[Zygomatic anchorage concept in full edentulism]. / Le concept de l'ancrage zygomatique dans l'édentation totale.

The zygoma anchorage concept for severe atrophy of the maxilla was developed by Brånemark in the 1980s. It concerned patients having undergone maxillectomy as well as patients with edentulous upper jaws and mild to severe maxillary atrophy. The concept was created and clinically developed in 1997, by placing two zygomatic implants and four standard ones to compensate sub-sinus bone resorption. It was applied later to patients presenting extremely severe maxillary atrophy, using the "zygoma quad" concept with the placement of four zygomatic implants. Zygoma anchorage is reliable in terms of osseo-integration and biomechanical support of screwed prostheses, according to frequently published data (overall survival rate ranging between 91 and 100%). The increasing practice of immediate loading makes it the treatment of choice for oral rehabilitation. It decreases surgical invasiveness and the delay between surgery and oral rehabilitation. It allows a quick social and professional reinsertion and increases the comfort and quality of life for patients with fully edentulous maxilla with mild, moderate, or severe atrophy.

Rehabilitation of totally atrophied maxilla by means of four zygomatic implants and fixed prosthesis: a 6-40-month follow-up.

The zygomatic implant is an alternative to bone grafting in extremely resorbed maxilla. This study evaluates the results of a consecutive cohort of 20 patients (mean age 56 years) with extremely resorbed maxillas provided with four zygomatic implants. The first 10 patients had a two-stage procedure, the next 10 next patients benefited from a one-stage surgical procedure and one of them had flapless guided surgery with Nobelguide in development and immediate function. The same surgical drilling protocol, according to Branemark's procedure, was applied to all the patients. Except for one patient who lost three implants, 18 patients received a fixed Procera implant bridge and another an overdenture retained by a screwed bar fixed on the four zygomatic implants. The cumulative survival rate after 40 months is 96%. Although bone augmenting procedures such as onlay grafts and sinus grafts are popular and well-documented, the four zygomatic implants procedure results in less morbidity, shorter delays between anatomical reconstruction and functional rehabilitation and can provide immediate or early loading with immediate function. Four zygomatic implants and a fixed bridge seem to be a valuable technique for the rehabilitation of extremely resorbed maxillas.

Neurosensory disturbances after immediate loading of implants in the anterior mandible: an initial questionnaire approach followed by a psychophysical assessment.

The aim of the study was to assess past and present neurosensory disturbances using a questionnaire and a psychophysical approach in patients treated with immediate loaded implants in the edentulous anterior mandible. A group of 65 patients (age range 30-84 years, mean 58 years, 30 women) was enrolled. All were treated by means of three immediately loaded implants (Branemark Novum System). A self-designed questionnaire was used for data collection. The response rate was 89%. Of the 58 responders, 33% (n=19) reported neurosensory disturbances after implant surgery. Nine of these patients (mean age 56 years, seven women) participated in an objective evaluation and were subjected to a psychological and several psychophysical tests. At the moment of the evaluation none of the nine patients still had clinical complaints. Psychological testing revealed no statistical differences between the patients, who had previously experienced subjective complaints, and the control group. Two-point discrimination and thermal sensation tests revealed no sensory lesions. The light touch sensation test at the lower lip indicated a more frequent reduction of tactility for the test group (p

The neurophysiology of osseointegrated oral implants. A clinically underestimated aspect.

Amputation of a limb or a tooth leads to the loss of a large number of exteroceptors. These play an important role in sensory perception and feedback, which tune the motor control. Even after rehabilitation with a prosthetic device, tactile function remains impaired. This can present a subsequent risk of overloading the prosthesis. The peri-implant interface of oral osseointegrated implants is characterized by the absence of a periodontal ligament, a crucial difference towards the natural dentition, from a biomechanical but also from a neurophysiologic point of view. Patients rehabilitated with osseointegrated implants seem subjectively not much impaired in their masticatory and other oral functions. This observation might be linked to the presence of some peripheral feedback pathway to the sensory cortex. It may be attributed to the activation of receptors in the peri-implant environment (either bone or periosteum). This phenomenon called osseoperception, when it relates to the consciousness of the applied stimuli, has been described for both oral and skeletal implants. In the present review, besides osseoperecption other neurophysiological aspects of oral implants, such their reflex function, will be outlined and their clinical meaning pointed out.

Embryology and epidemiology of cleft lip and palate.

Craniofacial anomalies, in particular cleft lip and palate, are major human birth defects with a worldwide frequency of 1 in 700 and substantial clinical impact. This article reviews the embryology of the face, lip, and palate to enhance the understanding of the pathogenesis of these lesions, with particular attention to the period of susceptibility during gestation, complexity, and the factors that may influence their development. It includes an overview of the prevalence and environmental and genetic causes of cleft lip-with or without cleft palate- and cleft palate.

Long-term follow-up of UCLP at the Reine Fabiola Children's Hospital.

BACKGROUND: The purpose of this retrospective of prospectively acquired data was to evaluate and to compare global evolution in children with complete unilateral cleft lip and palate treated at the Brussels cleft centre following two different surgical treatment protocols. METHODS: A series of forty-four patients operated for non-syndromic complete unilateral cleft lip and palate were included in this study at the age of approximately ten years. Twenty-six children (17 males, 9 females) were treated according to the Malek surgical treatment protocol: the soft palate was closed at a mean age of 3 months, followed by simultaneous repair of the lip and hard palate at a mean age of 6 months. Eighteen children (15 males, 3 females) underwent one-stage "all-in-one" closure of the lip, hard and soft palate at a mean age of 3 months. Craniofacial morphology was evaluated by means of digital lateral cephalometric analysis. Cephalometric data were compared to a control, non-cleft group (n = 40) matched according to age. Data concerning otological status and speech were collected in the same series of children. RESULTS: Statistical analysis showed that the inclination of the maxillary (MxPVSN) plane to the anterior cranial base was significantly increased (p <0.001) in both cleft groups compared to the non-cleft group and significantly increased (p = 0.002) in the Malek cleft group compared to the "all-in-one" cleft group. Otological status was not improved by an early complete closure but by close follow-up and the repeated placement of ventilating tubes. Speech was found to be satisfactory in the majority of children of both groups at six years after speech therapy. Only 15% needed further surgery with pharyngeal flaps. CONCLUSIONS: There were no significant differences in anteroposterior midfacial morphology between the Malek and "all-in-one" protocols at ten years of age. One-stage "all-in-one" closure resulted in less downward inclination of the maxillary plane to the anterior cranial base compared to the Malek protocol at ten years of age. Early complete closure of the cleft resulted in no significant change in otological status or the occurrence of nasality. However, early complete closure of the cleft allowed for earlier intelligibility of speech compared to the staged later closure.

[Treatment of cleft lip and palate in the children's Hospital Reine Fabiola in Bruxelles]. / Prise en charge des fentes labio-maxillo-palatines à l'hôpital des enfants Reine Fabiola de Bruxelles.

The priority in the treatment of facial clefts is to avoid the iatrogenic sequellae by restoring a normal anatomy of the face. The difficulty of this treatment is that the majority of the sequellae are only observed 15 years after the primary treatment. After having treated our children during more than 20 years by a primary closure of the lip at 6 months and closure of the palate by push back according to Veau Wardill at 18 months, we adopted the technique of René Malek since 1981 with early closure of the palate at 3 months then, without undermining of the palatal mucosa, closure of the bony palate with a vomer flap at the age of 6 months. Since 1988, in unilateral complete cleft, we perform a complete closure of the lip and palate at 3 months according to the same surgical principles. The study of the dental casts according to the Golson Yardstick at the age of 10 and the cephalometric study by lateral Xrays at the age of 15 show an excellent facial growth in the majority of the cases with only 6% needing a osteotomy at the end of growth. Moreover the phonation of these children was very good in the majority of the cases, 15% only needing a secondary surgery. The only remaining sequellae are in the auditory field with an abnormal frequency of sero mucous otitis. These could not be improved until now despite the early use of tympanic drains.

Midfacial morphology in children with unilateral cleft lip and palate treated by different surgical protocols.

The purpose of this study was to compare cranio-facial, particularly midfacial morphology, in two groups of children with complete unilateral cleft lip and palate (UCLP) treated at two different cleft centres (Hannover. Germany and Brussels, Belgium) following different surgical treatment protocols. A total of 62 children (40 males; 22 females) with non-syndromic UCLP were included in this study at approximately the age of 10. The Hannover group comprised 36 children, who had repair of the lip at a mean age of 5.83 +/- 1.16 months, followed by repair of the hard and soft palate at a mean age of 29.08 +/- 4.68 and 32.25 +/- 4.29 months. respectively. The Brussels group consisted of 26 children who underwent surgical treatment according to the Malek protocol: the soft palate was closed at a mean age of 3.04 +/- 0.20 months, followed by simultaneous repair of the lip and hard palate at a mean age of 6.15 +/- 0.68 months. Midfacial morphology was evaluated by means of cephalometric analysis according to Ross. The children in the Hannover UCLP group did not differ significantly from those in the Brussels group in the anteroposterior dimension of the midface. However, the maxillary plane was significantly more open in the Brussels group due to less posterior vertical maxillary development.

Clinical and radiographic evaluation of the papilla level adjacent to single-tooth dental implants. A retrospective study in the maxillary anterior region.

BACKGROUND: The regeneration of gingival papillae after single-implant treatment is an area of current investigation. This study was designed to determine: 1) whether the distance from the base of the contact point to the crest of the bone would correlate with the presence or absence of interproximal papillae adjacent to single-tooth implants, and 2) whether the surgical technique at uncovering influences the outcome. METHODS: A clinical and radiographic retrospective evaluation of the papilla level around single dental implants and their adjacent teeth was performed in the anterior maxilla in 26 patients restored with 27 implants. Six months after insertion, 17 implants were uncovered with a standard technique, while 10 implants were uncovered with a technique designed to generate papilla-like formation around dental implants. Fifty-two papillae were available for clinical and radiographic evaluation. The presence or absence of papillae was determined, and the effects of the following variables were analyzed: the influence of the 2 surgical techniques; the vertical relation between the papilla height and the crest of bone between the implant and adjacent teeth; the vertical relation between the papilla level and the contact point between the crowns of the teeth and the implant; and the distance from the contact point to the crest of bone. RESULTS: When the measurement from the contact point to the crest of bone was 5 mm or less, the papilla was present almost 100% of the time. When the distance was > or = 6 mm, the papilla was present 50% of the time or less. The mean distance between the crest of bone and the most coronal papilla level (interproximal soft tissue height) was 3.85 mm (SD = 1.04). When comparing the conventional and modified surgical technique, the relation shifted from 3.77 mm (SD = 1.01) to 4.01 mm (SD = 1.10), respectively. CONCLUSIONS: These results clearly show the influence of the bone crest on the presence or absence of papillae between implants and adjacent teeth. The data also show a positive influence for the modified surgical technique, aimed at reconstructing papillae at the implant uncovering.

Anterior esthetic rehabilitation on teeth and dental implants optimized with Procera technology: a case report.

With the latest developments of the Procera system, all-ceramic crowns have become an attractive solution to provide functional and esthetic rehabilitation on teeth and dental implants. The Procera AllCeram crown and Procera Abutment embrace the concept of computer-assisted design and computer-assisted machining (CAD/CAM) and can be used together for optimal esthetic result. The purpose of this case report was to illustrate the advantages of these new components for complex anterior rehabilitation. Three natural teeth and a Procera Abutment were restored using four Procera AllCeram crowns. Treatment planning and esthetic benefits are discussed.

Craniofacial distraction osteogenesis: a review of the literature: Part 1: clinical studies.

A review of the literature dealing with distraction osteogenesis (DO) of the craniofacial skeleton, provided by a PUBMED search (National Library of Medicine, NCBI; revised 3 April 2000) from 1966 to December 1999 was conducted. Key words used in the search were distraction, lengthening, mandible, mandibular, maxilla, maxillary, midface, midfacial, monobloc, cranial, craniofacial and maxillofacial. This search revealed 285 articles. One hundred and nine articles were clinically orientated and were analysed in detail in this study. The type of distraction, indications, age, type of surgery, distraction rates and rhythms, latency and contention periods, amount of lengthening, follow-up period, relapse, complications and the nature of the distraction device were analysed. This review revealed that 828 patients underwent DO of the craniofacial skeleton; 579 underwent mandibular DO, 129 maxillary DO, 24 simultaneous mandibular and maxillary DO and 96 midfacial and/or cranial DO. Craniofacial DO has proven to be a major advance for the treatment of numerous congenital and acquired craniofacial deformities. Treatment protocols and success criteria for craniofacial DO are suggested on the basis of these results. There is still, however, a lack of sufficient data, especially on follow-up and relapse, so that treatment strategies have to be validated by long-term studies in the future.

Adsorption of peroxidase on titanium surfaces: A pilot study.

The present study demonstrates the in vitro and in vivo adsorption of peroxidase onto titanium surfaces. Titanium foils (mean +/- SEM: 365 +/- 2 mm(2), n = 114) were incubated during 30 min with lactoperoxidase (4 mg in 5 mL 100 mM phosphate buffer pH 7). After 15 washings by H(2)O, titanium foils were incubated with o-phenylenediamine (6 mg/mL) and H(2)O(2) (7 mM) during 30 min. The reaction was then stopped by the addition of HCI 1M and the absorbance of the liquid phase was read on a spectrophotometer at 492 nm. In vitro adsorbed lactoperoxidase onto titanium surfaces was 0.70 +/- 0.05 ng/mm(2) (mean +/- SEM, n = 30). X-ray photoelectron spectroscopy confirmed the incorporation of protein nitrogen onto titanium surfaces: the nitrogen atomic percentage increased from 0.9 +/- 0.3 to 12.7 +/- 0.2% (n = 3) and from 3.7 +/- 0.1 to 14.4 +/- 0. 4% (n = 5) when titanium foils were incubated in the lactoperoxidase solution during 30 min and 24 h respectively. In vivo, oral peroxidases adsorbed on titanium healing abutments from 0.01 to 0.58 ng/mm(2) (n = 19) after 2 weeks in the oral environment.

Maxillary distraction osteogenesis: a method with skeletal anchorage.

Maxillary distraction osteogenesis is a challenging technique to treat severe maxillary retrusion. Maxillary advancement by distraction has the advantage to provide new bone in combination with simultaneous expansion of the soft-tissue functional matrix. Cleft lip and palate patients can present with severe maxillary retrusion and Class III malocclusion. Two 13-year-old patients, born with non-syndromic cleft lip and palate, underwent maxillary distraction--one had a bilateral, the other a unilateral complete cleft lip and palate. Maxillary advancement was performed using an external distraction device in combination with titanium miniplates as a skeletal maxillary anchorage. After a complete Lefort I osteotomy with pterygomaxillary disjunction, a latency period of 3 days was respected. On the fourth postoperative day, distraction was initiated at the rate of 1 mm/d. Preoperative clinical photographs, dental casts, lateral cephalograms, and panoramic radiographs were taken. Further lateral cephalograms were obtained after the latency period, after completion of the active period of distraction, at the completion of the consolidation period, and at 6 and 12 months postoperatively. The aesthetic outcome was excellent and skeletal advancement of 8 and 7 mm was measured without dentoalveolar compensations.

Maxillary distraction osteogenesis: a two-dimensional mathematical model.

Patients with cleft lip and palate with severe maxillary retrusion usually have a mandible with anterior-superior autorotation and subsequent overclosure and loss of the vertical facial dimension. Maxillary distraction osteogenesis can correct the sagittal maxillomandibular relationship and should simultaneously reestablish vertical dimension through maxillary vertical height increase and clockwise rotation of the mandible to restore facial balance. We present a two-dimensional mathematical model in the sagittal plane, which reestablishes sagittal and vertical skeletal deficiencies and proper occlusal alignment for planning maxillary advancement with distraction osteogenesis in patients with cleft lip and palate. The model is illustrated in a case of a 13-year-old boy with a complete bilateral cleft lip and palate and severe maxillary retrusion. The two-dimensional mathematical model described in this article allows the surgeon and orthodontist to calculate in a simple and accurate way the ideal distraction vector to advance the maxilla to its desired position.

Maxillary distraction in cleft lip palate patients: a review of six cases.

Cleft lip and palate patients can present with a maxillary retrusion with tendency to Class III malocclusion after cleft repair. Maxillary distraction osteogenesis is a technique that provides simultaneous skeletal advancement and expansion of the soft tissues. Six nonsyndromic cleft lip and palate patients, ages 12 to 16 years (mean, 13.8 years), underwent maxillary distraction; four had a unilateral and two a bilateral cleft lip and palate. After an incomplete LeFort I osteotomy; a latency period of 3 days was respected. On Postoperative Day 4, distraction was initiated through anterior traction on a Delaire facial mask using distraction forces of 900 gm. Photographs and lateral cephalometric radiographs were obtained preoperatively and 4 months after distraction. A cephalometric analysis was performed to compare the sagittal dentocraniofacial morphology before and after distraction. The aesthetic improvement obtained by maxillary distraction osteogenesis during the permanent dentition to correct maxillary retrusion in our cleft lip and palate patients was impressive. Skeletal advancement varying from 1 to 3.5 mm (mean, 1.7 mm) was found. However, significant dentoalveolar compensations occurred in three patients. This was due to the dental anchorage of the distraction device and can be avoided only by the use of skeletal fixation.

Neuro-ophthalmic complication after maxillary surgery.

We report an unusual case of ophthalmoplegia after maxillofacial surgery. A thirteen year old girl with unilateral left cleft lip and palate underwent maxillary advancement by distraction osteogenesis. Postoperatively she developed diplopia. The diplopia was not due to orbital lesions, most often seen after maxillofacial surgery, but to a haemorrhage posterior to the cavernous sinus.

Palatal sliding strip flap: soft tissue management to restore maxillary anterior esthetics at stage 2 surgery: a clinical report.

A new soft tissue flap design technique, called "the palatal sliding strip flap" (PSSF), has been developed to improve the soft tissue surgical results at stage 2 implant surgery. The purpose of this flap design is to help form papillae between implants and between natural teeth in the anterior area of the maxilla. The flap is designed and managed so that the palatal attached mucosa slides in a labial direction to create papillae and at the same time augment the labial ridge. This surgical approach is valid, predictable, and has a low risk-to-benefit ratio. This new flap design is indicated for a variety of clinical situations, especially for the problematic maxillary soft tissue reconstruction around teeth and implants.

Autologous bone graft to augment the maxillary sinus in conjunction with immediate endosseous implants: a retrospective study up to 5 years.

This study reports the successful use of osseointegrated implants to replace posterior teeth combined with the autogenous bone graft technique in the sinus. Preliminary data (1 to 6 years experience) of this one-stage procedure are presented. A total of 33 patients were treated--44 sinus grafts were augmented with bone from the anterior iliac crest. Reconstruction was completed with ceramic fixed partial dentures, and there was a follow-up of 3 to 80 months (mean 40.2 months) after loading. None of the 44 sinus grafts was lost. Of the 121 implants placed, eight failed, resulting in a failure rate of 6.6% and a cumulative failure rate of 6.8%. Of the 44 prostheses placed in the 44 sinuses, one failed, resulting in a prosthesis stability of 97.7%. Complications were encountered in three patients (three sinuses, eight implants); treatments were administered, symptoms subsided, and the implants integrated in two patients (two sinuses, six implants). One patient lost the two implants and the prosthesis, but the graft integrated. No other complications have since occurred. The results compare favorably with previous reports in terms of implant survival and stability. The implant survival rate approached that of implants placed in uncompromised maxillary bone.

Marginal bone levels at Brånemark system implants used for single tooth restoration. The influence of implant design and anatomical region.

In this retrospective study of Brånemark system oral implants, 75 consecutive patients were treated with 84 implants for single-tooth replacement from 1988 to 1993. Two implants were lost and not replaced: the first one before the abutment connection, the latter during the first year in function. The cumulative failure rate reached 2.4% during the 5-year period. Seventy-one percent of the implants were located in the incisor/canine region of both jaws. Twenty-six per cent of the implants were inserted in special presurgical or surgical conditions. The mean annual bone loss as scored on radiograph, was 0.8 mm during the first year and 0.1 mm the following years. Different implant designs were used, a more pronounced bone loss was observed for the conical implant. The present data shows that the cumulative failure rate for single Brånemark implants and radiographic bone loss is similar to that found around implants used for the treatment of complete and partial edentulism.