Soft tissue Management in Extreme Vertical Maxillary Bone Defects

Introduction: Dento-alveolar defects with vertical maxillary bone loss may be caused by tumor- resection, trauma or cystectomy. Reconstruction of such bone-defects with a cortico-cancellous iliac bone graft is a well established augmentation-method, suited to create a sufficient recipient area for dental implants. This approach is accepted for restoration of masticatory function and therefore oral rehabilitation of such patients and produces reliably good results. In extreme cases, however, the soft tissue coverage may become the limiting factor: Common methods of soft tissue coverage of the bone graft then fail and taking of a bone-graft altogether might fail. By demonstrating difficult clinical cases with extreme defects we suggest how to solve this problem. Methods: Intraoral examination in all these patients showed a pronounced vertical maxillary bone defect of the posterior maxilla with very difficult soft tissue conditions. By choosing a special type of buccal incision, we succeeded to cover our bone grafts by pedicled flaps form the palate, even though, we temporarily lost the buccal vestibule. Each of the iliac bone grafts had been fixed by two osteosynthesis-screws. Six months after graft-healing, dental implants were inserted without any further soft tissue reconstruction. After osseointegration of the dental implants vestibuloplasty was used to recreate the buccal vestibule, and, additionally a free palatal mucosal graft reconstructed the attached gingiva. Results: After successful healing of the bone-grafts, good osseointegration of the dental implants was also achieved. The oral vestibule was successfully reconstructed, and a keratinized gingiva was recreated successfully. Conclusion: With a special clinical approach and technique of soft tissue management it is possible to achieve coverage and healing of bone-grafts in vast vertical bone augmentation cases in the maxilla. The disadvantage of the temporary loss of the vestibule can be completely reversed in second step. Keywords: Alveolar ridge defect, Vertical augmentation, Soft tissue management