Restoring Severely Atrophic Edentulous Ridge of Mandible Using Self-Expanding Tissue Expander-A Case Report.

This report describes the use of Self Inflating Tissue Expanders (SITEs) to rehabilitate severely atrophic edentulous mandibular ridges, enabling successful bone grafting and implant placement. The treatment resulted in stable and complication-free implants over a seven-year follow-up, demonstrating SITEs' effectiveness in providing sufficient bone volume and soft tissue coverage for dental implants.

Buccally or Lingually Tilted Implants in the Lateral Atrophic Mandible: A Three-Year Follow-Up Study Focused on Neurosensory Impairment, Soft-Tissue-Related Impaction and Quality of Life Improvement.

Background and Objectives: In the severely resorbed posterior mandible, implant placement requires either bone regenerative procedures, subperiosteal implants or short implant placement with drawbacks including morbidity and increased treatment costs and duration. To overcome these inconveniences, some unconventional alternatives have been suggested, such as buccally or lingually tilted implants in the lateral mandible, bypassing the inferior alveolar nerve. The aim of the present retrospective study was to evaluate the three-year survival rate of implants inserted in the posterior atrophic mandible, bypassing the inferior alveolar nerve. The assessment was focused on the occurrence of postoperative complications related to neurosensory impairment and soft tissue impaction, as well as overall improvement in quality of life. Materials and Methods: Patients with severe bone atrophy in the lateral area of the mandible were included in the present study. Only the implants tilted either buccally or lingually to bypass the inferior alveolar nerve were analysed. The relation between peri-implant soft tissue and the healing abutment was assessed and a secondary revision surgery was performed when indicated. The Semmes-Weinstein pressure neurological test was used for qualitative assessment of inferior alveolar nerve function and the Geriatric Oral Health Assessment Index (GOHAI) was used for evaluating Oral-Health-Related Quality of Life (OHRQoL). Results: Fourteen implants were placed in nine patients during the evaluation period. Survival rate was 100%, temporary paraesthesia occurred in one patient and a limited definitive paraesthesia was seen in another patient. Mild or significant discomfort related to soft tissue impaction with healing abutment was observed in six out of nine patients. A statistically significant OHRQoL improvement was observed in all patients. Conclusions: Despite the limited number of patients and observation time, insertion of implants buccally or lingually bypassing the inferior alveolar nerve is a predictive treatment option for patients with severe bone atrophy in the posterior mandible.

Immediate Rehabilitation of the Severely Atrophic Maxilla Using Trans-Sinus Nasal Protocol and Extended Length Subcrestal Angulated Implants. Case Series With 1-Year Follow-Up.

Immediate fixed full-arch rehabilitation of the severely atrophic maxilla eliminates use of a tissue-supported prosthesis during the healing phase and maximizes patient comfort and quality of life. The surgical treatment options available for immediate rehabilitation of the severely atrophic maxilla are dependent on the location and availability of the residual alveolar ridge. When bone is only available in the intercanine region, a graftless approach using tilted distal implants may not provide adequate distance between implants for favorable biomechanics. Subsequently, zygomatic implants are the alternative to provide adequate posterior occlusal support. Use of extended length subcrestal angulated implants offers an additional implant option for the clinician to restore the severely atrophic maxilla immediately. The treatment protocol involves anchorage of the implant fixture to the lateral wall of the nasal bone. The distally tilted implant transverses an augmented sinus cavity and extends to the site of the first permanent molar. The novel implant subcrestal angulation and use of a multi-unit abutment promotes passivity of fit of a full-arch fixed immediate prosthesis. Five clinical case reports from private practice are presented that outline the clinical value of the novel implant design in the rehabilitation of the severely atrophic maxilla. In each case, the use of zygomatic implants would be the only alternative to provide an immediate fixed prosthesis due to the absence of residual alveolar bone in the maxilla premolar and molar regions. The use of extended-length subcrestal angulated (ELSA) implants with straight or angulated multiunit abutments have successfully restored the maxillary arch immediately.

Atrophic Maxilla Reconstruction With Autogenous Iliac Graft and Guided Dental Implants.

Oral rehabilitation with osseointegrated implants is frequently the best alternative for replacement of lost teeth. Several techniques and materials allow achievement of excellent function and esthetics. In the case of maxillary or mandibular atrophy, extensive grafting may be necessary before implants can be properly placed. This is a case of maxillary reconstruction with autogenous iliac crest bone grafts, followed by placement of guided implants. After integration of the grafts, planning and insertion of implants allowed installation of an implant-supported prosthesis, recovering the morphology, function, and esthetics.

Use of Recombinant Human Bone Morphogenetic Protein-2 Associated With Lyophilized Bovine Bone in Reconstruction of Atrophic Maxilla.

Cases of severely atrophic edentulous maxilla require reconstruction techniques employing bone grafts to promote adequate bone dimension for the successful placement of dental implants for prosthetic rehabilitation that reestablishes the patient's function and aesthetics. This study aims to present a severely atrophic edentulous maxilla reconstruction with the off-label use of recombinant human bone morphogenetic protein type 2 (rhBMP-2) associated with lyophilized particulate bovine bone xenograft for the prosthetic rehabilitation with osseointegrable dental implants. The paper describes a case of severely atrophic edentulous maxilla in a 42-year-old woman referred to the dental school with complaint of failure in adaptating to the dentures. The patient reported 27 years of maxilla edentulism and consecutive treatment failures, so the proposed therapy was the reconstruction of the maxilla with an association of rhBMP-2 and lyophilized bovine bone xenograft for increasing bone volume and further prosthetic rehabilitation with osseointegrated dental implants. The present report illustrates a case of atrophic edentulous maxilla in which the off-label use of rhBMP-2 was successful and the patient's prosthetic rehabilitation could be concluded. The 8 dental implants received prosthetic functional load during 1 year of follow-up with no complications. Based on the case presented, the association between rhBMP-2 and a bovine bone xenograft could be considered a viable option for the reconstruction of atrophic edentulous maxilla. After a year of functional prosthetic load follow-up, the patient is asymptomatic and satisfactorily adaptated to the prosthesis, which restored her functional and aesthetic demands.

Transalveolar Osteotomy of the Mandibular Canal Wall for the Treatment of Severely Atrophied Posterior Mandible.

PURPOSE: Treatment of severe bone atrophy of the posterior mandible requires an advanced surgical bone augmentation technique. This report describes a minimally invasive approach for a residual alveolar height less than 5 mm. MATERIAL AND METHODS: A retrospective case series was conducted in a single private dental clinic. Outcome variables were dental implant survival rate, intraoperative complications, occurrence of neurosensory disturbances, and marginal bone loss. Descriptive analysis was performed for patients' demographic data, postoperative healing, and implant details. Kaplan-Meier method was used to assess the implant survival rate. RESULTS: The mean age of the 19 patients was 60 ± 13 years. Twenty-eight implants (5.5 mm long) were placed in a residual alveolar bone height of 4.5 ± 0.6 mm. The implant survival rate was 96% at 5-year follow-up. CONCLUSIONS: Extra-short implants and transalveolar preparation of the inferior alveolar cortical bone could be a safe and effective treatment of severe mandibular atrophy.

Coronal Split Corpus Osteotomy of the Mandible: A Modified Visor Osteotomy Technique for Bone Volume Enhancement.

The bony augmentation of severely atrophied mandible is generally required for the purposes of prosthetic rehabilitations. The treatment strategies have been well defined in the literature ranging from osteotomy techniques to distraction osteogenesis. Visor osteotomy is the milestone of the reconstructive surgery for the atrophied mandible which has received some modifications. In the present study, the authors describe a new modification of visor osteotomy in which a complete coronal split osteotomy down to the inferior border at the mental region has been performed. The main advantage of this modification is to preserve the lingual cortex from the inferior border of the mandible up to the alveolar region without disturbance of the suprahyoid muscle attachments. The procedure is thought to be a "highly sensitive" one and undesired fractures may occur during splitting of the bony segments.

Management of Zygomatic Fixture Complication Case Using Extra-Short Implants.

The oral rehabilitation of a patient with atrophic maxilla is one of the main challenges in implant-supported rehabilitations. The implant placement in the posterior region of the maxilla is limited by a deficiency of bone quantity and quality, besides the anatomic restriction of the maxillary sinus. The use of zygoma fixtures, anchoraged in the zygomatic bone, is a useful technique to enable the full arch rehabilitation. However, complications related to this procedure bring a lot of difficulty in solving. This study presents the use of extra-short implants as a strategy to treat a patient in whom the zygoma fixture and the fixed prosthesis failed, associated with sinusitis and alveolar bone loss.

Autologous Bone Marrow-Derived Mononuclear Cells Combined With ß-TCP for Maxillary Bone Augmentation in Implantation Procedures.

Replacing missing bone or adding mass to existing bone is often essential to the success of a dental implant. A large variety of graft materials have been used for maxillary and mandibular atrophy. To date there has been no graft material, which can be regarded as completely satisfactory. Our experience with freshly isolated autologous bone marrow-derived mononuclear cells combined with ß-tricalcium phosphate for augmentation of the extremely atrophied maxilla is presented. These techniques are based on stimulation of natural events continuously present in living bone (ie, the process of bone remodeling). The property of the mixture material for bone augmentation to place dental implant was discussed.

Long-term outcomes of the use of allogeneic, radiation-sterilised bone blocks in reconstruction of the atrophied alveolar ridge in the maxilla and mandible.

Increasingly dental surgeons face the challenge of reconstruction of the height and/or thickness of the alveolar ridge as more and more patients wish to have permanent restoration of their dental defects based on intraosseous implants. Evaluation of human allogeneic bone tissue grafts in reconstruction of atrophied alveolar ridge as a pre-implantation procedure. The material comprised 21 patients aged 19-63, treated between 2009 and 2012 by the same surgeon. Restoration of bone tissue defects was performed with allogeneic, frozen, radiation-sterilised, corticocancellous blocks. The study included 26 grafting procedures with 7 procedures consisting in reconstruction of the alveolar ridge in the mandible and 19 in the maxilla. In all the cases the atrophied alveolar ridge was successfully reconstructed, which allowed placement of intraosseous implants in compliance with the initial treatment plan. After the treatment was completed the patients reported for follow-up annually. The average time of follow-up amounted to 39 months (28-50 months). None of the implants was lost during the follow-up period. There was one case of gingival recession causing aesthetics deterioration of the prosthetic restoration. In three cases the connector became unscrewed partially, which was corrected at the same visit. Frozen, radiation-sterilised, allogeneic bone blocks constitute good and durable bone-replacement material allowing effective and long-lasting reconstruction of the atrophied alveolar ridge to support durable, implant-based, prosthetic restoration.

Modern therapy for severe alveolar ridge atrophy.

This clinical report illustrates a modern method for oral rehabilitation of severe edentulous atrophic ridge. Shallow vestibule and small denture-bearing area of the maxilla provide insufficient retention, and only the symphyseal region of the mandible has obvious alveolar ridge. The surgery of deepening vestibule of the maxilla ridge was done by using tentative miniscrew combined with old denture and soft liner. The osseointegrated dental implants were installed over symphyseal region of the mandible to act as retentive devices for prostheses. In addition, functional reline with rebase material to build buccal-tongue contact over the retromolar area after denture delivery obtained high satisfaction from the patient. Many clinical conditions cannot be managed solely with implants or preprosthetic surgery alone, whereas a combination of the 2 can achieve successful outcome.

Vertical ridge augmentation of the atrophic posterior mandible with custom-made, computer-aided design/computer-aided manufacturing porous hydroxyapatite scaffolds.

The present study describes a new protocol for the manufacturing of custom-made hydroxyapatite scaffolds using computer-aided design/computer-aided manufacturing (CAD/CAM), to augment posterior mandibular bone and minimize surgery when severe atrophy is present. Computed tomographic images of an atrophic posterior mandible were acquired and modified into a 3-dimensional (3D) reconstruction model. This model was transferred as a stereolithographic file to a CAD program, where virtual 3D reconstructions of the alveolar ridge were performed, drawing 2 anatomically shaped, custom-made scaffolds. Computer-aided-manufacturing software generated a set of tool-paths for manufacture on a computer-numerical-control milling machine into the exact shape of the 3D projects. Clinically sized, anatomically shaped scaffolds were generated from commercially available porous hydroxyapatite blocks. The custom-made scaffolds well matched the shape of the bone defects and could be easily implanted during surgery. This matching of the shape helped to reduce the time for the operation and contributed to the good healing of the defects. At the 6-month recall, a newly formed and well-integrated bone was observed, completely filling the mandibular posterior defects, and implants were placed, with good primary stability. At the 1-year follow-up examination, the implant-supported restorations showed a good functional and esthetic integration. Although this is an interim report, this study demonstrates that anatomically shaped custom-made scaffolds can be fabricated by combining computed tomographic scans and CAD/CAM techniques. Further studies are needed to confirm these results.

The Custom Alveolar Ridge Splitting (CARS) Technique for Predictable Horizontal Ridge Augmentation in the Atrophic Posterior Mandible: A Case Report.

The Custom Alveolar Ridge Splitting (CARS) technique was recently reported as a less-invasive treatment option for augmentation of the maxillary anterior area in cases where alveolar width deficiency exists due to bone resorption and remodeling. This technique creates an intraosseous defect to improve success when horizontal ridge augmentation is attempted. The purpose of the present case report was to demonstrate implant placement in an atrophic posterior mandibular site using the CARS technique. This technique was used in the mandibular right second premolar area, followed by placement of a single implant. The restored implant showed stable soft and hard tissue outcomes at 6 months postloading.

Unusual anchor pins placement and protocol deviations during computer-based implant placement in a patient with severe mandibular bone atrophy. A case report.

The aim of the study was to describe an unusual method to stabilize the surgical template during the treatment of a severely resorbed edentulous mandible by means of computer-guided implant surgery. Pre-operative computer-based planning revealed the difficulty to stabilize the surgical template in a 67-year-old healthy woman. A deviation of the original NobelGuide™ protocol was performed to ensure the stability of the surgical template: four anchor pins were used to stabilize the surgical template, two in the buccal side of the anterior template and two unusual pins were placed in the lingual site. Four straight TiUnite® Nobel Biocare™ implants were then placed, according to a modified All-on-4™ concept procedure, to avoid graft procedures and to reduce the cumulative chair-side treatment time and costs. A temporary restoration was placed immediately after implant placement. Three months later a definitive, full acrylic restoration was delivered.

Additively Manufactured Lattice-like Subperiosteal Implants for Rehabilitation of the Severely Atrophic Ridge.

Subperiosteal implants represent an alternative implant approach for cases with severe bone atrophy. Although some successful clinical cases have been reported, the biomechanical stability of subperiosteal implants remains unclear, and more data are needed to confirm the feasibility of this approach. Therefore, this study investigated the biomechanical characteristics of subperiosteal implants based on histological observation, clinical cases, and finite element analysis. Finite element analysis indicated that subperiosteal implants with a lattice-like structure could better disperse the stress to the underlying bone surface. A novel customized subperiosteal implant was then digitally designed and fabricated using an additive manufacturing technology. Six beagle dogs received such customized subperiosteal implants. Histological and microcomputed tomography examination showed new bone growth into and around the implant. Patient-specific subperiosteal implants were placed into the edentulous mandibular bone, with immediate loading. The implant was functional, without pain or infection, over a 12 month observation period. Images taken 12 months post-operatively showed new bone formation and osseointegration of the device. This indicated that 3D-printed lattice-like subperiosteal implants have sufficient stability for the rehabilitation of severely atrophic ridges.

Managing the severely atrophic maxilla: Farewell to zygomatic implants and extensive augmentations?

BACKGROUND: Dental rehabilitation of severe atrophic upper jaws remains challenging. A new generation of subperiosteally placed and rigid multi-vector bone-anchored patient-specific implants proposes an innovative line extension in implant dentistry. This single-center retrospective study focused on treating severely atrophic maxillae using these implants. METHODS: All patients who were treated with a patient-specific implant (IPS Implant® Preprosthetic, KLS-Martin, Tuttlingen, Germany) at Hannover Medical School due to severe atrophy of the maxilla who had no history of malignancy, cleft lip or palate, or trauma were evaluated regarding implant stability and prosthetic restoration, as well as complications. RESULTS: Out of a total of 58 inserted implants, 13 implants in 10 patients, which were placed to treat a severely atrophic upper jaw, were identified. The mean follow-up period was 8.2 months (1-29 months). All implants were clinically stable over the entire period. All patients with an observation period of over 2 months received prosthetics for restoration. Minor complications, screw fractures, infection, and exposure of the framework were observed, but these did not lead to failure. CONCLUSION: This initial follow-up suggests that this new generation of implants represents a valuable treatment alternative, especially for patients with a history of failed dental implant placement. Larger numbers of cases and longer observation periods are required to confirm our findings.

Autogenous bone grafting with conventional implants vs zygomatic implants for atrophic maxillae: a retrospective study of the oral health-related quality of life.

INTRODUCTION: Autogenous bone grafting (ABG)-combined or not with Le Fort I osteotomy (LFIO)-and zygomatic implants (ZI) are two reliable techniques for the fixed rehabilitation of atrophic maxillae. ZI allow a reduced treatment duration with no need to graft, immediate loading and in principle less morbidity. The aim of this retrospective study was to compare these two protocols on oral health-related quality of life (OHRQoL). We also discussed implant and prosthetic survival rates, and biological complications. MATERIAL AND METHODS: All patients who benefited from ZI or ABG with conventional implants (CI) for a fixed maxillary rehabilitation, from November 2011 to April 2019, were included: 21 patients in the ABG group and 22 in the ZI group. OHRQoL was evaluated postoperatively by OHIP-14 questionnaire. RESULTS: OHIP-14 median scores were respectively 6.5 (interquartile range [IQR] 2.0-13.0) and 6.0 (IQR 3.0-10.0) without significant difference (p = 0.97). Implant/prosthetic survival rates were 97.9%/100% and 97.1%/95.5%. Biological complications rates were 33.3% and 36.4% without significant difference (p = 0.83). DISCUSSION: The type of surgery or prosthesis does not seem to affect final OHRQoL, implant and prosthetic survival rates or biological complications rates.

Treatment of posttraumatic fingertip pain using a great toe pulp graft.

Complications of fingertip injury include pain, hyper- or dyssensitivity, cold intolerance, and fingertip atrophy. Especially in cases of soft-tissue defect or atrophy which result from crushing injury, fingertip pain often occurs when a finger touches the objects. To overcome this problem, several techniques including local flaps or free flaps were suggested. But these methods require intricate and multistaged procedures.Twelve patients who had fingertip pain with pulp atrophy were treated with pulp graft between March 2004 and March 2006. Under the local anesthesia, we made a fish-mouth incision at the most prominent portion of fingertip and elevated volar flaps. Composite tissue was harvested from the lateral aspect of great toe, and inserted between the previously elevated volar flaps. The harvested composite pulp tissue contained about 3- to 5-mm thick fat layer. Moisture dressing was performed. The visual analogue scale (VAS) was used to evaluate the degree of pain postoperatively. The follow-up period was in the range between the 12 and 24 months (average, 19 months). Pre- and postoperative differences in VAS scores were analyzed for statistical significance, using the Wilcoxon rank sum test. In addition, patients were asked about their level of satisfaction with the procedure. To evaluate the postoperative sensation of the graft, we performed the Semmes-Weinstein monofilament test, and static and dynamic 2-point discrimination test at 1 year postoperatively.The size of the graft was ranged from 276 mm (12 × 23 mm) to 750 mm (25 × 30 mm). At final follow-up review, 5 patients were very satisfied and 7 were satisfied. Atrophy of the fingertip was also improved. Fingertip pain reduced from 8.5 preoperative to 3.1 postoperative on VAS. These improvements were statistically significant. Semmes-Weinstein monofilament test was green (∼2.83) in 9 patients (75%) and blue (3.22-3.61) in 3 of 12 patients (25%). Static and dynamic 2-point discrimination test results came out as 6 and 5 mm, respectively.Composite graft applied to the fingertip is a simple technique, and gives few complications. This procedure can be performed under local anesthesia and gives a fairly high degree of satisfaction to patients. We believe this method is useful for treating fingertip pain with atrophy of pulp.