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Clinical Science and Techniques

Reconstruction and Implant-Supported Rehabilitation of an Iatrogenically Caused Maxillary Alveolar Defect

Tüz, Hakan Hifzi DDS, PhD*; Koç, Onur DDS, PhD; Meral, Salih Eren DDS; El, Azime Sibel DDS, PhD§

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doi: 10.1097/ID.0000000000000910
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Bone quality and quantity are the main requirements for proper dental implant placement and long-term survival of an implant-borne prosthesis. Insufficient alveolar bone volume or density may compromise the support and stabilization of the implant resulting in the failure of the osseointegration as well as the functional prosthesis.1,2

Periodontitis is known as the main etiological factor for alveolar bone loss. Trauma, tumors, resorption after tooth extraction, osteomyelitis, medication-related osteonecrosis of the jaws, and medication-induced tissue damage are the other factors that may cause defective alveolar bone structure, which can later be needed for dental implant restoration. Devitalizing endodontic agents are also rarely reported to be responsible for the destruction of periapical tissues because of leaking out from root canal apices.3,4

Various methods are used to repair alveolar defects including autogenous, allogenic, xenogeneic, alloplastic graft materials, and guided bone regeneration.5 Among these, autogenous bone grafts are considered the gold standard for bone grafting.6

Extraoral (iliac, calvarium, costae, and tibia) and intraoral (ramus, chin, tuber, and zygomatic buttress) donor sites can be chosen for autogenous graft reconstruction according to defect character and size.2,6 Autogenous grafts induce bone regeneration by 3 different mechanisms: osteogenesis, osteoinduction, and osteoconduction. Cancellous grafts are usually considered to have greater potential to induce osteogenesis because of their high osteogenic cell content, whereas cortical grafts have a greater capacity of bone regeneration by osteoconduction.2

In this case report, reconstruction and implant-supported rehabilitation of a maxillary defect caused by a devitalizing agent are presented, and outcomes are discussed in light of the literature.

Case Report

A 42-year-old woman was referred to Hacettepe University Department of Oral and Maxillofacial Surgery for a dental implant–supported fixed crown restoration of her missing maxillary left 2nd premolar and 1st molar.

The patient reported that after the use of an endodontic devitalizing agent to treat her upper left 1st molar, she had persistent pain, which led to the loss of her tooth and an oroantral opening at the extraction site. Removal of the necrotic tissue residue, extraction of the 2nd premolar tooth, and repair of an oroantral fistula (OAF) has been completed with subsequent operations. Missing teeth have been rehabilitated with tooth-supported fixed dental bridges after the closure of the OAF before the referral of the patient to our clinic (Fig. 1). Because the patient was not satisfied with her prosthesis and she finds it uncomfortable and unattractive, 2 years later, she was referred to our department with the expectation of dental implant–supported fixed prosthesis rehabilitation instead of bridge restoration.

Fig. 1
Fig. 1:
Teeth-supported fixed dental bridge was fabricated before referral of the patient in an external center. The OAF closure operation–dependent excessive vertical defect can be seen. The huge space between the pontic and alveolar bone troubles the patient because of heavy food impaction.

Her clinical examination along with radiologic evaluation was consistent with the patient's previous statement. A fixed bridge restoration with long crown length had to be fabricated because of the vertical loss of alveolar bone, and poor hygiene around the restoration was observed as a result of nonanatomical hardware.

Her radiological evaluation showed loss of vertical and horizontal volume of the alveolar bone and a thin cortical bone layer as a result of previous interventions (Fig. 2). Cone-beam computerized tomography image measurements revealed 18 × 10 × 6 mm bone loss at the defective area.

Fig. 2
Fig. 2:
In the computed tomography section, the thin cortical bone formation can be seen after OAF closure. The presence of inadequate cortical bone before the referral of the patient makes healing of the bone graft more complicated.

The patient was operated under general anesthesia. The recipient site was exposed to observe the defective area. Block bone grafting was decided as the choice of treatment primarily to maintain enough bone volume for 2 implant insertions in the 1st molar and 2nd premolar locations. The anterior iliac crest (AIC) was preferred as a choice of autogenous bone. A corticocancellous bone block was harvested from the medial aspect of the AIC. The graft was remodeled for optimal adaptation to the recipient site and stabilized with 3 miniscrews. A tension-free soft-tissue closure was achieved with 3.0 nonresorbable sutures.

The patient was reoperated after 16 weeks of a trouble-free healing period. During this intervention, adequate bone volume for dental implant placement (Fig. 3) was observed, and 2 dental implants (Roxolid; Straumann Standard Plus, Basel, Switzerland) were placed without any complications after removal of the fixation screws. After the 3-month period of osseointegration, the patient was referred to the prosthodontist for fabrication of the implant-supported fixed prosthesis. After prosthetic rehabilitation, trouble-free maintenance of the rehabilitation site was observed during the follow-up period of 2.5 years with no patient discomfort (Fig. 4).

Fig. 3
Fig. 3:
After a 16-week healing period of the AIC grafting procedure in the left maxillary posterior region, the healing of the block graft seems uneventful. The minimum bone resorption after the block grafting procedure enhances success of the implant-borne fixed bridge rehabilitation.
Fig. 4
Fig. 4:
A 2.5-year follow-up radiograph of the implant-supported fixed bridge rehabilitation: Reasonable cervical bone resorption was observed around the implants. The implant-borne fixed bridge seems trouble-free without any patient discomfort, gingival erythema, and inflammation signs.


Bone quality is one of the most important factors for implant success and maintenance. The “quality of bone” refers to more than one parameter such as bone mineral density, bone height, width, 3-dimensional orientation, and architecture.7 Bone volume is a key factor for wider implant insertion, which plays a vital role in long-term implant stability and less bone resorption. Several studies pointed out that less bone density causes more stress in periimplant bone tissue and results in early bone loss adjacent to dental implants.8,9 Bone density also affects primary stabilization, which is essential for successful osseointegration.8

The posterior maxillary region is one of the sites where the most reconstruction is needed because of both alveolar bone resorption and excessive maxillary sinus enlargement. Defects in the posterior maxillary region may arise from long-term untreated periodontal disease, periapical cysts, traumas that result in bone loss, osteomyelitis, tumors that originated in hard (bone) or soft (minor salivary gland) tissues, and traumatic extractions of posterior maxillary teeth.4,10 Oroantral openings may occur and transform into OAFs if these defects are not treated properly. In our case, the reason for the maxillary defect was a rarely seen situation, which was expressed as devitalizing agent leakage at the upper left first molar with sinus opening.

Devitalizing agent–related bone resorption may cause alveolar defects depending on both the location and size of the bone loss. Osteomyelitis, gingival necrosis, neural disturbances such as paresthesia, and OAF may arise after the use of devitalizing agents in the maxillary molar region.11 Management of these fistulas is aimed to provide closure. Different surgical techniques including advancing or rotating intraoral soft-tissue flaps from buccal or palatal mucosa, buccal fat pad, and submucosal connective tissue or lingual flaps or the use of alloplastic materials such as metallic foil, gold foil, and titanium were demonstrated to close OAFs.10,12,13 In the present case, the OAF on the left maxillary region had been closed using intraoral soft-tissue flaps before referral of the patient to our department.

Despite the development of new graft materials, autologous bone grafts remain the gold standard because of their osteoinductive, osteoconductive, and nonimmunogenic features.6 Autologous bone grafts can be harvested from both extraoral and intraoral donor sites. The choice of donor sites is usually based on the amount, geometry, and type of bone required for reconstruction.14

The bone in the maxillary tuberosity is usually cancellous and used in fenestrations and sinus lifting procedures, whereas the mandibular ramus is primarily cortical with little cancellous content and is used as inlay/onlay grafts. The symphysis also provides a reasonable volume of corticocancellous bone and is used as both onlay and inlay grafts.15 Both symphysis and ramus grafts have demonstrated to be successful for the reconstruction of maxillary anterior horizontal defects with low resorption rates at 1-year follow-up, although ramus grafts are considered to have less postoperative donor site complications.16

Extraoral donor sites including tibia, fibula, ileum, calvarium, and costae should be considered when more bone volume is required. The AIC is one of the most preferred sites for it lies just beneath the subcutaneous layer of the skin and has a natural curve that is suitable for remodeling the curvature of alveolar bone. It has also ample cancellous bone, which provides better healing, with enough cortical component.17 Complications such as a hematoma, edema, pain, penetration of the abdomen, rupture of the lateral femoral cutaneous nerve, and difficulty walking are rare.18 It provides corticocancellous bone in large quantities with low morbidity.15,17

Patients having bone defects due to recurrent implant failures of the posterior maxillary region were shown to be reconstructed successfully with an AIC autogenous graft in the literature.18 Some studies demonstrated that the AIC was also a safe site for the alveolar cleft, neoplasm excision, and osteoradionecrosis sequestrectomy reconstructions in the head and neck region.19,20 One of the major disadvantages of grafts of the extraoral origin other than those of the calvarium is the fast resorption tendency due to their endochondral origin. This difference is probably because more cortical characteristics of the calvarial bone, which develops through intramembranous ossification, provide greater resistance to resorption.21 However, Dreiseidler et al22 pointed out that iliac crest grafting provides reasonable bone resorption until the implant placement stage.

Considering that there was a large amount of bone loss and the cancellous nature of the recipient site, the alveolar defect in our case was decided to be reconstructed by the anterior iliac autogenous graft based on both clinical and radiographic examinations. No complications were observed after the reconstruction procedure, and 2.5 years of follow-up controls revealed problem-free loading of implants.


Dental implants have significant benefits over conventional fixed dental prostheses. Dental implant–supported fixed restorations do not need preparation of the adjacent teeth when compared with conventional fixed prostheses.23 Moreover, dental implants are believed to provide an interface for the functional force transmission to the bone, which stimulates bone regeneration, preventing it from resorption. Autogenous grafting remains the gold standard for reconstructing dentoalveolar defects. In addition, an AIC of both appropriate quality and quantity may be considered as a good alternative as the donor site.


The authors claim to have no financial interest, either directly or indirectly, in the products or information listed in the paper.

Roles/Contributions by Authors

H. H. Tüz: Manager surgeon of the operation and co-writer. O. Koç: Assistant surgeon of the operation and co-writer. E. S. Meral: Assistant surgeon of the operation and co-writer. S. A. El: Assistant surgeon of the operation and co-writer.


No external funding was provided for this study.


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devitalizing leakage; iliac; implant

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