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 »  Home  »  Dental Implant 1  »  Rehabilitation of A Patient With Severe Dentoalveolar Injuries
Rehabilitation of A Patient With Severe Dentoalveolar Injuries
A Case Report With a 10-Year Follow-Up

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James A. Miller, DDS
Private Practice Oral and Maxillofacial Surgery, Clinical Director, Implant Dentistry Centre, St. John’s, NF, Canada.

An injured 20-year-old man was referred in 1990 by a physician associated with worker’s compensation for evaluation of severely injured dentition. This heavy construction laborer had recovered from serious intracranial trauma sustained during December 1988 when a large tire exploded during inflation and propelled the metal rim into the facial structures. The extensive loss of alveolar and basal bone had defied attempts to restore a youthful facial appearance and improve masticatory function by traditional prosthodontic methods.
At the initial examination, the injured anterior maxillary region, which was missing four avulsed teeth (numbers 6–9) and considerable alveolar bone, had a reduced vestibular sulcus restricted by scarring. The more severely damaged mandible, which was missing eight avulsed teeth (numbers 19–26), much of the alveolar ridge, and some of the basal bone had the remaining vestibular space greatly compromised by pronounced scarring and adhesions secondary to the facial trauma. The complete laceration of the lower lip and bone loss had caused anesthesia, primarily throughout the soft tissues supplied by the left mental nerve.
After examination of the patient, review of the study models, and analysis of the radiographs, a treatment plan was developed. With knowledge of and respect for the work of Axel Kirsch and Karl Ackermann, 1 the planned approach was potential placement of three titanium plasma-sprayed (TPS) implants in the maxilla and five TPS implants in the mandible. The complexity of the challenge is evident when looking at the artistic schema.
The patient was admitted to the hospital during September 1990, and after routine preparation, he was taken to the operating theater. Under general anesthesia supplemented with infiltration of a local anesthetic with a vasoconstrictor, the deficient ridge was exposed and carefully shaped with high-speed drills using copious saline irrigation to establish a minimal bone plateau of 5- to 6-mm width for implant placement. With internally irrigated precision shaped drills, four receptor sites of appropriate width and depth were created within the remaining mandibular bone, in the left first molar, left first bicuspid, and left lateral and right central incisor areas. Improper bone contour caused by the severity of the hard tissue avulsion prevented preparation of an additional implant receptor site in the left canine region. After ridge preparation in the maxilla, three bone holes were completed in the right canine as well as right and left central incisor areas. A total of seven TPS cylindrical implants with healing covers were secured. Multiple adhesions were released, and primary closure was achieved in both arches.
After a resting period of 3 months, excision of overlying tissue was performed, and the stability of each implant was gauged. To develop soft tissue collars, temporary abutment collars were positioned on 6 of the 7 implants, all except the implant in the mandibular bicuspid site. After one more month, the seventh implant was ready, and osseointegration now seemed well underway in all locations. Further vestibular surgery was performed to lessen adhesions and increase mobility of the labial tissues. The depth of the mandibular right central fixture presented some difficulty with maintenance of exposure at the interface of the implant and healing abutment.
The patient was transferred to a general dentist who, during a period of 8 months, completed the complex dental rehabilitation. The design of the metallic infrastructures, especially the mandibular, presented challenges for the dentist. The maxillary implant-supported framework proceeded rather routinely. The complicated mandibular infrastructure was a considerable task. The maxillary bridgework was first to be secured. The mandibular prosthesis was cemented to natural tooth anchorage and secured with screws to the intermediary abutments during late 1991. Custom-made transmucosal implant extensions were utilized widely, but the application of intramobile elements was avoided. After the bridgework was completed, the patient was quite pleased with the dramatic improvement in his appearance and immediately began to regain confidence.
The osseointegration resulted from the careful site preparation for placement of implants of adequate width and depth in bone of favorable type. The inferior alveolar nerve anesthesia, which provided unusual latitude for the surgeon with site preparation and location of the mandibular implants, likely favored longterm implant survival. Saadoun and LeGall2 reported an 8-year study showing that both the TPS-type and wider-diameter implants were less likely to fail. They stated that the failure rate was highest where the thickness of bone was ,4 mm and the length of the implant was #10 mm. In this case report, only 3 of the 7 implants were 4 mm in diameter, but 5 of the 7 implants were $11 mm. No implants were ,10 mm in length. During the 10 years of observation, two of the 4-mm-diameter implants developed the greatest amount of bone loss.