Dennis RohneiPeter BucherChristoph KunzBeat HammerRobert K. SchenkJoachim Prein

Treatment of severe atrophy of themaxilla with the prefabricated freevascularized fihula flap

Authors' affiliations:Dennis Rohnei. Peter Bucher. Cbhstoph Kunz.Beat Hammer, loacbim Prein, Department ofReconstructive Surgery, University of Basel,University Hospital, SwitzerlandRobert K. Scbenk, Institute of Pathophysiology,University of Bern, Switzerland

Correspondence to:Dennis RahnctDepartment of Reconstructive SurgeryUniversity Hospital, University of BaselSpitaistrasse 11CH-4051 BaselSwitzerlandTel: +41 61 265 75 40Fax: +41 6t 165 74 58e-mail: dennisrohner@h()Unail.com

Key words: prefabrication, free vascularized fibula flap, titanium implants, maxillaryatrophy, split skin graft

Abstract: Treatment of severe maxillary atrophy despite complex major surgery oftenends up with an unsatisfactory result. This paper presents the augmentation of themaxilla with a prefabricated free vascularized fibula flap in combination with ITI*implants {Straumann AG, Waldenburg, Switzerland) in A patients. The technique ofprefabrication for the reconstruction of maxillofacial defects is described based on theexperience with 17 patients. The key points of this treatment are i) preoperativeplanning and fabrication of the drilling template; ii) prefabrication of the fibula withITI® implants and performing of a "vestibuloplasty" using a skin graft; iii) technicalconstruction and fabrication of the suprastructure and the denture; iv) reconstruction ofthe maxilla using the prefabricated fibula as free vascularized flap. The reconstructionswith the fibula flaps were successful and the 18 ITI^ implants that have been insertedshowed good osseointegration without loss of attachment in all 4 patients after amean observation period of 12 months.

Date:Accepted t i March 2001

To Che this article:Rohner D, Buthtr P, Kunz C, Hammer B, Schenk RK,Prcm J. Treatmtnt of severe atrophy of the maxillawith .1 prefabricated free vascularizeil fibula (lapChn. Otal Imp!. Res. i j , looi; 44-51

Copyright O Munksgaard 1001

ISSN090S-7161

The aim of reconstructing a severelyatrophied maxilla is the recovery of anadequate masticatory function and theachievement of increased aesthetics. Op-timal fimction can only be acquiredusing an implant-borne prosthesis orbridge-construction. In severe atrophy(Cawood Class V & VI), the lack of bonemass often precludes sufficient stahilityand osseointegration for dental im-plants. The resorbed alveolar ridge basfirst to be treated (Toiman 1995). A com-monly used technique for the augmenta-tion of tbe posterior maxilla is the sinuslift procedure, which allows for insertionof implants simultaneously or in a sec-ond procedure [Khoury 1999). But im-provement of the skeletal relation be-tween upper and lower jaw can beachieved only witb onlay technique orLe Fort osteotomy in combination withfree bone grafts (Breine & BrSnemark

t98o; Cawood et al. 1994; van Steen-hergbe et al. 1997). However, tbese pro-cedures are time-consuming and associ-ated with an uncertain rate of bone re-sorption hecause of the use of freenonvascularized bone grafts.

Tbe reconstruction of bone defectsusing free vascularized tissue transfer isa technique that has become a reliableprocedure in recent years. Fibula, scap-ula and iliac crest are the commonlyused donor sites for the reconstructionof maxillofacial defects (Bahr 1996; Ka-zaoka et al. 1999; Nakayama et al. 1994,-Yim & Wei 1994). Recent reports high-lighted the prefahrication of free vascu-larized fiaps as a further development inthe field of reconstructive surgery (Igawaet al. 1998; Vinzenz at al. 1998; Rohneret al. 2000a; Rohner et al. 2000b].

The purpose of this report is to de-scribe the augmentation of a severely re-

44

Rohner et a l . Prefabricated free vascularized fibula flap in severe maxillary atrophy

sorbed maxilla witb our technique ofprefabrication using a free vascularizedfibula flap in combination witb ITI im-plants and split skin graft. The keypoints of our tecbnique are: i) preopera-tive planning and fabrication of a drillingtemplate for implant insertion and fibulaosteotomies; ii) placement of impiantsand creation of a stable peri-implant softtissue attachment in a first surgical pro-cedure at tbe donor site; iii) fabricationof dental prostbetics prior to tbe recon-struction; iv) reconstruction of the max-illa witb tbe prefabricated free vascular-ized fibula fiap and attached prostbetics;and v) immediate postoperative func-tional loading.

Patients and methods

From April 1998 until July 2000 we oper-ated on 17 patients using the prefabri-cated free vascularized fibula fiap. Max-illofacial defects, secondary to a majorhead injury or to tumour resection, werereconstructed with the prefabricatedfihula flap in 13 patients. In 4 patients theprefabrication was carried out to aug-ment a severe atrophy of tbe maxilla withCawood class V &. VI (Cawood & Howell1988). A total numher of 18 ITl* implantswitb the SLA surface (sand blasted, largegrit, acid etched) were inserted to fix tbe

bar-borne prosthesis in tbese 4 cases. Inall tbe patients, two additional implantswere inserted in the proximal part of thefihula for histological evaluation at sixweeks. Tbis was possihle because thetechnique of harvesting of the fihula re-quires in every case resection of the entirefihular shaft. This resection is necessaryfor sufficient dissection of the proximalfihular vessels. Therefore there was anoverplus of about 7-10 cm in all of thefibular bones that bad been resected inthe patients. All patients signed a writtendeclaration of consent to allow for thisadditional implant insertion and histo-logical evaluation. These two implantsshould show whether tbe time frame ofsix weeks between prefabrication pro-cedure and reconstruction was sufficientto ohtain osseointegration witb the SLAsurface.

Algorithm of treatment

The procedure is composed of four ele-ments. The alternation of two surgicalprocedures with two technical ones is tbemain feature of this procedure. The firsttechnical part is the planning and fabri-cation of surgical tools, followed hy theinitial surgical procedure as the secondpart or so-called "prefabrication". Thethird step is the technical construction ofthe prosthetics. The final procedure is the

reconstruction of the alveolar ridge withthe prefabricated free vascularized fibulaand the definite prosthetics. Both surgicalprocedures were done tmder general an-aesthesia.

Before planning and surgery, every pa-tient underwent MRI-angiography of thelegs to check tbe condition of the lowerlimb vessels.

i) Preoperative planningPlanning and modeling are done togetherwith the technician. At first the amountof tbe desired alveolar ridge has to be de-termined and built up onto tbe plastermodel. Tbe technician can shape theexisting prostbetics and fit them to thenew alveolar ridge. The surgeon definesthe position of tbe implants in relationto the prosthetics and to the new al-veolar ridge (Fig. i). The horseshoe formof tbe maxilla suits osteotomies of thefihula. Tbe location of tbe osteotomiesis evaluated hy tbe surgeon and indi-cated on tbe plaster model (Fig. 2). Thetechnician produces a drilling templateto allow for precise drilling of the holesfor insertion of the implants.

ii) Prefabrication of the fibulaTbe initial surgical procedure includestbe insertion of tbe implants into thefihula. The lateral approach to the fibulais carried out as first described by Gilbert

Fig. I. The prosthetics are reconstructed and adapted to a good occlusion.The position and direction of every implant is detennined using a drill.

Fig. 2. The drilling template is produced referring to the plaster mold. Thesegments for the prospective flbular osteotomies are drawn and can be trans-feired in the same dimensions to the template.

45 . Oral Impl. Res. i j , 1002 / 44-51

Rohner et al . Prefabricated free vascularized fibula flap in severe maxillary atropby

(1979). The drilling template is fixed witbtwo screws to tbe lateral aspect of thefibula (Fig, 3). With the appropriate drillsof 2.2 mm, 2.8 mm and 3.5 mm in diam-eter, the holes for tbe implants can behurred. The drilling template has to be re-moved to tap tbe tbread with the appro-priate thread-cutter. Tbe ITI® implantswith the SLA surface can be inserted. 8°ahutments for the bar construction aretemporarily fixed to the implants. A splitskin graft (0.4-0.5 mm thickness), wbichis harvested from tbe lateral thigh, coversthe fibula and is fixed with resorbable su-tures (Fig. 4). Througb small incisions,the abutments penetrate the skin graft. Asilicone material (Zerosil Supersoft®,Dreve GmbH, Germany) is used to castthe position of every implant togetherwitb tbe abutments (Fig. 5). Tbis im-pression transfers tbe exact location ofevery implant as accurately as possible toa plaster model for bar construction. The

ahutments are tben removed and the skingraft is covered with a GoreTex mem-brane, which is fixed to the hone witb twoscrews and resorhahle sutures (Fig. 6).The wound is closed and the leg is posi-tioned in a splint including tbe ankle forthree days. Afterwards the patient canfully load and walk.

iii) Technical construction of the bar and the

bar-borne prosthetics

The mold of the abutments can be usedas a model for the construction of thebar. Tbe har is made of titanium and theabutments are welded using a laser. Thepreoperative fahricated prosthetics canhe adapted to the har. Tbis technical parthas heen recently puhlished and dis-cussed in detail (Bucher et al. 2000).

iv) Reconstruction of the maxilla

The reconstructive surgical procedure isperformed witb two teams of surgeons.

One team is responsible for the prepara-tion of the recipient bed including thedissection of the vessels at the neck forthe transplantation of the flap. Tbe otherteam is in charge of the donor site.

- recipient site: Through a limited sub-mandibular incision, the vessel btmdlesof the carotid artery and tbe jugular veinare identified along the anterior borderof the sternocleidomastoid mtisde, Inmost of the cases the hranch of the lin-gual artery is chosen as tbe donor artery,whereas the internal jugular vein is se-lected for an adequate outfiow. Tlie max-illa is prepared and dissected through anincision along the aveolar crest. The al-veolar ridge is contoured and fiattenedwitb a burr to make room for tbe fihula.A tunnel for the Mood vessels, whichruns behind the tuber region, passesanteriorly arotind tbe condylar neck, fol-lows the outer plane of the ramus of themandible and ends in the upper triangle

Fig. 3. The template is fixed at the lateral aspect of the fibula with twotitanium screws being used as drilling guide.

Fig. 4. The fibula and the implants are covered with a split skin graft [0.4-0.$ mm).

Fig;. 5. Tbe abutments for the bar construction arc fixed in the implants. Thewound is protected using a gamma-sterilized rubber dam, which is perforatedby the abutments. The position and direction of every implant is exactly deter-mined using a silicone molding material. Tbis silicone mold is used for (ahri-cation of the bar construction.

46 [ Chn. Orallmpl Res. 13, 2002 / 44-si

Rohner et ill. Prefabricated free vasculaiized fibula flap in severe maxillary atrophy

Fig. 6. Tbe GoreTex membrane covers the .skin graft and tbe Sbula. Tbefixation is done using titanium screws and resorbable sutures.

Fig. 8. Tbe fibula is osteotomized and hcnt to the horseshoe form of tbemaxilla.

Pig. 7- Tbe fibula is cut along the hordcrs ul ilit i.i:mplate. Long centricscrews fix tbe template to tbe fibula. Tbe vessels tbat are located at the op-posite site of the fihula have to he carefully protected.

of the neck, is prepared with a blunt dis-sector.

- donor site: The approach to the fib-ula is performed through the fortnerscar. Between the extensor and flexortiiuscle groups of the lower hmb, the Go-reTex metnbrane is prepared and care-fully removed. The fibula is first osteo-tomized distally, at least 6-8 cm ahovethe outer malleolus, and secondly prox-imally, at least 8-io cm below the fibu-lar head. The interosseous membrane isdissected and the fihular vessels are dist-ally identified and ligated. Starting dist-ally, the fihula is prepared to the proxi-mal osteotomy preserving the attachedfihular vessels. The drilling template isfixed to the implants using long centricscrews. Along the guiding planes, theosteotomies are accomplished and the

fibula is shaped to the horseshoe-form(Figs 7 & 8). The 8° abutments are serew-ed to the implants and the bar construc-tion is Hxed to the abutments, stabil-izing the horseshoe form of the fibula(Fig. 9). The prosthetics can be attachedto the bar construction (Fig. 10).

- reconstruction: The fibular vesselsare proximally ligated. The bar-borneprosthetics together with the fibula arefitted to the recipient hed. The inter-maxillary relation is determined by theocclusion to the lower jaw (Fig. ii). Theflhula is fixated to the upper jaw with2.0 mm titanium miniplates and screws.The mucosa is sutured to the skin graftat the fibula to get a tight fitting. Thefihular artery is anastomosed end-to-endto the lingual or facial artery. One of thetwo fibular veins is connected end-to-

side to the internal jugular vein. Theanastomoses are performed under themicroscope using 9-0 nylon thread.

Results

The success rate was 100% for the fibulaflap. There was no loss of the implants.The mean ohservation period amountedto 12 months (7-18 months). The aver-age time needed for the initial stirgerywas z hours and for the reconstructivesurgical procedure 8-10 hours. For thefirst 16 hours after the reconstructiveprocedure the patients were monitoredin the intensive care unit, and were latertransferred to the general ward. An anti-biotic therapy with Augmentin® (s days2X375 mg daily) and a therapy with low

47 Oral Impl. Res. 15, 2002 / 44-52

Rohner ct al . Prefabricated fiee vascularized fibula flap in severe maxillary atropby

Fig. 12. The preoperative orthopantomogram |OPT) shows the severely re-sorbed maxilla.

Fig. 9. The titanium bar is fixed and stabilizes the fibula. The fibula is stillconnected to the vessels with adequate blood supply.

Fig. Ii. The piistoperative OPT demonstrates the Hxation of the fibula withfour miniplates. The increase of the height of the alveolar Hdgc is shown.

ro. The prcopciiiiively produced bar-hornc prosthetics can be fixed.

Fig. 11. The occlusion determines the positioning of the fibula. The osteo-synthesis is done with titanium miniplates and screws.

Fig. 14. The evaluation after 12 months demonstrates the remodelinj; ol thebicortical hone to a more homogenous cancellous bone. All the implants arewell osseointegrated without visible loss oi attachment and vertical hei^t .

dose Uquemin [Fraxiparine^ 2500 IU) asprevention of thrombosis were executedroutinely. The hospitalization for bothsurgical procedures amounted to 5 and12 days, respectively.

The prosthetics could be replaced aftersurgery to allow the patients to have a

soft and liquid diet beginning 24 hoursafter surgery. There were no postopera-tive complications and all patients wereable to walk without the help of a caneafter 5 days. The patients were kept ona soft diet for six weeks. Radiologicalcontrols were taken after 6 weeks, 6

months and i year (Figs. 12-14). In onepatient, two screws were loosened aftersix montbs, tberefore tbe plates andscrews were removed in this patient. Inall the otber patients tbe titanium plateswere not removed. Tbe ortbopantomo-gram (OPT) showed after 1 year a re-

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Robner et al . Prefabricated free vascularized fihula flap in severe maxillary atropby

modeling of the bicortical fibular bonetowards a more homogenous canceilousbone structure, but without loss of verti-cal height or loss of attachment aroundthe implants.

Histologicat evaluation

Block sections with the two additionalimplants were fixed in 4% formalde-hyde. The specimens were dehydratedand embedded in methacrylate. Axial-oriented sections with a final thicknessof about 60-80 |im and with the stainingof toluidine blue and hasic fuchsin couldbe evaluated.

The cross-sections of the fibulashowed an asymmetric form with thickcortical layers and little medullary cav-ity. Parts of the conical shoulder of them® implants were in contact with thecortical layer (Fig. 16).

The zones in the coronal region indi-cated an incongruity between the cor-tical bone and the smooth surface of theimplant. There were some defects at thecortical bone because of this com-pression. Further apically, there was alarger gap containing vital tissue (ves-

sels, marrow). A thin layer of new bonecovered the cortical hone (Fig. 15]

The cylindrical zone showed a perfectfit. The cortical hone was devitalized inthe contact area, hut the bone remodel-ing was obviously starting (Fig. 17).

The thick cortical hone of the fibulaproduced a good primary stability ofthe implants. However, the conical partof the ITI implant (implant shoulder)burst the cortical bone and thereforeled to mismatch of the bone-implantinterface.

Discussion

The reconstruction of the atrophiedmaxilla remains a challenge in treat-ment with dental implants. There arethree major prohlems in dealing with thedental reconstruction of atrophied jaws.Firstly, there is need to surgically aug-ment the alveolar ridge in order to in-crease the quality and quantity of hone,which is required for optimal implant in-sertion. Secondly, the soft tissue has tohe adjusted to thereby build up a stableperi-itTipknt surrounding. And thirdly.

the stirgeon has to consider hiomechan-ical and biological principles during theplacement of the implants.

0 Bone augmentation

In a situation with severe maxillary atro-phy, a reversed sagittal intermaxillaryrelation and an increased vertical dis-tance between the jaws can often befound. The loss of vertical bone height,which restilts in an unfavorable crown-root ratio, is only one of several disad-vantageous factors. An acceptable resultin function and aesthetics might beachieved with the combination of inlayand onlay grafts. A sinus lift procedurein addition to onlay grafts (iliac crest,calvarium or mandible) allows the sur-geon to gain height and width of the al-veolar crest, resulting in a better inter-maxillary relationship (Lundgren et al.1997; Neyt et al. 1997). Implants canthen he inserted simultaneously or in asecond procedure (Joos & Kleinheinz2000; Khoury 1999; Lenzen et al. 1999;Neyt et al. 1997).

Le Fort-I osteotomy is another poss-ihle surgical intervention. Sailer (1989)

Fig. ts. MicrDgr^ijili sliowin^ ciiutact zone ot

tbe coronal area (magnification xio|. The sec-lion is carried out 44 days after tbe placementof tbe implant. Cortical reaction is seen. Thetitanium surface is slightly covered witb boneiis seen downmost in the figure.

Fig. 16. Micrograpb showing longitudinal sectionthrough the ITI* implant, whicb is inserted hicorticallyin tbe fibula |magnification xi.6l.

Fig. 17- Micrograph showing a perfectly fit-ting hone-implant zone |magnification x8).

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Rohner et al . Prefabricated free vascularized flhula flap in severe maxillary atrophy

originally described tbe Le Fort-I osteo-tomy with interpositional iliac bonegraft and simultaneous insertion of im-plants. Li et al. I1996I reported tbat tbisone-stage technique allows a correctionof the maxillo-mandibular relationsbipand tberefore an improvement of the fa-cial contour. Nystrom et al. (1997) pre-sented tbeir experience using this tecb-nique based on a two-stage procedure.Tbe implants were placed six monthsafter the Le Fort-l osteotomy and bonegraft procedure.

Major disadvantages of tbese teeb-niques are wound bealing compli-cations witb infection, loss of nonvas-cularized free bone grafts and tbe pro-longed healing process of tbe aug-mented alveolar ridge because of osteo-conduction, wbich is seen typically innonvascularized bone grafts. Nonvascu-larized grafts firstly bave to be resorbedand are tben replaced witb bone fromtbe recipient bed. Tbe graft functionsas a non-viable scaffold for tbe in-growtb of hlood vessels and osteopro-genitor cells from tbe recipient site,with resorption and deposition of newbone (Motoki & Mulliken 1990).

On tbe otber hand, free vascularizedbone grafts microsujgically anastom-osed can beal primarily by osteogen-esis, as tbe blood supply to tbe bone-fonning cells is reconstituted (Goldberget al. 1987]. In addition, vascularizedbone grafts undergo little, if any, re-sorption, whereas nonvascularized bonegrafts can loose more than one-balftbeir volume {Disa et al. 1999; Fukutaet al. i99il- Tbe radiograpbic controlsin our 4 patients sbowed stable peri-implant conditions witbout any signsof resorption after 12 months. Tbe bi-cortical bone of tbe fibula bas beenslightly remodeled to a more homogen-ous cancellous bone.

The fibula is one of tbe favouriteflaps in head and neck surgery for tbereconstruction of defects in tbe man-dible and tbe maxilla (Cbang et al,1998; Cordeiro et al. 1999; Gurlek etal. 1998; Hayter & Cawood 1996; Hi-dalgo &. Rekow 1994; Reycbler & Orta-be 1994; Urken et al, 1991 & 1998).Some anatomic cbaracteristics makethe fibula a good option tor tbe recon-struction of a maxillary defect. Firstlytbe fibula is a long, straigbt bicortical

bone, tbat can be osteotomized andshaped to tbe horsesboe form of tbe al-veolar crest with sufficient blood sup-ply |Wei et ai. 1994; Chiodo et al.2000). Secondly, the fibular vessels arelong and large in diameter to bridge thedistance from the upper jaw to theneck for anastomosis and cormection tothe recipient vessels (carotid artery andjugular vein}. Thirdly, a large vascular-ized skin paddle can be harvested to-gether with tbe fibular bone to coverextended soft tissue defects if needed.Several autbors bave presented tbeir re-sults for tbe reconstruction of maxil-lary defects (Nakayama et al. 1994; Ka-zaoka et al. 1999; Yim ik Wei 1994I.Babr Ir996) described tbe reconstruc-tion of the severely resorbed maxilla.He sbowed several advantages of usingtbe free vascularized fibula flap such ascorrection of vertical height and inter-maxillary relation, bicortical insertionof dental implants, less resorption andfewer problems witb soft tissue healingbecause of the vascularity of tbe flap incomparison to nonvascularized freebone grafts. The results in our patientssbowed tbe same advantages. Optim-ally we could gain 1.5 cm of bone massin vertical height, wbicb was the limitbecause of tbe anatomy of the fibula(Frodel et al. 1992). But in addition toBabr's technique, we used tbe prefabri-cation, wbieb allowed for exact plan-ning of occlusion with prostbetics.Tberefore, tbe sagittal intermaxillaryrelation could be exactly correctedwitb regard to tbe preoperativelyplanned normocclusion. Tbe segmentalosteotomies of the fibula rendered itpossible to recreate the entire borse-sboe form of tbe alveolar ridge of tbemaxilla. Tbe OPT sbowed after 12months the same level of bone withoutsigns of resorption, wbicb has been re-cently described to be a major advan-tage of using free vascularized bonefiaps (Disa et al. 1999).

ii) Soft tissue adjustment

The correct management and adjust-ment of the soft tissue is a prerequisitefor long-term success of implants. Post-operative debiscence of the soft tissueclosure in augmentative proceduresusing nonvascularized bone grafts

causes infection and loss of tbe bonegraft. The soft tissue bealing aroundthe free vascularized bone fiap ismainly uneventful. Even a dehiscenceis not a danger for tbe transplant be-cause of tbe vitality and vascularity ofthe bone. A stable attacbment of softtissue around the implant minimizesany infiammatory process. Commonly,tbe creation of a soft tissue attacbmentis acbieved in a surgical procedure sec-ondary to tbe reconstruction with afree vascularized bone fiap (Cbang etal. 1999; Hayter & Cawood 1996). Tbeprefabrication creates tbe soft tissueattachment prior to the reconstructionwitb tbe free vascularized fiap. Vinzenzet al. (1998) presented tbe prefabri-cation of a free vascularized scapularflap for tbe reconstruction of tbe max-illa. Igawa et al. (1998) reported tbeprefabrication of an iliac crest to aug-ment an extended defect of the upperjaw. Botb tecbniques required 6 montbsto complete the treatment. Robner etal. (1000a) first described tbe prefabri-cation of a free vascularized fibula flapwith split skin graft and ITI'̂ implantsfor tbe reconstruction of upper andlower jaw defects using 3 montbs fortbe entire treatment.

iii) Implant stability

The fibula as bicortical bone offers goodprimary stability to an implant. Im-plants bicortically inserted in tbe fibulasbowed significantly bigher removaltorque as compared to the iliae crest andtbe scapula (Ivanoff et al. 1996; Niimi etal. 1997}. All tbe ITI* implants bicor-tically placed by conventional pre-tapmethods during the prefabricationsbowed good primary stability. Duringtbe reconstructive procedure all the im-plants were clinically stable. However,tbe fibula bad only few signs of osseoin-tegration 6 weeks after the prefabri-cation (Figs r4-i6). One could say tbatthe biological response of tbe fibulamigbt be slower because of the twothick cortical layers. On the otber hand,the primary stability of each implantwas forceful. In addition, tbe stabiliza-tion of implants amongst eacb otberwitb a bar construction was aii import-ant and successful issue for the immedi-ate loading of implants.

5 0 I Clin. Oral Imp]. Res. 1%, 1Q02 / i4s

Rohner et al . Prefabricated free vascularized fihula flap in severe maxillary atrophy

Conclusion

The reconstruction of the severely re-sorbed maxilla using the prefabricationtechnique with free vascularized fibulaflaps is a promising alternative to thecommonly used techniques witb nonvas-cularized bone grafts. Tbe use of free vas-cularized grafts bas become a reliabletecbnique. However, the procedure re-quires a team experienced witb free vas-cularized tissue transfers. Fully func-tional use of tbe bar-borne prostbeticswas acbieved in all tbe patients witbin loweeks of treatment. Tbe histologiealevaluation showed exact fitting of the im-plants, but witb only little osseointegr-ation at 6 weeks, Tbe tbick cortical boneof tbe fibula guaranteed a good primarystability of tbe implants. Tberefore, thesuccess rate was roo% after i year of ob-servation. These good results witb no lossof implants render tbis tecbnique as avaluable cboice for tbe reconstruction ofmaxillofacial defects including tbe severeatropby of tbe maxilla. Nevertheless, tbefinal evaluation of prefabricated fibulaflaps calls for a larger number of cases anda longer follow-up period.

Resume

l,L' tTaitement des atrophies maxillaires s^v^res malgreunt chirurgie majeure et complexe sc termine souventp!ir un tesultat non-satisfaisant. Ce manuscript d^critI'L-palssisscment du maxillaire ^ Taide d'un lanibeaud'os du ptroti6 vascularisfi et libre, pr^fabriqu^ et asso-

ct6 k des implants ITI* chez quatre patients. Latechnique de pr^fabiiation pour la reconstruction deslesions maxillu-facialcs esc d^crite, bas^e sur I'expgri-

ence acquise avec 17 patients. Les quatre points fortsde ce traitement sont i | un programme prtop^ratnireet la fahrication des plateaux de reference pour le fora-ge, 3.) la prSfabrication de !'os du p6rone avec les im-plants ITI* et la realisation de la vestihuloplastie enutilisant une greffe de peau, 3I la construction et lafabrication de la superstructure et de la prothese, 4) lareconstruction du maxillairc en utilisant Tos du pero-ne prefabriquS en tant que lambeau vascuIarisC libre.Les reconstructions avec les lambeaux du perime ontbien reussi et les ift implants ITI* insures ont montr^une bonne osteoint6gration sans perte il'attache chezles quatre patients aprfes une p6riode d'observationmoyenne de douze mois.

Zusammenfassung

Die fiehandlung einer ausgedehnten Oberkieferatro-phie endet trotz komplexen grOsseren ehirurgisehenEingriffen oft mit einem unbefriedigenden Resultat.Diese Arbeit stellt die Augmentation des Oberkiefersvon 4 Patienten mit Hiife eines vorgangig prSpariertenund durchbluteten Fibulalappens in Kombinacion mitITI*-Implantaten vnr (Straumann AG, Waldenburg,Schweiz). Die ntttigen Schritte zur Vorbereitung dieserRekonstruktion von maxiliofacialen Defekten wurdenan Hand den Erfahrungen an 17 Patienten beschrie-hen. Die vier SchlUsselstelJen dieser Behandlung sind:II die praoperative Planung und die Heretellung derBofirschablonei II] die Vorbereitung der Fibula mit1TI*-Implantaten und die Herstellung einer "Vcstibu-lumplastik" mit einem Hauttransplantat; III) techni-sches Design und Herstellung einer Suprastruktur mitProthesCi IV) die Rekonstruktion des Oberkiefers mitHiUe einer vorbereiteten Fibuia in Form eines freiendurchbluteten Lappens. Die Rekonstruktionen mitden Fibulalappen waren aile erfolgreich und die iS ge-aetzten m-Implantate zeigten bei alien vier Patientennach emer mittleren Beobaehtungszeit von 11 Mona-ten eine gute Osseointegration ohne Attachment ver-lust.

Resumen

El tratamiento de una atroBa maxilar severa a pesarde una cirugia mayor severa acaba frecuentemente eonun resultado no satisfactorio. Este trabajo presents elaumento del maxilar eon un colgajo prefabricado librevascularizado de perone en combinaci6n eon implan-tes ITI* IStrauman AG, Waldenburg, Switzerland) en4 paeientes. La tdcniea de la prcfabricaci6n para la re-construccicin de !os defectos maxilofaciales se descri-be basada en la experiencia con 17 paeientes. Los cua-trt) puntos clave de este tratamiento son i] planifica-ci6n preoperatoria y (abncacit^n de las plantillas deperforacioni ii) prefabricacii5n del peront con implan-tes ITI* y la realizacidn de una vestibuloplastia usan-do un injerto cutaneo; iii] construcci6n tccnica y fabri-caci6n de la supraestructura y la dentadura; lv) rccons-tnieci6n del maxilar usando el peron^ como colgaiolibre vascularizado. Las reconstrucciones con los col'gaios de peronfi tuivieron dxito y los 18 implantes IT!que se habian insertado mostraron una buena osteoin-tegraci6n sin perdida de inserei6n en los 4 pacientesdespufs de un periodo medio de obscrvaci6n de 11 me-ses.

« l ± 4 * ffl B «• I- *! I > T lTl® ^ y:/^ -.^ h

(Straumann AG, Waldenburg, P^^ ^

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