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)