Maxillary segmental osteoperiosteal flap with simultaneous placement of dental implants: case report of a novel technique
© The Author(s). 2017
Received: 6 December 2016
Accepted: 13 January 2017
Published: 19 January 2017
Dental restorative space from the opposing dentition requires adequate distance for restorative material for an acceptable restoration. Typically, long-standing edentulous alveolar ridges will have vertical and or horizontal defects that require alveolar ridge augmentation for ideal dental implant restorations. Along with these defects, one will see the opposing dentition supra erupt which can obliterate the restorative space. Multiple surgical techniques have been described to address these dilemmas. The use of osteoperiosteal flaps has been described to address vertical height deficiencies. The purpose of this paper is to document and introduce a maxillary segmental osteoperiosteal flap intrusion to increase the restorative space with simultaneous dental implant placement. As with most dilemmas in treatment planning dental implants, multiple acceptable treatment options are available to the practitioner. This technique is another of many that can be added to the available options. When appropriately planned in select cases, this technique will result with ideal dental implant restorations without compromising the esthetic and functional harmony of the native dentition.
Obtaining proper occlusal clearance to allow for a single unit crown restoration is a fundamental prerequisite for dental implant restoration. Long-standing edentulous sites are often fraught with disuse atrophy and unopposed supra-eruption of the opposing dentition. In the posterior maxillae/mandible, there are vital structures that have to be mobilized in order to allow space for either bone transposition or onlay/inlay grafting. There are several predictable techniques described to address these preprosthetic alveolar deficiency dilemmas [1–3].
The osteoperiosteal flap technique has made a strong contribution towards management of these defects. Mobilizing a segment of alveolus attached to the overlying soft tissue can obtain uni- or bi-directional augmentation. This case report describes an amplification of a vertical osteoperiosteal flap with concomitant placement of dental implants in a partially edentulous dental arch.
A suitable alternative surgical management of this particular case might have been to simply perform an alveoloplasty to produce the desired inter-occlusal clearance and proceed with placement of implant and simultaneous direct sinus lift. That would have left more of the apical portion of the implant within the grafted sinus and possibly modified the location of keratinized band of tissue. The location of the dental alveolar segment in relation to any antral septae also needs to be appreciated, as this described technique can be fraught with complication if such anatomical obstacles are not accounted for preoperatively .
The osteoperiosteal flap or “bone flap” commonly used in segmental orthognathic surgery is a bone fragment moved in space without detachment of the investing periosteum . The prerequisite for simultaneous implant placement in a vertical repositioning bone flap is adequate width within the transport segment. It is always a fine balance between allowing enough exposure to place the fixation device without significantly compromising periosteal vascular input into the bone segment. As it is well documented both clinically and experientially, full thickness mucoperiosteal releases will cause some degree of bone resorption at the labial plate .
Due to the presence of fixation plate and a sizeable sinus window, we decided to use a long-lasting resorbable membrane. In our experience and supported by the literature, placement of a membrane over the osteotomy site has been shown to increase the amount of bone formation . Considering we were only able to obtain one monocortical screw fixation on the mobilized portion of the maxillae, maintaining immobility during the critical phase of bone healing was an obvious liability. Animal studies which have investigated the biology of small segment wound healing have noted that after 2 weeks, revascularization of the small dento-osseous segment was noted . The cross application of such animal studies are helpful but do not completely capture the additional challenges in this case report. The studies in animals were looking at segmental dental alveolar segments which encompassed the natural teeth. In our case illustration, there were osteotomies made within the transport segment and healing of the overlying particulate allograft was contingent on biological stability of the respective segment. This is a clear illustration of how animal models can begin to provide a platform towards technical innovation, but there is always a parameter of uncharted terrain in translating to human clinical application.
A critical appraisal of the gingival architecture in the final end point of this case demonstrates some radiolucency through the soft tissue outlining the platform of the Nobel Biocare TiUnite implant. This would lead us to believe that either the transmucosal bone level placement attempt was inaccurate or excessive reflection of the labial tissue has caused some degree of resorption. This is another liability that needs to be carefully addressed if this application is recaptured within the esthetic zone. Perhaps slight subcrestal placement of the dental implant or platform switched body feature would minimize this outcome. In our application, we utilized an implant platform topography that is purported by the manufacture to allow soft tissue adhesion and minimize crestal bone loss.
This case highlights the evolving variations in dentoalveolar augmentation with an emphasis on concomitant implant placement. In the most traditional sense, a vertical osteoperiosteal flap technique would be bound with a stable basal bone that can be used to anchor simultaneous dental implant placement. Further refinement should consider minimizing crestal reflection and overall labial bone resorption.
TT was the staff surgeon for the case being presented and gave the final approval for submission. TW was the resident surgeon for the case being presented and was involved in drafting the manuscript and finalizing it for submission. Both authors read and approved the final manuscript.
Tibebu Tsegga and Thomas Wright declare that they have no competing interests.
Consent for publication
Written informed consent was obtained from the patient for the publication of this report and any accompanying images.
Ethics approval and consent to participate
No research/experimentation was completed on humans an d/or animals for this case reports.
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- Irinakis T. Efficacy of injectable demineralized bone matrix as graft material during sinus elevation surgery with simultaneous implant placement in the posterior maxilla: clinical evaluation of 49 sinuses. J Oral and Maxillofac Surg. 2011;69:134–41.View ArticleGoogle Scholar
- Chiapasoo M, Casentini P, Zaniboni M. Bone augmentation procedures in implant dentistry. Int J Oral Maxillofac Implants. 2009;24:237–69.Google Scholar
- Jenson OT. The osteoperiosteal flap: a simplified approach to alveolar bone reconstruction. Quintessence Pub; 2010.
- Stern A, Green J. Sinus lift procedures: an overview of current techniques. Dent Clin N Am. 2012;56:219–33.View ArticlePubMedGoogle Scholar
- Jenson OT. Dentoalveolar modification by osteoperiosteal flaps. In: Fonseca RJ, editor. Oral and maxillofacial surgery. 2nd ed. St. Louis, MO: Saunders; 2000. p. 471–8.Google Scholar
- Jensen OT, Cullum DR, Baer D. Marginal bone stability using three different flap approaches for alveolar expansion for dental implants—a one year clinical study. J Oral Maxillofac Surg. 2009;67:19–21.Google Scholar
- Herford AS, Nguyen K. Complex bone augmentation in alveolar ridge defects. Oral Maxillofacial Surg Clin N Am. 2015;27:227–44.View ArticleGoogle Scholar
- Jenson OT, Bell W, Cottam J. Osteoperiosteal flaps and local osteotomies for alveolar reconstruction. Oral Maxillofacil Surg Clin N Am. 2010;22:331–46.View ArticleGoogle Scholar