[Reconstraction of severe anterior maxillary ridge atrophy: combination of several surgical techniques]

D Schwartz-Arad
Journal of the Israel Dental Association 2017, 34 (1): 45-51
Achieving an esthetic and functional implant supported restoration in the maxillary anterior segment can be challenging especially in a severe atrophy. The reconstruction of atrophic alveolar ridges using autologous Onlay Bone Grafting (AOBG) was originally reported in 1975. It's still considered as the 'gold standard' bone-grafting material, as if combines all properties required in a bone graft material; osteogenesis, osteoinduction, and osteoconduction. The use of intraoral donor sites, such as the mandibular symphysis, and ramus, offers no cutaneous scarring, minimal discomfort, and less morbidity compared with the extraoral sources. In addition, intraoral sites comprises good bone quality, convenient surgical access, good incorporation with a short healing time, high biocompatibility and embryological proximity. Furthermore, recent studies describe extensive bone deficiency reconstruction using solely intraoral block bone grafts by means of the multities technique, possibly by re-harvesting bone from the same donor site. the anatomic configuration in the atrophic site, influences the surgical choices, i.e. when surgical reconstruction is performed in the anterior atrophic maxilla, the reference standard of care would be to perform subnasal augmentation procedure for vertical augmentation with additional vertical and/or horizontal AOBG augmentation if necessary. For the AOBG to be accepted in the augmented area, other elements are introduced for support and rehabilitation; Growth Factor (GFs) for example, are expressed during different phases of tissue healing and are therefore a key element in promoting tissue regeneration. Platelet Rich Plasma (PRP) is an inexpensive way to obtain many GFs in physiological proportion and therefore has gained wide interest as a therapy for both soft and hard tissue injuries. In addition, Platelet-Poor Plasma (PPP) is composed of acellular plasma containing fibrinogen and growth factors, and is used as a "biological membrane" to cover the entire augmented area and donor sites that were filled with bone substitutes saturated in PRP or BMAC (Bone Marrow Aspirate Concentrate)as scaffold. Mesenchymal stem cells (originated from the BMAC) can be differentiated into diverse tissues, including bones. It has been suggested that transplantation of autologous stem cells from bone marrow can as well enhance bone healing. Patient satisfaction is a key factor in the success of implant therapy, especially in the anterior maxilla. Defect in the gingival continuity of shape cannot be always compensated by the quality of the dental restoration only. The challenge is that hard and soft tissue augmentation is necessary to achieve a successful result. The challenge is that hard and soft tissue augmentation is necessary to achieve a successful result. The aesthetics of the patient can be improved using sub-epithelial connective tissue graft. The effectiveness of the combined surgical treatment described, is the fact that AOBG, was used fort he severe atrophic anterior maxilla reconstruction. Augmentation of atrophied maxilla through the positioning of horizontal and vertical AOBG, should be considered reliable, safe, and very effective in obtaining apico-coronal and bucco-lingual dimensions improving implant trajectory for high bone graft success rate following a high long-term implant survival rate.

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