Alveolar ridge atrophy in the edentulous jaw is a major problem for the patient and the dentist, and involves both functional and aesthetic aspects. Depending on the stage of alveolar bone resorption, a conventional denture may not be stabilized and implants may not be able to be placed to attach a removable or final denture. An inadequate fit of a prosthesis can even lead to discomfort due to pressure lesions causing the patient not to wear it. For a satisfactory solution to this problem, a bone-augmentation procedure becomes necessary to provide a sufficient bone height for implant placement or to rebuild an alveolar ridge for a proper fit of the conventional denture.
Today, several surgical techniques are performed to restore missing alveolar bone. The most common techniques are sinus floor elevation and ridge augmentation. Sinus floor elevation creates new bone in an atrophied maxillary antrum; however, it is restricted to the molar and premolar regions. A ridge-augmentation procedure can be performed anywhere in the mandible and maxilla, but a stabilization of the augmentation complex is necessary. If the remaining adjacent alveolar crest cannot provide it, stabilization can be achieved through the use of dimensional stable membranes (eg, titanium or expanded polytetrafluoroethylene foils). Admittedly, even these measures cannot stabilize a complete augmentation of an entire edentulous and atrophied maxilla. In this case a Le Fort I osteotomy is still required.
Le Fort I Osteotomy
Le Fort I Osteotomy is one of the most frequently performed skeletal movements in orthognathic surgery. 1,2 It is a versatile procedure that is used in oral and maxillofacial surgery for the correction of dysgnathias, like open bite deformity, and maxillary cleft deformations. 3 In neurosurgery and in the removal of tumors in the midface, it allows an easy approach to the surgical site and leaves no visible scars. The first reports on Le Fort I osteotomy appeared in the 1920–1930 period. In the late 1960s it became a standard procedure for surgical corrections of dysgnathias. 4,5 For a vertical lengthening of the maxilla, as presented in this paper, this procedure is rarely performed. 6
Stability of the repositioned maxilla is provided either by wire osteosynthesis or by ridge fixation with miniplates whereby ridge fixation, especially in inferior movement of the maxilla, has shown to be clearly superior to wire osteosynthesis. 2 Filling the resulting gap between the lowered maxilla and the skull has been a subject of discussion. Some authors did not find any significant differences in relapse between grafted and nongrafted patients, whereas others found large differences in the relapse potential superior to grafted advancements. 1,7 Meanwhile, grafting the augmentation site is regarded to be beneficial for the success of this treatment. It prevents an ingrowth of buccal soft tissue into the gap, which could compromise the bony union and potentially decrease stability, resulting in malocclusion and relapse. 1,7 A review of the literature suggests that a majority of Le Fort I osteotomies are performed with grafting materials, most with autogenous bone grafts harvested from the iliac crest. 6,8–11 However, stabilizing the maxilla with miniplates and grafting the gap minimize the risk of relapse, but neither of these measures can absolutely prevent it. 1,2,8
Bone Graft Materials
Today, a large number of materials is available that fulfill (more or less) the requirements of an ideal bone graft. The ideal graft material should not only be a bone substitute but a bone-regeneration material that is completely resorbed simultaneously with the formation of new bone. Furthermore, its decomposition products should be reused for building new bone. 12 Being osteoconductive, it should serve as scaffolding for bone to form and as a spacekeeper preventing the invasion of soft and connective tissue. Furthermore, it should not carry any immunologic risk. Autogenous bone grafts, which are still regarded as the “gold standard,” appear to be ideal as they comply with these conditions. Nevertheless, no randomized double-blind survey, demanded for every material to be compared to autografts, has been carried out. Additionally their availability and storability is limited, and a secondary surgical procedure with all its related risks and complications is required. A high percentage of patients still report problems 1 year after surgery, and approximately 18% report pain more than 2 years postoperatively. 13–15
Allogenic or xenogenic grafting materials do not require secondary surgery, are readily available, and can be stored. However, the risk of an immunologic reaction due to foreign proteins and the transmission of viral or other infections cannot completely be excluded, making their use questionable. 16–18 Moreover, the resorption of xenogenic material has been the subject of controversy. Particles of bovine material were identified histologically without clinical signs of resorption after more than 6 years. 19
Synthetic calcium phosphates such as hydroxyapatite and α- or β-tricalcium phosphate (TCP) are entirely artificial, sterilizable substances. They are free from any risk of material-induced infections and their availability is also unlimited. Hydroxyapatite is the actual bone mineral. Admittedly, synthetic hydroxyapatite does not undergo any pronounced resorption except due to specific cellular activities of macrophages and multinuclear giant cells. In contrast, α- or β-TCPs are resorbable. Being chemically identical, the α-modification is resorbed more slowly than the β-modification, and refractile microparticles of α-TCP were found within the lingual lymph nodes. 20 The monophasic β-TCP Cerasorb® (Curasan, Kleinostheim, Germany) is completely resorbed simultaneously with the formation of new bone without any residue; usually within 6 to 12 months. 21 The gradual dissolution and resorption of the pure-phase β-TCP in a physiological environment occurs predominantly through physicochemical means without osteoclast activity. The specific production procedure leads to an interconnecting porosity, allowing an invasion of fluids, the migration of cells, and the ingrowth of vessels and newly formed bone, thus being osteoconductive. Bone regeneration achieved with pure-phase β-TCP alone has shown to be comparable with that achieved using autogenous bone grafts. 22 Providing the patient with his/her own vital bone at the former defect site, the pure-phase β-TCP can be termed to be a bone regeneration material fulfilling all the requirements to be an ideal bone graft. With the admixture of autologous platelet-rich plasma (PRP), the regenerative potential of the pure-phase β-TCP can be improved considerably.
PRP is a concentrate of thrombocytes that is processed directly from the patient’s blood. The preparation can be performed at the dentist’s or cranio- and maxillofacial surgeon’s practice where it will be used. Responsible for the effect of PRP are the growth factors released from the thrombocytes. Platelet-derived growth factor (PDGF) and TGF-β1 + 2 (transforming growth factor β1 + 2) are the most important growth factors and are found in high concentrations in thrombocytes. 23 High concentrations of both factors were also isolated from the bone matrix. The content of TGF-β in bone and platelets is 100-fold higher than in most other tissues, indicating an important role in bone regeneration. Furthermore, the osteoblast surface contains the highest density of TGF-β-receptors. 24,25 Both PDGF and TGF-β attract a multitude of cells involved in the regeneration process to the defect and activate them. Among them are monocytes, macrophages, and fibroblasts, which subsequently release various growth factors by themselves to initiate regeneration and angiogenesis and keep it going. 24,26
Beside the general stimulation of the healing process, PDGF and TGF-β have a direct impact on osteoblasts. PDGF acts as a chemokine on osteoblast precursor cells, and TGF-β stimulates their differentiation and osteoblast proliferation. The activity of bone-degrading osteoclasts is inhibited by TGF-β. Additionally, both growth factors are able to increase the proliferation of stem cells. 27,28
Numerous cytokines are involved in bone regeneration, such as insulinlike growth factor, fibroblast growth factor, and bone morphogenetic proteins. However, a complete description of bone regeneration would go beyond the scope of this article and has been extensively described elsewhere. 23,28,29 The PRP method provides the surgeon with a scientifically proven, successful system for the optimization of augmentation. The Curasan–PRP system allows for in-office implementation of the chairside method with a minimum of effort. The amount of prepared PRP is variable so that it can be adapted to the size of the augmentation site. Thus, a minimal blood volume is required.
One should mention that the time of formation of new bone is not significantly accelerated by the application of PRP, but the woven bone reaches the mature stage of lamellar bone in a much shorter time. Furthermore, PRP does not only enhance bone regeneration but also has a significant positive effect on soft tissue regeneration.
Application of Pure-Phase β-TCP
For successful treatment, prior to application, the pure-phase β-TCP must be mixed with patient blood obtained from the defect. The thrombocytes penetrate the micropores of the granules where, induced by the calcium ions, they initiate clotting of the blood and release their growth factors. Migration and activation of fibroblasts, osteoblasts, and osteoblast precursors from the defect site is initiated, and the structure of the fibrin clot acts as a scaffolding. Within approximately 10 minutes after the addition of blood, the mixture forms a pasty substance, which is easily applicable and moldable and permits the level filling of the defect regardless of its shape. With the admixture of freshly prepared PRP, the gel-formation is accelerated and the concentration of released growth factors increases, resulting in the optimized bone regeneration and soft tissue healing described previously.
In our private clinic we successfully treated more than 3000 cases of bone defects in various indications using the pure-phase β-TCP, with and without admixture of PRP. The two cases presented in this article were treated with a combination of pure-phase β-TCP and autogenous cortical bone at a ratio of 4:1, mixed with PRP. The autograft was harvested at the chin region with a Safescraper (Divisione Medicale META, Italy).
A previous unfavorable anatomical situation due to advanced maxillary atrophy was managed with four endosteal implants to fix a complete denture with pushbuttons. Four years after this procedure, the first implant was lost in region 13 due to periimplantitis, followed by the loss of the implants in region 23 and 25 as a result of loosening and infection. The entire alveolar ridge was interspersed with connective and scarred tissue forming a considerable irritation fibroma. A stable fixation of the denture could not be achieved, as it moved with every masticatory movement of the jaw bone. This was the status quo prior to the treatment described here (Fig. 1). Planning for further treatment, it became obvious that the removal of the redundant tissue alone would not provide a sufficient denture base for a stable fixation. Thus, bone augmentation was necessary, whereby existing soft tissue was retained or used for the reconstruction of alveolar bone.
A maxillary osteotomy at the Le Fort I level was performed. A circumvestibular incision was made above the mucogingival junction and the mucoperiosteal flap was carefully detached from the bone wall (Fig. 2). The prepared bone wall was transected with a bone reamer. The nasal septum was separated in distal direction with a nasal septum chisel and the maxilla was luxated in a caudal direction (Fig. 3). Due to the progressed pneumatization of the nasal sinus, only a minimal transection of the lateral bone was necessary. The nasal mucosa and the Schneiderian membrane were detached cautiously to avoid disruption or perforation. At the fracture site the maxilla was dislocated in caudal direction without fracturing the bone of the pterygoid process. The luxation resulted in a gap of 20 mm. In this position the maxilla was bilaterally stabilized by two titanium miniplates (Aesculap, Germany) (Fig. 4) and the soft tissue was mobilized in oral direction. The gap was filled with the pure-phase β-TCP Cerasorb®(500–1000 μm). Prior to application, the bone-regeneration material was first mixed with blood obtained from the surgical site and approximately 20% autogenous cortical bone taken from the chin region with a Safescraper (Divisione Medicale META), followed by admixture of the freshly prepared PRP. The augmentation complex was applied and adjusted to the shape of the defect (Fig. 5). For an advanced wound healing of soft tissue, surplus PRP was applied onto the augmentation site, which was covered labially with a resorbable membrane (Fig. 6) and sutured tightly (Fig. 7).
Postoperative wound healing was uneventful. Three days after surgery, no swelling or hematoma was observed (Fig. 8). Although no externally visible swelling was noted (Fig. 9), the patient was left without a denture for 4 weeks to make sure that all visible and invisible soft tissue wounds healed before a temporary denture was applied. Three months postoperatively the final denture was relined and functionally adapted. At this time the augmentation was already stable and could be loaded without discomfort. The x-ray control did not show any irregularities (Fig. 10); the advancement of the procedure after 6 months amounted to 16 mm. Due to the absence of discomfort the miniplates were not removed. After complete healing of the soft tissue the patient was provided with a conventional interim denture, which led to a functionally satisfactory result. For this reason the patient decided against the placement of the two scheduled implants in the canine region.
After a total loss of maxillary teeth due to periodontal disease, the patient was provided with a full denture 5 years previously. Stabilized fixation of the denture was not achievable. The radiograph (Fig. 11) displayed a maxilla with an insufficient vertical height of approximately 1 mm, making an implant placement to apply a stable removable or fixed denture impossible. As a result of the instability, several mucosal lesions were persistent (Fig. 12), inducing the patient not to wear his denture.
Thus, an alveolar ridge augmentation using a Le Fort I osteotomy was performed. After a circular incision of the vestibulum oris from the second molar region from one side to the other, the maxillary bone wall was laid open. Fracturing the bone walls and detaching the septum nasi with a nasal chisel (MOBERG; Medicon, Tuttlingen, Germany), the alveolar ridge was carefully separated from the skull base and relocated in caudal direction. The nasal mucosa and the Schneiderian membrane were detached cautiously in accordance with a sinus floor elevation. The mobilized maxilla was internally fixed with two titanium miniplates in the premolar region (Fig. 13). A perforation of the nasal cavity through the preparation of septum nasi was covered with a resorbable polylactic membrane (Resolute, Gore Tex). The resulting gap was filled with the augmentation complex of pure-phase β-tricalcium phosphate Cerasorb® (500–1000 μm), mixed with blood from the defect, autogenous bone and PRP prior to application (Fig. 14). For a better wound healing the augmentation site was trickled with surplus PRP (Fig. 15), covered with two resorbable polylactic membranes and sutured tightly (Fig. 16). Under antibiotic prophylaxis all wounds healed uneventfully. The postoperative radiograph displayed an advancement of approximately 20 mm (Fig. 17). Although no complications occurred, the patient was advised not to wear a denture for 6 weeks. The denture applied after this initial period, which was intended for aesthetic reasons only, was used for another 6 weeks.
The x-ray control after 4 months displayed a relapse of the advancement of approximately one third achieved with the augmentation, still resulting in a total augmentation of more than 14 mm. Six months postoperatively the miniplates were removed, and after 8 months two implants were placed in the canine region (Fig. 18). At this time the pure-phase β-TCP was completely resorbed and replaced by vital bone. When preparing the alveolar ridge for the implant insertion, an excellent bone density was found in the area of augmentation. After a healing time of another 4 months, two overdenture ball-attachments (Sulzer-Calcitec, Freiburg i.Br., Germany) were applied to the implants providing a stable fixation of the final denture.
The combination of the pure-phase β-TCP with PRP was used successfully even for the augmentation of a completely mobilized, caudal relocated maxilla. No complications emerged in either case reported. Regarding the size of the augmentation site, using a synthetic bone graft material made a second surgery for iliac crest harvesting unnecessary, reducing costs and time for both the surgeon and patient. The cortical bone harvesting method presented in these cases was performed in the chin region during the same surgery. After an 8-month period in both cases, the pure-phase β-TCP was completely replaced by vital bone, and the x-ray control showed no residual granules in the defect site. The topical application of residual PRP resulted in a remarkable acceleration of soft tissue healing.
However, the relapse of almost one third of the initially achieved advancement in case 2 needs to be addressed. This relapse can be attributed to the combination of PRP with a resorbable membrane. Macrophages and granulocytes attracted by PRP are also responsible for the degradation of biodegradable membranes and suture material. Activated by the degradation of these materials, the cells systematically release more cytokines, which may attract more immune cells to the defect and lead to increased inflammatory reactions. Thus, the premature degradation of membrane or suture material and, as might have happened in case 2, an accelerated resorption of the pure-phase β-TCP may occur. The resorption does then not take place simultaneously with the formation of new bone, impairing the success of the treatment. In the presented case, despite the relapse, the treatment resulted in an advancement of approximately 14 mm, still allowing for the insertion of two implants to stabilize an otherwise unstable denture. The aim of the treatment in this patient was not completely successful, but in general the use of nonresorbable membranes, suture materials, and fixation systems in combination with pure-phase β-TCP and PRP is recommended to increase the predictability of the results.
The cases presented in this paper demonstrate successful grafting of bone defects after Le Fort I osteotomy with synthetic grafting material. The pure-phase β-TCP is a safe augmentation material that can be used even for regeneration of an atrophied maxilla at the advanced stage presented here. Autogenous bone from the bone collector and the chin region was added to the augmentation complex at a ratio of 4:1. Recent publications showed that pure-phase β-TCP leads to good results even without the admixture of autogenous bone graft, and that bone formation with pure-phase β-TCP alone is comparable to the results achieved with autogenous bone. The quality of the surrounding bone is considered to be of more relevance than whether pure-phase β-TCP or bone grafts were used. 22
The pure-phase β-TCP presents no risk of transmitting material-induced infections and makes surgery for harvesting autogenous bone grafts unnecessary. Because it is completely resorbed and replaced by vital bone, it is a bone-regeneration material providing real restitutio ad integrum. The combination with autologous PRP accelerates the maturation of woven bone into lamellar bone and improves its quality. Soft tissue healing is also significantly accelerated. However, for the combination of pure-phase β-TCP and PRP, the use of nonresorbable membranes and suture materials is recommended to prevent a premature degradation of both the membranes and sutures, as well as of the regeneration material. These results encourage the qualified cranio- and maxillofacial surgeon to use the pure-phase β-TCP Cerasorb®, even when performing an augmentation of substantial dimension.
The authors claim to have no financial interest in any company or product mentioned in this article.
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Abstract Translations [German, Spanish, Portuguese, Japanese]
AUTOR(EN): Ch. Foitzik, MD, DMD, PhD*, H. Staus, DMD**. *privat praktizierender Arzt, Darmstadt, Deutschland. ** privat praktizierender Arzt, Darmstadt, Deutschland Schriftvehrker: Ch. Foitzik, MD, DMD, PhD, Nieder-Ramstädter-Str. 18, 64283 Darmstadt, Deutschland. Telefon.:+49 - (0) 6151 - 2 66 44, Fax: +49 - (0) 6151 - 29 46 28. eMail: Foitzik@t-online.de
ABSTRACT: Am atrophierten Oberkieferknochen durchgeführte Le Fort-Osteotomie des Typus 1 und Knochengewebsaufbau mittels phasenreinem ß-Trikalziumphosphat und thrombozytreichem Blutplasma
ZUSAMMENFASSUNG: Die sogenannte Le Fort-Osteotomie des Typus 1 ist eine im medizinischen Bereich vielfach angewandte Operationsmethode: sie wird sowohl bei gesichts- und kieferchirurgischen Eingriffen zur Korrektur beispielsweise einer Dysgnathie als auch in der Neurochirurgie zur einfachen Offenlegung des Operationsfeldes angewandt. Eher selten kommt diese Methode allerdings zur Anwendung, wenn es sich um die Notwendigkeit einer vertikalen Vorverlagerung des Oberkieferknochens handelt. Das synthetische phasenreine ß-Trikalziumphosphat Cerasorb der Firma Curasan, Sitz Kleinostheim, Deutschland, wurde erfolgreich mittels dieser Methodik in Kombination mit autogenem Knochengewebe im Verhältnis 4:1 und unter gleichzeitiger Ausnutzung von patienteneigenem thrombozytreichem Blutplasma zur vertikalen Vergrößerung völlig atrophierter Oberkieferknochen eingesetzt. Der gemessene Oberkieferaufbau belief sich auf 16 bzw. 14 mm. Nach 8 Monaten war das ß-Trikalziumphospat vollständig resorbiert. Röntgenaufnahmen der behandelten Bereiche ergaben keinerlei Hinweise auf verbliebene Granula. Die Untersuchungen lassen den Rückschluss zu, dass sich das phasenreine ß-Trikalziumphosphat sehr gut zum Knochenaufbau eignet, da die betroffenen Stellen des Oberkieferknochens unter Anwendung dieses Stoffes innerhalb relativ kurzer Zeit die Ausbildung vitalen Knochengewebes aufwiesen. Daher war kein weiterer chirurgischer Eingriff zum Zweck der Knochengewebstransplantation, zum Beispiel aus dem Beckenkamm, notwendig. Der Gesamterfolg der Behandlung wurde im zweiten Fall auch nicht durch das Rezidiv ungefähr eines Drittels des Gewebes beeinträchtigt. Dieser Rückfall wurde vermutlich durch die Verbindung des patienteneigenen thrombozytreichen Blutplasma mit einer resorbierbaren Polylaktat-Membran hervorgerufen. Daher sollten bei Einsatz des phasenreinen ß-Trikalziumphosphats nicht resorbierbarer Membrane und Nahtmaterialien verwendet werden. Wir möchten daher die erfahrene Kollegenschaft zur Verwendung des phasenreinen ß-Trikalziumphosphats sogar bei solch komplexen Knochengewebsaufbaubehandlungen wie geschildert ermutigen.
SCHLÜSSELWÖRTER: Vergrößerung, Knochengewebsersatzstoff, vertikale Vorverlagerung
AUTOR(ES): Ch. Foitzik, MD, DMD, PhD*, H. Staus, DMD**. *Práctica privada, Darmstadt, Alemania. **Práctica privada, Darmstadt, Alemania. Correspondencia a: Ch. Foitzik, MD, DMD, PhD., Nieder-Ramstadter-Str. 18, 64283 Darmstadt, Alemania. Teléfono: 49 (0) 6151 2 66 44, Fax: 49 (0) 6151 29 46 28. Correo electrónico: Foitzik@t-online.de
ABSTRACTO: Le Fort I-Osteotomía es un procedimiento versátil en la cirugía oral y maxilofacial para corregir las disgnacias así como un método fácil al lugar de la cirugía en la neurocirugía. Se realiza muy raramente, para lograr un avance vertical de la maxila. Este trabajo presenta el uso exitoso de Cerasorb (Curasan, Kleinostheim, Alemania), un β-fosfato tricálcico de pura fase, junto con un hueso autógeno en una relación del 4:1, en combinación con el plasma rico en plaquetas del propio paciente (PRP) para lograr el aumento vertical de una maxila completamente atrofiada, lo cual resultó en un avance de 16 mm y 14 mm respectivamente. Después de un período de 8 meses, el β-fosfato tricálcico se reabsorbió totalmente y la radiografía de control demostró que no había gránulos residuales en el lugar del defecto. El β-fosfato tricálcico de fase pura demostró ser un material para la regeneración del hueso que proporciona al paciente con hueso vital en el lugar del defecto en un período razonable, haciendo que un segundo procedimiento quirúrgico para la recolección de hueso, por ej., en la cresta ilíaca, innecesario. La recaída de aproximadamente 1/3 en el segundo caso, no afectó el éxito del tratamiento y se atribuyó a una combinación de plasma rica en plaquetas con una membrana poliláctica reabsorbible. Por lo tanto, se recomienda el uso de membranas y materiales de sutura no reabsorbibles con la combinación de β-fosfato tricálcico de fase pura y plasma rica en plaquetas. Estos resultados sugieren que el cirujano cualificado use el β-fosfato tricálcico de fase pura para la regeneración del hueso inclusive cuando realiza aumentos de esta envergadura.
PALABRAS CLAVES: aumento, sustituto del hueso, avance vertical
AUTOR(ES): Ch. Foitzik, MD, DMD, PhD*, H. Staus, DMD**. *Clínica particular, Darmstadt, Alemanha. **Clínica particular, Darmstadt, Alemanha. Correspondências devem ser enviadas para: Ch. Foitzik MD, DMD, PhD., Nieder-Ramstädter-Str. 18, 64283 Darmastadt, Alemanha. Telefone: +49-(0)6151 2 66 44, Fax: +49-(0)6151 29 46 28. Email: Foitzik@t-online.de
SINOPSE: a osteotomia Le Fort 1 é um procedimento versátil na cirurgia oral e maxilofacial para a correção das disgnatias, bem como para um acesso facilitado ao campo cirúrgico durante uma neurocirurgia, sendo que tal procedimento é raramente realizado para o crescimento vertical da maxila. Esse relato apresenta o uso bem sucedido do β-Tricálcio-fosfato (β-TCP) de fase pura sintético da Cerasorb (Curasan, Kleinostheim, Alemanha), em conjunto com o osso autógeno em uma razão de 4:1, e em combinação com o plasma rico em plaquetas do próprio paciente para um acréscimo vertical das maxilas completamente atrofiadas. O resultado foi um crescimento de 16mm e 14mm, respectivamente. Após um período de 8 meses, houve a absorção completa do β-TCP e o controle da radiografia não apresentou nenhum grânulo residual nos campos defeituosos. O β-TCP de fase pura provou ser um material de regeneração óssea proporcionando ao paciente osso essencial no campo defeituoso em tempo hábil, fazendo com que seja desnecessária uma segunda cirurgia para a exploração óssea como, por exemplo, na crista ilíaca. A reincidência de aproximadamente 1/3 no segundo caso não afetou o sucesso do tratamento e foi atribuída à combinação do plasma rico em plaquetas com uma membrana poliláctida reabsorvível. Assim, recomenda-se o uso de membranas não reabsorvíveis e de materiais de sutura na combinação do β-TCP de fase pura com o plasma rico em plaquetas. Tais resultados incentivam o cirurgião competente a utilizar o β-TCP de fase pura para a regeneração óssea mesmo ao realizar acréscimos com estas dimensões.
PALAVRAS-CHAVES: acréscimo, substituto ósseo, crescimento vertical