Dennis Rohner Treatment of severe atrophy of the

Peter Bucher
Christoph Kunz
maxilla with the prefabricated free
Beat Hammer vascularized fibula flap
Robert K. Schenk
Joachim Prein

Authors’ affiliations:
Dennis Rohner, Peter Bucher, Christoph Kunz,
Beat Hammer, Joachim Prein, Department of
Reconstructive Surgery, University of Basel,
University Hospital, Switzerland
Robert K. Schenk, Institute of Pathophysiology,
University of Bern, Switzerland
Correspondence to:
Dennis Rohner
Department of Reconstructive Surgery
University Hospital, University of Basel
Spitalstrasse 21
CH-4031 Basel
Switzerland
Tel: π41 61 265 73 40
Fax: π41 61 265 74 58
e-mail: dennisrohner/hotmail.com
Key words: prefabrication, free vascularized fibula flap, titanium implants, maxillary
atrophy, split skin graft
Abstract: Treatment of severe maxillary atrophy despite complex major surgery often
ends up with an unsatisfactory result. This paper presents the augmentation of the
maxilla with a prefabricated free vascularized fibula flap in combination with ITIA
implants (Straumann AG, Waldenburg, Switzerland) in 4 patients. The technique of
prefabrication for the reconstruction of maxillofacial defects is described based on the
experience with 17 patients. The key points of this treatment are i) preoperative
planning and fabrication of the drilling template; ii) prefabrication of the fibula with
ITIA implants and performing of a ‘‘vestibuloplasty’’ using a skin graft; iii) technical
construction and fabrication of the suprastructure and the denture; iv) reconstruction of
the maxilla using the prefabricated fibula as free vascularized flap. The reconstructions
with the fibula flaps were successful and the 18 ITIA implants that have been inserted
showed good osseointegration without loss of attachment in all 4 patients after a
mean observation period of 12 months.

Date:
Accepted 12 March 2001
To cite this article:
Rohner D, Bucher P, Kunz C, Hammer B, Schenk RK,
Prein J. Treatment of severe atrophy of the maxilla
with a prefabricated free vascularized fibula flap
Clin. Oral Impl. Res. 13, 2002; 44–52
Copyright C Munksgaard 2002
ISSN 0905-7161
The aim of reconstructing a severely
atrophied maxilla is the recovery of an
adequate masticatory function and the
achievement of increased aesthetics. Op-
timal function can only be acquired
using an implant-borne prosthesis or
bridge-construction. In severe atrophy
(Cawood Class V & VI), the lack of bone
mass often precludes sufficient stability
and osseointegration for dental im-
plants. The resorbed alveolar ridge has
first to be treated (Tolman 1995). A com-
monly used technique for the augmenta-
tion of the posterior maxilla is the sinus
lift procedure, which allows for insertion
of implants simultaneously or in a sec-
ond procedure (Khoury 1999). But im-
provement of the skeletal relation be-
tween upper and lower jaw can be
achieved only with onlay technique or
Le Fort osteotomy in combination with
free bone grafts (Breine & Brånemark
1980; Cawood et al. 1994; van Steen-
berghe et al. 1997). However, these pro-
cedures are time-consuming and associ-
ated with an uncertain rate of bone re-
sorption because of the use of free
nonvascularized bone grafts.
The reconstruction of bone defects
using free vascularized tissue transfer is
a technique that has become a reliable
procedure in recent years. Fibula, scap-
ula and iliac crest are the commonly
used donor sites for the reconstruction
of maxillofacial defects (Bähr 1996; Ka-
zaoka et al. 1999; Nakayama et al. 1994;
Yim & Wei 1994). Recent reports high-
lighted the prefabrication of free vascu-
larized flaps as a further development in
the field of reconstructive surgery (Igawa
et al. 1998; Vinzenz at al. 1998; Rohner
et al. 2000a; Rohner et al. 2000b).
The purpose of this report is to de-
scribe the augmentation of a severely re-

44
 Rohner et al . Prefabricated free vascularized fibula flap in severe maxillary atrophy

sorbed maxilla with our technique of
prefabrication using a free vascularized
fibula flap in combination with ITI im-
plants and split skin graft. The key
points of our technique are: i) preopera-
tive planning and fabrication of a drilling
template for implant insertion and fibula
osteotomies; ii) placement of implants
and creation of a stable peri-implant soft
tissue attachment in a first surgical pro-
cedure at the donor site; iii) fabrication
of dental prosthetics prior to the recon-
struction; iv) reconstruction of the max-
illa with the prefabricated free vascular-
ized fibula flap and attached prosthetics;
and v) immediate postoperative func-
tional loading.
Patients and methods
From April 1998 until July 2000 we oper-
ated on 17 patients using the prefabri-
cated free vascularized fibula flap. Max-
illofacial defects, secondary to a major
head injury or to tumour resection, were
reconstructed with the prefabricated
fibula flap in 13 patients. In 4 patients the
prefabrication was carried out to aug-
ment a severe atrophy of the maxilla with
Cawood class V & VI (Cawood & Howell
1988). A total number of 18 ITIA implants
with the SLA surface (sand blasted, large
grit, acid etched) were inserted to fix the
bar-borne prosthesis in these 4 cases. In
all the patients, two additional implants
were inserted in the proximal part of the
fibula for histological evaluation at six
weeks. This was possible because the
technique of harvesting of the fibula re-
quires in every case resection of the entire
fibular shaft. This resection is necessary
for sufficient dissection of the proximal
fibular vessels. Therefore there was an
overplus of about 7–10 cm in all of the
fibular bones that had been resected in
the patients. All patients signed a written
declaration of consent to allow for this
additional implant insertion and histo-
logical evaluation. These two implants
should show whether the time frame of
six weeks between prefabrication pro-
cedure and reconstruction was sufficient
to obtain osseointegration with the SLA
surface.
Algorithm of treatment
The procedure is composed of four ele-
ments. The alternation of two surgical
procedures with two technical ones is the
main feature of this procedure. The first
technical part is the planning and fabri-
cation of surgical tools, followed by the
initial surgical procedure as the second
part or so-called ‘‘prefabrication’’. The
third step is the technical construction of
the prosthetics. The final procedure is the
reconstruction of the alveolar ridge with
the prefabricated free vascularized fibula
and the definite prosthetics. Both surgical
procedures were done under general an-
aesthesia.
Before planning and surgery, every pa-
tient underwent MRI-angiography of the
legs to check the condition of the lower
limb vessels.
i) Preoperative planning
Planning and modeling are done together
with the technician. At first the amount
of the desired alveolar ridge has to be de-
termined and built up onto the plaster
model. The technician can shape the
existing prosthetics and fit them to the
new alveolar ridge. The surgeon defines
the position of the implants in relation
to the prosthetics and to the new al-
veolar ridge (Fig. 1). The horseshoe form
of the maxilla suits osteotomies of the
fibula. The location of the osteotomies
is evaluated by the surgeon and indi-
cated on the plaster model (Fig. 2). The
technician produces a drilling template
to allow for precise drilling of the holes
for insertion of the implants.
ii) Prefabrication of the fibula
The initial surgical procedure includes
the insertion of the implants into the
fibula. The lateral approach to the fibula
is carried out as first described by Gilbert

Fig. 1. The prosthetics are reconstructed and adapted to a good occlusion. Fig. 2. The drilling template is produced referring to the plaster mold. The
The position and direction of every implant is determined using a drill. segments for the prospective fibular osteotomies are drawn and can be trans-
ferred in the same dimensions to the template.

45 | Clin. Oral Impl. Res. 13, 2002 / 44–52

Rohner et al . Prefabricated free vascularized fibula flap in severe maxillary atrophy

(1979). The drilling template is fixed with
two screws to the lateral aspect of the
fibula (Fig. 3). With the appropriate drills
of 2.2 mm, 2.8 mm and 3.5 mm in diam-
eter, the holes for the implants can be
burred. The drilling template has to be re-
moved to tap the thread with the appro-
priate thread-cutter. The ITIA implants
with the SLA surface can be inserted. 8æ
abutments for the bar construction are
temporarily fixed to the implants. A split
skin graft (0.4–0.5 mm thickness), which
is harvested from the lateral thigh, covers
the fibula and is fixed with resorbable su-
tures (Fig. 4). Through small incisions,
the abutments penetrate the skin graft. A
silicone material (Zerosil SupersoftA,
Dreve GmbH, Germany) is used to cast
the position of every implant together
with the abutments (Fig. 5). This im-
pression transfers the exact location of
every implant as accurately as possible to
a plaster model for bar construction. The
abutments are then removed and the skin
graft is covered with a GoreTex mem-
brane, which is fixed to the bone with two
screws and resorbable sutures (Fig. 6).
The wound is closed and the leg is posi-
tioned in a splint including the ankle for
three days. Afterwards the patient can
fully load and walk.
iii) Technical construction of the bar and the
bar-borne prosthetics
The mold of the abutments can be used
as a model for the construction of the
bar. The bar is made of titanium and the
abutments are welded using a laser. The
preoperative fabricated prosthetics can
be adapted to the bar. This technical part
has been recently published and dis-
cussed in detail (Bucher et al. 2000).
iv) Reconstruction of the maxilla
The reconstructive surgical procedure is
performed with two teams of surgeons.
One team is responsible for the prepara-
tion of the recipient bed including the
dissection of the vessels at the neck for
the transplantation of the flap. The other
team is in charge of the donor site.
- recipient site: Through a limited sub-
mandibular incision, the vessel bundles
of the carotid artery and the jugular vein
are identified along the anterior border
of the sternocleidomastoid muscle. In
most of the cases the branch of the lin-
gual artery is chosen as the donor artery,
whereas the internal jugular vein is se-
lected for an adequate outflow. The max-
illa is prepared and dissected through an
incision along the aveolar crest. The al-
veolar ridge is contoured and flattened
with a burr to make room for the fibula.
A tunnel for the blood vessels, which
runs behind the tuber region, passes
anteriorly around the condylar neck, fol-
lows the outer plane of the ramus of the
mandible and ends in the upper triangle

Fig. 3. The template is fixed at the lateral aspect of the fibula with two
titanium screws being used as drilling guide.

Fig. 4. The fibula and the implants are covered with a split skin graft (0.4–
0.5 mm).
Fig. 5. The abutments for the bar construction are fixed in the implants. The
wound is protected using a gamma-sterilized rubber dam, which is perforated
by the abutments. The position and direction of every implant is exactly deter-
mined using a silicone molding material. This silicone mold is used for fabri-
cation of the bar construction.

46 | Clin. Oral Impl. Res. 13, 2002 / 44–52

 Rohner et al . Prefabricated free vascularized fibula flap in severe maxillary atrophy

Fig. 6. The GoreTex membrane covers the skin graft and the fibula. The
fixation is done using titanium screws and resorbable sutures.

Fig. 8. The fibula is osteotomized and bent to the horseshoe form of the
maxilla.

Fig. 7. The fibula is cut along the borders of the template. Long centric
screws fix the template to the fibula. The vessels that are located at the op-
posite site of the fibula have to be carefully protected.

of the neck, is prepared with a blunt dis-
sector.
- donor site: The approach to the fib-
ula is performed through the former
scar. Between the extensor and flexor
muscle groups of the lower limb, the Go-
reTex membrane is prepared and care-
fully removed. The fibula is first osteo-
tomized distally, at least 6–8 cm above
the outer malleolus, and secondly prox-
imally, at least 8–10 cm below the fibu-
lar head. The interosseous membrane is
dissected and the fibular vessels are dist-
ally identified and ligated. Starting dist-
ally, the fibula is prepared to the proxi-
mal osteotomy preserving the attached
fibular vessels. The drilling template is
fixed to the implants using long centric
screws. Along the guiding planes, the
osteotomies are accomplished and the
fibula is shaped to the horseshoe-form
(Figs 7 & 8). The 8æ abutments are screw-
ed to the implants and the bar construc-
tion is fixed to the abutments, stabil-
izing the horseshoe form of the fibula
(Fig. 9). The prosthetics can be attached
to the bar construction (Fig. 10).
- reconstruction: The fibular vessels
are proximally ligated. The bar-borne
prosthetics together with the fibula are
fitted to the recipient bed. The inter-
maxillary relation is determined by the
occlusion to the lower jaw (Fig. 11). The
fibula is fixated to the upper jaw with
2.0 mm titanium miniplates and screws.
The mucosa is sutured to the skin graft
at the fibula to get a tight fitting. The
fibular artery is anastomosed end-to-end
to the lingual or facial artery. One of the
two fibular veins is connected end-to-
side to the internal jugular vein. The
anastomoses are performed under the
microscope using 9–0 nylon thread.
Results
The success rate was 100% for the fibula
flap. There was no loss of the implants.
The mean observation period amounted
to 12 months (7–18 months). The aver-
age time needed for the initial surgery
was 2 hours and for the reconstructive
surgical procedure 8–10 hours. For the
first 16 hours after the reconstructive
procedure the patients were monitored
in the intensive care unit, and were later
transferred to the general ward. An anti-
biotic therapy with AugmentinA (5 days
2¿375 mg daily) and a therapy with low

47 | Clin. Oral Impl. Res. 13, 2002 / 44–52

Rohner et al . Prefabricated free vascularized fibula flap in severe maxillary atrophy

Fig. 12. The preoperative orthopantomogram (OPT) shows the severely re-
sorbed maxilla.

Fig. 9. The titanium bar is fixed and stabilizes the fibula. The fibula is still
connected to the vessels with adequate blood supply.

Fig. 13. The postoperative OPT demonstrates the fixation of the fibula with
four miniplates. The increase of the height of the alveolar ridge is shown.

Fig. 10. The preoperatively produced bar-borne prosthetics can be fixed.

Fig. 14. The evaluation after 12 months demonstrates the remodeling of the
Fig. 11. The occlusion determines the positioning of the fibula. The osteo- bicortical bone to a more homogenous cancellous bone. All the implants are
synthesis is done with titanium miniplates and screws. well osseointegrated without visible loss of attachment and vertical height.

dose liquemin (FraxiparineA 2500 IU) as
prevention of thrombosis were executed
routinely. The hospitalization for both
surgical procedures amounted to 5 and
12 days, respectively.
The prosthetics could be replaced after
surgery to allow the patients to have a
soft and liquid diet beginning 24 hours
after surgery. There were no postopera-
tive complications and all patients were
able to walk without the help of a cane
after 5 days. The patients were kept on
a soft diet for six weeks. Radiological
controls were taken after 6 weeks, 6
months and 1 year (Figs. 12–14). In one
patient, two screws were loosened after
six months, therefore the plates and
screws were removed in this patient. In
all the other patients the titanium plates
were not removed. The orthopantomo-
gram (OPT) showed after 1 year a re-

48 | Clin. Oral Impl. Res. 13, 2002 / 44–52


modeling of the bicortical fibular bone
towards a more homogenous cancellous
bone structure, but without loss of verti-
cal height or loss of attachment around
the implants.
Histological evaluation
Block sections with the two additional
implants were fixed in 4% formalde-
hyde. The specimens were dehydrated
and embedded in methacrylate. Axial-
oriented sections with a final thickness
of about 60–80 mm and with the staining
of toluidine blue and basic fuchsin could
be evaluated.
The cross-sections of the fibula
showed an asymmetric form with thick
cortical layers and little medullary cav-
ity. Parts of the conical shoulder of the
ITIA implants were in contact with the
cortical layer (Fig. 16).
The zones in the coronal region indi-
cated an incongruity between the cor-
tical bone and the smooth surface of the
implant. There were some defects at the
cortical bone because of this com-
pression. Further apically, there was a
larger gap containing vital tissue (ves-
Fig. 15. Micrograph showing contact zone of
the coronal area (magnification ¿10). The sec-
tion is carried out 44 days after the placement
of the implant. Cortical reaction is seen. The
titanium surface is slightly covered with bone
as seen downmost in the figure.
Rohner et al . Prefabricated free vascularized fibula flap in severe maxillary atrophy
sels, marrow). A thin layer of new bone
covered the cortical bone (Fig. 15)
The cylindrical zone showed a perfect
fit. The cortical bone was devitalized in
the contact area, but the bone remodel-
ing was obviously starting (Fig. 17).
The thick cortical bone of the fibula
produced a good primary stability of
the implants. However, the conical part
of the ITI implant (implant shoulder)
burst the cortical bone and therefore
led to mismatch of the bone-implant
interface.
Discussion
The reconstruction of the atrophied
maxilla remains a challenge in treat-
ment with dental implants. There are
three major problems in dealing with the
dental reconstruction of atrophied jaws.
Firstly, there is need to surgically aug-
ment the alveolar ridge in order to in-
crease the quality and quantity of bone,
which is required for optimal implant in-
sertion. Secondly, the soft tissue has to
be adjusted to thereby build up a stable
peri-implant surrounding. And thirdly,
Fig. 16. Micrograph showing longitudinal section
through the ITIA implant, which is inserted bicortically
in the fibula (magnification ¿1.6).
the surgeon has to consider biomechan-
ical and biological principles during the
placement of the implants.
i) Bone augmentation
In a situation with severe maxillary atro-
phy, a reversed sagittal intermaxillary
relation and an increased vertical dis-
tance between the jaws can often be
found. The loss of vertical bone height,
which results in an unfavorable crown-
root ratio, is only one of several disad-
vantageous factors. An acceptable result
in function and aesthetics might be
achieved with the combination of inlay
and onlay grafts. A sinus lift procedure
in addition to onlay grafts (iliac crest,
calvarium or mandible) allows the sur-
geon to gain height and width of the al-
veolar crest, resulting in a better inter-
maxillary relationship (Lundgren et al.
1997; Neyt et al. 1997). Implants can
then be inserted simultaneously or in a
second procedure (Joos & Kleinheinz
2000; Khoury 1999; Lenzen et al. 1999;
Neyt et al. 1997).
Le Fort-I osteotomy is another poss-
ible surgical intervention. Sailer (1989)
Fig. 17. Micrograph showing a perfectly fit-
ting bone-implant zone (magnification ¿8).
49 | Clin. Oral Impl. Res. 13, 2002 / 44–52
Rohner et al . Prefabricated free vascularized fibula flap in severe maxillary atrophy
originally described the Le Fort-I osteo-
tomy with interpositional iliac bone
graft and simultaneous insertion of im-
plants. Li et al. (1996) reported that this
one-stage technique allows a correction
of the maxillo-mandibular relationship
and therefore an improvement of the fa-
cial contour. Nyström et al. (1997) pre-
sented their experience using this tech-
nique based on a two-stage procedure.
The implants were placed six months
after the Le Fort-I osteotomy and bone
graft procedure.
Major disadvantages of these tech-
niques are wound healing compli-
cations with infection, loss of nonvas-
cularized free bone grafts and the pro-
longed healing process of the aug-
mented alveolar ridge because of osteo-
conduction, which is seen typically in
nonvascularized bone grafts. Nonvascu-
larized grafts firstly have to be resorbed
and are then replaced with bone from
the recipient bed. The graft functions
as a non-viable scaffold for the in-
growth of blood vessels and osteopro-
genitor cells from the recipient site,
with resorption and deposition of new
bone (Motoki & Mulliken 1990).
On the other hand, free vascularized
bone grafts microsurgically anastom-
osed can heal primarily by osteogen-
esis, as the blood supply to the bone-
forming cells is reconstituted (Goldberg
et al. 1987). In addition, vascularized
bone grafts undergo little, if any, re-
sorption, whereas nonvascularized bone
grafts can loose more than one-half
their volume (Disa et al. 1999; Fukuta
et al. 1992). The radiographic controls
in our 4 patients showed stable peri-
implant conditions without any signs
of resorption after 12 months. The bi-
cortical bone of the fibula has been
slightly remodeled to a more homogen-
ous cancellous bone.
The fibula is one of the favourite
flaps in head and neck surgery for the
reconstruction of defects in the man-
dible and the maxilla (Chang et al.
1998; Cordeiro et al. 1999; Gurlek et
al. 1998; Hayter & Cawood 1996; Hi-
dalgo & Rekow 1994; Reychler & Orta-
be 1994; Urken et al. 1991 & 1998).
Some anatomic characteristics make
the fibula a good option for the recon-
struction of a maxillary defect. Firstly
the fibula is a long, straight bicortical
50 | Clin. Oral Impl. Res. 13, 2002 / 44–52
bone, that can be osteotomized and
shaped to the horseshoe form of the al-
veolar crest with sufficient blood sup-
ply (Wei et al. 1994; Chiodo et al.
2000). Secondly, the fibular vessels are
long and large in diameter to bridge the
distance from the upper jaw to the
neck for anastomosis and connection to
the recipient vessels (carotid artery and
jugular vein). Thirdly, a large vascular-
ized skin paddle can be harvested to-
gether with the fibular bone to cover
extended soft tissue defects if needed.
Several authors have presented their re-
sults for the reconstruction of maxil-
lary defects (Nakayama et al. 1994; Ka-
zaoka et al. 1999; Yim & Wei 1994).
Bähr (1996) described the reconstruc-
tion of the severely resorbed maxilla.
He showed several advantages of using
the free vascularized fibula flap such as
correction of vertical height and inter-
maxillary relation, bicortical insertion
of dental implants, less resorption and
fewer problems with soft tissue healing
because of the vascularity of the flap in
comparison to nonvascularized free
bone grafts. The results in our patients
showed the same advantages. Optim-
ally we could gain 1.5 cm of bone mass
in vertical height, which was the limit
because of the anatomy of the fibula
(Frodel et al. 1992). But in addition to
Bähr’s technique, we used the prefabri-
cation, which allowed for exact plan-
ning of occlusion with prosthetics.
Therefore, the sagittal intermaxillary
relation could be exactly corrected
with regard to the preoperatively
planned normocclusion. The segmental
osteotomies of the fibula rendered it
possible to recreate the entire horse-
shoe form of the alveolar ridge of the
maxilla. The OPT showed after 12
months the same level of bone without
signs of resorption, which has been re-
cently described to be a major advan-
tage of using free vascularized bone
flaps (Disa et al. 1999).
ii) Soft tissue adjustment
The correct management and adjust-
ment of the soft tissue is a prerequisite
for long-term success of implants. Post-
operative dehiscence of the soft tissue
closure in augmentative procedures
using nonvascularized bone grafts
causes infection and loss of the bone
graft. The soft tissue healing around
the free vascularized bone flap is
mainly uneventful. Even a dehiscence
is not a danger for the transplant be-
cause of the vitality and vascularity of
the bone. A stable attachment of soft
tissue around the implant minimizes
any inflammatory process. Commonly,
the creation of a soft tissue attachment
is achieved in a surgical procedure sec-
ondary to the reconstruction with a
free vascularized bone flap (Chang et
al. 1999; Hayter & Cawood 1996). The
prefabrication creates the soft tissue
attachment prior to the reconstruction
with the free vascularized flap. Vinzenz
et al. (1998) presented the prefabri-
cation of a free vascularized scapular
flap for the reconstruction of the max-
illa. Igawa et al. (1998) reported the
prefabrication of an iliac crest to aug-
ment an extended defect of the upper
jaw. Both techniques required 6 months
to complete the treatment. Rohner et
al. (2000a) first described the prefabri-
cation of a free vascularized fibula flap
with split skin graft and ITIA implants
for the reconstruction of upper and
lower jaw defects using 3 months for
the entire treatment.
iii) Implant stability
The fibula as bicortical bone offers good
primary stability to an implant. Im-
plants bicortically inserted in the fibula
showed significantly higher removal
torque as compared to the iliac crest and
the scapula (Ivanoff et al. 1996; Niimi et
al. 1997). All the ITIA implants bicor-
tically placed by conventional pre-tap
methods during the prefabrication
showed good primary stability. During
the reconstructive procedure all the im-
plants were clinically stable. However,
the fibula had only few signs of osseoin-
tegration 6 weeks after the prefabri-
cation (Figs 14–16). One could say that
the biological response of the fibula
might be slower because of the two
thick cortical layers. On the other hand,
the primary stability of each implant
was forceful. In addition, the stabiliza-
tion of implants amongst each other
with a bar construction was an import-
ant and successful issue for the immedi-
ate loading of implants.
 Rohner et al . Prefabricated free vascularized fibula flap in severe maxillary atrophy

cié à des implants ITIA chez quatre patients. La

Conclusion technique de préfabriation pour la reconstruction des Resumen

The reconstruction of the severely re-
sorbed maxilla using the prefabrication
technique with free vascularized fibula
flaps is a promising alternative to the
commonly used techniques with nonvas-
cularized bone grafts. The use of free vas-
cularized grafts has become a reliable
technique. However, the procedure re-
quires a team experienced with free vas-
cularized tissue transfers. Fully func-
tional use of the bar-borne prosthetics
was achieved in all the patients within 10
weeks of treatment. The histological
evaluation showed exact fitting of the im-
plants, but with only little osseointegr-
ation at 6 weeks. The thick cortical bone
of the fibula guaranteed a good primary
stability of the implants. Therefore, the
success rate was 100% after 1 year of ob-
servation. These good results with no loss
of implants render this technique as a
valuable choice for the reconstruction of
maxillofacial defects including the severe
atrophy of the maxilla. Nevertheless, the
final evaluation of prefabricated fibula
flaps calls for a larger number of cases and
a longer follow-up period.
Résumé
Le traitement des atrophies maxillaires sévères malgré
une chirurgie majeure et complexe se termine souvent
par un résultat non-satisfaisant. Ce manuscript décrit
l’épaississement du maxillaire à l’aide d’un lambeau
d’os du péroné vascularisé et libre, préfabriqué et asso-
lésions maxillo-faciales est décrite, basée sur l’expéri-
ence acquise avec 17 patients. Les quatre points forts
de ce traitement sont 1) un programme préopératoire El tratamiento de una atrofia maxilar severa a pesar
de una cirugı́a mayor severa acaba frecuentemente con
et la fabrication des plateaux de référence pour le fora-
ge, 2) la préfabrication de l’os du péroné avec les im- un resultado no satisfactorio. Este trabajo presenta el
aumento del maxilar con un colgajo prefabricado libre
plants ITIA et la réalisation de la vestibuloplastie en
utilisant une greffe de peau, 3) la construction et la
vascularizado de peroné en combinación con implan-
tes ITIA (Strauman AG, Waldenburg, Switzerland) en
fabrication de la superstructure et de la prothèse, 4) la
4 pacientes. La técnica de la prefabricación para la re-
reconstruction du maxillaire en utilisant l’os du péro-
né préfabriqué en tant que lambeau vascularisé libre. construcción de los defectos maxilofaciales se descri-
be basada en la experiencia con 17 pacientes. Los cua-
Les reconstructions avec les lambeaux du péroné ont
tro puntos clave de este tratamiento son i) planifica-
bien réussi et les 18 implants ITIA insérés ont montré
une bonne ostéoı̈ntégration sans perte d’attache chez
ción preoperatoria y fabricación de las plantillas de
perforación; ii) prefabricación del peroné con implan-
les quatre patients après une période d’observation
tes ITIA y la realización de una vestibuloplastia usan-
moyenne de douze mois.
do un injerto cutáneo; iii) construcción técnica y fabri-
cación de la supraestructura y la dentadura; iv) recons-
trucción del maxilar usando el peroné como colgajo
libre vascularizado. Las reconstrucciones con los col-
Zusammenfassung gajos de peroné tuivieron éxito y los 18 implantes ITI
que se habian insertado mostraron una buena osteoin-
tegración sin perdida de inserción en los 4 pacientes
Die Behandlung einer ausgedehnten Oberkieferatro-
phie endet trotz komplexen grösseren chirurgischen después de un periodo medio de observación de 12 me-
Eingriffen oft mit einem unbefriedigenden Resultat. ses.
Diese Arbeit stellt die Augmentation des Oberkiefers
von 4 Patienten mit Hilfe eines vorgängig präparierten
und durchbluteten Fibulalappens in Kombination mit
ITIA-Implantaten vor (Straumann AG, Waldenburg,
Schweiz). Die nötigen Schritte zur Vorbereitung dieser
Rekonstruktion von maxillofacialen Defekten wurden
an Hand den Erfahrungen an 17 Patienten beschrie-
ben. Die vier Schlüsselstellen dieser Behandlung sind:
I) die präoperative Planung und die Herstellung der
Bohrschablone; II) die Vorbereitung der Fibula mit
ITIA-Implantaten und die Herstellung einer ‘‘Vestibu-
lumplastik’’ mit einem Hauttransplantat; III) techni-
sches Design und Herstellung einer Suprastruktur mit
Prothese; IV) die Rekonstruktion des Oberkiefers mit
Hilfe einer vorbereiteten Fibula in Form eines freien
durchbluteten Lappens. Die Rekonstruktionen mit
den Fibulalappen waren alle erfolgreich und die 18 ge-
setzten ITI-Implantate zeigten bei allen vier Patienten
nach einer mittleren Beobachtungszeit von 12 Mona-
ten eine gute Osseointegration ohne Attachmentver-
lust.

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