YIJOM-2934; No of Pages 7

Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxx http://dx.doi.org/10.1016/j.ijom.2014.06.005, available online at http://www.sciencedirect.com

Clinical Paper Pre-Implant Surgery

Lower border bone onlays to augment the severely atrophic (class VI) mandible in preparation for implants: a preliminary report

A. Soehardi, G. J. Meijer, S. J. Berge, P. J. W. Stoelinga Department of Oral and Maxillofacial Surgery, Radboud University, Nijmegen Medical Centre, Nijmegen, The Netherlands

A. Soehardi, G. J. Meijer, S. J. Berge, P. J. W. Stoelinga: Lower border bone onlays to augment the severely atrophic (class VI) mandible in preparation for implants: a preliminary report. Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxx. # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. We present the preliminary results of a study involving a group of consecutive patients who underwent lower border onlay grafting, limited to the symphyseal area, in preparation for implant insertion. This technique allows for maximum-sized implants, followed by prosthetic rehabilitation. The main advantage of this method is the minimal risk of damage to the mental nerve. Sixteen patients were followed for a period of 6 months to 4 years and all were free of neurosensory disturbances. Eight had a removable overdenture placed and were satisfied with the result. This surgical approach allows the patient to wear their dentures during the healing period. A further advantage of lower border grafting over intraoral upper border grafting is that mucosal dehiscences are not seen.

Despite the advances made in the treatment of patients with severely atrophic mandibles (Cawood and Howell, class VI),1 the thin mandible remains a challenge for which no definitive solution has yet been found. Several authors recommend ultra-short implants,2,3 whilst others advocate augmentation before implants are to be inserted3–7 or combined with implant placement.8,9 All options have their specific advantages and disadvantages. 0901-5027/000001+07

Although with decreasing height, measured at the mandibular symphysis, the body of the mandible becomes wider,10 a recent study based on an inventory among Dutch oral and maxillofacial surgeons showed that mandibles with a height of less than 10 mm are at risk of fracture when short implants are used. These fractures do not necessarily occur immediately after insertion, but may take place years later.11 Short implants may be unfavourably loaded because of the increased le-

Keywords: preimplant surgery; atrophic mandible; lower border bone augmentation; dental implants. Accepted for publication 10 June 2014

verage caused by the increased intermaxillary distance. Augmentation by building up an ‘alveolar process’ via an intraoral route also has its shortcomings, in that neurosensory disturbance in the area of the mental nerve is not always avoidable. This happens both when onlay grafting is used and in cases of sandwich osteotomies.4,5,12 It is not uncommon when dealing with thin mandibles to find that the inferior alveolar nerve is located on top of the mandible,

# 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Soehardi A, et al. Lower border bone onlays to augment the severely atrophic (class VI) mandible in preparation for implants: a preliminary report, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.06.005

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Soehardi et al.

completely embedded in connective tissue. Dissecting this nerve free may itself cause a nerve neurosensory disturbance. Distraction might be another option, but in common with surgery to the ‘upper border’, nerve neurosensory disturbance may occur for the same reason as mentioned previously because the same ‘sandwich cut’ has to be made. This comes on top of the possible complications that may occur when the vector of the vertical distraction does not coincide with the planned vector, or when other complications occur, such as fracturing of the mandible.13–17 A somewhat forgotten technique that was proposed at the time when pre-prosthetic surgery was evolving is inferior border grafting.18–27 Although grafting of the lower border will circumvent the above-mentioned problems, a visible scar is the main disadvantage of this technique. It is thought that in the older population, the resulting submental scar might not be too much of a problem, particularly when weighed against the chances of permanent neurosensory disturbance of the lower lip or chin. The fact that the denture to be made will be supported by two implants of maximum length is reason to believe that sufficient retention and stability can be achieved without risk of early implant loss because of unfavourable loading. In this report, we present the preliminary results of a study involving a group of 17 consecutive patients who underwent lower border onlay grafting, limited to

the symphyseal area, in preparation for implant insertion. Materials and methods Patient selection

Seventeen edentulous patients (11 females and 6 males) aged 50–84 years (mean 66.7 years) with class VI mandibles, treated at the study medical centre from 2007 to 2010, were included in this study. All mandibles had a height of 9 mm or less in the bilateral canine region, as measured on cone beam computed tomography (CBCT) scans (i-Cat; Imaging Sciences International, Hatfield, PA, USA). Patient details are given in Table 1. All patients were informed about the procedure and the advantages and disadvantages were explained; alternative options were offered. The final choice of treatment was left to the patient. Patients, who had undergone radiation therapy or who had received chemotherapy or intravenous bisphosphonates were excluded from the study. One patient already suffered from dysesthesia of his left chin–lip area as a result of a previous distraction procedure that had failed. This side was not included in the current study. One patient in the study group suffered from type II diabetes and two smoked 10– 15 cigarettes per day. Surgical technique

The operation was carried out under general anaesthesia with nasotracheal intuba-

tion. All patients received one dose of 1000 mg cefazolin and 500 mg metronidazole 30 min before the operation began. A corticocancellous bone graft with dimensions of approximately 3 cm  3 cm was harvested from the anterior iliac crest. The donor site was then closed in layers using 3–0 Vicryl (Ethicon) and 5–0 Prolene (Ethicon) sutures. Subsequently, a 2.5-cm long, curved incision was made just behind the submental fold, following the curvature of the symphysis. The periosteum was then incised and dissected. The region of the mental nerves was not explored. After the lower border was completely exposed over an area of about 3 cm, the bone graft was modelled to fit the contour of the exposed bone. Via a submental approach, the graft was first temporarily fixed with one 11-mm long, 2.0-mm screw (KLS Martin) at the midline of the symphysis. When the position of the graft was judged to be satisfactory, the graft was permanently fixed using two 13- to 15-mm long, 2.0-mm screws (KLS Martin) via an intraoral approach, after which the extraorally placed screw was taken out. The previously harvested corticocancellous bone chips were carefully placed along the inferior and lateral aspects of the grafted part of the mandible extending as far as the canine region. The wounds were then closed in layers using 3–0 Vicryl (Ethicon) and 5–0 Prolene (Ethicon) sutures. The patients were discharged from hospital 1 or 2 days after surgery and were

Table 1. Relevant patient data.

Patient 1 2 3b 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Age, years

Gender

57 69 75 50 64 68 64 73 79 69 69 84 71 75 61 60 51

F F F F F M F F M M M M M F F F F

Follow-up after augmentation (months) 12 38 4 20 18 20 29 33 16 15 15 41 58 46 24 22 25

Neurosensory disturbance Normal Normal NA Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal

Dehiscence

Implants in place (months)

Types of implanta and lengths, mm, right/left

– – – – – – – – – – – – – – – – –

10 28 NA 12 13 19 22 27 22 6 35 38 38 34 19 13 17

RP 11.5/11.5 RP 15/NP 15 NA RP 15/15 RP 11.5/11.5 RP 15/15 NP 13/13 RP 11.5/11.5 RP 13/13 RP 13/13 RP 13/13 NP 13/13 NP 11.5/11.5 NP 13/13 RP 13/13 RP 13/15 RP 13/13

F, female; M, male; NA, not applicable. a Bra˚nemark Mk III Groovy: NP = narrow platform, diameter 3.3 mm; RP = regular platform, diameter 3.75 mm. b Patient died of natural causes.

Please cite this article in press as: Soehardi A, et al. Lower border bone onlays to augment the severely atrophic (class VI) mandible in preparation for implants: a preliminary report, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.06.005

YIJOM-2934; No of Pages 7

Lower border bone onlays for the class VI mandible allowed to wear their dentures during the healing period. Implants

Two endosteal implants were placed in each patient, 4–6 months after grafting, under local anaesthesia. Via an intraoral approach, the two screws were removed. Implant placement was carried out using the Nobel Guide procedure. Bra˚nemark Mk III Groovy implants with a regular platform (RP, diameter 3.75 mm) or narrow platform (NP, diameter 3.3 mm) were selected (Table 1). After integration of the implants in the bone, approximately 6 months later, the implants were exposed and prosthetic rehabilitation was completed with removable, implant-supported dentures, made by a specialist dentist (Fig. 1). Follow-up

All patients were seen at regular intervals to ensure that the healing was uneventful.

Fig. 1. Implants with locators in situ.

They were asked to complete a questionnaire at the last follow-up, in which they graded the whole procedure including bone grafting and denture function, using a visual analogue scale (VAS). CBCT scans were made of each patient preoperatively, immediately postoperatively, after 6 months, and at the last follow-up, which varied from 2 to 4 years. Bone height was assessed preoperatively, immediately postoperatively, at the time

3

of implant placement (4–6 months after grafting), and again at 24 months after bone grafting, when applicable (Fig. 2). After identifying the midline, the crosssections were measured at a distance of 12 mm (i-CAT Vision Software; Imaging Sciences International, Hatfield, PA, USA). Subsequently, the measured values for the left and right side were averaged. The percentage of height increase was calculated as follows: (height of original mandible plus bone graft in mm height of original mandible in mm)/height of original mandible in mm  100% = gain in height %. Resorption was calculated in a similar manner: (postoperative height in mm final height in mm)/postoperative height in mm  100% = height loss %. Assessment of nerve function

In addition to the light touch test evaluating the patient’s subjective perception of normal sensation versus neurosensory disturbance, Semmes–Weinstein monofilaments were used with index numbers

Fig. 2. (a) 3D CBCT scan after lower border bone onlay and (b) after implant placement.

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Fig. 2. (Continued ).

1.65, 2.83, and 3.22, corresponding to 0.008 g, 0.07 g, and 0.16 g of force, respectively (Fig. 3). Since the actual force value might differ, all filaments were cali-

brated using a top-loading balance and by calculating the mean of 10 force measurements per filament. Force values are expressed in millinewtons (mN; 1 mN =

100 mg). Force rather than pressure was appropriate for defining the stimulus magnitude of the monofilaments. A filament was gently moved perpendicular to and from a test site. The contact time was approximately 1.5 s (the examiner counted silently ‘21, 22’ at the correct pace). The upper lip was used as a control.

Results

Fig. 3. The three types of Semmes–Weinstein monofilaments with index numbers 1.65, 2.83, and 3.22.

Healing was uneventful in all patients and no dehiscence occurred, either intraorally or submentally. All scars were well hidden posterior to the submental fold. None of the patients thought this to be a drawback of the procedure. One patient died after the augmentation but before implant placement and mental nerve function testing, thus implants were placed in 16 patients. The whole treatment was completed, including the prosthetic rehabilitation, in nine patients. A total of 32 Bra˚nemark Mk III Groovy implants were inserted, 9 NP and 23 RP. Implant length varied from 11.5 to 15 mm (Table 1).

Please cite this article in press as: Soehardi A, et al. Lower border bone onlays to augment the severely atrophic (class VI) mandible in preparation for implants: a preliminary report, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.06.005

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Lower border bone onlays for the class VI mandible Table 2. Gain in height and resorption of the augmented bone on the lower border of the mandible at four different times-points. Mandibular height, mm

Patient Preoperative 1 2 3d 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Mean, mm

in the lip–chin area. One has to keep in mind that the method of testing used is very sensitive, as filaments of 1.65 mN were also not felt in the upper lip of five tested persons. These findings regarding the sensitivity of the method of testing are in accordance with those of earlier reports.28–30 The method used seems to be the most simple and reliable method to show the seriousness of nerve damage, such as paresthesia or anaesthesia, and to follow the recovery process over time.30 Ideally, the sensitivity of the mental region would be tested preoperatively, instead of using the upper lip as control. The VAS score revealed a high degree of satisfaction for the whole treatment process, despite the presence of a visible scar. As compared to the conventional augmentation (onlay technique) of the edentulous mandible, using the technique presented does not reduce the intermaxillary distance. Another disadvantage is the lack of improvement of the facial profile, because the augmentation does not provide support for the muscles of the lower lip. Compensation, of course, is provided by the prosthesis. Also, the procedure does not provide an opportunity to correct bony irregularities of the upper border, nor can the mental nerve be repositioned at the same time. When these procedures need to be done because of pressure pain, they need to be performed separately. One of the advantages of the method described is certainly the opportunity for the patient to wear their dentures during the healing period. A further advantage of lower border grafting over intraoral upper border grafting is that mucosal dehiscences are not seen.7,31 To the best of our knowledge there are three publications that have followed a similar pattern, with inferior border grafting of the mandible being carried out prior to implant placement. Quinn et al.21 used a cadaver cortical tray, filled with an autogenous bone marrow graft, also fixed with circum-mandibular sutures. This way they augmented not only the submental area but included the whole horizontal part of the mandible. Implant placement took

6 months postoperativeb

Postoperativea

8.2 6.9 8.5 8.2 6.5 8.7 7.4 5.4 8.8 8.4 6.2 5.6 7.4 8.9 7.2 8.3 8.2 7.6

13.8 16.4 16.4 15.9 12.7 16.7 15.7 12.2 16.1 15.0 14.7 14.4 12.7 15.7 13.5 16.2 14.8 14.9

2–4 years postoperativec

13.0 15.8 NA 15.6 12.5 16.0 15.0 11.7 15.1 14.4 14.0 13.5 12.4 15.3 13.1 15.8 14.4 14.2

– 15.1 NA – – – 14.3 11.6 – – – 13.1 12.2 14.6 13.0 – 14.1 (13.5)

NA, not applicable. a Mean height gain postoperatively 98%. b Mean height loss at 6 months 4.7%. c Mean height loss at 2–4 years 9.3%. d Patient died of natural causes.

The measurements of the height of the grafted mandibles are presented in Table 2. The height of the mandible varied between 5.4 and 8.9 mm (mean 7.6 mm) preoperatively, and between 12.2 and 16.7 mm (mean 14.9 mm) immediately after augmentation. The calculated mean height gain was 98%. Initial resorption after 6 months varied from 0.2 to 1.0 mm (mean 0.7 mm; 4.7%); resorption of 0.1–0.7 mm (mean 0.4 mm; 9.3%) was observed between 6 and 24 months. The last measurements were not complete, because the follow-up was shorter than 2 years for eight patients. Sixteen patients underwent mental nerve function tests (Table 3); however only one side was tested for one of these patients (see Materials and methods section). The light touch test expressing differences in threshold of neurosensory tactile perception was within the normal limits in this patient group. Monofilament 1.65 was not felt by seven of the 15

patients, but numbers 2.83 and 3.22 were felt by all 15 patients. The average VAS score for patient appreciation was 7.9 on a scale from 0 to 10, varying between 7 and 9. All 16 of the patients treated were satisfied with the result and would do it again. Discussion

Augmentation of the lower border appeared to be reasonably stable, but some resorption occurred in the first 6 months (Table 2), which continued at a lower rate in most cases for up to 2 years after augmentation. It appeared that the measured resorption took place at the periphery of the bone transplant. Long-term follow-up will be necessary to confirm this trend. The height gained allowed for insertion of implants, often of maximum size. Most importantly the results of the mental nerve testing showed normal sensitivity

Table 3. Results of mental nerve function tests for the three types of monofilament. Upper lip Monofilament index number 2.83

1.65

Normal sensitivity (n patients) Neurosensory disturbance (n patients)

Lower lip Monofilament index number 3.22

1.65

Left

Right

Left

Right

Left

Right

Left

12 3

13 2

15 0

15 0

15 0

15 0

8 7

2.83

Right 9 6

3.22

Left

Right

Left

Right

15 0

15 0

15 0

15 0

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Soehardi et al.

Table 4. Review of augmentation techniques for the atrophic mandible for implant placement. When not specifically mentioned, the bone grafts were taken from the iliac crest.

Number of patients

Study 3

Stellingsma et al. 2004 Satow et al.5 1997 Verhoeven et al.6 1997 Verhoeven et al.7 2006 McGrath et al.9 1996 Bell et al.12 2002 Enislidis et al.13 2005 Perdijk et al.15 2007 Raghoebar et al.16 2000 Raghoebar et al.17 2008 van der Meij et al.31 2005 Bianchi et al.32 2008 Ettl et al.33 2010 Haers et al.34 1991 Kent et al.35 1983 Stellingsma et al.36 1998 Vanassche et al.37 1988 Vermeeren et al.38 1996

Follow-up, months

Augmentation technique

Percentage of bone resorption (in n years)

Type of augmented materials

10% (2)

Nerve damage, %

20

24

Sandwich osteotomy

Autogenous bone

32

24

Sandwich osteotomy

13

29

36% (3)

13

106

Autogenous bone

51% (10)

18

17 48

Autogenous bone, HA Autogenous bone

20% (2)

14 9

27

One-stage upper border onlay One-stage upper border onlay One-stage upper border onlay Two-stage lower border (rib) onlay Distraction osteogenesis

Autogenous bone, HA Autogenous bone

45

36

Distraction osteogenesis

28%

3

6

Distraction osteogenesis

0%

46

72

Distraction osteogenesis

17

52

6

23

One-stage upper border onlay Sandwich osteotomy

36

54

Distraction osteogenesis

81

60

Sandwich osteotomy

47

48

Upper border onlay

10

31

Sandwich osteotomy

55

30

Sandwich osteotomy

31

60

One-stage upper border onlay

12.7% (2)

Wound dehiscence (number of patients)

10% 16%

1

0%

3

11.1%

33% (0.5)

None

8.7% Autogenous bone

15% (4)

Autogenous bone

29.4%

2 (+2)

15.5% (0.5) 21.1% (0.5)

Autogenous bone, HA Autogenous bone, HA Autogenous bone

23% (4)

Autogenous bone, HA Autogenous bone

30% (2.5)

23.4% 15% 0% 29%

50% (5)

HA, hydroxylapatite.

place 4 months after augmentation. Unfortunately, their case series does not mention the number of patients treated, nor has their preliminary report been followed up. Bell et al.12 did the dissection through skin, subcutaneous tissue, and platysma, and approached both the inferior, superior, anterior, and lateral borders of the mandible. The mental nerves were identified and protected. If necessary the inferior alveolar nerve was freed from its canal and repositioned laterally into the adjacent soft tissue. Previously harvested corticocancellous bone was then placed carefully along the superior and lateral aspects of the mandible extending as far posteriorly as the retromolar trigone. This method, however, results in a large scar, impairs the blood supply to the mandible, and carries a high risk of damage to the mental nerve.

Gutta and Waite18 stressed that augmentation of the lower border can be limited to the submental area only. However, these authors not only augmented the lower border but at the same time put bone strips in the upper part of the mandible, thereby compromising the blood supply to the atrophic mandible. They also advocated identifying the mental nerves, thereby increasing the risk of nerve damage. A review of the other augmentation techniques for severely atrophic mandibles in combination with implant placement is presented in Table 4.3,5–7,9,12,13,15– 17,31–38 Unfortunately, the data presented are difficult to compare because of the different techniques used to measure resorption and to define nerve damage. In conclusion, by limiting the lower border augmentation to only the submental area, certain advantages to existing

techniques are offered, notably avoiding mental nerve dysesthesia. Whether the long-term results will be equally satisfying remains to be seen. The authors plan to report these results in due course. Funding

None. Competing interests

None declared. Ethical approval

The study was approved by the CMO Regio Arnhem-Nijmegen (File number CMO: 2013/528). Patient consent

Not required.

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YIJOM-2934; No of Pages 7

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Address: Antariksa Soehardi Department of Oral and Maxillofacial Surgery Radboud University Nijmegen Medical Centre Nijmegen The Netherlands Tel.: +31 655355253 E-mail: [email protected]

Please cite this article in press as: Soehardi A, et al. Lower border bone onlays to augment the severely atrophic (class VI) mandible in preparation for implants: a preliminary report, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.06.005

Lower border bone onlays to augment the severely atrophic (class VI) mandible in preparation for implants: a preliminary report.

We present the preliminary results of a study involving a group of consecutive patients who underwent lower border onlay grafting, limited to the symp...
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