TECHNICAL STRATEGY
Simultaneous Le Fort I Osteotomy and Zygomatic Implants Placement With Delayed Prosthetic Rehabilitation Pier Francesco Nocini, MD, DDS,* Antonio D’Agostino, MD,* Luigi Chiarini, MD, DDS,† Lorenzo Trevisiol, MD,* and Pasquale Procacci, MD* Abstract: Patients affected by severe maxillary atrophy and skeletal malocclusion have been widely treated by simultaneous orthognathic surgical procedures, interpositional bone insertion and immediate or delayed implant placement. Although several authors have described that the “quad” technique using 4 zygomatic fixtures as an effective way to fully rehabilitate the severe atrophic maxilla, there are still no experiences relative to the use of zygomatic fixtures associated to maxillary osteotomies in case of large skeletal discrepancy. The aim of this study is to report a 1-step surgical rehabilitation of severe atrophic maxilla by means of Le Fort I osteotomy for maxillary forward repositioning and simultaneous insertion of 4 zygomatic implants with immediate prosthetic loading. Key Words: Jaw atrophy, osteotomy, zygomatic implant, prosthesis (J Craniofac Surg 2014;25: 1021–1024)
S
evere atrophic maxilla determines a tridimensional limit to implant insertion, especially if associated with sagittal and vertical bone defects due to the 3-dimensional resorption pattern of longstanding maxillary edentulism.1 Le Fort I osteotomy with downward and forward repositioning of the maxilla in association with interpositional grafting is a reliable procedure to obtain adequate bone volume restoration for implant placement and also a correct anatomical intermaxillary relationship.2–8 The surgical protocols described by Keller and Sailer provided a 2- or 3-step surgical procedures followed by the prosthetical restoration. The full rehabilitation has a medium duration of 18 months. Although the protocol showed satisfactory results in terms of implant survival rate,17 in the last decade several authors described different surgical protocols thought to minimize the morbidity and the duration of the whole treatment.9–11
From the *Department of Surgery, Section of Oral and Maxillo-Facial Surgery, University of Verona, Verona; and †Department of Neuroscience, Section of Dentistry and Oral and Maxillofacial Surgery, University Hospital of Modena and Reggio Emilia, Modena, Italy. Received June 24, 2013. Accepted for publication January 7, 2014. Address correspondence and reprint requests to Pasquale Procacci, MD, Department Surgery, Section of Oral and Maxillofacial Surgery, University of Verona, Policlinico “Giovanni Battista Rossi”, Piazzale Ludovico Antonio Scuro, 10, 37134 Verona, Italy; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000742
FIGURE 1. Intraoperative view of the incision. Note the 2 release incisions.
The use of computer-guided implant surgery added a new opportunity for the oral function rehabilitation in the edentulous patient. In fact, most of the surgical software today available allow the surgeon to obtain a precise planning of the implant insertion, even in those case where usually maxillary inlay or onlay bone grafts should be mandatory.12 Benech et al in 2011 described a case of simultaneous Le Fort I and computer-guided implant placement without any bone grafts. This study underlined that bone grafting could be avoided even in case of skeletal malocclusion.13 In case of severe maxillary atrophy associated to a skeletal intermaxillary discrepancy, the use of computer-guided implant surgery could allow the surgeon to avoid any bone graft procedure but cannot obtain functional correction of the skeletal discrepancies and safe stabilization of the osteotomized maxillary bone segments. The present clinical report describes the possibility to perform a simultaneous Le Fort I osteotomy and zygomatic fixtures placement without any bone grafts in selected patients affected by severe maxillary atrophy and skeletal class III malocclusion.
MATERIALS AND METHODS The surgical protocol was thought and realized at the Section of Oral and Maxillofacial Surgery, University of Verona, Italy. The
FIGURE 2. Once the Le Fort I osteotomy has been performed, the maxillary bone could be forward repositioned as well demonstrated in this intraoperative frontal view.
The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1021
Nocini et al
The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
FIGURE 3. The intraoperative use of surgical splint allows the surgeon to obtain an optimal repositioning of the maxilla with a satisfactory correction of the intermaxillary basal skeletal discrepancy.
FIGURE 5. The second zygomatic implant is positioned extrasinusally.
study was conducted over a period of 20 months (2011–2013) at the Section of Oral and Maxillofacial Surgery, University of Verona, Italy. Four patients with a mean age of 52 years were enrolled in the study. Healthy patients with severe edentulous maxillary atrophy (class V/VI Cawood and Howell 1988 classification)1 due to longtime dressing of removable denture, unphysiologic mucoperiosteal loading, sagittal maxillary deficiency, wide interarch distance, negative overjet, and an unfavorable facial appearance (aging face) were enrolled in the study. The exclusion criteria were smoking, major systemic disease, and previous sinus pathologies or surgeries. In all cases treated, the facial analysis showed that there was a wide sagittal skeletal discrepancy that could not be corrected by means of conventional implant-supported prosthetic rehabilitation. The clinical examination consisted of periodontal status evaluation of the residual mandibular dentition together with cephalometric evaluation of the intermaxillary relation and facial aesthetics. Radiographic examination was carried out by means of cone bean CT scans of the maxillofacial complex. Each patient underwent a radiological examination before surgery and 6 months after surgery. Photographic documentation consisted of 5 intraoral views which are a frontal view, 2 lateral views and occlusal views of the 2 arches, and 6 facial views which are a frontal view, 2 profile and frontal views at angles of 45 degrees to the sagittal plane. Impressions for study casts and a wax-up setup were performed. The preoperative analysis based on the diagnostic wax-up provided a Le Fort I osteotomy immediately followed by the positioning of 4 zygomatic implants. The surgical interventions were performed under general anesthesia. Our surgical treatment started with an incision extended from the palatal aspect of the second molar to the crestal aspect of the central-lateral incisor bilaterally, with 2 posterior release incisions (Fig. 1). A full-thickness flap was then elevated, and the anterolateral wall of the maxilla and the inferior part of the piriform aperture were exposed. A conventional Le Fort I osteotomy was performed with an oscillating saw; then the maxilla was mobilized and moved forward
as necessary. The maxilla was then repositioned approximately 5 to 7 mm anteriorly (Fig. 2). Once the maxillary segment has been mobilized, the surgical custom-made guides were positioned on both the alveolar arches. The surgical splints were stabilized by means of self-retaining screws. Using the surgical splints, the surgeon was able to identify the most suitable position for the correction of the intermaxillary sagittal bone discrepancy. The maxillary bone segment was then fixed with 2 titanium miniplates and screws (Osteomed, Addison, TX), one on each side of the piriform aperture and one on each side of the maxillary buttress (Fig. 3). An oval-shaped window was first drawn and was then opened through the upper aspect of the maxillary buttress using a large round diamond bur. These windows are used to check the right direction of the zygomatic fixtures during their insertion through the zygomatic bone. Once the maxillary buttress has been prepared bilaterally, the zygomatic implant insertion could start. The preoperative planning provided the insertion of 4 zygomatic fixtures (Branemark System Zygoma, Zygoma TiUnite Implant; Nobel Biocare, Goteborg, Sweden), one through the first molar area and one through the lateral incisor/canine area on both sides. First, the surgeon prepared the implant site with a medium round rotating bur through the alveolar ridge. In this phase, it is mandatory to use the bur with the right inclination to avoid wrong insetting of the fixtures head through the zygomatic bone. After the first bur, the surgeon goes deeper by means of the second and the third bur that are used to prepare the implant site inside the zygomatic bone (Figs. 4 and 5). The parallelism between the 2 heads of zygomatic implants were checked on both sides and then closure screws have been positioned on each implant (Figs. 6 and 7). Sixteen implants were positioned (Table 1) The reflected mucoperiosteal flap was then sutured with resorbable suture (Polysorb 4.0; Covidien, Mansfield, MA). Cortical steroids were administered for the first 2 postoperative days. A postoperative 10-day cycle of antibiotic therapy (amoxicillin 1000 mg tid) was administered. Analgesics were administered as required. Sutures were removed 15 days after surgery. A soft diet was recommended for the first 2 weeks, and the temporary denture was not allowed to be worn for 4 weeks postoperatively.
FIGURE 4. Once the implant site has been created, the implant was manually positioned.
FIGURE 6. Once the second implant has been positioned extrasinusally, the parallelism between the 2 implants’ heads is checked by means of 2 screw drivers.
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© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
FIGURE 7. Palatal intraoperative view of the final result.
Three months afterwards, abutments were connected (Fig. 8). The prosthetic loading started 1 month after abutments connection (Figs. 9 and 10).
RESULTS The average hospitalization time was 2 days. The postoperative recovery was uneventful in all cases. Besides normal swelling, subpalpebral and malar ecchimosis, and epistaxis, no serious complications occurred during the surgeries or the follow-up period. No wound dehiscence or implant failure occurred. Postoperative recovery after implant placement was uneventful in all patients. The prosthetic loading started at 5 months after implant placement. At the present time, no implant failure occurred. The radiological examination at 6 months did not register any sinus pathology in all cases.
DISCUSSION Skeletal malocclusion associated with severe atrophy of the upper maxilla still represents a challenging clinical situation for the maxillofacial surgeon. Nowadays, the use of Le Fort I osteotomy associated with interpositional bone grafting and implant positioning is the most common procedure to simultaneously correct atrophy and malocclusion. Although Le Fort I osteotomy in association with interpositional iliac bone grafts is a reliable surgical method to reposition a severe atrophic edentulous maxillae and to create adequate bone volume for a secondary implant placement stage and an implantsupported prosthetic restoration,2–8 it presents a high biological and economical cost due to the 3 surgical steps (Le Fort I and inlay grafts, implant surgery, and mucogingival surgery), hospitalization, and high morbidity of the donor site harvesting.14
A Novel Surgical Technique
Nowadays, patients frequently request a functional and aesthetic oral rehabilitation with the less possible morbidity and the shortest possible duration of the treatment. As a direct consequence of this request, many authors described some new implantsupported prosthetic rehabilitation clinical protocols to treat jaw atrophy. The common aim of these protocols is the reduction of the treatment duration and morbidity, avoiding bone graft harvesting or immediate loading of implants placed in a maxilla previously reconstructed by means of Le Fort I osteotomy and inlay bone grafts.9 While Sailer in 1989 described the possibility to insert implants simultaneously to the Le Fort I osteotomy and inlay autologous bone grafts,3 various authors have shown the opportunity to minimize both morbidity and treatment duration using fresh-frozen bone grafts associated with the insertion of dental implants with an immediate or delayed prosthetic loading.10,11 Although the whole morbidity of the treatment could be reduced by means of bone substitutes, maxilla forward repositioning could not be avoided in any case of prognathism or severe pseudoprognathism. In fact, a transversal skeletal discrepancy can be compensated with a well-designed prosthesis, but a sagittal discrepancy represents an unsolvable problem. Actually, a prosthesis can balance a sagittal bone discrepancy of 4/5 mm without any loading problems in terms of cantilever. In case of larger sagittal intermaxillary gaps, a unique prosthetical compensation could lead to implant failure, static and dynamic occlusal distortions, and, finally, temporomandibular joint affections. Computer-assisted preoperative planning and computerassisted 3-dimensional transfer represent an effective and useful support for the surgeon. The use of this new technology allows a flapless implant surgery in case of mid-low jaw atrophy. Moreover, it has been demonstrated to be effective even associated with a Le Fort I osteotomy in case of severe skeletal discrepancy.13 The use of conventional dental implants associated to Le Fort I osteotomy could not be always effective because, in some cases, the conventional implant length is not enough to obtain a firm fixation bicortically through the basal bone and the repositioned maxilla. Actually, the shape and location of the zygomatic fixtures allow a bi-tricortical implant bone osteointegration through the alveolar process and both the zygomatic bone cortical surfaces. Moreover, it has been also shown that 4 zygomatic implants can afford a satisfactory implant support to a prosthetic rehabilitation.15–17 Considering all the aforementioned characteristics, the association of osteotomy of the maxilla and the positioning of 4 zygomatic fixtures could be considered indicated in all those patients affected by a severe
TABLE 1. Implants Data Patient Date of Le Fort I osteotomy and simultaneous implant placement No. implants Implant site Implant length (mm)/13 Implant length (mm)/15 Implant length (mm)/23 Implant length (mm)/25 Implants diameter (mm) Abutment connection Removed implants Prosthetic loading (mo)
#1
#2
#3
#4
February 2011 4 13.15 23.25 35 42.5 35 42.5 RP July 2011 0 21
June 2011 4 13.15 23.25 30 40 30 40 RP November 2011 0 17
October 2011 4 13.15 23.25 35 42.5 35 42.5 RP April 2012 0 13
February 2012 4 13.15 23.25 35 40 35 40 RP August 2012 0 9
The table collects all implants features patient by patient. It is interesting to observe that zygomatic implant length is different considering anterior and posterior implant sites, while it is equal considering the corresponding site on both sides.
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1023
The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
Nocini et al
Le Fort I osteotomy can be an excellent new surgical option for the following advantages in selected cases: avoiding of 1 or 2 surgical steps as bone graft harvesting and mucogingival surgery, lower patient morbidity, decrease of the overall surgical time, and a shorter recovery time. The results of the present study indicate that the insertion of 4 zygomatic implants simultaneously to a Le Fort I osteotomy provides an excellent 1-step surgical oral rehabilitation in terms of maxillary bone repositioning, implant-supported prosthetic functional rehabilitation, and aesthetics. FIGURE 8. Intraoperative view of the second-stage surgery and abutments positioning.
FIGURE 9. Preoperative and postoperative lateral view of a patient.
maxillary atrophy associated to a third-class malocclusion or a severe pseudoprogenism. In our experience, the surgical procedure presented has ensured excellent functional and technical results regarding both maxillary functional and technical results regarding both maxillary bone repositioning and implant survival rate. The low incidence of complications is referable to the absence of a donor site and the design of the zygomatic fixtures that enable a satisfactory implant osteointegration mainly based on the bicortical zygomatic positioning. The surgical technique here described guarantees a satisfactory aesthetic and functional oral rehabilitation on the condition that a strict respect to the following rules is observed: • Precise assessment of the forward movement of the maxilla by means of CT scans, articulator mounting models, and the preoperative model surgery • Absolute sterility during all surgical steps • Rigid transient fixation of the surgical prosthetical guides • Positioning of the incision from the palatal aspect of the upper second molar to the crestal aspect of the lateral incisor • Strictly observance of the protocol sequence of the drilling burs to position zygomatic fixtures
CONCLUSIONS On the basis of the results we have obtained in our experience, we support the idea that zygomatic implant positioning associated to
FIGURE 10. Preoperative and postoperative CT scans of a patient.
1024
REFERENCES 1. Cawood JI, Howell RA. A classification of the edentulous jaws. Int J Oral Maxillofac Surg 1988;17:232–236 2. Keller EE, Van Rockel NB, Desjardins RP, et al. Prosthetic reconstruction of the severely resorbed maxilla with iliac grafting and tissue integrated prostheses. Int J Oral Maxillofac Implants 1987;2:155–165 3. Sailer HF. A new method of inserting endosseous implants in totally atrophic maxillae. J Craniomaxillofac Surg 1989;17:299–305 4. Cawood JI, Stoelinga PJW, Brouns JJA. Reconstruction of the severely resorbed (class VI) maxilla. A two-step procedure. I J Oral Maxillofac Surg 1994;23:219–225 5. Keller EE, Tolman DE, Eckert SE. Maxillary antral-nasal inlay autogenous bone graft reconstruction of compromised maxilla: a 12-year retrospective study. Int J Oral Maxillofac Implants 1999;14:707–721 6. Stoelinga PJW, Slagter AP, Brouns JJA. Rehabilitation of patients with severe (class VI) maxillary resorption using Le Fort I osteotomy, interposed bone grafts and endosteal implants: 1–8 years follow-up on a two-stage procedure. Int J Oral Maxillofac Surg 2000;29:188–193 7. Chiapasco M, Brusati R, Ronchi P. Le Fort I osteotomy with interpositional bone grafts and delayed oral implants for the rehabilitation of extremely atrophied maxillae: a 1–9-year clinical follow-up study on humans. Clin Oral Implants Res 2007;18:74–85 8. De Santis D, Trevisiol L, D’Agostino A, et al. Guided bone regeneration with autogenous block grafts applied to Le Fort I osteotomy for treatment of severely resorbed maxillae: a 4- to 6-year prospective study. Clin Oral Implants Res 2012;23:60–69 9. Pieri F, Lizio G, Bianchi A, Corinaldesi G, et al. Immediate loading of dental implants placed in severely resorbed edentulous maxillae reconstructed with Le Fort I osteotomy and interpositional bone grafting. J Periodontol 2012;83:963–972 10. Grecchi F, Zollino I, Parafioriti A, et al. One-step oral rehabilitation by means of implants’ insertion, Le Fort I, grafts, and immediate loading. J Craniofac Surg 2009;20:2205–2210 11. Nocini PF, Bertossi D, Albanese M, et al. Severe maxillary atrophy treatment with Le Fort I, allografts, and implant-supported prosthetic rehabilitation. J Craniofac Surg 2011;22:2247–2254 12. De Santis D, Trevisiol L, Cucchi A, et al. Zygomatic and maxillary implants inserted by means of computer-assisted surgery in a patient with a cleft palate. J Craniofac Surg 2010;21:858–862 13. Benech A, Mazzanti C, Arcuri F, et al. Simultaneous Le Fort I osteotomy and computer-guided implant placement. J Craniofac Surg 2011;22:1042–1046 14. Albert A, Leemrijse T, Druez V, et al. Are bone autografts still necessary in 2006? A three-year retrospective study of bone grafting. Acta Orthop Belg 2006;72:734–740 15. Stiévenart M, Malevez C. Rehabilitation of totally atrophied maxilla by means of four zygomatic implants and fixed prosthesis: a 6–40-month follow-up. Int J Oral Maxillofac Surg 2010;39:358–363 16. Kuabara MR, Ferreira EJ, Gulinelli JL, et al. Use of 4 immediately loaded zygomatic fixtures for retreatment of atrophic edentulous maxilla after complications of maxillary reconstruction. J Craniofac Surg 2010;21:803–805 17. Bedrossian E. Rehabilitation of the edentulous maxilla with the zygoma concept: a 7-year prospective study. Int J Oral Maxillofac Implants 2010;25:1213–1221
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Simultaneous Le Fort I Osteotomy and Zygomatic Implants Placement With Delayed Prosthetic Rehabilitation Pier Francesco Nocini, MD, DDS,* Antonio D’Agostino, MD,* Luigi Chiarini, MD, DDS,† Lorenzo Trevisiol, MD,* and Pasquale Procacci, MD* Abstract: Patients affected by severe maxillary atrophy and skeletal malocclusion have been widely treated by simultaneous orthognathic surgical procedures, interpositional bone insertion and immediate or delayed implant placement. Although several authors have described that the “quad” technique using 4 zygomatic fixtures as an effective way to fully rehabilitate the severe atrophic maxilla, there are still no experiences relative to the use of zygomatic fixtures associated to maxillary osteotomies in case of large skeletal discrepancy. The aim of this study is to report a 1-step surgical rehabilitation of severe atrophic maxilla by means of Le Fort I osteotomy for maxillary forward repositioning and simultaneous insertion of 4 zygomatic implants with immediate prosthetic loading. Key Words: Jaw atrophy, osteotomy, zygomatic implant, prosthesis (J Craniofac Surg 2014;25: 1021–1024)
S
evere atrophic maxilla determines a tridimensional limit to implant insertion, especially if associated with sagittal and vertical bone defects due to the 3-dimensional resorption pattern of longstanding maxillary edentulism.1 Le Fort I osteotomy with downward and forward repositioning of the maxilla in association with interpositional grafting is a reliable procedure to obtain adequate bone volume restoration for implant placement and also a correct anatomical intermaxillary relationship.2–8 The surgical protocols described by Keller and Sailer provided a 2- or 3-step surgical procedures followed by the prosthetical restoration. The full rehabilitation has a medium duration of 18 months. Although the protocol showed satisfactory results in terms of implant survival rate,17 in the last decade several authors described different surgical protocols thought to minimize the morbidity and the duration of the whole treatment.9–11
From the *Department of Surgery, Section of Oral and Maxillo-Facial Surgery, University of Verona, Verona; and †Department of Neuroscience, Section of Dentistry and Oral and Maxillofacial Surgery, University Hospital of Modena and Reggio Emilia, Modena, Italy. Received June 24, 2013. Accepted for publication January 7, 2014. Address correspondence and reprint requests to Pasquale Procacci, MD, Department Surgery, Section of Oral and Maxillofacial Surgery, University of Verona, Policlinico “Giovanni Battista Rossi”, Piazzale Ludovico Antonio Scuro, 10, 37134 Verona, Italy; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000742
FIGURE 1. Intraoperative view of the incision. Note the 2 release incisions.
The use of computer-guided implant surgery added a new opportunity for the oral function rehabilitation in the edentulous patient. In fact, most of the surgical software today available allow the surgeon to obtain a precise planning of the implant insertion, even in those case where usually maxillary inlay or onlay bone grafts should be mandatory.12 Benech et al in 2011 described a case of simultaneous Le Fort I and computer-guided implant placement without any bone grafts. This study underlined that bone grafting could be avoided even in case of skeletal malocclusion.13 In case of severe maxillary atrophy associated to a skeletal intermaxillary discrepancy, the use of computer-guided implant surgery could allow the surgeon to avoid any bone graft procedure but cannot obtain functional correction of the skeletal discrepancies and safe stabilization of the osteotomized maxillary bone segments. The present clinical report describes the possibility to perform a simultaneous Le Fort I osteotomy and zygomatic fixtures placement without any bone grafts in selected patients affected by severe maxillary atrophy and skeletal class III malocclusion.
MATERIALS AND METHODS The surgical protocol was thought and realized at the Section of Oral and Maxillofacial Surgery, University of Verona, Italy. The
FIGURE 2. Once the Le Fort I osteotomy has been performed, the maxillary bone could be forward repositioned as well demonstrated in this intraoperative frontal view.
The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1021
Nocini et al
The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
FIGURE 3. The intraoperative use of surgical splint allows the surgeon to obtain an optimal repositioning of the maxilla with a satisfactory correction of the intermaxillary basal skeletal discrepancy.
FIGURE 5. The second zygomatic implant is positioned extrasinusally.
study was conducted over a period of 20 months (2011–2013) at the Section of Oral and Maxillofacial Surgery, University of Verona, Italy. Four patients with a mean age of 52 years were enrolled in the study. Healthy patients with severe edentulous maxillary atrophy (class V/VI Cawood and Howell 1988 classification)1 due to longtime dressing of removable denture, unphysiologic mucoperiosteal loading, sagittal maxillary deficiency, wide interarch distance, negative overjet, and an unfavorable facial appearance (aging face) were enrolled in the study. The exclusion criteria were smoking, major systemic disease, and previous sinus pathologies or surgeries. In all cases treated, the facial analysis showed that there was a wide sagittal skeletal discrepancy that could not be corrected by means of conventional implant-supported prosthetic rehabilitation. The clinical examination consisted of periodontal status evaluation of the residual mandibular dentition together with cephalometric evaluation of the intermaxillary relation and facial aesthetics. Radiographic examination was carried out by means of cone bean CT scans of the maxillofacial complex. Each patient underwent a radiological examination before surgery and 6 months after surgery. Photographic documentation consisted of 5 intraoral views which are a frontal view, 2 lateral views and occlusal views of the 2 arches, and 6 facial views which are a frontal view, 2 profile and frontal views at angles of 45 degrees to the sagittal plane. Impressions for study casts and a wax-up setup were performed. The preoperative analysis based on the diagnostic wax-up provided a Le Fort I osteotomy immediately followed by the positioning of 4 zygomatic implants. The surgical interventions were performed under general anesthesia. Our surgical treatment started with an incision extended from the palatal aspect of the second molar to the crestal aspect of the central-lateral incisor bilaterally, with 2 posterior release incisions (Fig. 1). A full-thickness flap was then elevated, and the anterolateral wall of the maxilla and the inferior part of the piriform aperture were exposed. A conventional Le Fort I osteotomy was performed with an oscillating saw; then the maxilla was mobilized and moved forward
as necessary. The maxilla was then repositioned approximately 5 to 7 mm anteriorly (Fig. 2). Once the maxillary segment has been mobilized, the surgical custom-made guides were positioned on both the alveolar arches. The surgical splints were stabilized by means of self-retaining screws. Using the surgical splints, the surgeon was able to identify the most suitable position for the correction of the intermaxillary sagittal bone discrepancy. The maxillary bone segment was then fixed with 2 titanium miniplates and screws (Osteomed, Addison, TX), one on each side of the piriform aperture and one on each side of the maxillary buttress (Fig. 3). An oval-shaped window was first drawn and was then opened through the upper aspect of the maxillary buttress using a large round diamond bur. These windows are used to check the right direction of the zygomatic fixtures during their insertion through the zygomatic bone. Once the maxillary buttress has been prepared bilaterally, the zygomatic implant insertion could start. The preoperative planning provided the insertion of 4 zygomatic fixtures (Branemark System Zygoma, Zygoma TiUnite Implant; Nobel Biocare, Goteborg, Sweden), one through the first molar area and one through the lateral incisor/canine area on both sides. First, the surgeon prepared the implant site with a medium round rotating bur through the alveolar ridge. In this phase, it is mandatory to use the bur with the right inclination to avoid wrong insetting of the fixtures head through the zygomatic bone. After the first bur, the surgeon goes deeper by means of the second and the third bur that are used to prepare the implant site inside the zygomatic bone (Figs. 4 and 5). The parallelism between the 2 heads of zygomatic implants were checked on both sides and then closure screws have been positioned on each implant (Figs. 6 and 7). Sixteen implants were positioned (Table 1) The reflected mucoperiosteal flap was then sutured with resorbable suture (Polysorb 4.0; Covidien, Mansfield, MA). Cortical steroids were administered for the first 2 postoperative days. A postoperative 10-day cycle of antibiotic therapy (amoxicillin 1000 mg tid) was administered. Analgesics were administered as required. Sutures were removed 15 days after surgery. A soft diet was recommended for the first 2 weeks, and the temporary denture was not allowed to be worn for 4 weeks postoperatively.
FIGURE 4. Once the implant site has been created, the implant was manually positioned.
FIGURE 6. Once the second implant has been positioned extrasinusally, the parallelism between the 2 implants’ heads is checked by means of 2 screw drivers.
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© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
FIGURE 7. Palatal intraoperative view of the final result.
Three months afterwards, abutments were connected (Fig. 8). The prosthetic loading started 1 month after abutments connection (Figs. 9 and 10).
RESULTS The average hospitalization time was 2 days. The postoperative recovery was uneventful in all cases. Besides normal swelling, subpalpebral and malar ecchimosis, and epistaxis, no serious complications occurred during the surgeries or the follow-up period. No wound dehiscence or implant failure occurred. Postoperative recovery after implant placement was uneventful in all patients. The prosthetic loading started at 5 months after implant placement. At the present time, no implant failure occurred. The radiological examination at 6 months did not register any sinus pathology in all cases.
DISCUSSION Skeletal malocclusion associated with severe atrophy of the upper maxilla still represents a challenging clinical situation for the maxillofacial surgeon. Nowadays, the use of Le Fort I osteotomy associated with interpositional bone grafting and implant positioning is the most common procedure to simultaneously correct atrophy and malocclusion. Although Le Fort I osteotomy in association with interpositional iliac bone grafts is a reliable surgical method to reposition a severe atrophic edentulous maxillae and to create adequate bone volume for a secondary implant placement stage and an implantsupported prosthetic restoration,2–8 it presents a high biological and economical cost due to the 3 surgical steps (Le Fort I and inlay grafts, implant surgery, and mucogingival surgery), hospitalization, and high morbidity of the donor site harvesting.14
A Novel Surgical Technique
Nowadays, patients frequently request a functional and aesthetic oral rehabilitation with the less possible morbidity and the shortest possible duration of the treatment. As a direct consequence of this request, many authors described some new implantsupported prosthetic rehabilitation clinical protocols to treat jaw atrophy. The common aim of these protocols is the reduction of the treatment duration and morbidity, avoiding bone graft harvesting or immediate loading of implants placed in a maxilla previously reconstructed by means of Le Fort I osteotomy and inlay bone grafts.9 While Sailer in 1989 described the possibility to insert implants simultaneously to the Le Fort I osteotomy and inlay autologous bone grafts,3 various authors have shown the opportunity to minimize both morbidity and treatment duration using fresh-frozen bone grafts associated with the insertion of dental implants with an immediate or delayed prosthetic loading.10,11 Although the whole morbidity of the treatment could be reduced by means of bone substitutes, maxilla forward repositioning could not be avoided in any case of prognathism or severe pseudoprognathism. In fact, a transversal skeletal discrepancy can be compensated with a well-designed prosthesis, but a sagittal discrepancy represents an unsolvable problem. Actually, a prosthesis can balance a sagittal bone discrepancy of 4/5 mm without any loading problems in terms of cantilever. In case of larger sagittal intermaxillary gaps, a unique prosthetical compensation could lead to implant failure, static and dynamic occlusal distortions, and, finally, temporomandibular joint affections. Computer-assisted preoperative planning and computerassisted 3-dimensional transfer represent an effective and useful support for the surgeon. The use of this new technology allows a flapless implant surgery in case of mid-low jaw atrophy. Moreover, it has been demonstrated to be effective even associated with a Le Fort I osteotomy in case of severe skeletal discrepancy.13 The use of conventional dental implants associated to Le Fort I osteotomy could not be always effective because, in some cases, the conventional implant length is not enough to obtain a firm fixation bicortically through the basal bone and the repositioned maxilla. Actually, the shape and location of the zygomatic fixtures allow a bi-tricortical implant bone osteointegration through the alveolar process and both the zygomatic bone cortical surfaces. Moreover, it has been also shown that 4 zygomatic implants can afford a satisfactory implant support to a prosthetic rehabilitation.15–17 Considering all the aforementioned characteristics, the association of osteotomy of the maxilla and the positioning of 4 zygomatic fixtures could be considered indicated in all those patients affected by a severe
TABLE 1. Implants Data Patient Date of Le Fort I osteotomy and simultaneous implant placement No. implants Implant site Implant length (mm)/13 Implant length (mm)/15 Implant length (mm)/23 Implant length (mm)/25 Implants diameter (mm) Abutment connection Removed implants Prosthetic loading (mo)
#1
#2
#3
#4
February 2011 4 13.15 23.25 35 42.5 35 42.5 RP July 2011 0 21
June 2011 4 13.15 23.25 30 40 30 40 RP November 2011 0 17
October 2011 4 13.15 23.25 35 42.5 35 42.5 RP April 2012 0 13
February 2012 4 13.15 23.25 35 40 35 40 RP August 2012 0 9
The table collects all implants features patient by patient. It is interesting to observe that zygomatic implant length is different considering anterior and posterior implant sites, while it is equal considering the corresponding site on both sides.
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1023
The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
Nocini et al
Le Fort I osteotomy can be an excellent new surgical option for the following advantages in selected cases: avoiding of 1 or 2 surgical steps as bone graft harvesting and mucogingival surgery, lower patient morbidity, decrease of the overall surgical time, and a shorter recovery time. The results of the present study indicate that the insertion of 4 zygomatic implants simultaneously to a Le Fort I osteotomy provides an excellent 1-step surgical oral rehabilitation in terms of maxillary bone repositioning, implant-supported prosthetic functional rehabilitation, and aesthetics. FIGURE 8. Intraoperative view of the second-stage surgery and abutments positioning.
FIGURE 9. Preoperative and postoperative lateral view of a patient.
maxillary atrophy associated to a third-class malocclusion or a severe pseudoprogenism. In our experience, the surgical procedure presented has ensured excellent functional and technical results regarding both maxillary functional and technical results regarding both maxillary bone repositioning and implant survival rate. The low incidence of complications is referable to the absence of a donor site and the design of the zygomatic fixtures that enable a satisfactory implant osteointegration mainly based on the bicortical zygomatic positioning. The surgical technique here described guarantees a satisfactory aesthetic and functional oral rehabilitation on the condition that a strict respect to the following rules is observed: • Precise assessment of the forward movement of the maxilla by means of CT scans, articulator mounting models, and the preoperative model surgery • Absolute sterility during all surgical steps • Rigid transient fixation of the surgical prosthetical guides • Positioning of the incision from the palatal aspect of the upper second molar to the crestal aspect of the lateral incisor • Strictly observance of the protocol sequence of the drilling burs to position zygomatic fixtures
CONCLUSIONS On the basis of the results we have obtained in our experience, we support the idea that zygomatic implant positioning associated to
FIGURE 10. Preoperative and postoperative CT scans of a patient.
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© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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