Periodontology 2000, Vol.

47, 2008, 143161

Printed in Singapore. All rights reserved

 2008 The Authors.

Journal compilation  2008 Blackwell Munksgaard

PERIODONTOLOGY 2000

Strategies in reconstruction of
the atrophic maxilla with
autogenous bone grafts and
endosseous implants
S T E F A N L U N D G R E N , M A T S S J O S T R O M , E L I S A B E T H N Y S T R O M &
LARS SENNERBY

Regeneration of bone defects aims at re-establishing

the original skeletal contour and function. In bone
grafting, the desired outcome is a complete incorporation of the bone graft into existing bone in order
to accomplish a complete and long-lasting restoration of anatomy and function. The use of implantsupported bridges in reconstructive jaw surgery
frequently requires an integration of dental implants
into resorbed, regenerated or grafted bone. Regeneration of bone defects, incorporation of bone grafts
into existing bone, and implant integration into bone
constitute complex healing events that all need to
proceed in an orderly, regulated manner in order to
achieve a clinically acceptable outcome. Regeneration of bone defects and healing of bone grafts involve a competition between different tissues and, in
the case of nonoptimal healing, fractures, large defects and bone grafts may heal with a mixture of
fibrous scar tissue and bone, and long bones may
heal with cartilaginous tissue. A major task of
reconstructive surgery is therefore to ensure the best
possible conditions for optimal healing. In implant
dentistry, the surgical technique is critical, as are the
length of the healing period and the timing of bone
grafting and implant placement. Clinical research
and experience in dental implantology have identified determinants important for successful bone
regeneration grafting and for implant healing
(22). This article focuses on restoring severely
resorbed maxillae with autogenous bone grafts prior
to implant placement.

Review of the literature on the

clinical outcome of bone grafting
of the edentulous maxilla
A survey of the literature, without limitation regarding year of publication, was conducted using the
National Library of Medicine computerized bibliographic databases (MEDLINE and PubMed) with
links to related articles. The search words used were
edentulous maxilla, bone graft, reconstruction, titanium implants and their combinations. The reference
lists in the papers included were used to expand the
survey further. The following inclusion criteria were
applied:
The study had to be published in English, or to
have an English abstract, in a refereed journal.
The study had to include patients with an edentulous maxilla or, in studies with mixed total
edentulism partial dentition, it should be possible
to distinguish between the clinical variables of the
two clinical situations.
The reconstruction in the patients should have
been performed with free autogenous bone grafts.
The reconstruction technique used should be
identifiable.
The number of placed and failed implants in
grafted bone should be defined.
The follow-up period should be at least 12 months
following the implant placement, for all patients in
the study.

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Lundgren et al.

In cases of multiple reports on the same patient implant material, the most recent study with
the longest follow-up period was included.
A total of 25 publications met the criteria listed (1, 3,
818, 20, 2529, 35, 3841). Four papers (3, 14, 20, 33)
described respectively three, two, two and two different patient groups, each of which was analyzed as a
separate patient group. A total of 30 separate patient
groups were identified. The number of patients in the
30 patient groups ranged from 1 to 75, with a mean of
20 patients per group. A total of 597 patients with an
edentulous maxilla were included in the present
study. Twenty-two of the 30 patient groups reported
the gender of the patients: 66% were women. The
patient groups had a mean age at the time of the bone
graft of 54 years (range 4663 years). In patients in
whom the reconstruction was performed with onlay
or sinus inlay grafts, together with additional techniques, classification was made according to the
bone-grafting technique employed for the majority of
the implants. The onlay bone-grafting technique,
alone or with additional sinus inlay, or with sinus
inlay together with nasal inlay, was carried out in over
half of the patient groups (1, 9, 11, 13, 14, 17, 20, 25, 26,
28, 34, 35, 38, 40, 41). Sinus inlay grafts, alone or together with nasal inlay, were reported in eight groups
(3, 10, 14, 15, 20, 29, 39), and an interpositional bonegrafting technique was reported in seven groups (8,
12, 16, 18, 27, 33). The anterior iliac crest was the
donor site in 23 of the 30 patient groups. Other donor
sites described were the posterior iliac crest (two
groups), the mandibular symphysis (two groups) and
the calvarium (one group), the lateral sinus wall (one
group), and the rib (one group).
In 15 of 30 patient groups, implants and bone
grafts were placed simultaneously using a one-stage
technique (1, 3, 1118, 28, 38, 41). Eleven patient
groups had the implants placed post-grafting (3, 8
10, 20, 26, 27, 33, 35), and four patient groups had
some implants placed using a one-stage technique
and some implants placed using a two-stage technique (25, 29, 39, 40). The healing time between bone
grafting and implant placement in the two-stage
technique varied from 3 to 7 months, with a majority
having 6 months of healing. The follow-up time
ranged from 12 to 60 months, with a mean of
22 months and a median of 13 months. The 30
patient groups included a total of 3,273 implants
(range: 6326; mean per group, 106; median per
group, 92). During a follow-up period of at least
12 months, a total of 507 implant failures were
reported, which gave an implant survival rate of 85%
for all reported patients. Table 1 shows the number

144

Table 1. Implant survival rate in relation to the mode

of bone grating
Procedure

Total
no. of
implants

No. of
failed
implants

Implant
survival
rate (%)

Onlay bone
grafting

1559

225

86

Sinus inlay
bone grafting

1074

190

82

Interpositional
bone grafting

640

92

86

Table 2. Implant survival rate in relation to the mode

of the technique of implant placement
Procedure

Total
no. of
implants

No. of
failed
implants

Implant
survival
rate (%)

One-stage
technique

1500

317

79

Two-stage
technique

1048

108

90*

One- and
two-stage
techniques

725

82

89

*A significant difference was found between one-stage and two-stage

techniques in favor of the delayed technique (chi-squared test, P = 0.039).

of placed implants, failed implants and survival rate

for the three different bone grafting techniques
used. No significant clinical differences were found
between the grafting techniques. Table 2 reveals a
higher survival rate for implants placed after initial
healing of the bone grafts.

Reconstruction of the totally

edentulous maxilla: the Umea
experience
The goals of surgical-prosthetic reconstruction of the
totally edentulous jaw with bone grafts and dental
implants are: (i) to enable placement and integration
of dental implants, (ii) to rebuild a normal facial
morphology, (iii) to restore oral circumferential soft
tissue support, and (iv) to bring about good esthetics,
phonetics and function. Lack of bone volume for
implant placement is mainly a consequence of tooth
loss and sinus pneumatization with severely atrophic
maxillae (Cawood & Howell Class IVVI) (5, 6, 19).
However, the influence of the resorption process
on the maxillamandible inter-relationship differs

Strategies in reconstruction of the atrophic maxilla

between patients. In some patients, the end point of

resorption creates a reversed jaw relationship or an
increased distance between the jaws. In other
patients, the result of the resorption is a thin residual
alveolar process, and some patients lose the entire
vertical height of the alveolar process. The severity of
alveolar bone resorption and an altered jaw relationship may determine the type of technique used to
reconstruct the edentulous jaw (1, 27).
To facilitate treatment planning and selection of
surgical method, it is advisable initially to remove the
denture in the jaw planned for reconstruction, in
order to estimate the proper lip support. The profile
radiograph should focus on the opposing jaw and be
taken with the removable denture in place in order to
help determine the horizontal and vertical relationships between the maxilla and the mandible
(Fig. 1A). If the profile radiograph reveals a normal
vertical and horizontal interjaw relationship, and the
residual alveolar process is well preserved, the main
clinical concern is often lack of sufficient bone volume for placement and integration of implants. In
such patients, onlay bone grafts are frequently used
to increase the bone volume prior to implant placement. In rare situations, bone grafts at the maxillary
sinus floor and possibly the floor of the nasal cavity
can be the treatment of choice.
Placement of dental implants in the alveolar process of the maxilla with an unfavorable relationship
between the maxilla and the mandible can cause
considerable difficulties (Fig. 1B). Even if the bone
volume is sufficient for implant stabilization, a reversed relationship between the jaws may result in an
unfavorable loading of the implants, a bulky bridge
with long clinical crowns, and an obvious risk of
phonetic and aesthetic problems. It is often necessary
to correct the maxillamandible inter-relationship by,
for example, forwarding the maxilla. Le Fort I osteotomy with an interpositional bone graft is clearly
indicated in patients who present with a markedly
reverse jaw inter-relationship (with or without increased vertical distance) and a lack of alveolar bone
volume (Fig. 2). Le Fort I osteotomy and interpositional bone grafting is not indicated if resorption has
resulted in a thin alveolar process (Cawood & Howell
Class IV) (21, 27, 32, 36).

Rationale for using a two-stage

procedure
Successful reconstructive jaw surgery with bone
grafts and implant-supported bridges depends upon

Fig. 1. Lateral cephalograms showing (A) a patient with a

normal intermaxillary relationship and (B) a patient with
a reverse maxillamandibular inter-relationship.

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Lundgren et al.
A

One-stage
Osseo-integration
RB

RB
GB

GB

Time
Fig. 2. Schematic illustration showing Le Fort I osteotomy
and interpositional bone grafting for correction of a
reverse maxillamandibular inter-relationship and for
increasing the bone volume for implant placement.

Two-stage
Osseo-integration
RB

proper bone graft and implant integration. Reconstruction with bone grafts and implants is most frequently performed using a two-stage procedure. The
rationale for a healing period of the bone graft prior
to implant placement is to permit revascularization
and remodeling of the bone graft as well as new bone
formation. In addition, volume changes of the bone
graft as a result of bone remodeling need to be
quantified in order to place implants in a correct
three-dimensional position.
The preparation of an implant site in a free bone
graft, in contrast to normal bone, will not provoke a
repair process because of interrupted microcirculation and rapid cell death. Nevertheless, the residual
alveolar bone will respond to the surgical trauma and
initiate a healing process, which will lead to integration of the implant with the residual bone (Fig. 3A,B).
If surviving the early period of healing and loading,
and as indicated by the histology presented below,
grafted bone will eventually also integrate with the
implants.
The implant integration and stability of free cortical bone grafts were studied in two animal models
(30, 31). The bone grafts were retrieved from the skull
of rabbits and placed simultaneously with an implant, or were fixed with an osteosynthesis screw in
the tibia of the same animals 8 weeks prior to implant placement (Fig. 4). This study design allowed
comparison of simultaneous vs. delayed implant
placement in bone grafts, and comparison with implant placement in normal bone (30, 31). Measurements at 8, 16 and 24 weeks after surgery included
resonance frequency analysis and torque measurements to assess implant stability, impressions to
measure bone volume changes and histological
assessment of the boneimplant contact and bone fill

146

RB
GB

GB

Time
Fig. 3. (A) Schematic illustration showing healing of an
implant placed simultaneously with a bone graft. The
osseointegration process proceeds normally in the residual bone (RB) while a delayed response is seen in the
grafted bone (GB) because of the lack of vascularization.
(B) Schematic illustration showing healing of an implant
placed after initial healing of a bone graft. Normal
osseointegration can take place in both the residual bone
(RB) and the grafted bone (G) as a result of revascularization of the graft.

Fig. 4. An onlay bone graft from the skull of a rabbit is

placed simultaneously with an implant in the tibia.

within the implant threads. The findings revealed

that titanium implants do integrate when placed
simultaneously with a free cortical bone graft (Fig. 5).
However, a delay of 8 weeks of healing of the bone
graft prior to implant placement resulted in increased

Strategies in reconstruction of the atrophic maxilla

A

Fig. 5. Light micrograph showing osseointegration of a

titanium implant placed simultaneously with a bone graft
24 weeks earlier.

implant stability and more contacts between the

bone and the implant (Fig. 6A,B).
A better understanding of the healing process of
titanium implants in bone grafts requires controlled
clinical investigations and histological examination
of the bone grafttitanium interface. A novel research approach, which involves the placement and
subsequent retrieval of implants, has been used to
analyze the bone graftimplant interface in patients
with severely atrophic maxillae grafted with interpositional or buccal onlay bone grafts obtained
from the iliac crest (21, 34). Commercially pure
titanium micro-implants, installed according to a
one-stage or a two-stage procedure, were studied in
ten patients (21) (Fig. 7AC). Two threaded implants (2 mm in diameter, 5 mm long) were placed
in the bone grafts at the time of grafting without
contacting the underlying residual crest. After
6 months of healing, one of the micro-implants was
retrieved, using a trephine drill, for histology, and
conventional implants were installed. At the same
time, a third micro-implant was placed into the
healed bone grafts. After an additional 6 months,
the conventional implants were connected by
abutments and the remaining two micro-implants
were retrieved for histomorphometric analyzes of
the degree of direct boneimplant contact and the
amount of bone within the implant threads. This
research protocol made it possible to obtain three
implant specimens from each patient, representing:
(i) simultaneous implant placement and 6 months
of healing, (ii) simultaneous implant placement and
12 months of healing, and (iii) delayed implant
placement and 6 months of healing.

Fig. 6. Light micrographs of the boneimplant interface at

4 weeks after implant insertion using (A) a simultaneous
approach and (B) a delayed approach. A more mature bone
implant interface with a greater number of bone contacts is
seen for delayed placement (8 weeks after grafting).

Histological specimens of the micro-implants

placed simultaneously with the bone graft and
retrieved after 6 months of healing showed grafted

147

Lundgren et al.
A

degree of contact with the implant surface than was

the case with the immediately placed micro-implants
(Fig. 8C). Histomorphometrically, the delayed-placed
implants showed bone contact that was two to four
times higher, and more bone within the implant
threads, than implants in the other study groups
(Fig. 9). Also, micro-implants placed in interpositional
bone grafts tended to show more surrounding bone
than implants placed in buccal onlay grafts.
A second micro-implant study included 23 consecutive patients who were treated with bone grafts
and implants in edentulous maxillae (34). Eight
patients received interpositional bone grafts and 15
received buccal onlay grafts. Micro-implants were
placed and retrieved according to the protocol described above. The histomorphometrical analysis of
this larger study material confirmed the presence of
more bone around the delayed-placed implants than
around the immediately placed implants. There was
also a tendency of more bone around micro-implants
placed in interpositional bone grafts. The results from
these two histological studies support the concept of
using a two-stage procedure. However, additional
implants have to be examined in order to reach
statistical significance between the various study
groups.

Harvesting of bone grafts

Fig. 7. (A) A titanium micro-implant is to be placed in an

onlay bone graft. (B) Six months later at the time of implant retrieval. (C) A biopsy containing a micro-implant
with surrounding bone tissue obtained for histology.

bone, newly formed bone and loose connective tissue

rich in vessels and cells (21) (Fig. 8A). Active resorption of the grafted bone and formation of new bone in
contact with the implant surface were observed,
although the major part of the implant surface contacted grafted bone or loose connective tissue. After
12 months of healing, the bone surrounding the
micro-implants had a more mature appearance and it
was difficult to distinguish between grafted and newly
formed bone (Fig. 8B). The micro-implants placed
after 6 months of healing of the bone graft were surrounded by mature bone, which exhibited a higher

148

The iliac crest, the calvarium and the tibia are some
of the sources of autogenous bone grafts described in
the literature, (23, 24, 37). The main advantage of
using autogenous bone is related to the osteoconductive and osteo-inductive capacities of the graft,
and the disadvantage is the use of an additional
surgical site, with the risk of donor site morbidity.
The anterior iliac crest is a commonly used donor
site, especially when requiring both cortical and
cancellous bone. The medial or internal table of the
ileum is often a preferable donor site in the literature,
owing to its ease of access and low morbidity, especially when harvesting only cancellous bone. However, the medial table of the ileum has a thin cortical
plate compared with the superior or lateral border of
the iliac crest. On the other hand, the lateral or
superior iliac crest at the site of the insertion of the
medial gluteus muscle shows a high density and
thickness of the cortical bone. The lateral or superior
ileac crest can serve as a graft donor site when a large
amount of cortical bone is needed, but the potential
disadvantage of harvesting bone from the lateral iliac
crest is the interference with the insertion of the

Strategies in reconstruction of the atrophic maxilla

B

Fig. 8. Light micrographs showing (A) simultaneous

placement with 6 months of healing. The bone graft is
undergoing remodeling but only patchy boneimplant
contacts can be seen. (B) Simultaneous implant placement after 12 months of healing. The surrounding bone is

more mature than after 6 months but the boneimplant

contact degree is still low. (C) Delayed implant placement
and 6 months of healing. A normal mature boneimplant
interface is seen.

149

Lundgren et al.

70
60

50

06 months
012 months

612 months

40
30
20
Fig. 11. Schematic illustration of the superior part of the
iliac crest used to harvest grafts for onlay bone grafting.

10
0
Bone contact

Bone area

Fig. 9. Morphometric findings of retrieved micro-implants (21).*P < 0.05 when compared with other groups.

gluteus muscles and the inherent risk of gait disturbance (2). Also, excessive amounts of bone harvested
from the lateral or superior part of the iliac crest can
result in a change of the appearance of the hip contour. To obtain enough graft volume with sufficient
cortical content, our studies used the lateral and
superior area, instead of the medial aspect, of the
iliac crest as a donor site for inlay onlay grafting
(Figs 10,11) (7, 22).

Surgical technique and flap procedure

for bone grafts
The retrieve of iliac bone starts with an incision of
the skin 34 cm medial to the iliac crest, following the

Fig. 10. Schematic illustration of the lateral part of the

iliac crest used to harvest grafts rich in cortical tissue for
interpositional bone grafting.

150

skin lines in the posterior-lateral direction over the

crest, 34 cm behind the superior-anterior iliac spine;
the skin incision should not be extended beyond the
lateral border of the iliac crest. The dissection then
proceeds in the subcutaneous fat layer until the
aponeurosis between the abdominal and gluteal
muscles is identified. The direction of the incision is
then changed to follow the iliac crest in a posterior
direction and is carried out in contact with the bone.
The fascia lata is carefully dissected to ensure that it
is kept intact for optimal adaptation of the tissues
over the wound.
When the estimated length of the graft extends
5 cm, the access to the posterior part of the iliac crest
surface is managed by a soft tissue tunneling to avoid
hemorrhage from the muscles and injury of the
lateral cutaneous branches of the subcostal and
iliohypogastric nerves. After exposing the superior
surface of the iliac crest, dissection is made according
to the shape and size of the site to be grafted. For
interpositional bone graft with Le Fort I osteotomy,
the dissection of the fascia lata is extended along the
medial surface until reaching the harvesting area
(Fig. 10). For onlay grafting, the dissection of the
fascia lata is extended further along the superiolateral
border of the iliac crest close to the insertion of the
gluteus muscles. If the graft is harvested for a buccal
onlay procedure in a class IV case [according to Cawood & Howell (6)], the very superior part of the iliac
crest is harvested to form an L-shaped graft (Fig. 11).
If the bone graft is harvested for a class V or a class VI
case, the dissection is extended in a lateral direction
to include the thick cortical bone at the lateral border, where the gluteus muscles insert. This means
that some of the muscle fibers of the gluteus muscles
need to be stripped off the bone margin. The bone

Strategies in reconstruction of the atrophic maxilla

Fig. 12. Schematic illustration showing how the bone

from the superior part of the iliac crest is used for onlay
grafting.

from the iliac tubercle is used for anterior maxillary

reconstruction (Fig. 12).
After soft tissue dissection, the margins of the graft
are marked with surgical ink and outlined using a
sagittal saw, and the graft is then harvested using a
straight osteotome. Small amounts of bone wax can
be used to arrest profound hemorrhage from the
marrow space. A bone file can be used to remove
sharp edges in osteotomized sites.
The surgical wound is closed in layers. The first
layer (the fascia lata) is carefully re-adapted to enhance reformation of bone and to avoid the spread of
bone marrow into the surrounding soft tissue. An
activated vacuum drainage is positioned between the
fascia lata and the muscles and kept in place as long
as bleeding occurs, usually until the second postoperative day. The skin is closed with continuous
intracutaneous sutures using a resorbable material.
A pressure dressing is left in place for 24 h.

It is recommended to obtain a computerized

tomography radiogram to evaluate (ad modum
Cawood & Howell) the designated implant site. A
saddle graft is indicated if the implant site shows
inadequate height, and a buccal or veneer graft is
indicated if the implant site shows inadequate width.
A typical candidate for an onlay reconstruction is a
patient with a lack of vertical alveolar bone height in
the anterior maxilla (Fig. 13). If this bone loss is
caused by overloading from the residual mandibular
anterior dentition, the opposing jaw (the mandible)
needs to be rehabilitated first to avoid unfavorable
loading forces on the bone graft during the initial
healing when the graft is vulnerable as a result of
inadequate vascularization. The opposing jaw (mandible) can be rehabilitated using a removable denture, posterior implants, or a cantilevered bridge. In
patients with a high and thin alveolar process
(Cawood & Howell Class IV), the main focus should
be to increase the bone width using a veneer onlay
graft (Fig. 14AE). In both veneer and saddle-type
onlay grafting, the superior part of the iliac crest is
harvested using a peel-off technique in order to
avoid any negative influence on the hip contour. The
length of the graft in an anterior posterior direction
should be identical to the distance from the left to the
right infrazygomatical crest. After grafting, the total
bone height at the implant sites should correspond to
the planned length of the implants. The thickness of
the graft is determined by the thickness of the
residual alveolar process and the necessary bone
support of the lip and soft tissue.
Previous grafting treatments often combined onlay
grafts with sinus or nasal inlay grafts. The anterior
nasal floor inlay graft, either a particulated cortical
bone graft or a block bone graft, in the case of severe
anterior maxillary atrophy, is still used in patients

Onlay grafting
Indication
The major indication for onlay bone grating is an
atrophic edentulous maxilla, where the alveolar process needs to be reconstructed as a result of insufficient width or height, or both, but without a need for
correction of the maxillamandible relationship. An
onlay bone graft is also indicated if an inverted
maxillamandible inter-relationship is combined
with an alveolar process that has insufficient width to
host implants. Onlay grafting can be combined with
an anterior nasal floor inlay graft in patients who
show severe vertical resorption of the alveolar process of the anterior part of the maxilla.

Fig. 13. Orthopanthograph of a patient with severe maxillary atrophy scheduled for onlay bone grafting.

151

Lundgren et al.
A

Fig. 14. (A) Veneer and saddle bone grafts fixated to an

atrophic maxilla with micro-implants. (B) The patient
6 months later. Good graft incorporation is observed. (C)
Implant placement surgery. (D) At the time of abutment

connection another 6 months later. (E) The final metalceramic fixed bridge. A surgical guide has been used for
optimal implant placement.

with a short vertical height of the anterior maxilla.

However, grafting the posterior edentulous atrophic
maxilla with an onlay graft in combination with a

sinus inlay graft is no longer used. It has been

determined that grafting the posterior atrophic
maxilla with an onlay veneer graft gives a more

152

Strategies in reconstruction of the atrophic maxilla

Fig. 15. Tomography taken (A) 2 weeks after an onlay grafting procedure. Note bone grafts buccal to the maxillary
sinuses. (B) Six months post-surgery. Good healing and remodeling is seen. (C) Implants can be placed in the posterior
regions without the need for a sinus floor augmentation. (D) The final prosthetic outcome.

predictable outcome. Also, a veneer graft provides the

possibility for placing posterior maxillary implants in
a more vertical direction, which is favorable from a
loading point of view (Fig. 15AD).
Another way of optimizing graft healing and minimizing the risk of resorption is to focus on the
handling of the soft tissue. Tension in the surgical
flap can result in ischemia and increased pressure on
the graft. To achieve a tension-free flap closure, it is
recommended to use extensive horizontal periosteal
incisions, as well as vertical periosteal incision for the
posterior release incisions.

Surgical technique and flap procedure

Surgery is performed under general anesthesia. A
corticocancellous bone block is harvested from the
anterior iliac crest as follows. Local anesthesia is
infiltrated into the maxillary vestibulum. A midcrestal
mucosal incision is performed from one side of the
tuberosity to the other with only one vertical release
incision in the midline. Vertical release incisions in
the posterior maxilla are avoided as these could pose
a risk of wound dehiscence and graft exposure. The

nasal mucosa is dissected free from the anterior nasal

floor if an anterior nasal floor graft is planned. The
mucoperiosteal flap is reflected, exposing the lateral
sinus walls and the alveolar process. In order to reduce postoperative eccymosis, the periosteal incision
is carried out at the beginning of the surgery, when
vasoconstriction from the local anesthesia is optimal.
The anterior residual alveolar crest is extensively
perforated using a 1.2-mm twist drill in order to increase the blood supply to the hostgraft interface.
The distance from the left to the right infrazygomatical crest is measured using a ruler. The distance
corresponds to the length of the harvested corticocancellous bone graft. The harvested graft is stored in
saline solution or in blood-soaked gauze. The harvested bone block is divided into two to four blocks.
A try-in of the bone blocks is made and the
blocks are trimmed to fit onto the residual alveolar
bone with a large contact area. The trimmed bone
blocks are then fixed with titanium screws of
2.0 mm in diameter (using a minimum of two
screws per bone block). The length of the screws is
chosen to engage the palatal cortical bone to
ensure a solid graft fixation. After fixation, the bone

153

Lundgren et al.

blocks are extensively perforated with a 1.2-mm

twist drill to enhance the vascular supply to the
graft. A cortical bone block is required for grafting
of the anterior nasal floor. The graft should be
shaped for press fitness without screw osteosynthesis. The tension in the mucoperiosteal flap is
checked and, if necessary, an additional periosteal
incision is carried out. The mucosa flap is closed by
single sutures.

Le Fort I osteotomy and

interpositional bone grafts
Indication
A Le Fort I osteotomy and an interpositional bone
graft can be the method of choice in patients with a
Cawood & Howell Class VVI alveolar process, while
an onlay bone graft is indicated in patients with a
thin, atrophic alveolar process (Class IV). The
interpositional bone grafting technique is performed
in atrophic edentulous maxillae that have been
resorbed to the extent of a reverse maxillamandibular inter-relationship, and possibly with an
increased vertical interjaw distance. The grafting
technique requires an alveolar bone width large
enough to host implants without having to reduce
the bone height.
Correction of the maxillamandibular inter-relationship is performed using a Le Fort I osteotomy in
conjunction with an interpositional bone graft from
the iliac crest. This procedure can be carried out
under general anesthesia as an inpatient procedure. Sailer et al. (32) and Isaksson (12), who also
described short-term follow-up findings, carried out
the surgical technique simultaneously with placement of implants. When using a two-stage procedure, the Le Fort I osteotomyinterpositional bone
reconstructive procedure is carried out in one session, and the placement of implants is performed
after a healing period of 6 months. Nystrom et al.
(27) published a 2-year follow-up study of ten consecutively treated patients using a two-stage surgical
protocol.
A preoperative clinical and radiographic examination, including panoramic radiograph, cephalometric
radiogram and computerized tomography scan,
should precede Le Fort I osteotomy with an interpositional bone graft. The cephalometric radiogram
provides information about the maxillamandibular
inter-relationship and distance. The patients denture
should be kept in place in order to avoid over-rota-

154

tion of the mandible, which can be misleading for

choosing the most appropriate surgical technique.

Surgical technique and flap procedure

The Le Fort I osteotomy is performed under general
anesthesia. Corticocancellous bone blocks are
harvested from the anteromedial aspect of the ilium.
The harvested bone blocks are stored in saline solution or in blood-soaked gauze during the Le Fort I
osteotomy.
A midcrestal mucosal incision is made from the
right to the left second premolar area, with a bilateral
short vertical release incision in the direction of the
infrazygomatical crest. The mucoperiosteal flap is
dissected to free the lateral maxillary sinus wall.
Posteriorly, the dissection is terminated at the junction between the maxillary tuberosity and the pterygoid plate. Superiorly, care is taken to identify and
avoid the infra-orbital nerve, and the lateral bone
distal to the nasal piriform aperture is dissected free
from the fixation plate. Anteriorly, the mucosal dissection is extended to the lateral border of the piriform aperture. After dissecting the nasal aperture and
the nasal floor, starting from the lateral site under the
inferior turbine, the nasal mucosa is elevated from
the floor of the nose all the way to the posterior nasal
aperture. The mucosa is also dissected free from the
nasal septa by pushing the mucosa superiorly in the
nasal midline. A small hole is drilled through the base
of the anterior nasal spine and a 0.5-mm steel wire is
inserted through the hole. The steel wire is placed to
avoid an accidental fracture of a fragile atrophic
maxilla during the down fracture procedure and to
help the anterior positioning of the maxilla. Horizontal osteotomies are carried out using a surgical
sagittal saw. After completing the horizontal osteotomy in the lateral sinus wall on both left and right
sides, the nasal septa is osteotomized using a nasal
septum osteotome all the way back to the posterior
nasal aperture. The lateral nasal wall is then osteomized using a lateral nasal wall osteotome.
The separation of the posterior maxilla from the
pterygoid junction is completed with a straight osteotome held in a vertical position. The down fracture
can be performed as soon as all bone structures are
completely osteotomized. This is especially important in the severely atrophic maxilla in order to avoid
a midpalatal fracture during the down fracture of the
maxilla. The down fracture is performed manually
and the mobilization is carried out by means of one
or two disimpaction forceps. The cortical surface of
the maxillary sinus floor and the nasal floor are

Strategies in reconstruction of the atrophic maxilla

roughened and leveled using a bud bur in order to

increase the vascular supply to the corticocancellous
bone graft. The harvested corticocancellous bone
block, approximately 4 3 1.5 cm in size, is prepared for the receptor site (Fig. 16AC). The corticocancellous bone blocks are placed with the cancellous surface towards the receptor site surface.
Cancellous bone placed on the surface of the floor of
the nose, and on the sinus floor, helps to enhance the
revascularization and, indirectly, the healing of the
interface between the graft and the maxilla. The upward placed cortical surface helps to ensure a bicortical anchorage and thus a better implant stability.
After achieving good stability in the block grafts, the
maxilla is held in an anterior position, aided by the
steel wire placed in the drilled hole in the anterior
nasal spine. The anterior and inferior advancement,
and the stability of the graft maxilla segment, as well
as the occlusal plane and the maxillary midline, are
then checked. If incorrect, the maxilla is down fractured again and the necessary corrections are made.
The final check is to ascertain that the lateral sinus
wall along the osteotomy is closed by the grafted
bone. This is most important between the infrazygomatical crest and the lateral nasal piriform aperture
due to the placement of the future implants in that
area.
Finally, the maxilla is held in the anterior position
by pulling the steel wire in the anterior nasal spine,
and the maxilla is pushed superiorly with the index
finger held in the anterior part of the palate
(Fig. 16D). One 2.0-mm-thick titanium miniplate is
placed on each side of the lateral nasal wall just
posteriorly of the nasal aperture (Fig. 16EG). One
screw is engaged in the down fractured maxilla and
two screws are engaged above the osteotomy line.
The wound is then closed with single sutures along
the margin of the keratinized mucosa.

Implant surgery
Patients are scheduled for placement of implants
6 months after the reconstructive surgery. A midcrestal incision, usually along the scar from the former
surgery, is performed using vertical release incisions
in the midline and posterior of the planned position
of the most posterior implant. The posterior release
incision is terminated within the keratinized mucosa
of the alveolar process. The vestibular mucosa is reflected and the graft is exposed only as much as
needed to identify the fixation screws. The fixations
screws, as well as plates with the Le Fort I osteotomy,
are removed and the graft is inspected (Figs 14B and

17). The implant placement is carried out using the

surgical guide (Fig. 18A,B). The primary stability of
the inserted implants is checked using resonance
frequency analysis. Following the placement of cover
screws, the mucosa is re-adapted and closed with
single sutures. Patients are given an appointment at
2 weeks for the removal of sutures and for changing
the soft relining of the removable denture.
The healing time of the implants depends on a
number of factors. When turned (machined) titanium
implant surfaces are used, optimal clinical stability
is accomplished after about 6 months (Fig. 14D). If
implants show insufficient stability, either manually
or with resonance frequency analysis, it is advisable
to increase the healing time to 8 months. When using
implants with oxidized titanium surfaces, optimal
stability can be achieved with a healing time of only
3 months (4).
When implants show optimal stability with clinical
and resonance frequency analyzes, immediate loading with a temporary bridge on temporary abutments
may be considered (Fig. 19AD). The immediate
loading treatment can most successfully be performed for oxidized implants with inherent good
primary stability (4). The prosthetic phase follows the
routine procedures for fixed full-arch implant-supported bridges, which can be constructed by using
metal-acrylic or metal-ceramic material (Figs 14E
and 15D).

Complications
General complications
Nonintegrated implants constitute the most common complication in both grafted and nongrafted
patients. However, the frequency of nonintegrating
implants is declining, probably because of a greater
experience of the surgeons and possibly also as a
result of new implant surfaces with the potential for
higher initial implant stability. As heavy smoking can
negatively influence the healing of bone grafts and
the integration of endosteal implants, refraining from
smoking during the healing period of grafts and implants might result in a better prognosis. Also, efforts
should be undertaken to increase the implant stability during the initial healing phase, such as a
reduction of the drilling diameter, exclusion of the
use of a countersink, reduction of drilling length in
low-density bone and the use of rough surface implants. Late implant failure is a much rarer complication than early failures. Late implant failures may

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A

156

Strategies in reconstruction of the atrophic maxilla

A

Fig. 17. Six months after a Le Fort I osteotomy and interpositional bone grafting. The maxilla and bone grafts
show good healing.

be caused by overloading as a result of bruxism or

by other local prosthetic factors. Infection is a relatively rare complication, which mainly occurs in
the early graft-healing period and which may be
resolved by drainage, topical antiseptics or systemic
antibiotics.

Surgical technique-related complications

Unpredictable bone resorption during graft healing
in the onlay grafting technique can occur as a result
of many factors, including: employing low-density
bone grafts with too little cortical component to
withstand resorptive forces, resulting in significant
graft resorption; insufficient rigid fixation of the
corticocancellous graft to the residual bone, resulting
in micromovements and extensive graft resorption;
premature loading of the onlay grafts during the
initial healing phase, especially during the first
month of healing when the bone graft is not yet revascularized and is sensitive to pressure and overloading from the removable denture; and tension in
the flap covering the onlay graft, causing increased
graft resorption as a result of ischemia of the flap and
pressure on the graft.

Fig. 16. (A) The harvested bone block. (B) Harvested bone
block divided into four pieces. (C) The four pieces placed
on the nasal floor and the maxillary sinus. (D) The maxilla
stabilized by the grafts and held in the anterior position.
(E) The maxilla is fixed in the anterior position with a

Fig. 18 (A) Type of surgical guide used for optimal positioning of implants. (B) The placement of the guide in a
clinical case.

Massive hemorrhage may occur during interpositional grafting and Le Fort I osteotomy. These relatively invasive surgeries can give rise to hemorrhage
as a result of accidental laceration of the major
palatinal artery or other maxillary artery branches.
Hemorrhage is usually not of major concern if

titanium mini plate lateral to the nasal aperture on the

right side. (F) Fixation plate placed on the left side of the
nasal aperture. (G) Postoperative profile radiogram
showing the result.

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Lundgren et al.
A

Fig. 19 (A) Iliac crest bone graft harvested for an anterior

and posterior maxillary reconstruction. (B) After 6 months
of bone graft healing, fixation screws are removed and
simultaneously 6 implants (TiUnite MK III, Nobel Biocare

occurring during surgery performed under general

anesthesia. Hemorrhage occurring in the immediate
postoperative period necessitates proper intervention
to terminate the bleeding.

Surgical site-specific complications

Unpredictable bone resorption during graft healing is
also the most common complication in onlay grafting. It occurs more frequently in the reconstruction
of the atrophic edentulous mandible than of the
maxilla, probably because of different vascularization
patterns of the jaws. In contrast to the maxilla, the
periosteum constitutes the sole source for blood supply of the mandibular residual bone and associated
grafts, which decreases the potential for revascularization. However, excessive bone resorption can also
occur with large vertical onlay grafts in the anterior
maxilla. Bone resorption in the maxilla is probably
caused by a combination of insufficient revascularization as the result of a small contact area between
the host bone and the graft and because of difficulties
associated with establishing a tension-free flap.

158

AB) are placed and connected with healing abutments.

(C) A temporary bridge delivered to the patient within 1
week after implant surgery. (D) Occlusal view of the permanent bridge delivered 812 weeks after implant surgery.

Exposure of the grafted bone in the initial

healing period
Exposure of grafted bone occurs most frequently
in the reconstruction of atrophic edentulous mandibles. The cause is probably a combination of tension
on the mucoperiosteal flap as a result of lip and soft
tissue movement, and compromised vascularization
of the flap and the surrounding soft tissue. The use of a
vestibular incision instead of a midcrestal flap incision is the best way to avoid this complication. Wound
dehiscence and graft exposure can sometimes result if
posterior vertical incisions are used in posterior onlay
grafting. To avoid this complication, a midcrestal
incision extending along the tuberosity can be used as
an alternative to posterior vertical release incisions.

Follow-up findings
Patients treated with reconstructive surgery should
be scheduled for an annual clinical and radiographic
follow-up examination for at least the first 5 years

Strategies in reconstruction of the atrophic maxilla

Table 3. Clinical results from onlay and interpositional bone grafting (Umea results)
Procedure

No. of
patients

No. of
implants

Follow-up
period
in years

Implant
failures,
n (%)

Onlay bone grafting

44

334

813

27 (8)

44 (100)

Interpositional bone grafting

26

167

915

24 (14)

13

26 (100)

post-treatment. In our scientific studies, the longterm outcome was assessed by clinical and histological evaluations of the bone graftimplant
interface using the micro-implant technique and
resonance frequency analysis (21, 33, 34).

Onlay grafting of the edentulous maxilla

A substantial number of patients have been treated
with buccal onlay grafts from the tibia and delayed
placement of dental implants. Forty-four patients
and 334 implants were followed for a mean period of
10 years (range: 813 years). Twenty-seven implants
(8%) in 17 patients were lost; 23 of the failures
occurred before loading and four occurred during
loading, and 13 were losses of single implants. Six
new implants were placed, and all patients received
and maintained a fixed bridge during the follow-up
period (Table 3).

Interpositional bone grafting in

conjunction with a Le Fort I osteotomy
Since 1990, several patients have received interpositional bone grafting in conjunction with a Le Fort I
osteotomy and delayed placement of implants. A
total of 26 consecutive patients with 167 implants
were followed for a mean period of 12 years (range,
915 years). Twenty-four implants were lost (14%):
19 before bridge connection, and five during loading.
Failures included the loss of one (n = 7), two (n = 6),
three (n = 1) and five (n = 1) implants. Thirteen new
implants were placed and all patients received and
maintained a fixed bridge as a result of the treatment
(Table 3).

Concluding remarks
Treatment of patients with a severely resorbed maxilla
is challenging for dentists. Nevertheless, our experience and evidence from the literature show that
patients with an atrophic maxilla can be predictably
and successfully rehabilitated with bone grafts and a

No. of replacement
implants after
initial failure

Bridge
survival,
n (%)

two-stage implant procedure. Although grafted sites

are associated with more implant failures than nongrafted sites, very few bridges are lost as a consequence of implant failure. Refinement of bone
harvesting techniques from the iliac crest has reduced
the number of graft complications and morbidity. It is
also our opinion that the introduction of surfacemodified implants has further improved the clinical
outcome of reconstructive surgery. For instance, our
research group found a failure rate of 1.5% for oxidized titanium implants placed in interpositional or
onlay bone grafts in edentulous patients (4). This
success rate is better than the 10% failure rate experienced in our clinics with machined titanium
implants (33). However, reconstruction of the atrophic maxilla with bone grafts is a lengthy procedure,
usually lasting more than 1 year. Further development in implant dentistry ought to focus on shortening the treatment time. At present, we do not think
that it is possible to speed up bone graft incorporation
because healing and remodeling are preprogrammed
biological processes. However, it is probably possible
to reduce the healing time after implant insertion or
even using immediate-loaded implant protocols.
Those possibilities warrant further research.

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