In s o m e e d e n tu lo u s p a tie n ts , th e m a x illa ry rid g e is so re s o rb e d th a t re m a k in g o f d e n tu re s d o e s n o t p ro v id e a d e q u a te re te n tio n . F o r a fe w o f th e s e p a tie n ts , eve n s o ft tis s u e s u rg ic a l p ro c e d u re s s u c h as v e s tib u lo p la s ty d o n o t im p ro v e m a tte rs . In c a re fu lly s e le c te d in d iv id u a ls , re c o n s tru c tio n o f th e m a x illa ry re s id u a l rid g e by a u to g e n o u s rib g ra ftin g g iv e s a s u b s ta n tia l rid g e a n d g re a tly im p ro v e d d e n tu re s ta b ility . T h is p ro c e d u re s h o u ld be c o n s id e re d m o re fr e q u e n tly f o r use in p a tie n ts w ith in a d e q u a te d e n tu re re te n tio n .
Rehabilitation of the atrophic edentulous maxilla by bone grafting
Richard G. Topazian, DD S, A u g u s ta , Ga
Inadequate retention of complete maxillary den tures because of anatomic abnormalities is not common, and usually it is readily corrected by modification of the denture. However, those few patients who have great difficulty retaining the maxillary denture because of the minimal resid ual bony ridge present a serious and significant challenge to the dental profession. Resorption of edentulous jaws progresses throughout life. Although the majority of bone loss occurs in the mandible, the maxilla also is invariably affected, showing a loss, on the aver age, of about a fourth of that of the mandible.1 In some individuals, both jaws resorb at the same rate, whereas in others bone resorbs more rapid ly in the maxilla than in the mandible.2 The rate of resorption in both ridges may be accelerated by various factors including the wearing of a max
illary denture against natural mandibular anter ior teeth with no replacement of missing pos terior teeth. Despite even extensive loss of the maxillary residual ridge, complete dentures function satis factorily in most patients because of the periph eral seal and atmospheric pressure. In a few, however, bone loss is so extensive or muscle at tachments are so close to the crest of the resid ual ridge that dentures cannot be worn, and some type of surgical correction is necessary. Often, one of the sulcus extension procedures such as submucosal or skin graft vestibuloplasty results in adequate denture retention. In other patients, soft tissue corrective procedures are of little help because of severe bone atrophy. The problem of retention of dentures because of lack of bone height has been dealt with suc cessfully in the mandible by ridge augmentation with alloplastic and biologic materials.3,4 Aug mentation of the maxilla has only recently been reported, however.5 Alloplastic materials have great potential for ridge augmentation and their JADA, Vol. 90, March 1975 ■ 625
Fig 2 ■ Final result of bone grafting and skin graft vestibulo plasty (skin graft is represented by heavy oblique stripes). S plit thickness skin graft has been placed on periosteum on lateral aspect of ridge. C onsolidation o f rib, bone chips, and adjacent bone has taken place. A rrow indicates deepened sulcus.
Patient selection Fig 1 ■ Top, cross-section view o f atroph ic m axilla preoperatively shows loss of residual ridge and fla t vault. Bottom , m axil lary residual ridge In cross-section after transoral bone grafting shows rib placed on edge, surrounded by bone graft fragments. V estibule has been nearly obliterated because o f necessary m obilization and repositioning of soft tissue to cover graft.
use for this purpose has been reviewed recent ly.6 Although the need and promise of alloplas tic materials, including ceramics and polymers, is great, these substances cannot, as yet, be judged ready for wide, clinical application even in the mandible. Therefore, despite the disad vantages of hospitalization to obtain and place the graft, high cost, and health requirements, autogenous bone still appears to be the most pre dictably acceptable and useful material available for use today for ridge reconstruction. Maxillary ridge augmentation requires two surgical procedures. In the first, a crestal inci sion is made along the length of the maxillary ridge, and a section of autogenous rib is taken, shaped, and grafted to the maxilla (Fig 1). As the bone graft procedure obliterates whatever little sulcus was originally present, an autogenous split thickness skin graft vestibuloplasty is nec essary as a second procedure (Fig 2). Three to four weeks after vestibuloplasty, the new maxil lary denture is made. This article describes the surgical rehabilita tion of edentulous maxillas and the results from such treatment. This modality is strictly re served for patients who cannot be helped by con ventional prosthetic or by less aggressive surgi cal techniques and deserves wider application than it has received in the past. 626 ■ JADA, Vol. 90, March 1975
Patients are selected for maxillary ridge augmen tation only after certain factors have been care fully evaluated. These are the adequacy of pres ent dentures, the amount of remaining residual ridge, the emotional status of the patient, and the age and health of the patient. —Adequacy of present dentures. The ability to utilize dentures effectively is the sum of sever al factors, one of which is the presence of a resid ual ridge of at least modest dimensions. Many patients with poor retention of dentures have great improvement when dentures are remade with use of established principles of denture con struction. Ridge reconstruction should not be undertaken unless it is clearly established that adequate denture retention cannot be attained by nonsurgical means. —Amount of remaining residual ridge. The adequacy of the residual ridge should be deter mined clinically and radiographically. If a mod erate amount of residual ridge bone remains clin ically and as seen on a panoramic radiograph, soft tissue surgical procedures such as secon dary epithelization, skin or mucosal graft vestib uloplasty, or submucosal vestibuloplasty may be indicated rather than ridge augmentation.7,8 However, if little bone remains between the oral mucosa and the maxillary sinuses or floor of the nose, ridge reconstruction should be seriously contemplated. —Emotional status of the patient. Ridge re construction requires two operations with an interval of six months. An interim denture may be made three weeks after bone grafting, but this may lack good retention. A patient, therefore,
must be psychologically prepared for this period of time and assess realistically its impact on his life-style. Failure to do so will result in patient dissatisfaction. —-Age and health of the patient. Candidates for ridge reconstruction need to be in reason ably good physical health to present a good sur gical and anesthetic risk. For those in good health but with a limited life expectancy, vestibulo plasty without a bone graft may be a preferred compromise even though little bone remains. For the healthy patient with a substantial life ex pectancy, little bony ridge, and an inability to use carefully made dentures, ridge augmentation appears to be an important method to provide satisfactory retention of the maxillary denture.
Fig 3 ■ Autogenous rib adapted to sterile acrylic resin cast at operating table. Scoring of inner cortex perm its rib to readily assume arch form w ithou t fracturing.
T reatment Proper management of the patient before, dur ing, and after surgery requires careful planning. Preoperative, intraoperative, and postoperative management are of equal importance. ■ Preoperative management: In patients sel ected for ridge augmentation, casts and occlusal rims are made, the correct vertical dimension of occlusion and centric relations are determined, and the casts are mounted on the articulator us ing a face-bow transfer. An evaluation of the esthetic and phonetic re quirements of the patient assists in the establish ment of the interridge space required for ar rangement of teeth. Measurements are made from the crest of the maxilla in the midline and tuberosity regions to the mandibular occlusal rim, and 6 mm is subtracted from these measure ments to allow for the denture base and teeth. The figure remaining is the maximum height of bone that should be grafted. Human ribs measure about 12 mm in width and may be reduced to conform to the level of bone required, although the full width is com monly used. Measurements are made on the cast to determine the length of rib necessary for graft ing, and an acrylic resin surgical stent is made and preserved for use during the skin graft pro cedure. Two days before surgery, the patient’s dentures are removed from the mouth to de crease the irritation of the tissues before surgery. ■ Intraoperative management: —Procedure 1, transoral rib graft. The patient
is admitted to the hospital and routine preoper ative study is completed. Procaine penicillin, 1.2 million units intramuscularly, and preoper ative medications are administered about 45 minutes before the patient is taken to the oper ating room. A general anesthetic is administered through a nasoendotracheal tube. The operative sites are prepared and draped, and two 12-cm sections of rib, usually the fifth and seventh ribs on the left side, are removed. The chest incisions are closed and dressings placed. One rib is cut to the exact length of the ridge as determined from the preoperative cast, and a small strip of cortical bone is removed with a knife from the lower margin to expose the me dullary portion. A series of bur cuts, about 1 cm apart, are made in the medial cortex, perpen dicular to the long axis of the rib, until the rib will bend readily to the form of the dental arch (Fig 3). The second rib is cut into small pieces and stored with the other rib. The mucoperiosteum covering the maxillary residual ridge is incised at the junction of the at tached and unattached gingiva on the buccal as pect, and the incision is continued from tuberos ity to tuberosity. In the anterior region, the inci sion is directed out into the labial tissues to en sure adequate palatal coverage of the graft. The mucoperiosteal flap is reflected widely and four 24-gauge stainless steel wires are placed through bur holes made through the residual ridges in the second molar and canine regions bilaterally. The graft is placed on the ridge, wired to place, and pieces of rib are packed around the graft (Fig 4). The mucoperiosteum is closed with a continuous Topazian: REHABILITATION OF ATROPHIC MAXILLA ■ 627
Fig 4 ■ Left, photograph taken during transoral bone grafting procedure shows w ide reflection of mucoperiosteal flap and placem ent of transalveolar wires to be used to m aintain the rib graft in place. Right, rib graft w ired to place. Bone chips from a second section o f rib are placed around vertically positioned graft as wound is being closed from one tuberosity to other (Fig 1, bottom).
Fig 5 ■ Photograph taken during skin graft vestibuloplasty pro cedure. Labial mucosa flap has been dissected free from perios teum and sutured high on m axilla to create vestibule. Impres sion is made of th is newly created residual ridge.
horizontal nonabsorbable suture. The wires are removed five months after placement, with the patient under local anesthesia as an outpatient. —Procedure 2, skin graft vestibuloplasty. Six months after rib grafting, the patient is readmit ted to the hospital. With the patient under gener al anesthesia, the labial tissues are infiltrated with a saline solution containing 1:200,000 epi nephrine, and a crestal incision is made from tu berosity to tuberosity. A supraperiosteal flap is made labially in such a way that little soft tissue is left on the reconstructed ridge and the grafted bone is not exposed. The free margin of the flap is sutured high on the labial aspect of the maxilla (Fig 5). Then, the previously prepared surgical stent is lined with warm modeling compound, and an impression is made of the maxilla. A final 628 ■ JADA, Vol. 90, March 1975
Fig 6 ■ S plint partially covered by split thickness skin graft taken from lateral aspect of buttock ready to be secured in m outh fo r ten days w ith m idpalatal screw.
impression is made with use of a standard tech nique. A split thickness skin graft, measuring about 5x14 cm and 0.018 inch in thickness, is taken from the lateral aspect of the buttock. The graft is placed on the medial aspect of the flange of the stent, carried to the mouth, and secured with a single midpalatal screw (Fig 6). ■ Postoperative management: Recovery after the rib grafting and vestibuloplasty usually is rapid, and the patient can ordinarily be dis charged from the hospital on the third postoper ative day. Ten days after skin grafting, the stent is removed, and impressions are made for the final maxillary denture about three weeks later.
Fig 7 ■ Right, preoperative clinical photograph shows a troph ic maxilla. Retention of maxillary denture was poor despite remaking and relining of several den tures.
Bottom ,
preoperative
panoram ic
radiograph
shows little bone beneath sinuses (arrows) and floo r o f nose.
Report of treatm ent of a patient A 52-year-old woman was referred to the depart ment of oral surgery for surgical treatment of an atrophic maxillary ridge. She had been complete ly edentulous in the maxilla for 12 years, but re tained the mandibular first premolars and six an terior teeth. She had a complete maxillary and mandibular removable partial denture, but said that she had never been able to wear the mandib ular prosthesis. The maxillary anterior tissues had been inflamed and flabby and had been ex cised several years earlier. She had had a num ber of maxillary dentures but could not success fully retain any of them. H er maxillary denture had been reconstructed recently without im proved retention. H er present denture had little flange. Clinical and radiographic examination showed a greatly reduced residual ridge except in the tu berosity regions (Fig 7). The patient was highly motivated to accept surgical treatment, was in
good health, and understood that she might not be able to use even interim dentures for six months if surgery was performed. Because the mandibular anterior teeth were periodontally in volved, they were extracted. The first premo lars were treated endodontically and reduced to the level of the residual ridge in preparation for construction of an overlay denture. Transoral rib grafting was performed and was followed six months later by a skin graft vestibu loplasty. Three weeks later, new dentures were made. Excellent retention was reported by the patient who was enthusiastic with the result of treatment. No loss of bone or decrease in ves tibular depth measured clinically and radiographically has occurred one year after surgery (Fig 8,9).
Discussion Autogenous bone grafts have been used for treat ment of atrophy of the mandible for several Topazian: REHABILITATION OF ATROPHIC MAXILLA ■ 629
Fig 8 ■ Right, appearance of mouth tw o m onths after vestibuloplasty. Residual ridge is broad and high, and graft is firm ly fixed to underlying bone. Compare w ith Figure 7, right. Bottom , postoperative panoramic radiograph shows increase in ridge height and ves tib u la r depth. Note level of grafted bone beneath si nuses. Compare with Figure 7, bottom .
Fig 9 ■ New maxillary denture on left and old maxillary denture on right. Increase in flange height reflects increased height of reconstructed ridge. Patient reports good retention and is pleased w ith result.
years. Postoperatively, resorption of the graft occurs, primarily during the first year. Despite resorption, a resultant 50% overall increase in height, compared with that present preoperatively, has been observed for periods up to three years. The bone that remains appears on radio graphs to be dense and cortical in nature.3 No reports of long-term follow-up of maxil lary bone grafts have been published, but it is likely that resorption will occur over a period of time. Although bone from the ilium as well as the ribs has been used for mandibular ridge recon struction with good success, rib seems easier to 630 ■ JADA, Vol. 90, March 1975
shape and adapt to the ridge and patients have less postoperative discomfort when the chest do nor site is used rather than the hip. Since a bone graft does resorb, it is not the ideal substance for ridge augmentation. Additionally, the need for the patient to be in good health and the expense and discomfort of two hospitalizations and oper ations make this mode of treatment available to only a few of the many patients who potentially can benefit by ridge augmentation. If this service is to be widely available for many patients, investigation must be encour aged to discover suitable alloplastic or biologic materials and new techniques that will permit ridge augmentation to be performed readily for outpatients. At present, the use of autogenous transoral bone grafting appears to be an impor tant method to aid the patient with poor maxil lary denture retention because of severe atrophy of the residual ridge.
Sum m ary Transoral bone grafting is a useful method for the reconstruction of the atrophic maxillary re sidual ridge in patients who cannot retain com
plete dentures. The indications, criteria for pa tient selection, and the technique used have been presented.
The author thanks Floyd E. Hosmer, a graduate stud ent in the School of M edical Illustrations, Medical College of Georgia, fo r the line draw ings. Dr. Topazian is professor and chairm an of the de partm ent of oral surgery, Medical C ollege o f Georgia School o f Dentistry, Augusta, 30902. 1. Tallgren, A. The c o n tinuing reduction of the residual alveo lar ridges in com plete denture wearers: a m ixed-longitudinal study covering 25 years. J Prosthet Dent 27:120 Feb 1972. 2. A tw ood, D.A., and Coy, W.A. C linical, cephalom etric, and densitom etric study o f reduction of residual ridges. J Prosthet Dent 26:280 Sept 1971.
3. Davis, W.H., and others. Transoral rib grafting fo r m andib ular alveolar atrophy— a progress report. Trans IV C ongress of the International A ssociation o f Oral Surgeons, Amsterdam , May, 1971. Copenhagen, M unksgaard, 1973, p 206. 4. Obwegeser, H., and Steinhäuser, E. R ebuilding the alveo lar ridge w ith bone and cartilage autografts. Trans II Congress of the International A ssociation o f Oral Surgeons. Copenhagen, Munksgaard, 1967, p 203. 5. Terry, B.C.; A lbright, J.E.; and Baker, R.D. A lveolar ridge augm entation in the edentulous m axilla w ith use of autogenous ribs. J Oral Surg 32:429 June 1974. 6. Topazian, R.G., and others. Use o f alloplastics fo r ridge aug mentation. J Oral Surg 29:792 Nov 1971. 7. Guernsery, L.H. P reprosthetic surgery. Dent Clin North Am 15:455 A pril 1971. 8. M acintosh, R.B., and Obwegeser, H.L. P reprosthetic sur gery: a scheme fo r its effective em ploym ent. J Oral Surg 25:397 Sept 1967.
Foley’s Footnotes In the many years o f my reading o f British recollections, I have happily gathered a good flock o f anecdotes about bishops. Fortunately, many o f these have to do with dental observations or experiences. In his Final E dition: Memories o f People an d Places (1940), E. F. Benson, novelist and biog rap her and the son of an A rchbishop of Canterbury, tells a good story about A rchbishop Temple, “ a m onum ent o f the S tone Age,” who, because of the circum stances of m iddle age and rheum atic tw inges, was obliged to seek the advice of his physician. He scorned pain and physical ills as nonsense and rubbish, and was much harder on him self than on others. One day his d o c to r told him that he must have ail his teeth out and o ff he w ent to the dentist, but refused any anaesthetic. A fter a num ber o f d iffic u lt extractions had been made, the dentist said, "I th in k I'd better stop fo r today,” and his patient, bloody but unbowed, replied, “ I th in k you'd better go o n .” Benson also added to my fund of stories about the weird practices o f som e members o f the aristocracy in handling th e ir dentures. One night d inin g at her house (Lady S andhurst, the da ughter of M atthew Arnold), I fou nd myself, after the ladies had left us, sittin g next to a Duke. The w o rk o f mastication being over, he removed his false teeth and put them in his trouser-pocket. G a rd n e r P. H. Foley
Topazian: REHABILITATION OF ATROPHIC MAXILLA ■ 631
Rehabilitation of the atrophic edentulous maxilla by bone grafting
Richard G. Topazian, DD S, A u g u s ta , Ga
Inadequate retention of complete maxillary den tures because of anatomic abnormalities is not common, and usually it is readily corrected by modification of the denture. However, those few patients who have great difficulty retaining the maxillary denture because of the minimal resid ual bony ridge present a serious and significant challenge to the dental profession. Resorption of edentulous jaws progresses throughout life. Although the majority of bone loss occurs in the mandible, the maxilla also is invariably affected, showing a loss, on the aver age, of about a fourth of that of the mandible.1 In some individuals, both jaws resorb at the same rate, whereas in others bone resorbs more rapid ly in the maxilla than in the mandible.2 The rate of resorption in both ridges may be accelerated by various factors including the wearing of a max
illary denture against natural mandibular anter ior teeth with no replacement of missing pos terior teeth. Despite even extensive loss of the maxillary residual ridge, complete dentures function satis factorily in most patients because of the periph eral seal and atmospheric pressure. In a few, however, bone loss is so extensive or muscle at tachments are so close to the crest of the resid ual ridge that dentures cannot be worn, and some type of surgical correction is necessary. Often, one of the sulcus extension procedures such as submucosal or skin graft vestibuloplasty results in adequate denture retention. In other patients, soft tissue corrective procedures are of little help because of severe bone atrophy. The problem of retention of dentures because of lack of bone height has been dealt with suc cessfully in the mandible by ridge augmentation with alloplastic and biologic materials.3,4 Aug mentation of the maxilla has only recently been reported, however.5 Alloplastic materials have great potential for ridge augmentation and their JADA, Vol. 90, March 1975 ■ 625
Fig 2 ■ Final result of bone grafting and skin graft vestibulo plasty (skin graft is represented by heavy oblique stripes). S plit thickness skin graft has been placed on periosteum on lateral aspect of ridge. C onsolidation o f rib, bone chips, and adjacent bone has taken place. A rrow indicates deepened sulcus.
Patient selection Fig 1 ■ Top, cross-section view o f atroph ic m axilla preoperatively shows loss of residual ridge and fla t vault. Bottom , m axil lary residual ridge In cross-section after transoral bone grafting shows rib placed on edge, surrounded by bone graft fragments. V estibule has been nearly obliterated because o f necessary m obilization and repositioning of soft tissue to cover graft.
use for this purpose has been reviewed recent ly.6 Although the need and promise of alloplas tic materials, including ceramics and polymers, is great, these substances cannot, as yet, be judged ready for wide, clinical application even in the mandible. Therefore, despite the disad vantages of hospitalization to obtain and place the graft, high cost, and health requirements, autogenous bone still appears to be the most pre dictably acceptable and useful material available for use today for ridge reconstruction. Maxillary ridge augmentation requires two surgical procedures. In the first, a crestal inci sion is made along the length of the maxillary ridge, and a section of autogenous rib is taken, shaped, and grafted to the maxilla (Fig 1). As the bone graft procedure obliterates whatever little sulcus was originally present, an autogenous split thickness skin graft vestibuloplasty is nec essary as a second procedure (Fig 2). Three to four weeks after vestibuloplasty, the new maxil lary denture is made. This article describes the surgical rehabilita tion of edentulous maxillas and the results from such treatment. This modality is strictly re served for patients who cannot be helped by con ventional prosthetic or by less aggressive surgi cal techniques and deserves wider application than it has received in the past. 626 ■ JADA, Vol. 90, March 1975
Patients are selected for maxillary ridge augmen tation only after certain factors have been care fully evaluated. These are the adequacy of pres ent dentures, the amount of remaining residual ridge, the emotional status of the patient, and the age and health of the patient. —Adequacy of present dentures. The ability to utilize dentures effectively is the sum of sever al factors, one of which is the presence of a resid ual ridge of at least modest dimensions. Many patients with poor retention of dentures have great improvement when dentures are remade with use of established principles of denture con struction. Ridge reconstruction should not be undertaken unless it is clearly established that adequate denture retention cannot be attained by nonsurgical means. —Amount of remaining residual ridge. The adequacy of the residual ridge should be deter mined clinically and radiographically. If a mod erate amount of residual ridge bone remains clin ically and as seen on a panoramic radiograph, soft tissue surgical procedures such as secon dary epithelization, skin or mucosal graft vestib uloplasty, or submucosal vestibuloplasty may be indicated rather than ridge augmentation.7,8 However, if little bone remains between the oral mucosa and the maxillary sinuses or floor of the nose, ridge reconstruction should be seriously contemplated. —Emotional status of the patient. Ridge re construction requires two operations with an interval of six months. An interim denture may be made three weeks after bone grafting, but this may lack good retention. A patient, therefore,
must be psychologically prepared for this period of time and assess realistically its impact on his life-style. Failure to do so will result in patient dissatisfaction. —-Age and health of the patient. Candidates for ridge reconstruction need to be in reason ably good physical health to present a good sur gical and anesthetic risk. For those in good health but with a limited life expectancy, vestibulo plasty without a bone graft may be a preferred compromise even though little bone remains. For the healthy patient with a substantial life ex pectancy, little bony ridge, and an inability to use carefully made dentures, ridge augmentation appears to be an important method to provide satisfactory retention of the maxillary denture.
Fig 3 ■ Autogenous rib adapted to sterile acrylic resin cast at operating table. Scoring of inner cortex perm its rib to readily assume arch form w ithou t fracturing.
T reatment Proper management of the patient before, dur ing, and after surgery requires careful planning. Preoperative, intraoperative, and postoperative management are of equal importance. ■ Preoperative management: In patients sel ected for ridge augmentation, casts and occlusal rims are made, the correct vertical dimension of occlusion and centric relations are determined, and the casts are mounted on the articulator us ing a face-bow transfer. An evaluation of the esthetic and phonetic re quirements of the patient assists in the establish ment of the interridge space required for ar rangement of teeth. Measurements are made from the crest of the maxilla in the midline and tuberosity regions to the mandibular occlusal rim, and 6 mm is subtracted from these measure ments to allow for the denture base and teeth. The figure remaining is the maximum height of bone that should be grafted. Human ribs measure about 12 mm in width and may be reduced to conform to the level of bone required, although the full width is com monly used. Measurements are made on the cast to determine the length of rib necessary for graft ing, and an acrylic resin surgical stent is made and preserved for use during the skin graft pro cedure. Two days before surgery, the patient’s dentures are removed from the mouth to de crease the irritation of the tissues before surgery. ■ Intraoperative management: —Procedure 1, transoral rib graft. The patient
is admitted to the hospital and routine preoper ative study is completed. Procaine penicillin, 1.2 million units intramuscularly, and preoper ative medications are administered about 45 minutes before the patient is taken to the oper ating room. A general anesthetic is administered through a nasoendotracheal tube. The operative sites are prepared and draped, and two 12-cm sections of rib, usually the fifth and seventh ribs on the left side, are removed. The chest incisions are closed and dressings placed. One rib is cut to the exact length of the ridge as determined from the preoperative cast, and a small strip of cortical bone is removed with a knife from the lower margin to expose the me dullary portion. A series of bur cuts, about 1 cm apart, are made in the medial cortex, perpen dicular to the long axis of the rib, until the rib will bend readily to the form of the dental arch (Fig 3). The second rib is cut into small pieces and stored with the other rib. The mucoperiosteum covering the maxillary residual ridge is incised at the junction of the at tached and unattached gingiva on the buccal as pect, and the incision is continued from tuberos ity to tuberosity. In the anterior region, the inci sion is directed out into the labial tissues to en sure adequate palatal coverage of the graft. The mucoperiosteal flap is reflected widely and four 24-gauge stainless steel wires are placed through bur holes made through the residual ridges in the second molar and canine regions bilaterally. The graft is placed on the ridge, wired to place, and pieces of rib are packed around the graft (Fig 4). The mucoperiosteum is closed with a continuous Topazian: REHABILITATION OF ATROPHIC MAXILLA ■ 627
Fig 4 ■ Left, photograph taken during transoral bone grafting procedure shows w ide reflection of mucoperiosteal flap and placem ent of transalveolar wires to be used to m aintain the rib graft in place. Right, rib graft w ired to place. Bone chips from a second section o f rib are placed around vertically positioned graft as wound is being closed from one tuberosity to other (Fig 1, bottom).
Fig 5 ■ Photograph taken during skin graft vestibuloplasty pro cedure. Labial mucosa flap has been dissected free from perios teum and sutured high on m axilla to create vestibule. Impres sion is made of th is newly created residual ridge.
horizontal nonabsorbable suture. The wires are removed five months after placement, with the patient under local anesthesia as an outpatient. —Procedure 2, skin graft vestibuloplasty. Six months after rib grafting, the patient is readmit ted to the hospital. With the patient under gener al anesthesia, the labial tissues are infiltrated with a saline solution containing 1:200,000 epi nephrine, and a crestal incision is made from tu berosity to tuberosity. A supraperiosteal flap is made labially in such a way that little soft tissue is left on the reconstructed ridge and the grafted bone is not exposed. The free margin of the flap is sutured high on the labial aspect of the maxilla (Fig 5). Then, the previously prepared surgical stent is lined with warm modeling compound, and an impression is made of the maxilla. A final 628 ■ JADA, Vol. 90, March 1975
Fig 6 ■ S plint partially covered by split thickness skin graft taken from lateral aspect of buttock ready to be secured in m outh fo r ten days w ith m idpalatal screw.
impression is made with use of a standard tech nique. A split thickness skin graft, measuring about 5x14 cm and 0.018 inch in thickness, is taken from the lateral aspect of the buttock. The graft is placed on the medial aspect of the flange of the stent, carried to the mouth, and secured with a single midpalatal screw (Fig 6). ■ Postoperative management: Recovery after the rib grafting and vestibuloplasty usually is rapid, and the patient can ordinarily be dis charged from the hospital on the third postoper ative day. Ten days after skin grafting, the stent is removed, and impressions are made for the final maxillary denture about three weeks later.
Fig 7 ■ Right, preoperative clinical photograph shows a troph ic maxilla. Retention of maxillary denture was poor despite remaking and relining of several den tures.
Bottom ,
preoperative
panoram ic
radiograph
shows little bone beneath sinuses (arrows) and floo r o f nose.
Report of treatm ent of a patient A 52-year-old woman was referred to the depart ment of oral surgery for surgical treatment of an atrophic maxillary ridge. She had been complete ly edentulous in the maxilla for 12 years, but re tained the mandibular first premolars and six an terior teeth. She had a complete maxillary and mandibular removable partial denture, but said that she had never been able to wear the mandib ular prosthesis. The maxillary anterior tissues had been inflamed and flabby and had been ex cised several years earlier. She had had a num ber of maxillary dentures but could not success fully retain any of them. H er maxillary denture had been reconstructed recently without im proved retention. H er present denture had little flange. Clinical and radiographic examination showed a greatly reduced residual ridge except in the tu berosity regions (Fig 7). The patient was highly motivated to accept surgical treatment, was in
good health, and understood that she might not be able to use even interim dentures for six months if surgery was performed. Because the mandibular anterior teeth were periodontally in volved, they were extracted. The first premo lars were treated endodontically and reduced to the level of the residual ridge in preparation for construction of an overlay denture. Transoral rib grafting was performed and was followed six months later by a skin graft vestibu loplasty. Three weeks later, new dentures were made. Excellent retention was reported by the patient who was enthusiastic with the result of treatment. No loss of bone or decrease in ves tibular depth measured clinically and radiographically has occurred one year after surgery (Fig 8,9).
Discussion Autogenous bone grafts have been used for treat ment of atrophy of the mandible for several Topazian: REHABILITATION OF ATROPHIC MAXILLA ■ 629
Fig 8 ■ Right, appearance of mouth tw o m onths after vestibuloplasty. Residual ridge is broad and high, and graft is firm ly fixed to underlying bone. Compare w ith Figure 7, right. Bottom , postoperative panoramic radiograph shows increase in ridge height and ves tib u la r depth. Note level of grafted bone beneath si nuses. Compare with Figure 7, bottom .
Fig 9 ■ New maxillary denture on left and old maxillary denture on right. Increase in flange height reflects increased height of reconstructed ridge. Patient reports good retention and is pleased w ith result.
years. Postoperatively, resorption of the graft occurs, primarily during the first year. Despite resorption, a resultant 50% overall increase in height, compared with that present preoperatively, has been observed for periods up to three years. The bone that remains appears on radio graphs to be dense and cortical in nature.3 No reports of long-term follow-up of maxil lary bone grafts have been published, but it is likely that resorption will occur over a period of time. Although bone from the ilium as well as the ribs has been used for mandibular ridge recon struction with good success, rib seems easier to 630 ■ JADA, Vol. 90, March 1975
shape and adapt to the ridge and patients have less postoperative discomfort when the chest do nor site is used rather than the hip. Since a bone graft does resorb, it is not the ideal substance for ridge augmentation. Additionally, the need for the patient to be in good health and the expense and discomfort of two hospitalizations and oper ations make this mode of treatment available to only a few of the many patients who potentially can benefit by ridge augmentation. If this service is to be widely available for many patients, investigation must be encour aged to discover suitable alloplastic or biologic materials and new techniques that will permit ridge augmentation to be performed readily for outpatients. At present, the use of autogenous transoral bone grafting appears to be an impor tant method to aid the patient with poor maxil lary denture retention because of severe atrophy of the residual ridge.
Sum m ary Transoral bone grafting is a useful method for the reconstruction of the atrophic maxillary re sidual ridge in patients who cannot retain com
plete dentures. The indications, criteria for pa tient selection, and the technique used have been presented.
The author thanks Floyd E. Hosmer, a graduate stud ent in the School of M edical Illustrations, Medical College of Georgia, fo r the line draw ings. Dr. Topazian is professor and chairm an of the de partm ent of oral surgery, Medical C ollege o f Georgia School o f Dentistry, Augusta, 30902. 1. Tallgren, A. The c o n tinuing reduction of the residual alveo lar ridges in com plete denture wearers: a m ixed-longitudinal study covering 25 years. J Prosthet Dent 27:120 Feb 1972. 2. A tw ood, D.A., and Coy, W.A. C linical, cephalom etric, and densitom etric study o f reduction of residual ridges. J Prosthet Dent 26:280 Sept 1971.
3. Davis, W.H., and others. Transoral rib grafting fo r m andib ular alveolar atrophy— a progress report. Trans IV C ongress of the International A ssociation o f Oral Surgeons, Amsterdam , May, 1971. Copenhagen, M unksgaard, 1973, p 206. 4. Obwegeser, H., and Steinhäuser, E. R ebuilding the alveo lar ridge w ith bone and cartilage autografts. Trans II Congress of the International A ssociation o f Oral Surgeons. Copenhagen, Munksgaard, 1967, p 203. 5. Terry, B.C.; A lbright, J.E.; and Baker, R.D. A lveolar ridge augm entation in the edentulous m axilla w ith use of autogenous ribs. J Oral Surg 32:429 June 1974. 6. Topazian, R.G., and others. Use o f alloplastics fo r ridge aug mentation. J Oral Surg 29:792 Nov 1971. 7. Guernsery, L.H. P reprosthetic surgery. Dent Clin North Am 15:455 A pril 1971. 8. M acintosh, R.B., and Obwegeser, H.L. P reprosthetic sur gery: a scheme fo r its effective em ploym ent. J Oral Surg 25:397 Sept 1967.
Foley’s Footnotes In the many years o f my reading o f British recollections, I have happily gathered a good flock o f anecdotes about bishops. Fortunately, many o f these have to do with dental observations or experiences. In his Final E dition: Memories o f People an d Places (1940), E. F. Benson, novelist and biog rap her and the son of an A rchbishop of Canterbury, tells a good story about A rchbishop Temple, “ a m onum ent o f the S tone Age,” who, because of the circum stances of m iddle age and rheum atic tw inges, was obliged to seek the advice of his physician. He scorned pain and physical ills as nonsense and rubbish, and was much harder on him self than on others. One day his d o c to r told him that he must have ail his teeth out and o ff he w ent to the dentist, but refused any anaesthetic. A fter a num ber o f d iffic u lt extractions had been made, the dentist said, "I th in k I'd better stop fo r today,” and his patient, bloody but unbowed, replied, “ I th in k you'd better go o n .” Benson also added to my fund of stories about the weird practices o f som e members o f the aristocracy in handling th e ir dentures. One night d inin g at her house (Lady S andhurst, the da ughter of M atthew Arnold), I fou nd myself, after the ladies had left us, sittin g next to a Duke. The w o rk o f mastication being over, he removed his false teeth and put them in his trouser-pocket. G a rd n e r P. H. Foley
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