Mandibular Sub-Apical Osteotomy as Adjunctive in Maxillary Rehabilitation With Dental Implants

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Severe maxillary atrophy is still a challenge in dental implants rehabilitation, because the Class III relationship is secondary to mandibular auto-rotation and anterior maxillary bone loss. Also, gravity forces mandibular soft tissues to descend increasing the lip to lower tooth show and lower facial third aging look. This study analyzes the functional and cosmetic results of including a mandibular sub-apical osteotomy with infero-posterior repositioning in the patient treatment planning combined with maxillary edentulous rehabilitation. Ten patients (6 female and 4 male) aged between 45-65 years old (average 52.3) underwent maxillary dental implants insertion to treat edentulism combined with anterior mandibular osteotomy to reposition the bony-dental segment inferiorly and posteriorly. The dental implants were either standard fixtures or zygoma implants placed as anterior as possible to eliminate the anterior crossbite or anterior canti-lever. The mandibular sub-apical osteotomies were performed through small incisions, minimal periosteal detachment and were fixated with bicortical screws. Some posterior mandibular fixtures were combined for maxillo-mandibular rehabilitation. All 10 patients were treated 3-D and the evaluation included clinical, radiograph and photograph analysis, pre- and postoperative; all patients were followed for a minimum of 12 months. The mean value for the anterior segment posterior and inferior repositioning was calculated postoperatively base on the lateral and PA cephalic radiographs. All patients were treated with provisional dental maxillary rehabilitation the day of the surgery. All final rehabilitations were installed within 5 months and remarkable esthetics improvement, Class I occlusions and ideal tooth-to-lip (-2 mm) relation were obtained. In the sub-apical osteotomy the posterior reposition was 4 to 7 mm (average 5.8 mm) and 3 to 5 mm (average 4.2 mm) of intrusion. This procedure was combined with zygoma (30) and conventional (27) implants in maxillary atrophy and conventional implants (37) in posterior edentulous mandibular area. No patients had intra- or postoperative complications. Mental nerve paresthesia was present in 2/10 and resolved in the following 6 months. The mandibular sub-apical osteotomy represents an excellent adjunctive surgical procedure to include in the treatment planning of total maxillary edentulous patients. This surgical alternative it is a highly predictable procedure, improves the esthetics, decreases the antero-posterior relation and helps occlusion biomechanics.