Rehabilitation of A Patient With Severe Dentoalveolar Injuries
http://www.implantoloji.info/articles/4/1/Rehabilitation-of-A-Patient-With-Severe-Dentoalveolar-Injuries/Page1.html
By JDI editor
Published on 01/9/2001
James A. Miller, DDS
Private Practice Oral and Maxillofacial Surgery, Clinical Director, Implant Dentistry Centre, St. John’s, NF, Canada.
This clinical report describes the emotional and physical rehabilitation of a young man. The impact of the injuries sustained and repeated failure of traditional dental treatment methods had caused the patient to become quite withdrawn. A successful outcome followed surgical placement of multiple titanium plasma-sprayed cylindrical fixtures in severely damaged dental supporting tissues to serve as intermediary abutments for complex maxillary and mandibular fixed prostheses. The loss of crestal bone during the postprosthetic years is determined. The advantages only implant dentistry could bring are identified.
Private Practice Oral and Maxillofacial Surgery, Clinical Director, Implant Dentistry Centre, St. John’s, NF, Canada.
This clinical report describes the emotional and physical rehabilitation of a young man. The impact of the injuries sustained and repeated failure of traditional dental treatment methods had caused the patient to become quite withdrawn. A successful outcome followed surgical placement of multiple titanium plasma-sprayed cylindrical fixtures in severely damaged dental supporting tissues to serve as intermediary abutments for complex maxillary and mandibular fixed prostheses. The loss of crestal bone during the postprosthetic years is determined. The advantages only implant dentistry could bring are identified.
A Case Report With a 10-Year Follow-Up
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.
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.
Case Report - References.
All seven implants remain firmly anchored and generally healthy, despite somewhat limited maintenance measures at times. A bureaucratic misunderstanding caused the patient to be without dental care for 3 years. The maxillary left bicuspids became carious and had to be extracted. When the surgeon learned of this, the responsibility for continuing dental care was reestablished. In 1997, an IMZ fixture was positioned in each of the healing extraction wounds. A failure of one of these to integrate in the poor quality of bone led to insertion of a Steri-Oss Replace hydroxylapatite threaded implant (Nobel Biocare, Yorba Linda, CA). The buccal area around this implant was grafted with autogenous cells and bioactive glass. Connected crowns, where were supported on these implants, are evident on a later radiograph.
Callan et al, in a retrospective study of 350 dental implants, reported on findings contributing to crestal bone loss. The implants evaluated averaged 4.2 years after prosthetic restoration. By applying an American Dental Association guideline of 0.4 mm of bone loss per year, they considered a loss of $3 mm to be a valid criterion for inferior performance. Of the 350 implants studied, 270 (77%) met the established requirement for failure. Although 109 of 111 cylindrical implants (98%) met the criteria, none of these had an extended smooth collar. They reported that implants with the greatest amount of bone loss, based on radiographic analyses, exhibited greater probing measurements. They also noted that implants with confirmed crestal bone loss did not necessarily have the concurrent changes in tissue color or texture that usually indicate an inflammatory reaction.
In this patient, all seven cylindrical implants were placed level with the surrounding bone. An extended smooth collar is a feature of the IMZ design and highly polished titanium alloy extensions were used to form the implant transmucosal abutment interface at each site. If one were to apply the same American Dental Association guidelines 9 years after prosthetic attachment, then crestal bone loss $3.6 mm would be worrisome. Three of the seven implants now exceed that degree of bone loss. The highest percentages of bone loss developed at locations 6 and 19, where the larger 4-mmdiameter implants were positioned. As evident on a 1999 radiograph, at each of these sites, the alveolar bone sloped sharply away from the adjacent natural tooth, which served as anchorage for a prosthesis. The lowest percentages of bone loss occurred at locations 23 and 25, where the severe injuries had left each of these locations with little alveolar bone.
A scalar depiction of bone loss measured during 10 years at locations 19 and 25 reveals that both sites lost the greatest amount of bone during the first 3 years after prosthetic loading. During the following 6 years, the loss at location 25 has been only one-half of that lost in the first 3 years. At location 19, the rate of bone loss did slow to an approximate rate of 0.4 mm/y during the 6-year period since 1994. Despite the extent of crestal bone loss, the periimplant tissues have seemed to be healthy except at locations 6 and 19, where moderate signs of inflammation are present. The implants with the greatest radiographic indication of bone loss provided the highest probing measurements in concurrence with reported findings.3 None of the four mandibular implants benefited from the presence of normal gingiva. The three maxillary implants only contacted keratinized tissues on their palatal boundary. Nevertheless, both the maxillary and mandibular implantsupported fixed prostheses continue to function well without any noticeable mobility. The porcelain surfaces have begun to show signs of wear. Surprisingly, during the decade, normal sensation has returned to the cutaneous and mucosal surfaces of the lower lip.
The severity of the dentoalveolar injuries had profoundly troubled this young man. Although the intracranial trauma had diminished his capacity to retain studied information, it was the failure of traditional dental modalities that wrought the greatest negative effect. For this patient, the marvels of dental implantology clearly did transcend the limitations of titanium and porcelain. It enabled this young man to overcome a major emotional obstacle to a normal lifestyle. (Today, he is a father of three children and is married to a young woman he met shortly after the tangibles of implant dentistry were in place.)
REFERENCES
Callan et al, in a retrospective study of 350 dental implants, reported on findings contributing to crestal bone loss. The implants evaluated averaged 4.2 years after prosthetic restoration. By applying an American Dental Association guideline of 0.4 mm of bone loss per year, they considered a loss of $3 mm to be a valid criterion for inferior performance. Of the 350 implants studied, 270 (77%) met the established requirement for failure. Although 109 of 111 cylindrical implants (98%) met the criteria, none of these had an extended smooth collar. They reported that implants with the greatest amount of bone loss, based on radiographic analyses, exhibited greater probing measurements. They also noted that implants with confirmed crestal bone loss did not necessarily have the concurrent changes in tissue color or texture that usually indicate an inflammatory reaction.
In this patient, all seven cylindrical implants were placed level with the surrounding bone. An extended smooth collar is a feature of the IMZ design and highly polished titanium alloy extensions were used to form the implant transmucosal abutment interface at each site. If one were to apply the same American Dental Association guidelines 9 years after prosthetic attachment, then crestal bone loss $3.6 mm would be worrisome. Three of the seven implants now exceed that degree of bone loss. The highest percentages of bone loss developed at locations 6 and 19, where the larger 4-mmdiameter implants were positioned. As evident on a 1999 radiograph, at each of these sites, the alveolar bone sloped sharply away from the adjacent natural tooth, which served as anchorage for a prosthesis. The lowest percentages of bone loss occurred at locations 23 and 25, where the severe injuries had left each of these locations with little alveolar bone.
A scalar depiction of bone loss measured during 10 years at locations 19 and 25 reveals that both sites lost the greatest amount of bone during the first 3 years after prosthetic loading. During the following 6 years, the loss at location 25 has been only one-half of that lost in the first 3 years. At location 19, the rate of bone loss did slow to an approximate rate of 0.4 mm/y during the 6-year period since 1994. Despite the extent of crestal bone loss, the periimplant tissues have seemed to be healthy except at locations 6 and 19, where moderate signs of inflammation are present. The implants with the greatest radiographic indication of bone loss provided the highest probing measurements in concurrence with reported findings.3 None of the four mandibular implants benefited from the presence of normal gingiva. The three maxillary implants only contacted keratinized tissues on their palatal boundary. Nevertheless, both the maxillary and mandibular implantsupported fixed prostheses continue to function well without any noticeable mobility. The porcelain surfaces have begun to show signs of wear. Surprisingly, during the decade, normal sensation has returned to the cutaneous and mucosal surfaces of the lower lip.
The severity of the dentoalveolar injuries had profoundly troubled this young man. Although the intracranial trauma had diminished his capacity to retain studied information, it was the failure of traditional dental modalities that wrought the greatest negative effect. For this patient, the marvels of dental implantology clearly did transcend the limitations of titanium and porcelain. It enabled this young man to overcome a major emotional obstacle to a normal lifestyle. (Today, he is a father of three children and is married to a young woman he met shortly after the tangibles of implant dentistry were in place.)
REFERENCES
- Kirsch A, Ackermann KL. The IMZ osteointegrated implant system. Dent Clin North Am. 1989;33:733–791.
- Saadoun A, LeGall M. An 8-year compilation of clinical results obtained with Steri-Oss endosseous implants. Compendium. 1996;17:669–688.
- Callan DP, O’Mahony A, Cobb CM. Loss of crestal bone around dental implants: A retrospective study. Implant Dent. 1998;7:258–264.