CC
A 65-year-old female is referred to our clinic with the chief complaint of missing teeth in her upper right jaw.
HPI
The patient underwent surgery about 2 years ago to remove several radicular cysts along with all teeth in the upper right quadrant except for the incisors. No attempt to rehabilitate the occlusion in the upper right quadrant has been made so far neither by a removable nor a fixed prosthesis. The patient reports no signs and symptoms related to the previous pathology since the surgery.
PMH/PDHX/medications/allergies/SH/FH
Noncontributory except for the aforementioned surgery in the upper right quadrant 2 years ago.
Examination
General. The patient is healthy and well-nourished in general with no apparent distress.
Maxillofacial. A severe vertical defect had remained after the surgery with apparent loss in both hard and soft tissues ( Fig. 33.1 ). There are no signs pertaining to a remaining or recurring pathology. No apparent oroantral fistulas were detected at clinical inspection. The keratinized tissue was scarce, yet the soft tissue seemed inflammation free.
Imaging
Preoperative cone-beam computed tomography shows severe horizontal and vertical bone loss across the upper right alveolar ridge. The sinus seems free of illness, and a thin sinus floor is the only remaining bony structure in parts of the molar region ( eFig. 33.2 ).
Labs
The patient was prepared for an iliac–bone graft, so laboratory tests included a complete blood count, electrolyte check, and coagulation tests; the results were all normal.
Assessment
Severe horizontal and vertical hard and soft tissue loss because of respective surgery requires three-dimensional (3D) augmentation. Considering the size of the defect, the patient must be worked up for an autogenous iliac bone graft to augment the bone vertically (by both sinus lifting and onlay grafting) and horizontally. Occlusal rehabilitation by dental implants is planned after the augmentation is achieved.
Treatment
To restore soft and hard tissue three dimensionally, the patient was prepared for a bone augmentation procedure by an autogenous iliac graft under general anesthesia. After applying local anesthesia (lidocaine 2% and epinephrine 1/100,000) locally, a flap was elevated with the incision placed near the vestibular depth in mobile tissue ( Fig. 33.3 ). This allows for easier closure with no tension after the bone beneath has been augmented. It also places the incision away from where the graft for vertical augmentation is fixed. A mucoperiosteal flap was elevated.
A window in the lateral sinus wall was created using a diamond bur. The schneiderian membrane was meticulously elevated from the sinus floor. A small perforation in the schneiderian membrane in the superolateral aspect of the window was repaired using sutures fixating the membrane to the lateral sinus wall through two holes made by a small-diameter fissure bur ( Fig. 33.4 ).
Then autogenous corticocancellous graft was harvested from the right ileum ( Fig. 33.5 ). Cancellous bone chips mixed with autoplastic particulate bone graft were used to fill in the sinus floor where the membrane was elevated ( Fig. 33.6 ), and bone blocks were used as overlay grafts to enhance both bone width and height ( Fig. 33.7 ). The remaining gaps between the bone grafts were also filled with autoplastic bone material ( Fig. 33.8 ). To ensure two-layer closure, regain soft tissue volume, and boost bone augmentation, a pedicled buccal fat graft was mobilized and sutured to the palatal soft tissue over the bone grafts ( Fig. 33.9 ). This vascularized pedicle flap is a potent source of stem cells and progenitor cells, which can potentially turn to osteoblasts and fibroblasts, contributing to bone and soft tissue formation. Finally, the incision was sutured free of tension ( Fig. 33.10 ). The postoperative radiograph shows proper bone healing with the sinus floor elevated substantially, no evidence of sinus pathogenesis, and proper vertical bone height ( Fig. 33.11 ).
