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Clinical examples of what can be

achieved with osseointegration


in anatomically severely
compromised patients
Daniel van Steenberghe, Marc Quirynen, Barbro Svensson &
Per-Ingvar Branemark
The present chapter will illustrate by means of as
series of examples of patient treatments how far one
can go in the rehabilitation of patients with extremely
compromised jaw bones using osseointegrated im-
plants. Those happen to be the patients who often
are the most in need of this treatment. This contribu-
tion presents a series of patients with different types
of very compromising situations, ranging from con-
genital defects to major jawbone resection because
of cancer. The clinical examples also show that the
team approach, where high-level skills from different
disciplines join forces, can go beyond what routine
clinical practice may envisage. It is important that
patients who are suffering because of certain anato-
mical or functional defect are being offered this treat-
ment option. Therefore it is important that clinicians
become familiar with the far-reaching possibilities
offered by this approach, even if they do not provide
the treatment themselves.
Extremely resorbed maxillae
A long period of edentulism and/or untreated severe
periodontitis can result in a nearly complete resorp-
tion of the alveolar process in the maxilla, rendering
the retention of an ordinary complete denture nearly
impossible. Such patients can be rehabilitated with
osseointegrated implants after the reconstruction of
the jawbone (via a grafting procedure or guided bone
regeneration).
Onlay graft
The surgical protocol for this procedure has been
outlined in papers by Branemark and co-workers
(2, 8). The reconstruction of the jawbone and implant
insertion is an excellent example of a synchronized
team approach with a patient under general anesthe-
sia, where periodontists can work at the oral site
while another surgical team harvests grafts at the
hip site (14, 15).
After local inltration of analgesics in the vestibular
fold of the mouth, a bevel incision is made about 2 cm
apical of the remaining alveolar crest from maxillary
tuberosity to tuberosity. The mucosa is dissected in a
slightly coronal direction and the periosteum is cut
just coronal of the base of the apertura piriformis.
The mucoperiosteal ap is further dissected taking
special care to maintain the integrity of the perios-
teum. The gross size of the remaining alveolar crest is
evaluated via a series of prefabricated horseshoe-
shaped templates. This information is given to the
second team working at the hip. The nasopalatine
neurovascular bundle is sacriced and the canal
thoroughly curetted to be free of fatty tissue (Fig. 1a)
and to be lled with bone chips. The incisal canal site
often has some remaining bone, which can serve to
harbor an implant. Periosteal remnants on the dis-
sected bone are removed. The cortex of the recipient
jawbone is perforated with a small round bur at sev-
eral sites to allow proper blood supply. Blood con-
tains the necessary ingredients for optimal healing
(cells, growth factors).
In the meantime, the team at the hip surgical site,
separated by a screen of sterile drapes over the
patient's abdomen, has prepared the donor site.
The skin incision is made on top of the palpable crest
and, after multilayered dissection, the periosteum is
cut over a length of 5 cm on top of the crest starting
some 2 cm dorsal of the spina iliaca anterior. Both
90
Periodontology 2000, Vol. 33, 2003, 90104 Copyright
#
Blackwell Munksgaard 2003
Printed in Denmark. All rights reserved
PERIODONTOLOGY 2000
ISSN 0906-6713
periosteum and gluteus muscle are reected. A tem-
plate corresponding to that used in the oral cavity is
placed on the lateral surface of the iliac bone and,
under continuous cooling, a series of holes are drilled
around it. These holes are connected with each other
by means of an oscillating saw or by using osteo-
tomes. Finally, the graft is freed in the vertical plane
from the underlying squamous part of the iliac bone
with large thin bone scissors, starting from the top of
the crest. As such, a horseshoe-shaped cortico-cancel-
lous bone graft is progressively retrieved (Fig. 1b,c,d).
At the same time, some additional cancellous bone is
collected from the iliac defect together with some
blood (see later). While the team at the oral site takes
Fig. 1. (a) Uncovered mandible with the curetted nasopa-
latine canal. (b, c, d) The surgical team at the hip side
prepares, while a horseshoe-shaped corticocancellous
graft is progressively mobilised. (e) The cancellous part
is adapted to the jaw bone crest to achieve a stability of
the graft. (f, g) The graft is immediately xed by a series of
self-tapping implants. h) 3-D CT-scan image of the pelvic
bones showing a remaining defect on the left iliac crest
after bone harvesting. (i) Connecting the abutments by a
rigid prosthesis should be done as soon as possible to
spread the occlusal loading. (j) After some time the nal
prosthesis can be installed. (k) During the rst months
after installation of an autologous bone graft a deminer-
alization occurs which can be detected on the radiographs.
This will be reversed later. (l, m) With a team approach and
good cooperation with the restorative dentist it seems pos-
sibletomaintainmarginal bone levels for years. Patient with
a full maxillary graft at year 1 and after 10 years.
Osseointegration in severely compromised patients
91
over the graft, the surgical team at the hip starts the
closure in a routine multilayered manner, often
together with the installation of Redon suction to
deal with any postoperative bleeding.
Once the team at the oral site receives the graft, it
immediately starts to adapt the cancellous side of the
graft to the anatomy of the remaining jaw bone crest
by means of rongeurs and a foil adapted to the crest
(Fig. 1e). The latter is prepared from tin foil. To pre-
vent undue bone damage, no rotating instruments
are used except sometimes for a major reduction of
the cortical plate of the graft at the end of the pro-
cedure before closing the wound. The nasopalatine
canal and other undermining cavities are lled with
cancellous bone. Once an optimal t is obtained (the
graft should already be stable by itself), the graft is
xed to the maxilla via several implants (Fig. 1f).
With this team approach, the graft is outside the
body for less than 10 min.
The installation of the self-tapping implants starts
with one implant in the front area. During this pro-
cedure the surgeon has to pay special attention to
immobilizing the graft. The stability obtained with this
rst implant together with the optimal t renders the
remaining implant insertion a routine intervention.
The remaining space between graft and basal bone
is packed with the earlier retrieved bone chips. The
wound is closed with a one-layered monolament
suture with three mattress sutures and a series of
supercial sutures. However, in order to prevent
Fig. 1. continued
92
van Steenberghe et al.
perforations due to the graft, it is sometimes neces-
sary to dissect the labial mucoperiosteal fold.
After 47 days the patient can leave the hospital,
but complaints of difculties and pain upon walking
are frequently encountered. Indeed, some perma-
nent defects can occur at the iliac crest (Fig. 1h). A
denture cannot be worn during the rst 2 months.
Before using the old denture, a meticulous adapta-
tion with soft liner is essential. The abutments can be
inserted no earlier than 8 months after implant
insertion. Immediately after abutment connection, a
rigid provisional prosthesis is prepared which should
be ready within 2 weeks (Fig. 1i). In the meantime,
and even during the rst months with the provisional
prosthesis, a soft diet is instituted. The nal prosthe-
sis is installed 6 months or 1 year later (Fig. 1j) to
allow a stable, soft tissue adaptation and to compen-
sate for early graft remodeling and any supercial
resorption, thus achieving good esthetics.
Several follow-up studies have reported survival
rates around 85% (3); the above-mentioned proce-
dure led to a cumulative survival rate for individual
xtures of more than 90% after 10 years of function
(15). Sometimes an initial bone resorption/remodel-
ing of 12 mm (1) has been observed during the rst
12 months of loading, followed by a further bone loss
that falls within the 0.1 mm range, which is consid-
ered success using the criteria of Albrektsson and
Sennerby (4). The two-team approach and the
immediate xation of the autologous graft by means
of self-tapping implants led to minimal marginal
bone resorption (Fig. 1k,l,m).
Onlay graft in maxilla with congenital
discontinuities
In cleft palate patients (Fig. 2a) a similar procedure
as described above can be followed, except that the
bone graft adaptation to the complex anatomic situa-
tion requires more time. Instead of a horseshoe-
shaped graft, a full bone plate in installed (Fig. 2b).
If a connection with the nasal cavity is still present,
soft tissue handling by means of a sliding ap should
achieve a hermetic closure (Fig. 2c,d). The inserted
implants can later either be used to support a full
bridge or often to anchor an overdenture (Fig. 2e,f).
Guided bone regeneration using a
occlusive titanium membrane
Some patients badly want a xed prosthetic recon-
struction in the maxilla but are reluctant to undergo
an autologous hip bone graft procedure because of
the postoperative pain and limping (15). These
patients can be helped with a guided bone regenera-
tion procedure via the placement of a subperiosteal,
rigid, commercially pure titanium, barrier mem-
brane. Although it is still in a clinical development
stage, the concept is inspired by guided bone
augmentation techniques under hermetically closed
membranes (13) but this time applied for a larger size.
The approach, previously described in detail by
van Steenberghe and co-workers (17) for a series of
10 patients, is briey summarized by the clinical
achievement in a 31-year-old female patient with
extreme resorption of the maxilla (Fig. 3a,b), who
Fig. 1. continued
93
Osseointegration in severely compromised patients
was in the need of a xed full bridge but who refused
harvesting of a hip graft to obtain the necessary bone
volume. With the use of the data from the spiral CT
scan of the maxilla, a stereolithographic model was
prepared (Fig. 3c) to which the amount of desired
bone was added by a wax-up technique (Fig. 3d).
The blocked out model was used to press a 0.2 mm
custom-t commercial pure titanium membrane
with a perfect adaptation (Fig. 3e). The latter serves
as rigid membrane below which undisturbed bone
regeneration can occur.
The crest of the maxilla was exposed under local
anesthesia via a mucoperiosteal ap with an incision
in the vestibular fold from molar to molar region.
Special attention was paid to maintaining an intact
periosteum. All periosteal remnants were removed
Fig. 2. (a) Patient with a bilateral cleft palate. (b) The
autologous graft should have a large surface to close the
entire oroantral and or oronasal communication. (c, d)
When soft tissue defects are still present, they should be
closed by a multilayered technique. One can see from this
view that the patient could not wear a denture. (e, f) The
clinical result (two pictures 13 years apart) on two
implants only (the ones immediately installed over the
congenital defect did not integrate) which can retain an
overdenture. (g, h) Radiographic outlook before surgery
and some years after. (i, j) In this female patient suffering
from a bilateral palatoschisis, four implants could be
installed in an autologous graft. (k) The same patient after
some 12 years with a stable situation concerning implants
but with gingivitis due to a Candida infection (she did not
remove her denture at night).
94
van Steenberghe et al.
from the dissected bone. The cortex of the recipient
jawbone was, as for a grafting procedure, perforated
with a small round bur at many sites to allow proper
blood supply. The individualized membrane ts very
well (Fig. 3f) and a few xation screws were installed
(Fig. 3g) to guarantee the immobility when the
patient was allowed to wear his denture again or
preferably 2 months after insertion. The volume con-
tained under the membrane lls itself by blood,
which will allow a progressive ossication as has
been demonstrated from experiments on the rabbit
skull (17). The postoperative pain is limited but swel-
ling can be substantial for 2 weeks.
After 12 months the membrane was removed and
a whitish dense and eventually hard tissue lled the
entire space (Fig. 3h). Implants can be installed
(Fig. 3i) and, 6 months later, abutments. The patient
received a xed prosthesis with very satisfying
result from both a functional and esthetic point of
view (Fig. 3j). Intraoral control radiographs after
3 years show the perfect stability of the marginal
bone level.
A total of 10 patients have been treated in Leuven
via this approach (17). In all but three patients suf-
ciently large bone volume increases, up to 13 mm in
height, were obtained to install implants. The failures
were related to an early perforation of the mem-
brane. The latter can be prevented by the following:
an optimal ap design and possibly dissection of
the labial fold of the vestibulum
optimal postoperative care
2-month healing without denture
perfect adaptation of the denture for the following
6 months
Fig. 2. continued
95
Osseointegration in severely compromised patients
From a total of 39 implants, one failed. The mean
bone loss around the remaining implants remained
within the success criteria formulated by Albrektsson
& Sennerby (4).
Guided bone regeneration but for smaller volumes
can also be obtained with disposable membranes as
illustrated by Becker (5). One can conclude that
membrane techniques are predictable and therefore
Fig. 3. (a) The preoperative view illustrates the knife-edge
jaw anatomy. (b) Panoramic radiograph of the referring
dentist illustrates an extremely radiolucent maxilla with a
relative good height of the crest. The canine and molar
were removed at surgery to allow a guided bone regenera-
tion over the entire maxilla. (c, d) An example of a litho-
graphic model prepared with the data from the spiral CT
scan of the maxilla on which the augmentation will be
mimicked with some wax-up and later transformed to a
plaster model. (e) Such a blocked out model is used to
press a 0.3 mm custom-t commercial pure titanium
membrane with a perfect adaptation. (f) The borders of
the individualized membrane ts perfectly to the basal
bone. Before inserting the membrane it is lled with
patient's blood retrieved after perforating the crest. (g)
Close up picture of optimal t between occlusive mem-
brane and basal bone. To stabilize the membrane, small
xation screws are added. (h) The bony tissue volume at
12 months is impressive when compared to the initial
situation. A whitish dense and underlying hard tissue lls
the entire space below the membrane. The supercial
layers showa good blood supply. (i) The bone regeneration
allows the insertion of six implants even following indica-
tions of the dentist to achieve the optimal implant loca-
tion/angulation. j) The provisional prosthesis is in place
on the bulky crest.
96
van Steenberghe et al.
should be offered to patients with, at rst sight, too
little bone for an implant-based rehabilitation. This
should be done even if patients have to be referred to
a more skilled surgeon.
Extremely resorbed mandible
An extreme resorption of the mandible often renders
retention of the full prosthesis impossible. Such
patients, who are used to living with a denture, often
only seek more retention of their denture. The inser-
tion of two implants interconnected with a dolder
bar offers a satisfactory solution for most patients
and seems reliable in the long-term (16). For some
patients, however, even such a minor surgical inter-
vention becomes risky because of the extremely
resorbed jawbone volume. In such patients a grafting
procedure can recommended. The procedure is illu-
strated via another clinical case.
In this patient, a 45-year-old man, edentulous
since he was 18, which presented an extreme resorp-
tion of both edentulous jaws, the risk of fracture
during or soon after implant could not be ignored.
Furthermore, the distance to the occlusal plane was
more than 3 cm, which would lead to an unfavorable
relationship between the lengths of the endosseous
implant and of the prosthetic suprastructure. It was
agreed with the patient that an autologous hip graft
would be installed to heighten the mandible,
together with implant installation. The patient asked
only for a sufcient retention of his denture, so just
two implants to retain an overdenture were planned.
A horseshoe-shaped hip graft was taken and imme-
diately xed by means of three screw-shaped
implants (Branemark system) (Fig. 4a). The graft
reached the molar region since this is where mucosal
support for the overdenture is needed. It has also
been observed that the bone resorption of the mand-
ible in this distal region is increased when implant-
retained overdentures are placed (7). Although for an
overdenture retention only two implants are needed
(10, 11, 16), the third implant was installed as a
reserve in case one of the other two did not integrate.
As can be seen from the panoramic radiograph
taken some 6 months after the grafting procedure,
a reduced bone density is evident (Fig. 4b). Only two
abutments were installed on the lateral implants.
They were connected by a bar and to anchor the
overdenture with clips. After more than 12 years
the patient still happily functions with his abut-
ment-retained overdenture. The panoramic radio-
graph (Fig. 4c) shows only a partial resorption of
Fig. 3. continued
97
Osseointegration in severely compromised patients
the graft, especially in the distal areas where no x-
tures had been inserted. The intraoral, long cone
radiographs taken at his last visit (13 years after abut-
ment connection) demonstrate the stable peri-
implant conditions (Fig. 4d).
Anatomic defects/discontinuities
after resection surgery
Oncologic surgery in the head and neck region
often includes the resection of major parts of the
jawbones. Today's maxillofacial surgical approaches
can almost guarantee the re-establishment of tissue
continuity. However, tissue repair is not synony-
mous with functional rehabilitation. Osseointegrated
implants can be essential to re-establish normal oro-
facial function.
Mandibular discontinuity
As seen in this female patient (65 years old) who
underwent a subtotal mandibulectomy (together
with chemotherapy and radiotherapy) for a spinocel-
lular epithelioma of the oor of the mouth, the
resulting intraoral situation did not allow a proper
retention of a full removable denture (Fig. 5a). A
plastic surgeon performed a subtotal reconstruction
of the resected mandible by means of an iliac crest
bone graft (Fig. 5b). This involved an arterial end-to-
end anastomosis between the arteria circumexa
and the facial artery to insure a proper vasculariza-
tion of the graft after the irradiation the patient had
undergone. The clips of arterial anastomosis can be
seen (Fig. 5b). This element encouraged us to try for
a functional rehabilitation by means of endosseous
implants from this orally seriously disabled patient.
Indeed, the concavities of the lower crest and the
intraoral skin graft that had accompanied the
bone graft were unfavorable elements for a prosthe-
tic retention. Skin does not offer the moisture nor-
mally encountered with oral mucosae, which
guarantees the vacuum effect under the custom-t
removable denture. Intraoral hair growth was also
disturbing.
In 1987, six implants were inserted under general
anesthesia, which all uneventfully integrated, as
Fig. 4. (a) An autologous graft immediately xed by three
self-tapping implants leads to an ample jaw bone volume.
(b) The panoramic image, taken immediately prior to
abutment connection, shows a reduced density of the
graft. The three implants seem to be well integrated. (c)
The panoramic radiograph taken after 12 years shows only
a partial resorption of the graft, especially in the distal
areas where no xtures had been inserted. (d) The
intraoral, long cone radiographs taken at the last visit
(13 years after abutment connection), demonstrate an
acceptable marginal bone level.
98
van Steenberghe et al.
could be checked at the abutment surgery some
6 months later (Fig. 5c,d). On these abutments a
xed prosthesis was installed by the Department of
Prosthetic Dentistry, which, according to the
patient's reactions, gave an enormous improvement
of her quality of life (Fig. 5e).
The maintenance of inammation-free soft tissues
around the abutments demanded a meticulous
Fig. 5. (a) As part of the treatment of a spinocellular
epithelioma of the oor of the mouth, a subtotal mandi-
bulectomy had been performed in this 65-year-old women
by a plastic surgeon. Even though the patient had under-
gone a subtotal reconstruction of the resected mandible by
means of an iliac crest bone graft, the resulting intraoral
situation did not allow a proper retention of a full remo-
vable denture. (b) The intraoral view shows the skin graft
and compromised anatomy, which explain the lack of
retention of the denture. (c) It was decided to install six
Bra nemark system implants under general anesthesia,
which all uneventfully integrated, as shown by this radio-
graph taken just before abutment connection at 8 months.
(d) During the abutment insertion, all implants were
mechanically diagnosed as well integrated. (e) Up to the
molar region, a 10-unit bridge, installed by the prostho-
dontist, gave the patient satisfactory function. (f) The same
patient after 15 years with a stable functional situation,
even though a slight inammation of the gingiva and
mucosa is apparent. (g) Since the patient had other prio-
rities in her life, she did not seek a more esthetic solution
in the maxilla.
99
Osseointegration in severely compromised patients
plaque control, which the patient, although very moti-
vated, was not always able to achieve. Around the
most distal implants a pocket deepening occurred
and after some years this became purulent, though
this did not lead to subjective complaints (Fig. 5f).
This peri-implantitis was treated by means of
repeated rinsing with a chlorhexidine gel at each con-
trol visit. It did not seem to improve whatever was
tried. After some time, the most distal implant in the
3rd quadrant failed. The latter was replaced by two
new implants. All remaining implants remained
functional and even after 15 years the appearance
was good. The patient passed away because of an
unrelated illness.
Bilateral maxillectomy
A male adult patient had undergone a total bilateral
maxillectomy in 1968 (in another department)
because of a carcinoma. Only the palatal bones
and some of the lateral walls of the maxillae were
left (Fig. 6a). The patient experienced great difcul-
ties in chewing and speech functions. He could not
wear a retention prosthesis because of pain due to
the fragility of the sinusal epithelial linings after the
irradiation. Even subtle contacts of those mucosae
many years after the irradiation still led to bleeding.
The patient normally wore tissues in the sinusal cav-
ities to allow a more or less understandable speech.
When he consulted the Department of Periodontol-
ogy in 1988, the option of rehabilitation by means of
endosseous implants was considered, even though
the prognosis at that time before hyperbaric oxy-
gen therapy was routinely used, was reserved (6).
Explorative surgery was performed to search for any
available bone volume to harbor implants. Since no
bone whatsoever could be found in the anterior areas,
it was decided to insert two long implants in the
zygomatic bone. At that time no special design was
available (9), so two long (25 mm) self-tapping im-
plants were inserted in the zygoma through an infra-
zygomatic arch approach. To allow the insertion of
two more implants, a split crestal hip bone graft was
xed on top of each of the palatine bones, and two
implants were screwed in these grafts (Fig. 6b). After
8 months of healing abutment surgery took place and
all four implants seemed rigidly anchored. On top of
that, a complex two-piece frame was constructed by
the Department of Prosthetic Dentistry to retain an
overdenture (Fig. 6c,d). Although there was no frontal
support, this superstructure functioned properly for
6 years. After that time, one of the zygomatic implants
fractured and had to be replaced (Fig. 6e). The pros-
thetic framework was replaced by a shorter framework
(Fig. 6f,g), which also gave a comfortable retention.
The psychologic benets for the patient of re-estab-
lished phonetic and chewing functions are enormous.
After more than 15 years this patient happily enjoys
his implant-supported rehabilitation.
Resection of maxillary and nasal
structures
A male patient had undergone a resection of maxillary
and midfacial structures for carcinoma treatment in
1980. He was given xtures in the frontal and zygo-
matic bones to support a metallic frame which
allowed him to anchor both an oral and a midfacial
prosthesis. All implants functioned well, although the
patient had been fully irradiated, until he passed away
11 years later from an unrelated cause (Fig. 7ae).
Anatomic defects after traumatic
injuries
In a number of instances, traumatic loss of jaw struc-
tures can exclude the insertion of any implant or lead
to unfavorable biomechanical outcomes. If the length
of the abutment plus the prosthetic superstructure to
reach the occlusal plane is larger than the endoss-
eous part, overloading can occur with loss of integra-
tion (12). Therefore it can be mandatory to increase
the available bone volume prior to or together with
the implant insertion.
Fig. 5. continued
100
van Steenberghe et al.
In a young patient (21 years of age) who suffered a
trafc accident (Fig. 8a), besides dental trauma a
substantial part of the periodontal tissues was lost
in the symphyseal area. To achieve a proper recon-
struction, a small hip graft was taken, inserted on top
of the remaining symphyseal bone and xed with
two screw-shaped xtures (Fig. 8b,c). At abutment
surgery (Fig. 8d,e) an optimal situation was encoun-
tered and a xed prosthesis was installed (Fig. 8f),
which thanks to the increased bone and gingival
Fig. 6. (a) The bilateral maxillectomy to resect the tumor
created severe difculties in chewing and speech for this
patient. Only the palatal bones were left and some of the
lateral walls of the maxillae. As such, the conchae came
into direct contact with the oral cavity. (b) A split crestal
bone graft was xed on top of each of the palatine bones
and two implants were screwed in these grafts, as can be
seen on this panoramic radiograph. (c, d) After abutment
connection, an inventive frame work in two connected
parts was created by the prosthodontist to support a
large overdenture. The latter signicantly increased the
patient's oral function. The chronic inammatory state
of the soft tissues was uncontrollable. (e) After several
years, a new shorter prosthetic framework was install-
ed which gave a similar degree of comfort to the
patient.
101
Osseointegration in severely compromised patients
Fig. 7. (a) The patient with his mid-
facial postresection defect. (b)
Although the patient has been irra-
diated, a number of xtures are
inserted in the frontal bone and in
the zygomatic bone. (c) The dentist
can now apply the prothesis on
the metallic framework. (d) The ana-
plastologist has adapted the mid-
facial prosthesis on the same
framework illustrating the team
approach. (e) Radiographic frontal
view of the implants and the metallic
superstructure.
102
van Steenberghe et al.
volume offered a good phonetic and esthetic out-
come. Indeed, the patient uncovered her lower front
teeth during function. When a control radiograph
was taken after 3 months a decreased bone density
could be observed, indicating a high turn-over
(Fig. 8g). This is often observed with autologous
bone grafts during the rst year.
The bone mineral density increased again and at
the last control after 10 years the two implants
seemed perfectly stable (Fig. 8h).
Fig. 8. (a) The oral situation after a trafc accident in this
youngster indicates besides dental traumata, a loss of large
parts of the periodontium. (b) To achieve a proper restora-
tion of the tissues, a small hip graft was inserted by the
periodontist on top of the remaining symphyseal bone
and xed with two screw-shaped self-tapping implants.
(c) The clinical situation after 2 months of healing shows
a promising basis for further reconstruction. (d) Abutment
stage: the optimal healing and vitality of the graft is
illustrated by the implants surrounded with bone up to the
shoulder. The bone crest has been completely recon-
structed. (e) The osseointegration and quality of the graft
are illustrated by this radiograph taken shortly after abut-
ment connection. (f) Control of passive t of the metal
framework by the prosthodontist. (g) The aesthetic out-
come achieved with the bridge. (h) A control radiograph
taken some 10 years later shows an optimal marginal bone
level around the implants.
103
Osseointegration in severely compromised patients
Conclusion
The oral and maxillofacial treatments described here
contrast with cosmetic endeavors which sometimes
are limited to the treatment of a single gingival
papilla. From the present series of clinical illustra-
tions it appears that even for major anatomic defects
the combined use of autologous bone grafts with
endosseous implants canprovideimpressiveimprove-
ments in patients' quality of life. The survival rates of
individual implants in this type of reconstructive
therapy canbe similar totheones reportedfor conven-
tional implant treatments. Alternatives using guided
bone regeneration may soon offer less invasive alter-
natives. These complex surgical approaches should
be encouraged using the skills of different specialists
and implant approaches that have been sufciently
documented to guarantee optimal results for this
special category of patients.
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2. Adell R, Eriksson B, Lekholm U, Branemark P-I, Jemt T. A
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Fig. 8. continued
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