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J Oral Maxillofac Surg 64:290-296, 2006

Alveolar Segmental Sandwich Osteotomy for Anterior Maxillary Vertical Augmentation Prior to Implant Placement
Ole T. Jensen, DDS, MS,* Lee Kuhlke, DDS, MS, Jean-Francois Bedard, DMD, FAAMP, and Dawn White, DDS
Over a 5-year period, 10 partially edentulous patients with anterior vertical maxillary deciency were treated consecutively with segmental osteotomy and interpositional bone grafting prior to dental implant placement. Alveolar vertical projection and papillary form proved to be stable in all patients up to 5 years postsurgery. Implant aesthetic results were judged to be satisfactory. The technique is an alternative to alveolar distraction osteogenesis but is limited to a vertical increase of about 5 mm in the anterior maxilla. 2006 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 64:290-296, 2006 Edentulous dental implant sites in the anterior alveolar region of the maxilla that have moderate vertical deciency can be vertically augmented using a segmental osteotomy in conjunction with interpositional bone grafting. A common pattern for vertical bone deciency in this location is the loss of bone due to periodontitis or to trauma or subsequent to dental extraction1,2 (Figs 1-3). If socket preservation is not done, the alveolus narrows and alveolar vertical dimension is often reduced.3-6 Although the palatal alveolar wall may maintain absolute alveolar vertical, buccal plate deciency can easily be 4 to 5 mm in healed extraction sites in the anterior region, which is a difcult defect to manage for aesthetic implant placement.7-9 We report here a study of 10 consecutive cases treated over the past 5 years in which sandwich osteotomy was done as an alternative to block onlay graft or distraction osteogenesis.

Methods
Ten consecutive patients with edentulous sites in the anterior maxilla were elected for sandwich osteot*Private Practice, Denver, CO. Private Practice, Englewood, CO. Private Practice, Englewood, CO. Private Practice, Denver, CO. Address correspondence and reprint requests to Dr Jensen: 303 Josephine St, Suite 303, Denver, CO 80230; e-mail: drjensen@dslmail.com
2006 American Association of Oral and Maxillofacial Surgeons

FIGURE 1. Lateral view of tooth socket with complete osseous root coverage. Jensen et al. Maxillary Anterior Segmental Sandwich Osteotomy. J Oral Maxillofac Surg 2006.

0278-2391/06/6402-0021$32.00/0 doi:10.1016/j.joms.2005.10.021

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FIGURE 2. A typical facial bone resorption pattern evident postextraction in which 2 or 3 mm of facial marginal bone is lost. Jensen et al. Maxillary Anterior Segmental Sandwich Osteotomy. J Oral Maxillofac Surg 2006.

FIGURE 3. Severe bone loss is frequently more extreme on the facial plate postextraction. Jensen et al. Maxillary Anterior Segmental Sandwich Osteotomy. J Oral Maxillofac Surg 2006.

omies.10,11 Vertical deciencies ranged from 3 to 7 mm. The technique used a vestibular incision made high in the vestibule. With a sagittal saw, the alveolar bone was segmentalized through a vestibular incision using a horizontal cut about 10 mm below the crest of the ridge and connecting vertical cuts to free the segment. Segments were 3 to 6 teeth in length inclusive of the incisor region. Segments were moved down about 5 mm crestally. A cortical wedge of bone harvested from the ramus was placed interpositionally to establish the desired alveolar height. Particulate autograft was also used to ll in the gap. Bone plating was not required in most instances. After 4 months of healing, implants were placed using a percutaneous approach with the aid of a guide stent.

Results
Figure 4 shows the result of the 10 patients treated with sandwich bone grafting and followed retrospectively. Vertical gain ranged from 3 to 6 mm.

FIGURE 4. Ten patients treated over a 5-year period had 3- to 6-mm vertical alveolar augmentation. Interpositional autograft was used to support elevated alveolar segments. Most implant sites lost bone (1 mm) over the study period, but absolute segmental vertical dimensions remained stable due to persistence of interdental implant alveolar bone. Jensen et al. Maxillary Anterior Segmental Sandwich Osteotomy. J Oral Maxillofac Surg 2006.

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FIGURE 5. Final restoration. Jensen et al. Maxillary Anterior Segmental Sandwich Osteotomy. J Oral Maxillofac Surg 2006.

FIGURE 8. Interoperative view showing osteotomy and interpositional graft placement. Jensen et al. Maxillary Anterior Segmental Sandwich Osteotomy. J Oral Maxillofac Surg 2006.

FIGURE 6. Preoperative view of a case where there is mild vertical atrophy and the lateral incisor has a 3-mm dehiscence facially. Jensen et al. Maxillary Anterior Segmental Sandwich Osteotomy. J Oral Maxillofac Surg 2006.

FIGURE 9. Postoperative view with wound closed and bridge in place. Jensen et al. Maxillary Anterior Segmental Sandwich Osteotomy. J Oral Maxillofac Surg 2006.

FIGURE 7. Occlusal view of alveolar ridge postextraction of lateral incisor. Jensen et al. Maxillary Anterior Segmental Sandwich Osteotomy. J Oral Maxillofac Surg 2006.

FIGURE 10. Postsurgical restoration. Jensen et al. Maxillary Anterior Segmental Sandwich Osteotomy. J Oral Maxillofac Surg 2006.

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FIGURE 11. Preoperative view. Jensen et al. Maxillary Anterior Segmental Sandwich Osteotomy. J Oral Maxillofac Surg 2006.

FIGURE 14. One week postoperative with temporary bridge in place. Jensen et al. Maxillary Anterior Segmental Sandwich Osteotomy. J Oral Maxillofac Surg 2006.

FIGURE 12. Occlusal view postextraction of failing anterior teeth. Jensen et al. Maxillary Anterior Segmental Sandwich Osteotomy. J Oral Maxillofac Surg 2006.

FIGURE 15. Preoperative view of atrophic maxillary ridge. Jensen et al. Maxillary Anterior Segmental Sandwich Osteotomy. J Oral Maxillofac Surg 2006.

FIGURE 13. Intraoperative view showing osteotomy and interpositional graft placement. Jensen et al. Maxillary Anterior Segmental Sandwich Osteotomy. J Oral Maxillofac Surg 2006.

FIGURE 16. Postoperative view with modied temporary bridge in place. Jensen et al. Maxillary Anterior Segmental Sandwich Osteotomy. J Oral Maxillofac Surg 2006.

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FIGURE 17. Preoperative radiograph. Jensen et al. Maxillary Anterior Segmental Sandwich Osteotomy. J Oral Maxillofac Surg 2006.

FIGURE 18. Postoperative radiograph. Jensen et al. Maxillary Anterior Segmental Sandwich Osteotomy. J Oral Maxillofac Surg 2006.

The 10 patients, followed over a 5-year period of time, demonstrated very stable and aesthetic results. Implant integration (n 15/15) and bone levels remained stable postrestoration. The technique provided papillary support interdentally. Although bone marker x-ray verication was not done in this clinical series, there was no signicant bone resorption observed prior to implant placement. Most implant locations had bone loss of about 1 mm at the xture sites postosseointegration (Fig 5), but the interimplant bone height within the segment maintained the orthoalveolar form. Figure 6 shows an example of a patient with atrophic anterior maxilla in which the left lateral incisor was to be removed, and the left central incisor was restored. The site was treated with a sandwich osteotomy on the day of extraction of the left lateral incisor (Figs 7, 8). The segmental osteotomy extended from the left central incisor to the left second bicuspid, enabling a vertical movement of 4 mm. The prosthetic surgical restoration is shown in Figures 9 and 10. A second case, similar to the rst case, is shown in Figures 11 through 14, and a third case is shown in Figures 5 and 15 through 20.

Discussion
The sandwich graft is a throwback to the 1970s, when Schettler rst proposed a similar procedure for the edentulous mandible to augment for denture retention.12-14 A number of modications followed, all

FIGURE 19. Implant placed 4 months later. Jensen et al. Maxillary Anterior Segmental Sandwich Osteotomy. J Oral Maxillofac Surg 2006.

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295 The moderately atrophic anterior maxilla can be vertically augmented up to 5 mm with enhanced aesthetic results using a segmental osteotomy with interpositional bone graft. The technique can be used to augment the alveolus prior to implant placement to provide soft tissue emergence of implant restorations and establish orthoalveolar form.

References
1. Boyne PJ: Osseous repair of the postextraction alveolus in man. Oral Surg Oral Med Oral Pathol 21:805, 1966 2. Pietrokovski J, Massler M: Alveolar ridge resorption following tooth extraction. J Prosthet Dent 17:21, 1967 3. Becker W, Becker BE, Caffesse R: A comparison of demineralized freeze-dried bone and autologous bone to induce bone formation in human extraction sockets. J Periodont 67:1025, 1996 4. Becker W, Clokie C, Sennerby L, et al: Histologic ndings after implantation and evaluation of different grafting materials and titanium micro screws into extraction sockets: Case reports. J Periodont 69:414, 1998 5. Froum S, Cho S, Rosenberg E, et al: Histologic comparison of healing extraction sockets implanted with bioactive glass or demineralized freeze-dried bone allograft: A pilot study. J Periodont 73:94, 2002 6. Vance G, Greenwell H, Miller R, et al: Comparison of an allograft in an experimental putty carrier and a bovinederived xenograft. Used in ridge preservation: A clinical and histologic study in humans. Int J Oral Maxillofac Implant 19:491, 2004 7. Nemcovsky C, Artzi Z, Moses O, et al: Healing of dehiscence defects at delayed-immediate implant sites primarily closed by a rotated palatal ap following extraction. Int J Oral Maxillofac Implant 15:550, 2000 8. Salama H, Salama M: The role of orthodontic extrusive remodelling in the enhancement of soft and hard tissue proles prior to implant placement: A systematic approach to the management of extraction site defects. Int J Periodont Restor Dent 13:313, 1993 9. Nir-Hadar N, Palmer M, Soskolne WA: Delayed immediate implants: Alveolar bone changes during the healing period. Clin Oral Implants Res 9:26, 1998 10. Politi M, Robiony M: Localized alveolar sandwich osteotomy for vertical augmentation of the anterior maxilla. J Oral Maxillofac Surg 57:1380, 1999 11. Moloney F, Stoelinga PJ, Tideman H: The posterior segmental maxillary osteotomy: Recent applications. J Oral Maxillofac Surg 42:771, 1984 12. Holtermann W, Schettler, Schnee L: Tierexperimentelle Untersuchungen zur Sandwichplastik mittels polychromer sequenzmarkierung. Bad Homburg, Germany, Vortr Jahrestagung arbeitsgemeinschaft fur Kieferchirurgie, 1976 13. Schettler D: Sandwichtechnik mit Knorpeltransplantat zur alveolarkammerhohung im Unterkiefer. Fortschr Kiefer-u Geisichtschir, Bd. XX. Stuttgart, Germany, Thieme, 1976 14. Schettler D, Holtermann W: Clinical and experimental results of a sandwich-technique for mandibular alveolar ridge augmentation. J Maxillofac Surg 5:199, 1977 15. Harle F: Visor osteotomy to increase the absolute height of the atrophied mandible: A preliminary report. J Maxillofac Surg 3:257, 1975 16. Stoelinga PJ, Leenen RJ: Combined mandibular vertical ramus and body step osteotomies for correction of unusual skeletal and occlusal anomalies. J Craniomaxillofac Surg 20:233, 1992 17. Stoelinga PJ, Blijdorp PA, Ross RR, et al: Augmentation of the atrophic mandible with interposed bone grafts and particulate hydroxylapatite. J Oral Maxillofac Surg 44:353, 1986 18. Egbert M, Stoelinga PJ, Blijdorp PA, et al: The three-piece osteotomy and interpositional bone graft for augmentation

FIGURE 20. Radiographic ndings after implant placement. Jensen et al. Maxillary Anterior Segmental Sandwich Osteotomy. J Oral Maxillofac Surg 2006.

having to do with improving denture retention.15-20 There have been numerous clinicians, as well, who reported success with interpositional bone graft for the osteotomized atrophic maxilla.21,22 The maxillary interpositional Le Fort I bone graft has demonstrated stable healing.23,24 This work has generally taken a total jaw approach and was thought to be a more stable augmentation technique than onlay bone grafting.24-26 In this report, the interpositional graft procedure is used segmentally for alveolar augmentation prior to implant placement in order to regain lost vertical dimension in the esthetic zone. The procedure can be done anywhere in the arches but is perhaps most indicated in the anterior maxilla, where, without it, long clinical crowns result from apically placed implants. Distraction osteogenesis can effect the same result, but what is being advocated here is to simply do the sandwich osteotomy when the magnitude of correction is small, in the order of 3 to 6 mm of vertical movement, a relatively common nding.27,28 For the anterior maxilla, the maximum vertical movement for the sandwich graft is about 5 mm. Efforts to displace the segment greater than 5 mm not only risk the potential for vascular embarrassment by detaching periosteal blood supply but also can excessively rotate the segment palatally, compromising aesthetic gingival projection.

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of the atrophic mandible. J Oral Maxillofac Surg 44:680, 1986 Vanassche BJ, Stoelinga PJ, De Koomen HA, et al: Reconstruction of the severely resorbed mandible with interposed bone grafts and hydroxylapatite. A 2-3 year follow-up. Int J Oral Maxillofac Surg 17:157, 1988 Frost De, Fonseca RJ, Koutnik AW: Total subapical osteotomy: A modication of the surgical technique. Int J Adult Orthod Orthognath Surg 1:119, 1986 Stroud SW, Fonseca RJ, Sanders GW, Burkes EJ Jr: Healing of interpositional autologous bone grafts after total maxillary osteotomy. J Oral Surg 38:878, 1980 Frost DE, Fonseca RJ, Burkes EJ Jr: Healing of interpositional allogenic lyophilizd bone grafts following total maxillary osteotomy. J Oral Maxillofac Surg 40:776, 1982 Nystrom E, Lundgren S, Gunne J, et al: Interpositional bone grafting and LeFort I osteotomy for reconstruction of the atro-

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phic edentulous maxilla. A two-stage technique. Int J Oral Maxillofac Surg 26:423, 1997 Moloney F, Tideman H, Stoelinga PJ, et al: Interpositional bone-grafting of the atrophic edentulous mandible. A review. Aust Dent J 30:211, 1985 Frost DE, Gregg JM, Terry BC, et al: Mandibular interpositional and onlay bone grafting for treatment of mandibular bony deciency in the edentulous patient. J Oral Maxillofac Surg 40:353, 1982 Chow T, Yu C, Fung S, et al: Pyriform rim osteotomy: A new regional osteotomy for correction of a para-alar deciency. J Oral Maxillofac Surg 62:259, 2004 Jensen OT, Ueda M, Laster Z, et al: Alveolar distraction osteogenesis. Select Readings Oral Maxillofac Surg 10:1, 2002 Jensen OT, Cockrell R, Kuhlke L, et al: Anterior maxillary alveolar distraction osteogenesis: A prospective 5-year clinical study. Int J Oral Maxillofac Implant 17:52, 2002

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