zygomaticomaxillary buttress as a donor site

RUNGTA COLLEGE OF DENTAL SCIENCES &

RESEARCH, KOHKA, BHILAI, C.G.

ZYGOMATICOMAXILLARY

BUTTRESS : AS A POTENTIAL

DONOR SITE FOR BONE

GRAFT IN IMPLANT THERAPY

A CLINICAL STUDY AND REVIEW OF LITERATURE

Guided by -DR. SUNIL C DUTT, Prof. & HOD

DR. M. SATISH, Reader

DR. DEEPAK THAKUR, Reader

DR. MANISH PANDIT, Senior Lecturer

Presented by – DR. SHEETAL KAPSE

2ND YEAR P.G. STUDENT2

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INCLUSIONS

INTRODUCTION

AIM & OBJECTIVE OF STUDY

ANATOMY

CLINICAL PRESENTATION

DISCUSSION WITH REVIEW OF LITERATURE

CONCLUSION

RESOURCES

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INTRODUCTION

• Augmentation of maxillary alveolar bone defects for placement of implant still poses a clinical challenge for the surgeons.

• In addition to autogenous bone & alloplastic materials, synthetic bone substitutes as well as denatured bovine bone & coral structures, are all possible alternatives available for use as augmentation material.

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• But the use of autogenous bone graft

still remains the ‘gold standard’ for

both cancellous & cortical bone

grafting applications.

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• After bone harvesting from this area, postoperative trismus as well as injury to the adjacent soft tissues with profuse hemorrhage can occur.

Maxillary Tuberosity

Gellrich NC, Held U, Schoen R, Pailing T, Schramm A, Bormann KH. Alveolar Zygomatic Buttress: A New Donor Site for Limited Preimplant Augmentation Procedures J Oral Maxillofac Surg .2007;65:p275-280.

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Palatal Graft

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Osteodistraction

• This method might be considered by some clinicians and patients alike to be a rather involved and time-consuming alternative.

Schlegel KA, Neukam FW: Augmentationen, Knochenersatzmaterialien, Membranen, in Reichart PA, Hausamen J-E, Becker J, Neukam FW, Schliephake H, Schmelzeisen R (eds): Zahnärztliche Chirurgie I. Berlin, Quintessenz, 2002, pp 434-459

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ZYGOMATICOMAXILLARY BUTTRESS GRAFT

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AIM & OBJECTIVE

• Why the Zygomaticomaxillary buttress……

• Advantages and limitations ……..

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ANATOMY OF

ZYGOMATICOMAXILLARY BUTTRESS REGION

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ZYGOMATICOMAXILLARY BUTTRESS

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• Vase shaped

• Boundaries - Inferiorly- alveolar process and roots of teeth medially - roots and sinus superiorly joins the zygoma posteriorly infratemporal fossa

• Bone quality – cortical & cancellous• Intramembranous ossification• Function - Provides pressure absorption and

transduction in the facial skeleton. • Pathologies and variations not known

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CBCT images……

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For the Zygomaticomaxillary buttress harvest

• Subsulcular

or

Extended crestal incision

• Elevation…superiorly till the ZM suture

• These designs will expose the entire buttress.

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• The minimum donor site surface area should be approximately 10 mm X 15 mm and accessible with the instrument at an angle between 5° and 50°.

Peleg M, Garg AK, Misch CM, Mazor Z. Maxillary sinus and ridge augmentations using a surface-derived autogenous bone graft. J Oral Maxillofac Surg. 2004 Dec;62(12):1535-44.

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Technical note

• Use of ultrasound based dissection with piezosurgery causes no trauma to sinus membrane.

Gellrich NC, Held U, Schoen R, Pailing T, Schramm A, Bormann KH. Alveolar Zygomatic Buttress: A New Donor Site for Limited Preimplant Augmentation Procedures J Oral Maxillofac Surg .2007;65:p275-280.

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ADVANTAGES

1. Accessibility to site & excellent visibility.

2. Same morphology & Same architecture.

3. Good quality & adequate quantity.

4. No muscular or neurovascular injury.

5. Less prone to resorption.

6. 1.5 to 2 cm - not compromise the strength of the

lateral midface frame.

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LIMITING FACTORS

• Damage to maxillary sinus membrane.• Damage to tooth root.• Limited volume of graft.• Contraindicated in patients with sinus problem

Montazem A, Valauri D, St-Hilaire H, Buchbinder D. The mandibular symphysisas a donor site in maxillofacial bone grafting: a quantitative anatomic study. J Oral Maxillofac Surg 2000: 58: 1368–1371.

Misch CM. Comparison of intraoral donor sites for onlay grafting prior to implant placement. Int J Oral Maxillofac Implants 1997: 12: 767–776.

Sindet-Pedersen S, Enemark H. Reconstruction of alveolar clefts with mandibular or iliac crest bone grafts: a comparative study. J Oral Maxillofac Surg 1990: 48: 554–558.

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Case report.......

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• A 26 year old male visited us for rehabilitation of lost teeth following RTA, Was treated in 2010 for pan facial fractures by ORIF.

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Treatment plan• Following clinical, radiological and model

assessments Maxillary rehabilitation was planned using implants supported prosthesis bridge .

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• Bone height was found satisfactory except in the canine region where a crater of about 1cm was present.

• Zygomaticomaxillary buttress grafting under local anesthesia.

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• Zygomaticomaxillary buttress grafting under local anesthesia.

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• Implant site was exposed through crestal incision and grafting site exposed through a Subsulcular incision .

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• A 5mm trephine was used to harvest the graft from the buttress region.

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• A hole for accommodating implant drilled in the graft.

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• Graft was held in place and a 3.75 X 16 mm implant was carefully inserted into the previously prepared site.

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Immediate post operative……..

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Follow up visits.........

• found healing uneventful.Weekly for 1

month

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• prosthetic rehabilitation. 4 months

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CBCT –1 year Post-Operative

• No mobility, resorption or any other complications were noted.1 year

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Discussion & review of literature

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• To achieve a good esthetic result and long-term functional stability, positioning of the implant is crucial.

• Alveolar crest defects have been particularly scrutinized because they are the limiting factor in optimal implant positioning.

• If the bony recipient site does not fulfill the later implant- based prosthodontic requirements, failure of the whole treatment is likely to occur.

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Supporting articles

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Gellrich NC, Held U, Schoen R, Pailing T, Schramm A, Bormann KH. Alveolar Zygomatic Buttress: A New Donor Site for Limited Preimplant Augmentation Procedures. J Oral Maxillofac Surg .2007;65:p275-280.

Gellrich et al in 2007Peleg et al in 2004

Michael Peleg, Arun K. Garg, Craig M. Misch, Ziv Mazor, Maxillary Sinus and Ridge Augmentations Using a Surface-Derived Autogenous Bone Graft. J Oral Maxillofac Surg. 2004; 62:1535-1544.

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Conclusion

Many advantages

Few disadvantages

Stick to protocol

Surer to have a good

result……

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References 1. Gellrich NC, Held U, Schoen R, Pailing T, Schramm A, Bormann KH.

Alveolar Zygomatic Buttress: A New Donor Site for Limited Preimplant Augmentation Procedures J Oral Maxillofac Surg .2007;65:p275-280.

2. Schlegel KA, Neukam FW: Augmentationen, Knochenersatzmaterialien, Membranen, in Reichart PA, Hausamen J-E, Becker J, Neukam FW, Schliephake H, Schmelzeisen R (eds): Zahnärztliche Chirurgie I. Berlin, Quintessenz, 2002, pp 434-459

3. Michael Peleg, Arun K. Garg, Craig M. Misch, Ziv Mazor, Maxillary Sinus and Ridge Augmentations Using a Surface-Derived Autogenous Bone Graft. J Oral Maxillofac Surg. 2004; 62:1535-1544.

4. Kainulainen VT, Sàndor GK, Oikarinen KS, Clokie CM. Zygomatic bone: an additional donor site for alveolar bone reconstruction. Technical note. Int J Oral Maxillofac Implants. 2002 Sep-Oct;17(5):723-8.

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References

5. Montazem A, Valauri D, St-Hilaire H, Buchbinder D. The mandibular symphysis as a donor site in maxillofacial bone grafting: a quantitative anatomic study. J Oral Maxillofac Surg 2000: 58: 1368–1371.

6. Misch CM. Comparison of intraoral donor sites for onlay grafting prior to implant placement. Int J Oral Maxillofac Implants 1997: 12: 767–776.

7. Sindet-Pedersen S, Enemark H. Reconstruction of alveolar clefts with mandibular or iliac crest bone grafts: a comparative study. J Oral Maxillofac Surg 1990: 48: 554–558.

THANK YOU…

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