Self-bone graft and simultaneous application of implants in the upper jawbone

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(1)original article. APPLICATION OF IMPLANTS IN UPPER JAWBONE P. VITTORINI VELASQUEZ* , G. FALISI**, M. GALLI***. te. RIASSUNTO Innesto di osso autologo ed applicazione simultanea degli impianti nel seno mascellare La riabilitazione implanto supportata dei settori postero superiori, a volte, risulta condizionata dalla pneumatizzazione del seno mascellare riducendo la possibilità dell’applicazione dei soli impianti quando la disponibilità ossea risulta inferiore ai 4 mm (condizione limite per la stabilità primaria). Il grande rialzo del seno mascellare e l’applicazione simultanea degli impianti è sicuramente la condizione che ha le migliori garanzie di successo rispetto alla sola applicazione del materiale da riempimento. Molte sono le tecniche chirurgiche introdotte nell’utilizzo di osso autologo (cresta iliaca, calvaria, perone) e l’applicazione degli impianti. In questo articolo si vuole portare all’attenzione di una nuova tecnica per ridurre al minimo l’invasività del prelievo e la morbilità del paziente. È stato eseguito uno studio longitudinale su 21 casi consecutivi ed esemplificato da un caso clinico, evidenziando un successo del 94.5%. I vantaggi di questa tecnica sono: 1) Recupero funzionale e anatomico dell’antro mascellare 2) Applicazione immediata degli impianti con spessore di osso residuo inferiore ai 4 mm 3) Riduzione dei tempi chirurgici 4) Morbilità ridotta del paziente 5) Anestesia loco regionale.. IC. Ed. iz. io. ni. In. SUMMARY Self bone graft and simultaneous application of implants in upper jawbone. The implant supported rehabilitation of upper back sectors, sometimes, is conditioned to the pneumatization of the jawbone and so, reducing the possibility to apply the implants when the bone portion is inferior to 4 mm (important condition for the primary stability). The great rise of the jawbone and the simultaneous application of implants is, surely, the condition to have the best success guarantees compared to the only application of filling material. The surgical technologies used in the self bone grafts are various (Ilium crest, calvaria, fibula) and so also for implant applications. In this article we want to put in evidence a new technology in order to reduce at the minimum the invasive surgery of the removal and the patient morbidity. It has been executed a longitudinal study on 21 consecutive cases and illustrated by a clinical one; the success was of 94.5%. The advantages of this technique are: 1) Functional and anatomical recovery of the jaw cavity 2) Immediate application of implants with a thickness of remaining bone in fervor to 4 mm. 3) Reduction of surgical times 4) Reduced morbidity of the patient 5) Local an anesthesia.. rn a. * MDS, ** PhD, DDS *** MD Professor Sapienza University of Rome. zi on al i. SELF BONE GRAFT AND SIMULTANEOUS. ©. C. Key words: Self bone graft, jawbone surgery, simultaneous implants.. Introduction. The pneumatization of the jawbone is frequent when there is a loss of teeth elements, causing a reduction in vertical sense of the bone condition, limiting the insert of implants for prosthesis recovery aims.. Parole chiave: innesto autologo, chirurgia seno mascellare, impianti simultanei.. The approach to this anatomic zone has been always disputed, for the surgical approach as well as for postsurgical complications. Different techniques have been introduced in order to bypass this zone; use of pterygoid implants and transzygomatic ones, even though with this late technique the jawbone is anyhow invaded, to search the bicorticalism and obtain the primary implant stability.. ORAL & Implantology - Anno II - N. 4/2009. 11.

(2) te. rn a. zi on al i. Inclusion standards: • Bone height inferior to 4mm. by means of x-ray • Bone disposal of the removal zone in jaw ramussymphysis • Permission of the patient to participate at study • The will to submit himself to the clinical periodic follow up. 330 patients were excluded of the total 400. Among the selected ones, 30 have not consented the treatment, 19 have not submitted them selves to the follow up, the remaining group was composed of 21 patients. Among the 21 ones, 13 were men of about 58.2 years old, and 8 women of about 59.8 years old. In all patients we have inserted cone implants and the surface was treated with Tps in combination with SLA (micro-porous surface and plasma spray). The total number of implants was 37, so distributed: 6 in zone 16; 3 in zone 17; 12 implants in zone 26; 11 in zone 27. The length of inserted implants has been of 11.5 mm for 16 ones and for 21 implants of 13 mm with a diameter of 3.75 mm (schedule 1). All implants have been submitted to a functional and progressive charge after 6 months from the insertion.. Surgical technique. Ed. iz. Materials. io. ni. In. original article. When the bone surface is higher than 4mm. the international literature allowes the filling of the jawbone and the simultaneous setting of implants, while in case the bone surface is inferior to 4 mm. Misch classification (4) is important to operate with a first reconstructive-regenerating phase, and then pass to a second surgical phase to insert implants. Some authors (5) suggest the possibility of implants in the same surgical moment with the use of an extraoral self bone graft (fibula or hip ) in order to obtain the primary stabilization; this technique has, however, different disadvantages: • The need of a protective environment, private clinic or hospital, in which it is possible to operate in total anesthesia. • The removal of the giving zone must be effected by a qualified operator (orthopedist). • The deambulation of the patient and his morbidity. • The high cost, biological and economic. Under these considerations, the authors want to present a new alternative surgical technique allowing the simultaneous insertion of implants where the bone height is inferior to 4 mm, with the removal of the graft in intraoral zone and local anesthesia.. ©. C. IC. At the Clinica Dentomaxillofacciale Vittorini Sangueza, Cochabamba, Bolivia, between 2002 and 2003 about 400 patients were visited for the supported implants rehabilitation of superior back sectors. All patients have been studied according to our clinical implant protocol, for a successful prosthesis rehabilitation. During this period patients have been selected through the following standard of exclusion and inclusion in a group of study consisting of 21 patients. Exclusion standards: • Insufficient dental care • Acute and chronic sinusitis of the jawbone • Patient with high risk factors • Patients undergoing Cadwell Luc treatments • Patients having radiotherapy • Patients with a bone height superior to 4 mm.. 12. Asepsis of surgical portion: intraoral with mouthwash of clorexidine gluconate at 0.2% for 2 minutes, extraoral with Povidona (polivinilpirrolidona PVP). Isolation of surgical zone with sterile materials. Local anesthesia with mepivacaine chloridrate at 1:100.000 ui, in the troncular and plexus jawbone (retro-molar trigon, vestibular palatal and retro-incisor duct), troncular jaw and plexus vestibular.. Preparation of the receiving site Edge design, primary crestal incision and second release incisions in all thickness (trapezoidal edge). (Fig. 2).. ORAL & Implantology - Anno II - N. 4/2009.

(3) original article Table 1 - Specimen description. Implant site. Implants h mm. Diameter mm. f m m m f m m m f m m m m f f f f f m m m. 53 46 55 57 51 60 53 64 62 67 71 52 65 73 70 60 52 58 50 66 51. 26-27 26 27 17 27 16 26 26 16-17-26-27 26-27 16 16 26- 27 26 16 26-27 16 26 26-27 27 16-17-26-27 26-27 16-17-26 27. 11,5 -11,5 11,5 11,5 13 13 13 - 13 13 11,5-11,5-11,5-11,5 13 - 13 13 11,5 13 - 13 13 11,5-11,5-11,5 13 – 13 13 – 13 13 11,5-11,5-11,5-11,5 13 – 13 13 - 13 - 13 13. 3,75 3,75 3,75 3,75 3,75 3,75 3,75 3,75 3,75 3,75 3,75 3,75 3,75 3,75 3,75 3,75 3,75 3,75 3,75 3,75 3,75. rn a. zi on al i. Age. In. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21. Sex. te. Patients. dehydratation (Fig. 4). The Snaider membrane decollement is executed starting with the back portion and then front and inferior one with delicate movements to achieve the complete detachment exposing the bone portion of the medial wall of jawbone (Fig. 4). Washing of oral cavity with an antibiotic solution (gentamicina 80 mg).. ©. C. IC. Ed. iz. io. ni. Edge decollement by means of Freeman periosteal elevator (Fig. 2). Exposure of vestibular cortical bone surface of the malar up to the retro molar tuberosity (Fig. 2). Osteotomy of the vestibular wall of the jawbone by means of a vibrating saw (Fig. 3). The detachment of osteotomized wall with the exposure of Snaider membrane. The bone fragment of the hole is placed in a sterile container in which there is physiological solution in order to prevent the. Figure 1 X Ray pre.. Figure 2 Crestal incision.. ORAL & Implantology - Anno II - N. 4/2009. 13.

(4) zi on al i rn a. te. Figure 5 Selection of the donor site.. io. ni. In. original article. Figure 3 Osteotomy of the vestibular bone.. Figure 4 Exposure of Snaider membrane.. Ed. iz. Figure 6 Preparation of bone.. C. IC. It is also prepared the implantologic surgical tooth socket. In order to maintain the new membrane position, a tnt gauze soaked in the same antibiotic solution used for washing, is inserted.. ©. Preparation of donor site. 14. Edge design, primary paramarginal incision following the fore board of the jawbone ramus, starting with the retromolar trigone and ending in the distal zone of 4.6 (Fig. 5). Whole thickness décollement. Preparation of the surgical tooth socket in the same manner we want to place the implant executing all the passages of the cutters to prepare the tooth socket and the edging (as in the fit to fit technique) (Fig. 6). The successive phase provides the use of trephine with a diameter of 8mm. to execute the osteotomy and the removal of the bone to graft (Figs. 7-8). Under physiological solution jet, the implant with graft is proved and it is possible to value the friction level and the adaptation (Fig. 9). Application of implant and graft in the receiving zone (Fig. 10). Spaces filling with self bone or/and filling material (Figs. 11-12). Repositioning of the bone hole (Fig. 13). Suture with separated stitches.. ORAL & Implantology - Anno II - N. 4/2009.

(5) rn a. zi on al i. original article. Figure 10 Implant with graft inside.. iz. Figure 11 Filling material.. ©. C. IC. Ed. Figure 8 Removing the graft.. io. ni. In. te. Figure 7 Osteotomy with Triphine.. Figure 9 Thread of graft.. Results The test of results, obtained from the follow up enabled to carry out the following evaluations (list.2). The follow up has been executed following the clinician and radiographic dictates (OPT), to prove the osteointegration and stability as well as the empiric test of percussion and, also, the control torque of 30 newton one. After three months among 37 implants, at the first clinical and radiographic control, in the grafted implants and surrounding tissues and clinical and radiographic modification was noticed. Six months later, with the beginning of the implan-. ORAL & Implantology - Anno II - N. 4/2009. 15.

(6) zi on al i rn a. te. Figure 14 Ray inspection.. io. ni. In. original article. Figure 12 Application.. Figure 15 Aplication of abutment after 6 months.. iz. Figure 13 Repositioning of the bone window.. Ed. Table 2 - Follow-up.. Patients 3 Months. ©. C. IC. 1 2 3 4 5 6 9 10 11 12 13 14 15 16 17 18 20 21. 16. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0. 6 Months. 1 Year. 2 Years. 3 Years. 5 Years. 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0. Total of lost implants. ORAL & Implantology - Anno II - N. 4/2009. 1. 1.

(7) Figure 17 Definitive prosthesis.. the need of the onlay graft.. The benefits are. In. tological function, 2 implants (5.5%) were lost, one because the patient has continued to wear a mobile prosthesis, the other because the implant has not been osteointegrated, while the remaining 35 patients (94.5%), had a good stability. After the final rehabilitation of the 35 implants, in controlling them after 1-2-3-5 years, there were no radiologic changes but only the classical ones as those from function ( marginal crestal reabsorption) and clinical with a negative perimplant probing.. te. Figure 16 X Ray after 5 years.. rn a. zi on al i. original article. io. ni. 1) Functional and anatomical recovery of the jawbone cavity. 2) Immediate application of implants having a remaining bone thickness inferior to 4 mm. 3) Reduction of surgical times. 4) Reduced patient morbidity. 5) Local anesthesia. This method is surely a therapeutical alternative, appointed the clinical results comparable to other techniques described in medical literature, but it needs a histomorphometric study and a larger specimen.. Ed. iz. Discussion and conclusions. IC. The self bone intraoral graft, for the reconstruction of the jawbone and the simultaneous implants application, allows the reduction of surgical times in order to have a primary stability necessary for the osteointegration, and so for the prosthesis rehabilitation implant supported.. ©. C. The disvantages 1) The impossibility to use implants with a diameter superior to 3.75 mm; so because the use of superior diameters would involve a fracture of the graft during the screwing phase. 2) The bone graft can not be superior to 8mm. of diameter for the anatomical structure of oral cavity. 3) Impossibility to use this technique when there is. Clinical case A53 years old patient, with the need of a prosthesis rehabilitation in the left superior sector, zone 2.6, with a bone surface in height inferior to 4 mm.. References 1. Aparicio C, Ouazzani W, Garcia R, Arevalo X, Muela R, Fortes V. A prospective clinical study on titanium implants. ORAL & Implantology - Anno II - N. 4/2009. 17.

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Extraction site bone grafting in general dentistry. Review of applications and principles. Dent Today. 2004 May;23(5):108-13. 25. Wallace SS. Maxillary sinus augmentation: evidencebased decision making with a biological surgical approach. Compend Contin Educ Dent. 2006 Dec;27(12):6628; quiz 669, 680.. ©. C. IC. Ed. iz. io. ni. In. original article. in the zygomatic arch for prosthetic rehabilitation of the atrophic edentulous maxilla with a follow-up of 6 months to 5 years. Clin Implant Dent Relat Res. 2006;8(3):114-22. 2. Busenlechner D, Huber CD, Vasak C, Dobsak A, Gruber R, Watzek G. Sinus augmentation analysis revised: the gradient of graft consolidation. Clin Oral Implants Res. 2009 Jun 10. 3. Chiapasco M, Zaniboni M, Rimondini L. Dental implants placed in grafted maxillary sinuses: a retrospective analysis of clinical outcome according to the initial clinical situation and a proposal of defect classification..Clin Oral Implants Res. 2008 Apr;19(4):416-28. Epub 2008 Feb 11. 4. 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Handschel J, Simonowska M, Naujoks C, Depprich RA, Ommerborn MA, Meyer U, Kübler NR. A histomorphometric meta-analysis of sinus elevation with various grafting materials. Head Face Med. 2009 Jun 11;5:12. 9. Kahnberg KE, Henry PJ, Hirsch JM, Ohrnell LO, Andreasson L, Brånemark PI, Chiapasco M, Gynther G, Finne K, Higuchi KW, Isaksson S, Malevez C, Neukam FW, Sevetz E Jr, Urgell JP, Widmark G, Bolind P. Clinical evaluation of the zygoma implant: 3-year follow-up at 16 clinics. J Oral Maxillofac Surg. 2007 Oct;65(10):2033-8. 10. Kamal D, Abida S, Jammet P, Goudot P, Yachouh J. Outcome of oral implants after autogenous bone reconstruction.Rev Stomatol Chir Maxillofac. 2009 Apr;110(2):868. Epub 2009 Mar 26. French 11. Kübler NR, Will C, Depprich R, Betz T, Reinhart E, Bill JS, Reuther JF.Comparative studies of sinus floor elevation with autologous or allogeneic bone tissue. Mund Kiefer Gesichtschir. 1999 May;3 Suppl 1:S53-60. German. 12. Misch CE. Implants and the general practitioner. Dent Today. 2007 Aug;26(8):48, 50, 52 13. Misch C. The use of ramus grafts for ridge augmentation. Dent Implantol Update. 1998 Jun;9(6):41-4. 14. Pjetursson BE, Tan WC, Zwahlen M, Lang NP. A systematic review of the success of sinus floor elevation and. 18. Correspondence to: Dott. Giovanni Falisi Via del Vivaio 19 - 00172 Roma Tel.: 062304775 E-mail:[email protected]. ORAL & Implantology - Anno II - N. 4/2009.

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