Particulate Inlay Nasal Graft With Immediate Dental ... · of Craniofacial Anomalies (HRAC/ USP), Bauru, Brazil. His chief com-plaint was the poor esthetics of a par-tial removable

Particulate Inlay Nasal Graft WithImmediate Dental Implant Placement

in a Patient With Repaired Alveolar Cleft:Case Report

Maria Lucia Rubo de Rezende, DDS, PhD,* Luiz Gustavo Nascimento de Melo, DDS, MS,†Marcelo Matida Hamata, DDS, MS,† and Flavio Monteiro-Amado, DDS, MS, PhD‡

The premaxilla represents achallenge for prosthetic reha-bilitation with osseointegrated

implants because when available,bone in this area is usually less densethan mandible bone.1 In addition, thepresence of maxillary sinuses andthe nasal cavity can limit the volumeof surrounding bone.2

Rehabilitation with implant-supported prostheses becomes difficultwhen the dimensions in the anteriormaxillary region are reduced. Alveolarbone loss is, in part, associated withtooth loss by periodontal disease or trau-matism. After single or multiple extrac-tions in the adult individual, the alveolarridge is submitted to an atrophy pro-cess.3–8 In the premaxilla, anterior ridgeloses 25% of the width in the first yearafter tooth loss and 40% to 60% in 3years.7

Other factors may also influencethe dimensions of the alveolar ridge inthe premaxilla, such as resection pro-cedures for treatment of pathologicallesions and the presence of develop-mental defects.9

Cleft lip and palate is a congenitalstructural deficiency caused by the lackof coalescence among developing em-bryonic facial processes.10 Whenever

the anatomical extension of the cleft in-volves the alveolar ridge, significant al-terations in alveolar morphology can beobserved. The edentulous maxilla is of-ten so atrophic that the volume of theremaining alveolar bone is inadequatefor conventional implant surgery.11 Inpatients with bone loss, decreased suc-cess is expected because of such ana-tomical limitation.12

Misch13 recommended that the re-cipient bone bed should be no lessthan 5 mm wide and 10 mm high forthe successful placement of standard-diameter root-form implants. Whenthis situation is not present, ridgeaugmentation with bone graftingshould be considered. More specifi-cally, when the remaining alveolarridge presents adequate horizontaldimensions but not enough height,an onlay bone graft and/or nasalfloor elevation associated with par-ticulate bone graft may be consid-ered to provide adequate height forimplant installation.

Sinus floor elevation and graftingtechniques for prosthetic purposes are

well known.14–20 With the advent ofosseointegration and development ofbone grafting, several practitioners de-veloped different surgical techniquesto allow elevation of the sinus mem-brane and graft placement.9,21,22 Pro-spective studies have demonstratedthat the sinus elevation technique ispredictable, providing a high successrate for implants installed in thisregion.12,13,22–24

In patients with cleft lip and pal-ate, initial bone graft for closure of thecleft does not always provide sufficientbulk or height for ideal placement ofendosseous implants.9 Thus, second-ary procedures are often needed.25 Ourexperience has showed that many pa-tients with clefts need secondary bonegrafts to obtain adequate bone volumeand height in previously grafted areas.

Therefore, the purpose of thisreport is to describe a case of nasalfloor elevation associated with inlaybone graft and immediate implantinstallation in a patient with cleft lipand palate.

*Periodontist and Implantologist, Hospital for Rehabilitation ofCraniofacial Anomalies (HRAC/USP), Bauru, Brazil.†Graduate student in Dental Implantology at the HRAC/USP,Bauru, Brazil.‡Specialist in Dental Implantology by the HRAC/USP, Bauru,Brazil.

ISSN 1056-6163/08/01703-332Implant DentistryVolume 17 • Number 3Copyright © 2008 by Lippincott Williams & Wilkins

DOI: 10.1097/ID.0b013e3181861fee

Primary bone grafts in congen-ital cleft alveolus do not alwaysprovide sufficient bulk or height ofbone for ideal placement of endos-seous implants. Thus, maxillary si-nus or nasal floor elevation andinlay bone grafts in previouslygrafted areas are not exceptions inthe daily routine. This case reportstresses the need of a detailed treat-

ment plan and careful surgicalmanagement of nasal floor eleva-tion with particulate autogenousbone graft to successfully providethe patient with osseointegratedprostheses. (Implant Dent 2008;17:332–338)Key Words: maxillary sinus, den-tal implants, cleft lip and palate

332 PARTICULATE INLAY NASAL GRAFT WITH IMMEDIATE DENTAL IMPLANT PLACEMENT

CASE REPORTS

A 23-year-old man with surgicallyrepaired bilateral cleft lip and palatepresented to the Implantology Depart-ment of the Hospital for Rehabilitationof Craniofacial Anomalies (HRAC/USP), Bauru, Brazil. His chief com-plaint was the poor esthetics of a par-tial removable prosthesis in theanterior region of the maxilla. In-traoral examination revealed ab-sence of all 4 maxillary incisors andan implant-supported prosthesis wasplanned. Radiographs and dental castswere obtained preoperatively. Thepanoramic radiograph revealed insuf-ficient bone height for implant place-ment at the right side as a result of thecongenital cleft (Fig. 1). Thus, nasalfloor elevation combined with thegrafting procedure was planned.

Surgical Procedure

Infraorbital anesthesia (mepiva-caine with adrenaline 1:100,000) wasperformed bilaterally before anestheticinfiltration into the lip mucosa andpalatal region, to provide maximumcomfort to the patient and avoid ex-cessive bleeding during the procedure.

An incision was made on the cen-ter of the alveolar ridge of the anteriormaxilla, involving the canines, andvertical releasing incisions were madeat the distal surfaces of those teeth(Figs. 2A and B). The periosteum wasreflected to expose the piriform rim(Figs. 3A and B), and curettes indi-cated for maxillary sinus elevationwere used to reflect the nasal mucosa.Bleeding could be observed but it waseasily controlled with gauze hemostasisprocedures. Four acid-etched, screw-shaped titanium implants (Titanium Fix,AS Technology, S. J. Campos, Brazil)were placed, 3.75 � 1.5 mm, at the

areas of the maxillary right central andlateral incisors and 3.75 � 0 mm at theareas of the maxillary left central andlateral incisors (Figs. 4A and B).

The remaining bone height wassufficient for stabilization of implants,but some threads were left exposed inthe nasal cavity underneath the mu-cosa. Autogenous bone was harvestedfrom the mandibular ramus, ground ina bone mill, and inserted in the spacebetween implants and nasal mucosa

(Figs. 5A and B). Placement of implantsbefore grafting allows safe entrance tothe nose and space maintenance duringbone graft insertion. Bone graftingwas required only at the right side ofthe nose; at the left side, isolated de-tachment of the mucosa was sufficientfor adequate implant placement. Thewound was closed with a 4.0 silk su-ture. The patient went on a soft,nonchewing diet, and the provisional

Fig. 1. Panoramic radiograph. Absence of all4 maxillary incisors and lack of bone height.

Fig. 2. A and B, Incision made on the alveolarridge of anterior maxilla, involving canines,and vertical releasing incisions were made atthe distal surfaces of those teeth.Fig. 3. A and B, Elevation of nasal mucosa.

Fig. 4. A and B, Implants in place, entering inthe nose.Fig. 5. A and B, Milled bone graft harvestedfrom the mandible filling the space betweenthe nasal mucosa and nasal floor.

IMPLANT DENTISTRY / VOLUME 17, NUMBER 3 2008 333

prosthesis was conditioned with a softliner. Antibiotics (amoxicillin 500 mg)were taken by the patient 1 hour be-fore surgery and maintained for 7 daysthereafter, 3 times daily. Analgesics(paracetamol, 4 times daily for 3 days)and decongestants (oxymetazoline)were also recommended, so ostialdrainage could be improved and symp-tomatic relief obtained. The patient wasinstructed to use a chlorhexidine-digluconate mouth-rinse twice a day,and refrain from blowing the nose orsucking liquids through a straw toavoid negative pressure that coulddamage the nasal mucosa.

Figure 6 shows the radiographicaspect at the moment of placement ofhealing abutments, 12 months aftersurgery. Gingival tissue was condi-tioned by provisional crowns and themetal-ceramic prosthesis has been infunction for 5 years without any unde-sirable signs and symptoms.

DISCUSSION

A major challenge faced by theclinician in restoring the lost dentitionor facial structure is insufficient bone.Reconstructive procedures for bonelosses have been significantly im-proved since introduction of the os-seointegration concept.9,24

Anterior alveolar congenital cleft issuch a situation, mainly because of thenasal floor defect, which is difficult tobe evenly repaired by primary surgeries.Even when autogenous bone harvestedfrom iliac crest is employed to recon-struct the alveolar process, the unavoid-able remodeling events that take placemay result in a very small bone bridgebetween the maxillary segments, pre-venting implant placement.24

The onlay graft26–28 was not con-

sidered in this case, because it couldlead to reduction of interarch spacewith change in the arch form to anonideal shape. The autogenous bonewas chosen instead of alloplastic ma-terials, because it does not trigger animmune response, presents good pre-dictability and low cost for the patient.Intraoral donor sites present additionaladvantages as convenient surgical ac-cess and reduced operative and anes-thetic time.29 Moreover, mandibularbone seems to have inherent biologicbenefits, which have been attributed toits embryological origin.30

Indications for the maxillary sinusor nasal floor inlay graft include uni-lateral or bilateral edentulism, wherebone quantity/quality is inadequate forplacement of a sufficient number andlength of endosseous implants.31 Im-plants can be placed simultaneouslywith the sinus grafting procedure orafter healing and graft consolidationperiod of 3 to 6 months. The immedi-ate placement of implants eliminatesthe need for an additional surgery, butrequires an adequate amount of crestalbone (3–4 mm) for achievement ofimplant stabilization.22

Although the prophylactic use ofdecongestant medications has notbeen shown to diminish complica-tions, patients are encouraged to uti-lize them postoperatively, ad libitum.Topical decongestants shrink the mu-cous membrane, improving ostialdrainage and providing symptomaticrelief.32 The vasoconstrictor actionof oxymetazoline lasts for approxi-mately 5 to 8 hours, compared with 1hour for phenylephrine and, thus, be-ing preferable.33

The immediate implant placementin ideal position in this case was viabledue to the sufficient amount and qual-ity of the remaining bone, which alsofavored implant stabilization. Yet,there is always a risk of osseointegra-tion failure, which is somewhat higherin the maxilla30; thus, careful ap-proaches are recommended.

The risk of perforating the nasalfloor mucosa during the lifting proce-dure is a concern that should be kept inmind, and the surgeon must be skillful,because rupture of the nasal mucosaprovides a way for contamination of

the implant. Besides, bleeding can oc-cur postoperatively.34

This case report is intended tostress the need of careful planning andexecution of the surgical procedure toensure the success of therapy ingrafted and nongrafted cleft areas.

CONCLUSION

Nasal floor elevation associatedwith inlay bone graft and immediateimplant installation can be considereda feasible option in restorative treat-ment. In this case report, the treatmenthad a good long-term prognosis andthe patient was completely satisfiedbecause his functional and esthetic ex-pectations were met.

Disclosure

The authors claim to have no fi-nancial interest, directly or indirectly,in any entity that is commercially re-lated to the products mentioned in thisarticle.

ACKNOWLEDGMENT

The authors thank Luiz GustavoNascimento de Melo for drawing theillustrations for this article.

REFERENCES

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Fig. 6. Radiographic aspect after implantplacement (compare with Fig. 1).


8. Hedegård B. Some observationson tissue changes with immediate maxil-lary dentures. Dent Pract. 1976;13:70-78.

9. Triplett RG, Schow SR, Laskin DM.Oral and maxillofacial surgery advances inimplant dentistry. Int J Oral Maxillofac Im-plants. 2000;15:47-55.

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12. Keller EE, Eckert SE, Tolman DE.Maxillary antral and nasal one-stage inlaycomposite bone graft. J Oral MaxillofacSurg. 1994;52:438-447.

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16. Hallman M, Sennerby L, LundgrenS. A clinical and histologic evaluation ofimplant integration in the posterior maxillaafter sinus floor augmentation with autog-enous bone, bovine hydroxyapatite, or a20:80 mixture. Int J Oral Maxillofac Im-plants. 2002;17:635-643.

17. Schlegel KA, Zimmermann R,Thorwarth M, et al. Sinus floor elevationusing autogenous bone or bone substitutecombined with platelet-rich plasma. Oral

Surg Oral Med Oral Pathol Oral RadiolEndod. 2007;104:e15-e25.

18. Sekine H, Taguchi T, Seta S, et al.Dental implant treatment with differenttechniques for sinus floor elevation—Acase report. Bull Tokyo Dent Coll. 2007;48:87-91.

19. Ten Bruggenkate CM, Van denBerg JPA. Maxillary sinus floor elevation: Avaluable pre-prosthetic procedure. Peri-odontology 2000. 1998;17:176-182.

20. Woo I, Le BT. Maxillary sinus floorelevation: Review of anatomy and twotechniques. Implant Dent. 2004;13:28-32.

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27. Neyt LF, De Clercq CAS, AbeloosJVS, et al. Reconstruction of the severelyresorbed maxilla with a combination of si-

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Reprint requests and correspondence to:Flavio Monteiro Amado, DDS, MSRua Jose Goncalves da Mota Junior103, Sao VicenteSP, Brazil CEP 11390-050Phone: �55 13 34686598Fax: �55 14 32347818E-mail: [email protected]

Abstract Translations

GERMAN / DEUTSCHAUTOR(EN): Maria Lucia Rubo de Rezende, DDS, PhD;Luiz Gustavo Nascimento de Melo, DDS, MS; MarceloMatida Hamata, DDS, MS; Flavio Monteiro Amado DDS,MS, PhD. Korrespondenz an: Flavio Monteiro Amado,DDS, MS, Rua Jose Goncalves da Mota Junior, 103, SaoVicente, SP–Brasilien CEP 11390-050. Telefon: �55 1334686598/ Fax: �55 14 32347818, eMail: [email protected] Inlay-Nasaltransplantat mit sofortigerZahnimplantatsetzung bei einem Patienten mit wiederherg-estelltem alveolarem Spalt: Eine Fallstudie

ZUSAMMENFASSUNG: Bei angeborener Alveolus-Spaltebieten primare Knochentransplantate nicht immer ein aus-reichendes Maß an Knochenmasse bzw. Knochenhohe, umideale Bedingungen fur die Einpflanzung von Implantatenin das Knochengewebe zu schaffen. Daher stellenAnhebungen des Oberkiefersinus oder Nasalbodens sowieInlay-Knochentransplantate in zuvor bereits mit Transplan-tat versehenen Bereichen keine Ausnahme in der taglichenBehandlungspraxis dar. Die vorliegende Fallstudie betont dieNotwendigkeit eines detaillierten Behandlungsplans sowieeines sorgfaltigen chirurgischen Behandlungsmanagementsbei der Anhebung des nasalen Bodens mit Partikelformigenautogenem Knochengewebstransplantat, um den Patienten


erfolgreich mit einer Knochengewebsintegrierenden Protheseausstatten zu konnen.

SCHLUSSELWORTER: Oberkiefersinus, Zahnimplantate,Lippen- und Gaumenspalte

SPANISH / ESPAÑOLAUTOR(ES): Maria Lucia Rubo de Rezende, DDS, PhD;Luiz Gustavo Nascimento de Melo, DDS, MS; Marcelo Ma-tida Hamata, DDS, MS; Flavio Monteiro Amado DDS, MS,PhD. Correspondencia a: Flavio Monteiro Amado, DDS, MS,Rua Jose Goncalves da Mota Junior, 103, Sao Vicente,SP–Brazil CEP 11390-050. Telefono: �55 13 34686598/ fax:�55 14 32347818, Correo electronico: [email protected] nasal de partıculas con colocacion inmediata de unimplante dental en un paciente con un paladar hendidoalveolar reparado: Informe de un caso

ABSTRACTO: Los injertos principales de hueso en alveoloscongenitos del paladar no siempre proporcionan suficientemasa o altura del hueso para la colocacion ideal de implantesendooseos. Por lo tanto, la elevacion del piso nasal o senomaxilar e injertos con incrustaciones de hueso en areas injer-tadas previamente no son excepciones en la rutina diaria. Esteinforme de un caso refuerza la necesidad de un plan detratamiento detallado y cuidadosa gestion quirurgica de laelevacion del piso nasal con un injerto de partıculas de huesoautogeno para proporcionar exitosamente una protesis os-eointegrada al paciente.

PALABRAS CLAVES: seno maxilar, implantes dentales,labio y paladar hendido

PORTUGUESE / PORTUGUÊS

AUTOR(ES): Maria Lucia Rubo de Rezende, Cirurgia-Dentista, PhD; Luiz Gustavo Nascimento de Melo, Cirurgiao-Dentista, Mestre em Ciencia; Marcelo Matida Hamata,Cirurgiao-Dentista, Mestre em Ciencia; Flavio MonteiroAmado Cirurgiao-Dentista, Mestre em Ciencia, PhD. Corre-spondencia para: Flavio Monteiro Amado, DDS, MS, RuaJose Goncalves da Mota Junior, 103, Sao Vicente, SP–BrasilCEP 11390-050. Telefone: �55 13 34686598/ fax: �55 1432347818, e-mail: [email protected] Nasal de Inlay Particulado com Colocacao deImplante Dentario Imediato num Paciente com Fenda Al-veolar Reparada: Relato de Caso

RESUMO: Os enxertos de osso primario em alveolos comfenda congenita nem sempre fornecem volume ou altura sufici-ente de osso para colocacao ideal de implantes endosseos. As-sim, a elevacao da cavidade maxilar ou superfıcie nasal e osenxertos de osso de inlay em areas previamente enxertadas naosao excecoes na rotina diaria. Este relato de caso enfatiza anecessidade de um planto de tratamento detalhado e tratamento

cirurgico cuidadoso da elevacao da superfıcie nasal com enxertode osso autogeno particulado para fornecer com sucesso pro-teses osseointegradas ao paciente.

PALAVRAS-CHAVE: cavidade maxilar, implantes dentarios,labio e palato com fenda

RUSSIAN /

��: Maria Lúcia Rubo de Rezende, �� -��, �� ; Luiz Gustavo Nasci-mento de Melo, �� , �� ;Marcelo Matida Hamata, �� , ��-�� ; Flávio Monteiro Amado �� -��, �� , �� . �� : Flávio Monteiro Amado, DDS, MS, RuaJosé Gonçalves da Mota Júnior, 103, São Vicente, SP –Brazil CEP 11390–050. ��: �55 13 34686598/��: �55 14 32347818. �� :[email protected]�� -�� -�� : ��

�!"#$!. �� . �� -�� . ! �� - �� -�� " �� .

%&#'!��! (&��: �� ,�� , �� .

TURKISH / TURKCEYAZARLAR: Maria Lucia Rubo de Rezende, DDS, PhD;Luiz Gustavo Nascimento de Melo, DDS, MS; Marcelo Ma-tida Hamata, DDS, MS; Flavio Monteiro Amado DDS, MS,PhD. Yazısma icin: Flavio Monteiro Amado, DDS, MS, RuaJose Goncalves da Mota Junior, 103, Sao Vicente, SP–BrezilyaCEP 11390-050. Telefon: �55 13 34686598/ faks: �55 1432347818, e-posta: [email protected]


Onarılmıs Alveoler Yarıgı Olan bir Hastada Partikullu In-lay Nazal Grefti ve Hemen Dental Implant Yerlestirme: BirOlgu Raporu

OZET: Konjenital alveoler yarık olgularında primer kemikgreftleri, kemik ici implantların ideal bir sekilde yerles-tirilmesi icin her zaman yeterli kemik miktarı ya da yuk-sekligi saglamayabilir. Bu nedenle, maksiller sinus veyanazal zemin elevasyonu ve daha onceden greftlenmis alan-

larda inlay kemik greftleri gunluk rutin icin istisna teskiletmez. Bu olgu raporu, hastaya osseoentegre protez sag-lanabilmesi icin detaylı bir tedavi planının ve partikulluotojen kemik grefti ile nazal zemin elevasyonunda dikkatlicerrahi yonetiminin gereksinimini vurgulamaktadr.

ANAHTAR KELIMELER: maksiller sinus, dental implant-lar, yarık dudak ve damak.

JAPANESE /

CHINESE /


KOREAN /


Documents

Particulate Inlay Nasal Graft With Immediate Dental ... · of Craniofacial Anomalies (HRAC/ USP), Bauru, Brazil. His chief com-plaint was the poor esthetics of a par-tial removable