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Revista Española de Cirugía Oral y Maxilofacial

versión On-line ISSN 2173-9161versión impresa ISSN 1130-0558

Rev Esp Cirug Oral y Maxilofac vol.28 no.1 Barcelona ene./feb. 2006

 

CASO CLÍNICO

 

Reconstruction of the maxilla by means of transport of the alveolar process.
A case report

Reconstrucción del maxilar superior mediante transporte del proceso alveolar.
Presentación de un caso

 

 

A. Bilbao1, R. Cobo2, M. Hernández4, R. Rocha3, J.M. Albertos1

1 Doctor en Medicina y Cirugía. Especialista en Cirugía Oral y Maxilofacial. Facultativo especialista de Área. 
Complejo Hospitalario de Santiago de Compostela. Práctica Privada Santiago de Compostela.
2 Médico especialista en Estomatología. Práctica privada. O Barco de Valdeorras. Ourense.
3 Odontólogo Práctica privada. O Barco de Valdeorras. Ourense.
4 Odontólogo. Alumno de Postgrado Universidad Complutense Madrid. Práctica privada, Madrid, España

Dirección para correspondencia

 

 


RESUMEN

La osteogénesis mediante distracción aplicada a la reconstrucción del proceso alveolar es una técnica sobradamente contrastada en la literatura, al igual que la utilización del transporte óseo en la reconstrucción de defectos segmentarios mandibulares.
Presentamos en este artículo un caso de reconstrucción de un defecto segmentario del maxilar superior mediante transporte de proceso alveolar y su posterior rehabilitación protésica implantosoportada. Mostramos tanto la técnica quirúrgica como el manejo de del vector de distracción utilizando elásticos de ortodoncia y tornillos de bloqueo intermaxilar.

Palabras clave: Distracción; Transporte óseo; Proceso alveolar; Maxilar superior.


ABSTRACT

Osteogenesis by means of distraction applied to the reconstruction of the alveolar process is a well-documented technique in the literature, as is the use of bone transport in the reconstruction of mandibular segment defects.
In the present article we report on a case of reconstruction of a segment defect in the maxilla using the alveolar transport process, and on the subsequent rehabilitation by means of an implant-supported prosthesis. Both the surgical technique and the handling of the distraction vector using orthodontic bands and inter-maxillary fixation screws are shown.

Key words: Distraction; Bone transport; Alveolar process; Maxilla.


 

 

 

Introduction

Maxillary reconstruction after tumor resection is an important challenge for oncological surgeons, since obtaining soft tissue and bony tissue at the same time implies, on most occasions, the use of free flaps in order to obtain enough volume to carry out an implant-supported rehabilitation.1

The application of osteogenesis techniques by distraction for reconstructing the alveolar process was described by Block2 on dogs and by Chin3 on humans. Since then, multiple descriptions of intraosseous and juxtaosseous distractor designs have appeared, and the technique has also been applied on toothed or edentulous segments.

One of the uses of osteogenic distraction both with long bones and mandibles has been for the reconstruction of segment defects, and this same technique has been used for maxillopalatine fissure closure.4

The application of this technique for reconstructing other kinds of segment defects in the maxilla is less common.5,6 Yet, it can be an excellent alternative in those cases in which obtaining a good segment for carrying out the transport is possible, and when a safe resection with regards to the tumor is guaranteed, as has already been attested in the case of the mandible bone.7

 

Case report

Male, 56 years old, formerly a heavy smoker (20 cigarettes a day), presented with a vegetative ulcerous lesion in the rear part of the left maxilla, his biopsy showing welldifferentiated squamous cell carcinoma. The pre-operative study was normal and the patient was scheduled to undergo surgery.

Using general anesthesia, the patient underwent surgical intervention, which consisted in complete ipsilateral functional resection of cervical ganglion cells plus lesion resection by maxillectomy of the rear part of the maxilla, including teeth 2.5, 2.6 and 2.7 in the resection specimen (Figs. 1 and 2).

A Bichat’s fat-pad flap was used for reconstructing the soft tissue (Fig. 3) and the alveolar process osteotomy was planned distally from tooth 2.2, including in the segment teeth 2.3 and 2.4. Care was taken to maintain the point of union with the palatine mucoperiosteum in order to guarantee blood circulation in the fragment, which is essential for the success of the treatment.8

A MODUS® modular distractor (Medartis AG, Basel, Switzerland) and a 15 mm. rod in open position were placed so as to execute the transport by closing the distractor. In order to secure the distraction vector, an intermaxillary fixation screw and a 4 1/2 ounce orthodontic band were put in place9 to prevent the vector from veering in an occlusal and palatine direction, which is commonly observed during the distraction process in the anterior sections of the maxilla (Figs. 4 and 5).

The pathology report was of well-differentiated squamous cell carcinoma with a maximum diameter of 3 cm. No bone infiltration was observed and the margins were tumor-free. There was 1/24 isolated nodal swelling with encapsulated squamous cell metastasis with a diameter of one centimeter. The patient was not given complementary radiation therapy treatment.

There were no complications during the postoperative period and, after a five-day latency phase, distraction of the fragment started at a rate of 0.75 mm. per day (three cycles of 0.25 mm.) for 20 days until the 15 mm. planned was achieved (Fig. 6), with a simultaneous increase of keratinized gum.

After a consolidation phase that lasted 10 weeks, two implants measuring 4.1 by 12 mm, Esthetic plus, ITI® system (Straumann AG, Waldenburg, Switzerland) (Fig. 7) were placed. These were rehabilitated 16 weeks later with a screw-retained SynOcta® prosthetic abutment system (Straumann AG, Waldenburg, Switzerland). Endodontic treatment of teeth 2.3 and 2.4 was carried out, which were then covered with a porcelain crown with a morphological compound of a second premolar and first molar, respectively, even though pulp vitality tests were positive.

Then, on removing the distractor, a graft of connective tissue harvested from the tuberosity of the right maxilla was placed for aesthetic improvement, because the neck of the implant in the mesial position was visible after the restoration (Fig. 8). This resulted in stability both in the mucosa and in the osseous region, with the implants behaving as though they had been attached to original bone, with a bone loss of less than 0.1 mm after 12 months (Fig. 9).

 

Discussion

The efficiency of distraction osteogenesis for transporting a segment of the maxilla was proved in this case, both from the aesthetic and functional point of view. Excellent results were achieved using a technique that is less aggressive and that has a reasonable economic cost. It can be carried out simultaneously with resection surgery and it is also recommended for mandibular resection.6

Achieving good aesthetic results by means of conventional implantology techniques is possible when there is a simultaneous increase in soft tissue and new bone formation.

The experimental studies carried out show that there is enough bone formation, both radiologically and histologically, to permit implant placement three months after callus consolidation, which also occurs in reconstructions by means of vertical distraction.10 The reconstruction of relatively large defects without resorting to grafts is also facilitated.11,12 Great advantages can be seen in the application of this technique (as well as in other applications described) given that no donor sites are needed as vital bony tissue is used resulting in a simultaneous gain of soft tissue. As a result we believe that it should be included in the therapeutic arsenal for reconstructing the maxilla,6 in the same way that it is used for mandibular reconstruction.

One of the advantages over reconstruction by means of microvascularized flaps that should be pointed out is the elimination of donor site morbidity. Surgical time is also reduced together with the postoperative hospital stay. The distraction process is carried out on an outpatient basis, as the patient is given instructions during the postoperative period. However, there is a close following of the clinical situation of the tissues and of the distraction vector aided by the elastic guides as previously described.

As occurs in other reconstructions, complementary techniques on bone as well as soft tissue can later be carried out, in order to improve the end-result of the implant reconstruction.

One of the disadvantages is the difficulty of obtaining an adequate morphology with regard to the curved segments, which may make two distraction phases necessary, although in segments such as the one described in this paper it is not an obstacle for obtaining good aesthetic and functional results.

It is important to emphasize the fact that the treatment of bone defects by distraction osteogenesis can be carried out on patients likely to require combined therapy including surgery and radiotherapy.13,14 In these cases hyperbaric oxygen may be used as adjuvant treatment,15 although the necessary time for the callus to mature is greater than in patients that do not undergo radiotherapy.14

 

Conclusion

Given the results obtained in this case report both from the aesthetic and functional point of view, and given the low aggressiveness and the high predictability of the technique, we consider bone transport a good tool for the reconstruction of small and medium-size defects.

 

 

Dirección para correspondencia
Dr. Arturo Bilbao Alonso
Servicio de Cirugía Oral y Maxilofacial.
Hospital de Conxo.
Ramón Baltar s/n
15705 Santiago de Compostela, España
e-mail Arturo.Bilbao.Alonso@Sergas.es

Recibido: 27.06.2005
Aceptado: 21.11.2005

 

 

References

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