Case presentation:
The presented case is a 21-year-old male with a history of right-side palatal (PA) who had undergone subtotal maxillectomy in 2008, which resulted in a large communication between the oral and nasal cavities and maxillary sinus (figure 1) along with subsequent anesthetic problems. He used a partial removable denture to seal the gap and replace the lost teeth for 6 years. However, lack of stability and retention as well as poor aesthetic were the drawbacks of the prosthetic treatment. He also complained about unstable occlusion, chronic soft tissue irritation, and inflammation, as well as the removable nature of the prosthesis.
In respect to his chief complaints, the treatment goal was to provide a fixed implant-supported prosthesis, for which soft and hard tissue reconstruction seemed necessary.
First, the soft tissue closure of the defect was obtained in two layers. The inner layer was nasal epithelium and a part of palatal mucosa, which was sutured to the sinus epithelium, and the outer layer was buccal fat pad, which was sutured to vascular-pedicle palatal full-thickness flap. A Tetracycline-mixed tie-over was placed as a dressing on the exposed bone for one week. (figure2).
Bone reconstruction was performed 7 months later. Prior to the surgery, a complete wax-up reconstruction of the defect was performed on stereolithography model and a dental splint was made to replicate the final prosthesis (figure 3). The recipient site was prepared by a dissection between the sinus lining mucosa and the palatal mucosa with Metzenbaum scissors through a palatal incision. Considering the defect size and the amount of corticocancellous bone needed, the anterior iliac crest was chosen as the donor site. A bone block of 40*30*13 millimeters (mm) was harvested and placed into the defect with regard to the dental splint. The graft was fixed with titanium mesh plates and screws. Tension-free soft tissue closure was also obtained (figure 4).
Five months later the titanium mesh and screws were removed and 4 dental implants (Dentium Co., Korea) were placed in the teeth position 2 (4.5*14 mm), 3 (4.5*10 mm), 7 (3.6*14 mm) and 8 (4*14 mm). Guided bone regeneration was also performed on buccal surfaces of 2 and 6 implants using allograft material and collagen membrane. Due to adequate primary stability, healing abutments were also placed (figure 5). Four months later, the definite fixed implant-supported prosthesis was delivered to the patient.
At the 24th month follow-up, no signs of pain or implants luxation, discharge or irritation of peri-implant soft tissue were noticed. No bleeding was observed on probation at the depth of 2 to 4 mm. Radiographic examination showed 1 mm bone loss around implants in the position of teeth number 7 and 8. (figure 6)