Vertical Deficiency Research Articles

Efficacy of alveolar sandwich osteotomy with simultaneous implant placement for the management of vertical deficiency

Objectives: The aim of this present study was to evaluate the efficacy of the alveolar sandwich osteotomy with simultaneous implant placement for the management of vertical deficiency. Materials and Methods: This study was conducted in the Department of Oral and Maxillofacial Surgery, Ragas Dental College, Chennai. A total of 10 partially edentulous patients with reduced alveolar ridge height were selected for the study and sandwich osteotomy with simultaneous implant placement was done. All patients underwent radiographic evaluation preoperatively and postoperatively at 0, 1, and 3 months, respectively. Results: Of the 20 implant sites, the pre-operative ridge height varied from a minimum of 6 mm to the maximum of 8 mm with the mean of 7 ± 0.4 mm. The mean length of the alveolar ridge achieved during immediate postoperative period was 10.6 ± 3 mm and at 1st-month post-operative period it was 10.5 ± 3 and at 3-month post-operative period, it was 10.4 ± 3, all patients were followed up for a period of 3-month postoperatively. Conclusion: Sandwich osteotomy with simultaneous implant placement can be successfully used in patients with moderate alveolar deficiency to increase alveolar bone height.

Alveolar ridge augmentation in mandible by use the modified distractor.

Objective: The aim of the present study was to evaluate the horizontal and the vertical alveolar distraction osteogenesis using modified alveolar distractor.Study design: The sample consisted of 7 patients presenting horizontally and vertically deficient edentulous ridges were treated by distraction osteogenesis with a modified Alveolar distractor. The surgical procedure was carried out with the patient under local anesthesia. After the osteotomy was performed with pizosurgery, the distractor was placed on the segmental bone over the gingiva for 3 months. The rate of distraction was 0.5 mm/twice a day.Results: The mean of horizontal alveolar before using the distractor was 4.70 mm (SD 0.31 mm) The mean of horizontal alveolar after using the distractor was 8.30 mm (Sd 0.59 mm). The mean of actual gain in bone horizontal at the end of the distraction period was 3.58 mm (SD 0.15 mm). The mean of height alveolar before using the distractor was 6.67 mm (SD 0.46 mm) The mean of height alveolar after using the distractor was 12.59 mm (SD 0.52 mm). The mean of actual gain in bone height at the end of the distraction period was 5.92 mm (SD 0.25 mm).Conclusion: It was concluded that the modified alveolar distractor seems to be an effective to treat horizontal and vertical alveolar ridge deficiencies, and distraction osteogenesis can be considered a safe and effective procedure for gaining bone in the horizontal and the vertical dimension of the alveolar.

Is Resonance Frequency Analysis a Reliable Evaluation for Primary Stability of Implants Without Apical Contact?

The primary stability of dental implants is one of the most crucial factors for providing long-term success of osseointegration. Vertical deficiencies, such as those due to maxillary sinus pneumatization, may cause a severe vertical limitation to residual bone height. This study aimed to examine the primary stabilization of implants without apical contacts. Eighty bone-level implants (4.1-mm diameter/10-mm length) were placed into polyurethane test blocks without apical contacts. According to coronal bone-to-implant contact, groups were set as 4, 6, 8, and 10 mm, respectively. Resonance frequency analysis (RFA) using a SmartPeg was performed separately toward the transversal and horizontal axes by two independent researchers. Data were statistically compared for interobserver and among groups. Interobserver reliability varied from moderate to excellent (intraclass correlation coefficient [ICC]: 0.629 to 0.985). There were no significant differences among the 6 mm, 8 mm, and 10 mm groups, although the 4 mm group showed the significantly lowest stability (P < .001). Transversal and longitudinal measurements of the same groups did not show a parallel correlation statistically. RFA values may be affected by the finger torque in tightening of the SmartPeg among different researchers. Fully placed implants did not significantly show the highest stability among various apically contactless groups. Consequently, RFA should not be used alone to evaluate primary stability for implants without an apical contact.

Sub-antral volumetric variation after a modified trephine sinus elevation approach: An 8-month prospective study

Aim To overcome vertical deficiency of atrophic posterior maxilla, sinus floor elevation has been used for several decades either through a transcrestal or a lateral approach. In 1999, Fugazzotto et al. described a modified trephine/osteotome technique for sinus floor augmentation at the time of maxillary molar extraction without implant placement. A trephine was used to create a bone core in the middle of the extraction site and was gently malleted apically. In 2002, Fugazzotto et al. used the same principle to place dental implants in healed maxillary molars sites with limited residual height (RH). This procedure demonstrated a 98.3% implant survival rate at 4 years but lacked radiographic information. The aim of the present study was to assess the efficacy of the modified trephine/osteotome sinus elevation with implant placement, using a clinical and a radiographic cone beam evaluation. Materials and methods Twenty-one implants were placed in premolar and molar sites with 3≤ RH ≤6mm using the modified trephine/osteotome sinus elevation approach and were evaluated clinically and radiographically at baseline (T1), 3 (T3) and 8 (T8) months. Results Implant survival was 100% at 8 months. Sub-antral volumetric bone gain between T1 and T8 was 20.34%. Linear bone gain was 2.1 ± 1.1 mm buccally; 2.0 ± 1.4 mm palatally; 2.5 ± 1.6 mm mesially; and 1.5 ± 1.5 mm distally. Mean linear bone gain was 2.0±1.1 mm calculated on the CBCT. Implant stability quotient (ISQ) at T1 was 66.378±7.931, and 67.921±14.369 at T3 without a statistically significant difference between the two measurements. Residual height was positively correlated to vestibular, palatal, and mesial bone gain. Signs of Schneiderian membrane tearing were noticeable in one case. Conclusion This study demonstrated that sufficient subantral bone formation can be obtained with the modified trephine/osteotome technique with high implant survival rate and low post-operative morbidity.

Sinus Pack for maxillary sinus augmentation: a new technique

Aims Maxillary sinus lift is a surgical procedure suitable to restore vertical deficiencies of the posterior maxilla and can be executed either with a lateral or with a crestal approach. One of the most important aspects of a bone regeneration is the stability of the graft. The aim of this study is to introduce a new grafting technique for sinus lift with a lateral approach, which is called Sinus Pack Technique. Methods Four patients with severe vertical atrophy of the alveolar bone in the posterior maxilla who needed unilateral dental implant rehabilitation of the edentulous maxillary region were treated according to the Sinus Pack technique- After 6 months a Computed Tomography scan was taken to assess the obtained bone volumes, implants were placed, and a bone sample was obtained with a 4mm trephine bur. Results Three males and one female (age range 36-75 years) were treated; no intra- and post-operative complications were recorded. According to the measurements performed on the CT scan before surgery and six months after surgery we found an average vertical gain of 6.95 mm. According to the histological and histomorphometric analysis the membrane was completely resorbed, new bone had formed and only a slight percentage of bone-filling granules was still present. Conclusion The Sinus Pack technique has the advantage of being a minimally invasive and safe surgery procedure, with results similar to other sinus lift techniques. More reports are needed to confirm the lower hypothesized complication rate and its efficacy.

Vertical bone augmentation utilizing a titanium-reinforced PTFE mesh: A multi-variate analysis of influencing factors.

To clinically evaluate the use of a titanium-reinforced PTFE mesh for vertical bone augmentation (VBA) of deficient alveolar ridges. This case series documented consecutive patients treated for VBA with a newly developed PTFE mesh. VBA was performed in anterior and posterior, maxillary and mandibular arches using anorganic bovine bone combined with autogenous graft in a 1:1 ratio. Healing time from initial surgery to re-opening was recorded. Baseline vertical deficiency, absolute bone gain (gross height gained), and relative gain (percentage of defect fill with respect to the baseline deficiency) were registered. Fifty-seven patients (65 defects) were included in the analysis. The mean baseline vertical deficiency was 5.5±2.6mm. The mean absolute bone gain was 5.2±2.4mm. A relative gain of 96.5±13.9% was achieved. Overall, 89.2% of cases showed complete regeneration, which occurred in all sites with baseline deficiencies of <5mm, in 95.6% of sites with 5-8mm deficiencies, and in 89.4% of sites with >8mm deficiencies. Each 1-mm addition to the baseline height deficiency increased the likelihood of incomplete bone regeneration by 2.5 times. Defect location had a statistically significant but a limited clinical impact on the bone height gained (<0.5mm). Complications were observed in three cases (3%). Vertical bone augmentation with titanium-reinforced PTFE mesh and a mixture of autologous bone and xenograft is a safe and predictable procedure. The extent of the baseline vertical deficiency influences the percentage of bone gained.

Analysis of strengthened short deficient rubberized concrete-filled steel tubular columns

Concrete-filled steel tubular (CFST) columns are broadly used in many structural systems for their well-known merits. This paper presents a finite element investigation on the structural behaviour of short circular deficient steel tubes filled with rubberized concrete (RuC), under axial compressive load. To accomplish this study, a validation of the proposed three-dimensional nonlinear finite element model; using ANSYS software; was carried out showing good accurateness. The analysis involved two different concrete mixes with 5% and 15% replacement of fine aggregate volume with crumb rubber particles. Columns strength reduction due to horizontal or vertical deficiencies was handled by increasing the thickness of the steel tube or wrapping the columns with two different types of FRP sheets. Five strengthening arrangements were studied using GFRP sheets and CFRP sheets. The results indicated that the ultimate bearing capacity of the RuCFST columns was increased with increasing the steel tube thickness. application of FRP sheets for strengthening the deficient RuCFST columns efficiently managed to retrieve the strength-lost due to either horizontal or vertical deficiency. Moreover, an enhancement in the columns’ ductility was observed especially when using GFRP sheets

Maxillary Split Crest And Sinus Augmentation With Piezosurgery And Growth Factors

One of the most common anatomic limitation which prevents a correct implant placement, is horizontal and vertical bone deficiency. Modern surgical techniques allow predictable rehabilitation of these severe defects, using on one side the great regenerative potential of autologous growth factors, on the other side instruments that allow more bone preservation and less trauma on hard and soft tissues, crucial criteria for successful surgeries

Management of the Vertical Dimension in the Camouflage Treatment of an Adult Skeletal Class III Malocclusion

Treating skeletal class III malocclusions is one of the biggest challenges in Orthodontics. Given the complexity of these cases, orthognathic surgery is often the best treatment option. However, many patients refuse this treatment due to its risks, morbidity, and costs involved. Alternatively, dental compensation can be planned for some of these skeletal problems. This case report presents a dentoalveolar compensation in the orthodontic treatment of a 20-year-old female patient with class III malocclusion, concave profile, anterior crossbite, mandibular prognathism, maxillary retrusion, and a vertical deficiency in the posterior region. Treatment planning involved a multiloop edgewise archwire (MEAW) associated with intermaxillary elastics with counterclockwise rotation of the occlusal plane in the posterior region of the maxilla aiming at obtaining an increased posterior vertical dimension. After 24 months of treatment, the severe anterior crossbite was corrected, and the skeletal class III relationship was camouflaged. At the end of the orthodontic treatment, it was possible to observe an improved facial profile, a nice smile, and a functional occlusion. The results remained stable at a three-year follow-up. The MEAW, associated with the use of elastics, seems to be an effective treatment option for class III camouflage with reduced posterior vertical dimension with no need for additional anchoring devices but requiring adequate bending of wires and patient compliance.

A Combined Orthodontic and Surgical Treatment Approach to Treat Vertically Diverse Skeletal Class II Malocclusions: A Case Series

Malocclusions in the vertical plane are more difficult to treat as compared to the malocclusions in the sagittal plane as they often require multidisciplinary (surgical) approach. Skeletal vertical deficiency and excess causes jaw discrepancies in the sagittal vector too due to rotation of the mandible, thus presenting a complex situation which requires astute treatment planning and implementation. In this article, two cases treated with combined orthodontics and orthognathic surgery to treat skeletal class II malocclusion with vertical deficiency and excess are shown and all details of treatment planning are discussed.

Two-stage distalization of the mental foramen to manage posterior mandibular vertical bone deficiency—a prospective observational study

Inferior alveolar nerve (IAN) transpositioning is a modality utilized to manage posterior mandibular vertical deficiency. Several complications have been reported including improper implant positioning, mandibular body fracture, and neurosensory disturbance. The aim of this prospective observational study was to introduce a two-stage mental foramen distalization technique to minimize the complications associated with IAN transpositioning. Ten patients with severely atrophied mandibular ridges were included. Cone beam computed tomography was ordered to accurately locate the position of the IAN and its incisive terminal branch before designing the outline of two cortical osteotomies anterior and posterior to the mental foramen. The osteotomies were created using a piezoelectric device, followed by separation and identification of the nerve. The incisive branch was severed to freely transpose the IAN. A new foramen was created far distally and the cortical windows were repositioned and fixed with two screws. Healing was uneventful for all patients. Neurosensory recovery was assessed by MRC scale. All cases showed full recovery within 6 weeks, except for two patients who showed complete recovery after 16 weeks. Four months postoperative, all patients showed complete consolidation of the cortical windows without any signs of failure implants were placed at the pre-planned surgical sites. Histomorphometric analysis of core biopsies from seven surgical sites showed bone area percentages ranging from 46% to 63%. The two-stage mental foramen distalization technique is a predictable and safer technique for IAN transpositioning specifically in cases of vertical bone deficiency associated with limited inter-arch space.

Management of Atypical Symmetrical Ankylosis of Maxillary Deciduous First Molars with Permanent Successors: A Single Case Report

Dentoalveolar ankylosis is the union between the tooth root and the dentoalveolar bone. Clinically, the affected tooth is unsuccessful to erupt, exhibits an infraocclusal position within the dentoalveolar arch, elicits a metallic sound on percussion, and has reduced or absent mobility. Objective: This single case report illustrates the management of idiopathically ankylosed maxillary deciduous first molars. Case report: The patient was a 6-year-old female with maxillary deciduous first molars in infraocclusal position due to idiopathic ankylosis. The ankylosed deciduous teeth were monitored regularly. After a 27-month follow-up, the infraocclusion became severe. No vertical deficiencies in other alveolar regions were detected. The ankylosed maxillary deciduous molars were extracted. After the extractions, vertical growth of the alveolar bone became normal and the maxillary first premolar successors erupted spontaneously. Conclusion: Conservative monitoring of ankylosed deciduous molars would be beneficial and preferred to prevent the impaction of permanent successors and manage the occlusion in a growing child. In case of severe infraocclusion, the deciduous molars may be extracted.

Alternativas para reabilitação com implantes dentários em mandíbula posterior atrófica

An adequate bone volume is mandatory for a favorable long-term prognosis in patients treated with dental implants. The vertical deficiency of posterior mandible is a common condition in partially edentulous patients, in which vertical bone augmentation procedures or inferior alveolar nerve transposition become necessary for the dental implant rehabilitation. Thus, the aim of this study was to discuss options of vertical bone augmentation techniques in atrophic posterior mandibles and to present, as case reports, alternatives for the rehabilitation of patients with this condition. So, three alternatives of treatment were presented: the use of Cytoplast titanium-reinforced membrane over autogenous and xenogenous particulate bone graft; sandwich osteotomy; and nerve transposition. In the three reported cases, the chosen surgical techniques showed to be appropriated and allowed the placement of longer implants. No significant complications were observed and all the patients were satisfied with the performed treatment. It is possible to conclude that the reconstruction of atrophic posterior mandible remains a challenge to the professionals, who must know the various existing techniques and choose the most suitable one to each patient.

Numerical and Experimental Study on Deficient Short Steel Tubes Strengthened with CFRP Under Compression

In view of development and repair costs, support of structures is imperative. Several factors, for example, design and calculation errors, absence of appropriate installation, change of structures application, exhaustion, seismic tremor, fire and natural conditions diminish their strength. In such cases, structures have need of rehabilitation and restoration to achieve their original performance. One of the most up to date materials for retrofitting is carbon fiber reinforced polymer (CFRP) that can provide an amount of restriction to postpone buckling of thin steel walls. This paper provides a numerical and experimental investigation on CFRP strengthened short steel tubes with initial horizontal and vertical deficiency under compression. Ten square and circular specimens were tested to study effects of the following parameters: (1) position of deficiency, horizontal or vertical; (2) tube shape, square or circular; (3) CFRP strengthening. In the experiments, axial static loading was gradually applied and for the numerical study three-dimensional (3D) static nonlinear analysis method using ABAQUS software was performed. The results show that deficiency reduces load-bearing capacity of steel columns and the impact of horizontal deficiency is higher than the impact of vertical deficiency, in both square and circular tubes. Use of CFRP materials for strengthening of short steel columns with initial deficiency indicates that fibers play a considerable role on increasing load bearing capacity, reducing stress at the damage location, preventing deformation caused by deficiency and delaying local buckling. Both numerical and experimental outcomes are in good agreement, which underlines the accuracy of the models adopted.

Mandibular Vertical Growth Deficiency After Botulinum-Induced Hypotrophy of Masticatory Closing Muscles in Juvenile Nonhuman Primates.

The purpose of this study was to investigate the relationship between masticatory muscular hypotrophy and mandibular growth in juvenile nonhuman primates (cynolmolgus monkeys, Macaca fasicularis). We hypothesized that botulinum toxin (BTX)-induced neuro-muscular junctional block and its resultant hypotrophy of masticatory muscles would produce mandibular growth disturbances in size and shape. Ten male cynomolgus monkeys were divided into three groups: group I (control; n = 3), group II (unilateral BTX; n = 4), and group III (bilateral BTX; n = 3). The unilateral or bilateral muscular hypotrophy of major masticatory closing muscles was induced by synchronous BTX application to masseter, medial pterygoid, and temporal muscle. Mandibular growth was tracked by linear, angular, area and volume measurements using three-dimensional (3D) computed tomography imaging before BTX treatment and after 3 and 6 months. After unilateral hypotrophy of masticatory muscles in group II, vertical growth deficiency was prominent on the BTX side, with compensatory overgrowth on the control side. The bilateral muscular hypotrophy in group III also showed smaller ramal height and width than that of control (group I) and control side (group II). Moreover, ramal sagittal angles (posterior tilt) increased on the BTX side of both groups II and III, but coronal angles (lateral tilt) did so on the BTX side of group II, resulting in asymmetry. The results confirmed our hypothesis that functional activity of masticatory closing muscles is closely related to mandibular growth in size and shape of juvenile nonhuman primates. In addition, the focused growth disturbances on the ramal height and posterior-lateral tilt suggested the possible role of masticatory closing muscles for ramal vertical and angular growth vector of the mandible.

Staged orthodontic treatment in preparation for immediate implant placement: A clinical report with a 5-year follow-up

Anterior implant restoration is one of the most challenging restorative procedures, especially for sites with vertical and/or horizontal hard and soft tissue deformities. Orthodontic extrusion before implant placement may be the best means of overcoming vertical deficiencies. This article describes a modification to the standard technique, involving staged orthodontic extrusion and buccal root torque. The main advantage of this modification is that it encourages bone and soft tissue development, thereby allowing the patient to receive immediate or early implant treatment. A clinical procedure is presented to illustrate the modified technique that resulted in an esthetically pleasing and stable 5-year outcome.

Orthognathic Surgery Combined with Glossectomy and Mandibular Constriction: A Case Report

Background: Conventional orthognathic surgery can become challenging when multiple goals such as correction of transverse and anteroposterior discrepancies of the dental arches are aimed. Thus, additional procedures such as midline mandible osteotomy for mandibular constriction and tongue reduction due to true macroglossia may be alternatives to a more functional and aesthetical outcome. Case Report: A treatment of a 35-year-old female patient with Class III sagittal skeletal pattern marked by an increased angle facial profile, maxillary retrusion, vertical maxillary deficiency, and mandibular protrusion, a Class III malocclusion associated to an edentulous maxilla, partially dentate mandible, transverse mandibular excess and true macroglossia. With an Index of Orthognathic Functional Treatment Need (IOFTN) grade 5, the patient underwent bimaxillary orthognathic surgery, mandible constriction and partial glossectomy. After about a year of follow-up, the patient demonstrated skeletal stability for the orthognathic procedures as well preservation of tongue function. Conclusion: The combination of the techniques performed was effective in the treatment of the multifaceted deformities, providing satisfactory function, harmonious facial aspect and enabling effective prosthetic rehabilitation to the patient.

Anterior maxillary sandwich osteotomy technique with simultaneous implant placement: A novel approach for management of vertical deficiency.

The introduction of sandwich osteotomy technique with simultaneous implant placement allowed various procedures to be carried out with a level of great precision and accuracy thus saving time for the patient and clinician. The aim of the current study is to evaluate the efficacy of this new technique regarding increasing the anterior maxillary alveolar height with simultaneous implant placement. Nine patients suffering from multiple missing anterior maxillary teeth were selected with vertical dimension not less than 10 mm. anterior maxillary sandwich osteotomy technique was carried out for all patients using xenograft bone particulate with simultaneous implant placement at single stage surgery. For two patients, four implants showed significant marginal bone loss with maximum marginal bone loss up to 2.8 mm. However, the immediate postoperative follow up went uneventful for all nine patients included in the present study. None of them showed any complication regarding postoperative wound dehiscence, infection, or segment mobility. Four months postoperative upon the prosthetic phase, all the 18 placed implant were clinically osseointegtated. All 18 implants were successfully integrated in the present study. The prosthetic phase started after 4 months for all cases and there was no need for harvesting of autogenous bone from the patient. But further studies are required to evaluate the viability of such approach in single implant placement cases.

PC363: Rehabilitation of a patient with vertical and horizontal bone deficiency with dental implants in the aesthetic region of a patient who has had a traffic accident

PC363: Rehabilitation of a patient with vertical and horizontal bone deficiency with dental implants in the aesthetic region of a patient who has had a traffic accident

The modified lip-tooth-ridge classification: a guide for edentulous maxillary arches

According to the width and height of the maxillary alveolar ridge, the maxillary edentulous jaws can be divided into three categories by using modified lip-tooth-ridge (MLTR) classification. Class Ⅰ is characterized by sufficient bone available for implants in the vertical and horizontal aspects and is suitable for fixed implant-supported prostheses. Class Ⅱ is characterized by sufficient bone amount available for implants in a horizontal aspect but insufficient for lip support and is suitable for a fixed detachable implant-supported prosthesis. Class Ⅲ is characterized by inadequate amount of bone for implants (with vertical or horizontal components) and is suitable for the use of zygomatic implants or traditional complete denture. Patients belonging to Class Ⅰ can be further classified into two sub-categories according to the height of the alveolar ridge. The first subclass is characterized by minimal bone deficiency and is suitable for a conventional implant-supported "crown and bridge" prosthesis. The second subclass is characterized by a larger vertical deficiency than that of the first subclass and is suitable for implant-supported hybrid prosthesis. The MLTR classification system can help the dentist to determine whether the patient is suitable for implanting dentures and whether fixed denture or removable denture is appropriate for the patient, select indications, reduce complications, and achieve long-term results.