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ORIGINAL ARTICLE
Year : 2013  |  Volume : 3  |  Issue : 1  |  Page : 42-45

Gaining vertical interarch space for implant placement: The surgical protocol - Series of five cases


Department of Oral and Maxillofacial Surgery, School of Dental Science and Hospital, Krishna Institute of Medical Sciences, Karad, India

Date of Web Publication10-May-2013

Correspondence Address:
Prashant A Punde
Department of Oral and Maxillofacial Surgery, School of Dental Science and Hospital, Krishna Institute of Medical Sciences, Karad - 415 110, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-6781.111689

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   Abstract 

Purpose of the Study: Compromised inter-arch space stand as a difficult clinical situation for placement of implants in opposite arch. This study aims towards finding out efficacy of posterior maxillary segmental osteotomy (PMSO) in providing adequate interarch space.
Materials and Methods: The study comprised of five patients with supraerrupted maxillary posterior teeth. All patients underwent PMSO under GA. Postoperative interarch distance measured and compared with the preoperative value.
Main results: On an average, about 4 mm of clearance was achieved from the existing pre-operative clearance, which facilitated restoration of dentition in the opposing arch. The results were stable without complications over 16-18 months post-operatively.
Conclusion: PMSO is a simple quick alternative technique and can be combined with implant placement and a successful technique for increasing the interocclusal clearance, and thereby facilitating restoration of the dentition in the opposite arch.

Keywords: Decreased inter-arch distance, mock surgery, posterior maxillary segmental osteotomy, supraerupted teeth


How to cite this article:
Punde PA. Gaining vertical interarch space for implant placement: The surgical protocol - Series of five cases. J Dent Implant 2013;3:42-5

How to cite this URL:
Punde PA. Gaining vertical interarch space for implant placement: The surgical protocol - Series of five cases. J Dent Implant [serial online] 2013 [cited 2022 Jan 25];3:42-5. Available from: https://www.jdionline.org/text.asp?2013/3/1/42/111689


   Introduction Top


Masticatory function is a specialized activity requiring the coordination of neural and muscular activity. Teeth in the oral cavity play a vital role. Along with the number of teeth, the position of the teeth also is important for effective mastication. Whenever tooth is lost/removed and not rehabilitated prosthetically for a long period of time, it will lead to supraeruption of the opposing tooth, thereby decreasing interocclusal clearance.

Conventionally to achieve interocclusal clearance, the most commonly used technique was extraction of the offending supraerupted tooth or teeth. Over a period time, various options have been proposed, i.e., performing an intentional root canal therapy for the supraerupted tooth and crown shortening, orthodontic intrusion of teeth using implants, or by performing posterior maxillary segmental osteotomy (PMSO). [1]


   Materials and Methods Top


The study comprised of five patients in the maxillary arch. Three patients were males and two were females. The age group was between 25 years and 35 years. All the included patients gave a history of undergoing extraction of teeth in the opposing arch and had not got replacement for the same. Pre-operative assessment was done which included orthopantomogram, model surgery, and routine blood investigations; pre-operative and post-operative interocclusal measurements were done on models and radiographs [Figure 1], [Figure 2], [Figure 3] and [Figure 4]. Surgery was done under general anesthesia.
Figure 1: Supraerupted right maxillary posterior teeth

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Figure 2: Pre-operative orthopentamogram

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Figure 3: Pre-operative models

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Figure 4: Mock surgery done and posterior segment repositioned for splint fabrication

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Vestibular incision placed extending from first premolar to second molar and full thickness mucoperiosteal flap was raised. Osteotomy cuts were placed 5 mm above the apices of teeth and at interdental bone with the help of fine surgical burs, [Figure 5] care was taken not to damage the roots of the teeth. Trans-antrally with the help of osteotomies, palatal cuts were completed. Anterior cut was made interdentally and posterior cut was limited to the socket of the third molar tooth. The segment was down fractured and sufficient amount of bone was removed superiorly and the segment was repositioned as planned pre-operatively [Figure 6].
Figure 5: Osteotomy cuts placed 5 mm above the apices of molars

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Figure 6: Superiorly placed posterior segment

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The posterior maxillary segment was secured across the osteotomy site with the help of miniplates and screws. Every case was evaluated clinically [Figure 7] and radiographically [Figure 8] at the end of 6 months.
Figure 7: Post-operative result after 6 months

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Figure 8: Post-operative OPG

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   Discussion Top


The partial dentate state may be the fate of many elderly dentate patients in the future, as the prevalence of edentulousness decreases in the population. The main positional change to be expected in unopposed teeth, retained root stump, and carious teeth is over eruption. Kiliaridis et al. identified that over eruption >2 mm occurred in unopposed teeth. In other words, he demonstrated that about 82% of supraeruption are due to unopposed teeth. [2]

If we replace the edentulous area with the prosthesis, without correcting the supraerupted teeth, it may lead to inefficiency in the masticatory function due to improper distribution of masticatory force, deviation in the mandibular movement, and problems in the temporomandibular joint. The various treatment modalities described in literature for correction of supraerupted teeth are:

  • Coronoplasty (enameloplasty)
  • Molar intrusion using orthodontic temporary anchorage devices
  • Intentional root canal therapy
  • Extraction of supraerupted tooth
  • Orthognathic surgery: Posterior segmental osteotomy. [2]
If supraeruption is not severe enough, the coronoplasty, root canal treatment with shorter crowns, etc., have been tried. But the supraeruption is very severe and of more than one tooth, the posterior segmental osteotomy acts as a simple alternative technique. [3]

Compare to the extraction of the opposing supraerupted teeth, segmental osteotomy becomes more conservative approach.

The procedure is very simple but known to be a precise technique; if this procedure is not done precisely, it might lead to poor occlusion. Special attention should be given to buccal gingiva to maintain adequate blood supply to the fragment. Inadvertent tearing of the buccal or the palatal mucoperiosteum flap may jeopardize the vitality of the segment. The horizontal cut has to be precisely given to prevent non-vitality of teeth.

Schuchardt was the first person to perform PMSO in 1954 as a two-staged procedure for the correction of anterior open bite. Kufner introduced one-stage procedure by modifying Schuchardt technique in 1960. [4]

In 1984, Moloney et al. [5] performed this procedure for elimination of edentulous spaces by advancing the posterior segment.

Posterior segmental osteotomy is extremely suitable for advancing and rotating the lesser fragment in unilateral cleft patient or for repositioning both posterior fragments in bilateral cleft patient with simultaneous bone grafting. Long-term results had proven predictable and stable results (Stoelinga et al. 1987). [5]

Posterior segmental osteotomy is considered versatile and useful treatment is alternative for variety of Dentofacial condition, especially in case of bilateral distal extension RPD construction Bell and Levy [6] described that the vertical osteotomy cut should be 5 mm above the apices of the posterior teeth and they considered this distance to be safe with regards to the neurovascular regeneration of the pulp of the teeth involved.

West and Epker in 1972 provided an extensive review about the versatility of this procedure.

The basic indications for PMSO Include [7]

  • For correction of posterior cross bite
  • For correction of supraerupted posterior teeth
  • Correction of posterior open bite
  • Transverse excess or deficiency
  • Distal repositioning of posterior maxillary fragment
  • To provide space for eruption of impacted cuspids and bicuspids.


In our study, the patients were evaluated for interocclusal clearance pre-operatively and post-operatively on the models and on the radiograph [Table 1].
Table 1: Interocclusal clearance before and after the procedure

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On an average, about 4 mm of clearance was achieved from the existing pre-operative clearance, which facilitated restoration of dentition in the opposing arch. No wound breakdown, no persisting fistula, no sinusitis with infection reported over 16-18 months post-operatively. The results were stable. No patient developed sensitivity in the post-operative period. Vitality of the teeth bearing segment was maintained and none of the patients developed complications related to maxillary sinus.


   Conclusion Top


Muller de van stated that "the preservation of that which remains is of utmost importance than the meticulous replacement of that which has been lost." This holds true in case of management of supraerupted teeth. PMSO is a simple quick alternative technique and can be combined with implant placement and a successful technique for increasing the interocclusal clearance, and thereby facilitating restoration of the dentition in the opposite arch. The technique involves minimal or almost no complication if executed properly.

 
   References Top

1.Joshi U, Patil SK, Siddiqua A, Thakur N.Posterior maxillary segmental osteotomy for management of supraerupted teeth-a case report. Int J Dent Clin 2010;2:64-7.  Back to cited text no. 1
    
2.Mahoorkar S, Moldi A, Puranik S, Chowdhary R, Majge B. Management of supraerupted teeth. Review. Int J Dent Clin 2010;2:27-30.  Back to cited text no. 2
    
3.Kim C, Kim M, Kim D. Upward repositioning of the extruded posterior maxillary alveolar segment osteotomies. IJOMS 1999;28:13.  Back to cited text no. 3
    
4.Rosen PS, Forman D. The role of orthognathic surgery in the treatment of severe dentoalveolar extrusion. J Am Dent Assoc 1999;130:1619-22.  Back to cited text no. 4
    
5.Moloney F, Stoelinga PJ, Tideman H. The posterior segmental maxillary osteotomy: Recent applications. J Oral Maxillofac Surg 1984;42:771-81.  Back to cited text no. 5
    
6.Bell WH, Levy BM. Revascularization and bone healing after posterior maxillary osteotomy. J Oral Surg 1971;29:313-20.  Back to cited text no. 6
    
7.Ataoglu H, Kucukkolbasi H, Ataoglu T. Posterior segmental osteotomy of maxillary edentulous ridge: An alternative to vertical reduction. Int J Oral Maxillofac Surg 2002;31:558-9.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1]



 

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