmenting procedure. However, they are not without risks and longer follow-ups are required to confirm the validity of the treatment in long term.

Los tratamientos convencionales con implantes no siempre pueden ser usados para rehabilitar pacientes edentulos con atrofia maxilar avanzada. Los implantes dentales zigomáticos son usados por los pasados 20 años como alternativa de tratamiento a las reconstrucciones óseas. El objetivo de este meta-análisis es evaluar la sobrevida de implantes y prótesis en pacientes no oncológicos con maxila severamente atrófica. Esta revisión también pretende entender al promedio de complicaciones peri operatorias en esta cohorte de pacientes. Una búsqueda sistemática en bases de datos múltiples (PubMed, MEDLINE, EMBASE y CINAHAL) fue desarrollada de acuerdo a recomendaciones de Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Cualquier estudio clínico aleatorizado de participantes humanos donde se utilizaron los implantes zigomáticos fueron incluidos. Después de eliminar duplicados, un total de 4 estudios cumplieron los criterios de inclusión para esta meta análisis. Con todos los estudios incluidos se obtuvieron 174 pacientes tratados con implantes zigomáticos. El promedio de éxito fue de 98,03 %. El promedio de éxito de la rehabilitación fue de 96,4 %. La complicación mas frecuente fue la sinusitis. Basados en los datos limitados en la literatura, los implantes zigomáticos representan una alternativa valida a los procedimientos de aumento óseo. Sin embargo, estos no están libres de riesgos y seguimientos de mayores periodos son necesarios para confirmar la validez de los tratamientos en el largo plazo.

Influence of implant number, length, and tilting degree on stress distribution in atrophic maxilla: a finite element study.

This study aims to evaluate the stress values, created in peri-implant region as a consequence of loading on fixed hybrid dentures that was planned with different implant numbers, lengths, or tilting angulations. Thirteen three-dimensional (3D) finite element analysis models were generated with four, five, or seven implants (group A, B, and C). Except the distal implants, all implants were modeled at 4.1 mm (diameter) and 11.5 mm (length) in size. Distal implants were configured to be in five different lengths (6, 8, 11.5, 13, and 16 mm) and three different implant inclination degrees (0°, 30°, and 45°). A 150-N load was applied vertically on prosthesis. Released stresses were evaluated comparatively. The lowest von Mises stress values were found in group C, in the 11.5-mm implant model. Tilting the distal implants 30° caused higher stress values. In 45°-tilting implant models, lower stress values were recorded according to the 30°-tilting models. The ideal implant number is seven for an edentulous maxilla. Tilting the implants causes higher stress values. A 45° inclination of implant causes lower stress values according to the 30° models due to a shorter cantilever. The ideal implant length is 11.5 mm.