Rehabilitation of critical maxillary bone loss in war contexts

Since the start of the conflict in Ukraine in February 2022, surgeons have been facing an unprecedented number of complex maxillofacial traumas related to firearms and mine explosions. These high-energy injuries result in critical osteomucosal substance losses (often exceeding 3 cm), for which conventional reconstruction relies on vascularised autogenous grafts. However, the donor site morbidity and the prolonged healing times of these procedures are poorly compatible with functional urgency and resource constraints in wartime.

This study reports the management of two military patients presenting with critical-sized maxillary defects (approximately 3 cm) resulting from gunshot and shrapnel wounds. The objective is to describe an accelerated rehabilitation protocol using monoblock implants with cortical anchorage — including tubero-pterygoid implants — combined with immediate loading via a fixed metal-acrylic hybrid prosthesis. The hypothesis tested is that engaging the basal bone allows for sufficient primary stability to restore oral functions and facial aesthetics without resorting to prior extensive bone grafts, thereby drastically reducing the therapeutic timeline.

Methodology

This study reports the rehabilitation of two military patients presenting with critical-sized maxillary defects (approximately 3 cm), following war trauma from gunshot wounds or mine explosions. Management followed the SCARE 2025 guidelines.

• Imaging and planning: Preoperative evaluation by Cone Beam (CBCT) (94 kV, 7.7 mA, 0.18 mm slices) with measurements of residual bone height via EZ3D software at the tuberosity and pterygomaxillary region.
• Surgical protocol: Under general anesthesia, the treatment included the extraction of non-restorable teeth and the placement of monoblock implants with cortical anchorage. For the first case, ten implants were inserted, combining compression screws (KOS® X and KOS® Micro) and tubero-pterygoid implants (TPG®). Anchorage was achieved in the basal bone, particularly at the level of the pterygoid processes of the sphenoid bone.
• Prosthetic rehabilitation: Impressions were taken immediately after surgery. An immediate loading protocol was applied with the placement of a fixed metal-acrylic hybrid prosthesis.
• Follow-up and analysis: The control of prosthetic integration and implant stability was performed by clinical examinations and radiographs (panoramic and CBCT). A 12-month follow-up was documented for one of the patients (a 54-year-old male), the second having been recalled to active service.

Clinical results and loading protocols

The study reports the successful rehabilitation of two patients presenting critical-sized maxillary defects (approximately 3 cm) resulting from war injuries. The therapeutic approach avoided heavy bone grafting procedures while ensuring rapid functional restoration.

Cas n°1 : Complex maxillary reconstruction

A 54-year-old military officer, victim of an anti-personnel mine (2.5 cm palatal defect), underwent a complete rehabilitation protocol in the upper maxilla:

• Surgery: Extraction of non-restorable teeth (18, 14, 21, 23, 28) and alveolar ridge reduction.
• Implantology: Placement of 10 monobloc implants, including 8 compression implants (KOS® X and KOS® Micro) and 2 tubero-pterygoid implants (TPG®).
• Anchorage: Bicortical fixation at the level of the nasal floor and the pterygoid processes of the sphenoid bone.
• Timeline: Surgery on March 19, framework try-in on March 24, and placement of the final hybrid prosthesis on March 26 (i.e., 7 days after the procedure).

The 12-month follow-up confirms total implant stability, peri-implant soft tissue health, and the absence of biological or prosthetic complications.

Case n°2: Gunshot trauma

A 64-year-old patient presented with a bullet-induced right maxillary fracture with bone loss and partial edentulism. Treatment consisted of the placement of monobloc implants with cortical anchorage followed by immediate loading with a fixed metal-acrylic hybrid prosthesis.

Qualitative and radiographic observations

CBCT imaging and postoperative panoramic radiographs validated the accuracy of implant positioning and the fit of the infrastructures. In both cases, the authors note that the engagement of the maxillary basal bone provided stable support for the hybrid prostheses, despite significant destruction of hard and soft tissues. The aesthetic and functional results were deemed satisfactory by both practitioners and patients.

Clinical analysis and limitations of cortical anchorage implants

This case study illustrates the potential of cortical-anchored implants for the immediate rehabilitation of critical-size maxillary defects (approximately 3 cm) resulting from ballistic trauma and landmine explosions. Clinically, these results show that engaging the basal bone (nasal floor and pterygoid processes) achieves sufficient primary stability for immediate loading, even in the presence of significant hard and soft tissue loss. This approach bypasses conventional vascularized bone grafting protocols, which are often burdensome and associated with significant donor site morbidity.

The major benefit for the practitioner lies in the drastic reduction of treatment time. Unlike the standard of care involving grafts followed by a 3 to 6-month waiting period before implantation, this protocol allows for almost instantaneous functional and aesthetic restoration. This is a critical advantage in a war context where medical resources are saturated and where rapid patient recovery is a priority.

Nevertheless, the study presents methodological limitations inherent to the format. The sample size is small (n=2) and long-term clinical follow-up is insufficient: while the first case shows stability at 12 months, the follow-up for the second patient could not be documented due to their return to active duty. Furthermore, the technique requires precise expertise in monobloc implant surgery and a rigorous knowledge of maxillofacial cortical anatomy.

Summary of results

This case study demonstrates the viability of cortical-anchored monoblock implants for the immediate rehabilitation of critical maxillary defects (~3 cm) resulting from war injuries. In the two patients treated, the use of tubero-pterygoid implants and bicortical compression screws allowed for stable immediate loading; the 12-month follow-up for the first patient confirms the absence of biological or prosthetic complications, although follow-up is lacking for the second patient who is still on active duty.

In concrete terms, for the practitioner:

• Alternative to grafts: In the presence of major bone loss, anchoring in the basal bone (pterygoid processes and nasal floor) avoids complex autogenous reconstructions and their associated morbidities.
• Primary stability and loading: Prioritize monoblock implants engaging at least two cortices to guarantee the torque required for immediate prosthetic rehabilitation, even on traumatic sites.
• Clinical caution: Although these results are encouraging for rapidly restoring function and aesthetics, the small sample size (n=2) requires rigorous monitoring of osseointegration maintenance under functional loading.

Technical lexicon of the study

Cortically anchored single-piece implants: Single-piece implant systems designed for direct fixation in the cortical bone. This architecture eliminates the abutment-implant interface, optimizing primary stability in areas of low bone volume without requiring complex grafting procedures.

Tubero-pterygoid implants: Specific implants anchored in the dense cortical bone of the pterygoid processes of the sphenoid bone. They are essential in this study to ensure stable support for hybrid prostheses despite critical-sized posterior maxillary defects.

Critical-size maxillary defects: Bone gaps (approximately 3 cm in these cases) exceeding the patient's natural regeneration capacities. Following ballistic trauma, these defects require basal anchoring strategies to bypass the morbidities associated with vascularized autogenous grafts.

Immediate loading protocol: Prosthetic loading performed only a few days after surgery (maximum D+7 here). This protocol allows for rapid aesthetic and functional restoration, a major challenge for the reintegration of wounded military personnel.

Basal bone: Highly mineralized part of the maxillary skeleton, stable against resorption. Its use as a cortical anchorage zone ensures the mechanical durability of prosthetic rehabilitation in patients with massive loss of alveolar bone.

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