The Journal of Craniofacial Surgery
Correspondence
FIGURE 2. A, Teeth impacted in the symphysis region during surgery. B, Bone defects after teeth impaction. C, Microgranular bovine bone graft to guide bone regeneration. D, Mandibular premolars being removed. E, Supernumerary tooth of the left maxillary region bring removed. F, Maxillary premolar and supernumerary tooth in the right maxillary region being extracted.
suture was performed with 4-0 nylon (Figs. 2D–F). One year postoperatively, complete bone regeneration was verified, with great healing aspect and significant improvement in patient’s occlusion, who is still under orthodontic treatment (Figs. 1E, F). The surgical procedure was performed in some stages because there were many teeth to be extracted. As bone defect created by the procedure was great, it was established to perform bone grafting with lyophilized bovine bone and guide bone regeneration. Therefore, despite considering the genetic theory of etiology, it is still quite unclear. It is known that genetics does not follow a simple Mendelian pattern, and environment can have such an important influence; therefore, cases have been reported in nonsyndromic patients with no family history of dental anomalies.1,2,6,7,10 Pedro Henrique Silva Gomes-Ferreira, DDS Beneficent Portuguese Hospital Bauru, Sa˜o Paulo Brazil Gabriel Ramalho-Ferreira, DDS, MSc Gustavo Antonio Correa Momesso Matheus da Silva Brasilino Sabrina Ferreira, DDS, MSc Aracatuba Dental School Univ Estadual Paulista (UNESP) Sa˜o Paulo, Brazil Joa˜o Lopes Toledo-Filho, DDS, PhD Gustavo Lopes Toledo, DDS, PhD Beneficent Portuguese Hospital Bauru, Sa˜o Paulo Brazil Leonardo Perez Faverani, DDS, PhD Aracatuba Dental School Univ Estadual Paulista (UNESP) Sa˜o Paulo, Brazil [email protected]
REFERENCES 1. Gu¨ndu¨z K, Mug˘lali M. Non-syndrome multiple supernumerary teeth: a case report. J Contemp Dent Pract 2007;8:81–87
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2. Leco Berrocal MI, Martı´n Morales JF, Martı´nez Gonza´lez JM. An observational study of the frequency of supernumerary teeth in a population of 2000 patients. Med Oral Patol Oral Cir Bucal 2007;12:E134–E138 3. Yagu¨e-Garcı´a J, Berini-Ayte´s L, Gay-Escoda C. Multiple supernumerary teeth not associated with complex syndromes: a retrospective study. Med Oral Patol Oral Cir Bucal 2009;14:E331–E336 4. Cobourne MT, Sharpe PT. Making up the numbers: the molecular control of mammalian dental formula. Semin Cell Dev Biol 2010;21:314–324 5. Fleming PS, Xavier GM, DiBiase AT, et al. Revisiting the supernumerary: the epidemiological and molecular basis of extra teeth. Br Dent J 2010;208:25–30 6. Scheiner MA, Sampson WJ. Supernumerary teeth: a review of the literature and four case reports. Aust Dent J 1997;42:160–165 7. Holzhausen M, Gonc¸alves D, CorreˆaFde O, et al. A case of Zimmermann-Laband syndrome with supernumerary teeth. J Periodontol 2003;74:1225–1230 8. Richardson A, Deussen FF. Facial and dental anomalies in cleidocranial dysplasia: a study of 17 cases. Int J Paediatr Dent 1994;4:225–231 9. Duncan BR, Dohner VA, Priest JH. The Gardner syndrome: need for early diagnosis. J Pediatr 1968;72:497–505 10. Dı´az A, Orozco J, Fonseca M. Multiple hyperodontia: report of a case with 17 supernumerary teeth with non syndromic association. Med Oral Patol Oral Cir Bucal 2009;14:E229–E231
Prosthetic Rehabilitation Using Short Dental Implants Associated With Homogenous Bone Graft To the Editor: At present, oral rehabilitation with the use of osseointegratable implants is a highly successful treatment modality1–3 that is well accepted by patients.4 However, there are some factors, such as unsatisfactory quality and quantity of bone, implant length and location, denture type and location, that may be considered risk factors of the treatment.2 Therefore, various studies have sought alternative that favors the success of implants, making them a feasible treatment even in less favorable conditions. One of the main challenges to face in implant dentistry is the placement of implants in areas with deficient bone tissue, without causing damage to important anatomic structures. In the maxilla, the most frequent concern to the face is related to the proximity of the maxillary sinus to the crest of the alveolar ridge in posterior implants, and in the anterior region, its proximity to the floor of the nasal fossa and palatine canal. In the mandible, the mandibular canal is the main structure to be preserved. Therefore, in order to rehabilitate areas with an insufficient quantity of bone with implants, considering the anatomic structures, it is necessary to perform previous treatment of the area. The placement of short implants, that is, less than 10 mm long,5–7 may, in certain cases, eliminate or minimize this treatment. That is why, for these areas, this treatment is considered less complex, invasive, and traumatic.8,9 Moreover, more recent studies have suggested the use of these implants for oral rehabilitation in situations of limited vertical bone height.7 Therefore, the purpose of this article was to relate a clinical case of rehabilitation with short implants associated with homogeneous bone graft in the posterior region of the mandible. #
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 3, May 2015
Correspondence
CLINICAL CASE The patient, a 46-year-old, partially edentulous woman, sought rehabilitative treatment to replace teeth 34, 36, 37, 45, and 46, in order to achieve better masticatory quality. By means of tomographic analysis, it was verified that the posterior region of the patient’s mandible presented significant limitation in bone height (approximately 3 mm measured from the rest of the ridge to the external cortical of the mandibular canal) and thickness, making it unfeasible to perform rehabilitation with implants, including the short type (Fig. 1). Therefore, bearing in mind the insufficient availability of bone tissue in intraoral donor areas, and the patient’s refusal to remove bone from extraoral sites, the option was taken for bone reconstruction of these areas with the use of homogeneous bone (Unimar–Universidade da Cidade de Marı´lia, SP, ‘‘UNIOSS–Banco de Ossos’’). Before the bone reconstruction surgery, the fabrication of a tridimensional prototype model of the patient’s mandible was requested for preparation and adaptation of the homogenous bone blocks (Fig. 2), with the aim of reducing the surgical time and consequent morbidity of the procedure. The patient received preventive antibiotic therapy (2 capsules of 500 g of amoxicillin 1 hour before the surgical procedure). After this, anesthetic nerve block of the inferior alveolar, oral, and lingual nerves was performed by means of the direct pterygomandibular technique using 4% articaine with adrenaline 1:100,000 (DFL, Rio de Janeiro, Brazil), bilaterally. After incision and mucoperiostal detachment on both sides, preparation of the receptor bed was performed with tapered-trunk cutters (701) to promote grooves and consequent tissue bleeding in the homogenous bone receptor areas (Figs. 3 and 4). After this, each block preadapted to the prototype model was removed, transferred to the mandibular posterior region, and fixed according to the predetermined position (Figs. 3 and 4). In the molars areas, the blocks were adapted to the bone crest bilaterally, in the shape of a saddle, to allow restoration of the bone framework in the 2 dimensions. After a period of 8 months for bone regeneration (Fig. 5), it was observed that although the graft had not provided a gain in width and height, because of the preexistent reduced bone height (3 mm), the placement of 2 short implants on both sides was planned and 1 long implant in the region of the left first premolar (Connect AR, 3.75 11.5 mm; Conexa˜o Sistemas de Pro´tese Aruja´, Sa˜o Paulo, Brazil). A supracrestal incision, full-thickness flap, and preparation of the surgical bed were performed, followed by the placement of 4
FIGURE 1. Initial computed tomographic scan and panoramic radiograph. Note the reduced alveolar bone height in the edentulous areas corresponding to teeth 34, 36, 37, 45, and 46.
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2015 Mutaz B. Habal, MD
FIGURE 2. A, Homogeneous bone tissue block. B, Prototype three-dimensional model of the patient’s mandible for preparation and adaptation of the homogeneous bone blocks. C, Right-side view of the block adapted to the model. D, Left-side view of the block adapted to the model.
short implants (these being in the region of teeth 36, 37 and 46: 5.0 6.0 mm (Bicon Dental Implants, Boston, MA); of tooth 45: Connect AR, 3.75 8.5 mm; Conexa˜o Sistemas de Pro´tese Aruja´, Sa˜o Paulo, Brazil). The implant presented primary stability of 50 N cm (Figs. 6–8). Four months postoperatively, transfer molding was performed for fabrication of the implant supported dentures (Fig. 9). Special attention was paid to occlusal adjustment. The clinical case, which has been followed for 5 years, has been shown to be satisfactory (Fig. 10).
DISCUSSION Rehabilitation by means of osseointegrated implants was indicated in this clinical cause because it was an excellent strategy for replacing the lost natural teeth and provided adequate masticatory quality, predictability, and high success rates of the procedure.1 –3,10 The rehabilitated area in the current clinical case presented limited bone availability. For this reason, the option was taken for an
FIGURE 3. A, Mucoperiostal displacement showing evidence of the receptor bed with grooves in the region of teeth 45 and 46. B, Positioning and fixation of the bone block for the receptor region preadapted to the model. C, Smoothing the bone tissue block, using a multibladed cutter at low speed. D, Block fixed and adapted to the receptor bed.
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Correspondence
The Journal of Craniofacial Surgery
FIGURE 4. Mucoperiostal displacement showing evidence of the receptor bed with grooves in the region of teeth 34, 36, and 37. B, Mucoperiostal flap released to promote approximation of the edger after the bone graft. C, Positioning and fixation of the bone block for the receptor region preadapted to the model. D, Suture with nylon thread.
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FIGURE 7. A, Mucoperiostal displacement 8 months after the homogeneous bone graft. Placement of 2 implants in the region of tooth 34. B, Receptor bed of the implant in the region of tooth 34. C, Suture with nylon thread after placement of implants in the region of teeth 34, 36, and 37. D, Radiograph showing the position of implants in relation to the adjacent structures.
FIGURE 8. Panoramic radiograph of the implants placed.
FIGURE 5. A, Mucoperiostal displacement 8 months after the homogeneous bone graft. B, Positioning parallel pins to guide implant positioning.
approach with the association of homogeneous bone grafting and the use of short implants to favor successful treatment. The aim of bone reconstruction by means of homogeneous bone tissue graft was to diminish the lack of bone height in the implant receptor area. The proximity to the mandibular canal would have compromised even the placement of short implants. Other
FIGURE 6. A, Placement of 2 short implants in the region of teeth 45 and 46. B, Adaptation of the autogenous bone tissue scrapings during osteotomy for covering the cervical spirals of the implants. D, Radiograph showing the position of short implants in relation to the adjacent structures.
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alternatives such as lateralization of the inferior alveolar nerve11 and osteogenic distraction12 could have been considered with the same objective but were not, because they presented greater morbidity to the patient. The use of short implants alone, in some cases, may be sufficient to overcome the lack of bone height. In this clinical case, however, the proximity of the mandibular canal to the bone crest was critical (3 mm), and even with reducing the implant length, it would not have been possible to use it. The most indicated option in these cases is the use of an adjunct therapy, and the use of
FIGURE 9. A, Right-side view of the abutments for the fabrication of metalceramic dentures. B, Left-side view of the abutments for the fabrication of metalceramic dentures. C, Metal-ceramic dentures cemented in the region of teeth 45 and 46. D, Metal-ceramic dentures cemented in the region of teeth 34, 36, and 37.
#
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 3, May 2015
Correspondence
alternative that may favor the rehabilitation of areas with lack of bone tissue. Nevertheless, to minimize the risk of failures, careful periodic follow-up is indicated. Roge´rio Margonar, DDS, PhD Thallita Pereira Queiroz, DDS, PhD Department of Health Sciences, Implantology Post Graduation Course, Dental School, University Center of Araraquara–UNIARA, Sa˜o Paulo, Brazil
FIGURE 10. A, Periapical radiograph of short implants in the region of teeth 45 and 46. B, Periapical radiograph of the implant in the region of tooth 34. C, Periapical radiograph of the implant in the region of teeth 36 and 37. Five years of follow-up.
short implants associated with it would result in a reduction in the degree of invasiveness of the procedure.13 As regards the material used for bone reconstruction, autogenous bone is the type that presents the most favorable qualities. However, to obtain it requires greater technical skill and causes more surgical morbidity.14 In this rehabilitation, the availability of bone tissue in the intraoral donor areas was insufficient, and the patient did not agree to removing bone from extraoral areas. Therefore, homogeneous grafts were indicated to the patient and accepted by her as an alternative. Moreover, with regard to longterm osseointegration, the homogenous material presented a satisfactory result, similar to that of autogenous bone.15 Previously, according to some authors, short implants presented greater risk of failures when compared with the long type. However, more recent studies have related that the use of short implants alone presents a success rate of 84% to 98.7%.7,16,17 This fact may be related to the modifications in the design and microstructure on the implant surfaces, which have occurred in the last decade and that probably enabled the length of implants to be diminished.18 These changes have favored osseointegration and the distribution of forces, which justified the high degree of success and feasibility of short implants, because the same crown-root proportion in natural dentition predisposes to failures. Therefore, the contemporary short implants similarly present success and longevity to the percentages obtained for long implants. Apart from this, the use of short implants simplifies treatment in maxillary and mandibular posterior regions and reduces the number of situations in which an adjunct therapy is required13; they present less surgical morbidity and lower risk of complications, diminish the time without the use of a stable denture, and require less technical skill in the approach to areas with insufficient bone tissue.19 Adequate surgical prosthetic planning, considering the position and quality of fixations, appropriate selection and use of implants, suitable longitudinal follow-up and observation of the biomechanical principles with the use of texturized surface implants,20 optimization of initial stability, adequate anchorage of the implants with a reduction in the incidence of nonaxial forces and reduced stresses and occlusal overloads are determinant factors for the success of short implants. Implant failures, in turn, appear to be related to bone quality rather than to the length of implants.6,7
CONCLUSIONS From the results obtained, one observes that the use of short implants associated with homogeneous bone grafting is a feasible #
2015 Mutaz B. Habal, MD
Ce´lia Tomiko Matida Hamata Saito, DDS, PhD Eloa´ Rodrigues Luvizuto, DDS, PhD Department of Surgery and Integrated Clinic, UNESP–Univ Estadual Paulista, Arac¸atuba Dental School Sa˜o Paulo, Brazil [email protected] Walter Betoni-Ju´nior, DDS, PhD Department of Oral Surgery, Dental School, University of Cuiaba´ –UNIC, Mato Grosso, Brazil Ju´lio Ce´sar Silva de Oliveira, DDS, MS Department of Surgery and Integrated Clinic, UNESP–Univ Estadual Paulista, Arac¸atuba Dental School, Sa˜o Paulo, Brazil E´lcio Marcantonio, DDS, PhD Department of Diagnosis and Surgery, UNESP–Univ Estadual Paulista, Araraquara Dental School, Araraquara, Sa˜o Paulo, Brazil
REFERENCES 1. Simonis P, Dufour T, Tenenbaum H. Long-term implant survival and success: a 10–16-year follow-up of non-submerged dental implants. Clin Oral Implants Res 2010;21:772–777 2. Jang HW, Kang JK, Lee K, Lee YS, et al. A retrospective study on related factors affecting the survival rate of dental implants. J Adv Prosthodont 2011;3:204–215 3. Jung RE, Fenner N, Hammerle CH, et al. Long-term outcome of implants placed with guided bone regeneration (GBR) using resorbable and non-resorbable membranes after 12–14 years. Clin Oral Implants Res 2013;24:1065–1073 4. Johannsen A, Wikesjo U, Tellefsen G, et al. Patient attitudes and expectations of dental implant treatment—a questionnaire study. Swed Dent J 2012;36:7–14 5. Deporter DA, Caudry S, Kermalli J, et al. Further data on the predictability of the indirect sinus elevation procedure used with short, sintered, porous-surfaced dental implants. Int J Periodontics Restorative Dent 2005;25:585–593 6. Misch CE, Steignga J, Barboza E, et al. Short dental implants in posterior partial edentulism: a multicenter retrospective 6-year case series study. J Periodontol 2006;77:1340–1347 7. Annibali S, Cristalli MP, Dell’Aquila D, et al. Short dental implants: a systematic review. J Dent Res 2012;91:25–32 8. Arlin ML. Short dental implants as a treatment option: results from an observational study in a single private practice. Int J Oral Maxillofac Implants 2006;21:769–776 9. de Santis D, Cucchi A, Longhi C, et al. Short threaded implants with an oxidized surface to restore posterior teeth: 1- to 3-year results of a prospective study. Int J Oral Maxillofac Implants 2011;26:393–403 10. Rodriguez AM, Orenstein IH, Morris HF, et al. Survival of various implant-supported prosthesis designs following 36 months of clinical function. Ann Periodontol 2000;5:101–108 11. Vasco MA, Hecke MB, Bezzon OL. Analysis of short implants and lateralization of the inferior alveolar nerve with 2-stage dental implants by finite element method. J Craniofac Surg 2011;22:2064–2071 12. Marcantonio E, dela Coleta R, Spin-Neto R, et al. Use of a tooth-implant supported bone distractor in oral rehabilitation: description of a personalized technique. J Oral Maxillofac Surg 2008;66:2339–2344
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Correspondence
The Journal of Craniofacial Surgery
13. Ferrigno N, Laureti M, Fanali S. Dental implants placement in conjunction with osteotome sinus floor elevation: a 12-year life-table analysis from a prospective study on 588 ITI implants. Clin Oral Implants Res 2006;17:194–205 14. Aghabeigi B, Bousdras VA. Rehabilitation of severe maxillary atrophy with zygomatic implants. Clinical report of four cases. Br Dent J 2007;202:669–675 15. Pelegrine AA, Sorgi da Costa CE, Sendyk WR, et al. The comparative analysis of homologous fresh frozen bone and autogenous bone graft, associated or not with autogenous bone marrow, in rabbit calvaria: a clinical and histomorphometric study. Cell Tissue Bank 2011;12: 171–184 16. Renouard F, Nisand D. Short implants in the severely resorbed maxilla: a 2-year retrospective clinical study. Clin Implant Dent Relat Res 2005;7 (suppl 1):S104–S110 17. das Neves FD, Fones D, Bernardes SR, et al. Short implants—an analysis of longitudinal studies. Int J Oral Maxillofac Implants 2006;21:86–93 18. Goene R, Bianchesi C, Huerzeler M, et al. Performance of short implants in partial restorations: 3-year follow-up of Osseotite implants. Implant Dent 2005;14:274–280 19. Pommer B, Frantal S, Willer J, et al. Impact of dental implant length on early failure rates: a meta-analysis of observational studies. J Clin Periodontol 2011;38:856–863 20. Sohrabi K, Mushantat A, Esfandiari S, et al. How successful are small-diameter implants? A literature review. Clin Oral Implants Res 2012;23:515–525
Surgical Approach in a Large Ameloblastic Fibrodentinoma To the Editor: The ameloblastic fibrodentinoma (AFD) is a rare odontogenic tumor of epithelial origin, associated with the odontogenic ectomesenchyme, and presents the formation of calcified material.1 Because of the peak of prevalence in the first 2 decades of life,2 there is a treatment direction and planning based on the growth process.3 The AFD is an extremely rare lesion in pediatric epidemiologic4 surveys, and the knowledge about their biologic characteristics is due to case reports and literature reviews.1 –3 This study aimed to discuss the conservative approach and oral rehabilitation in a young patient with AFD. A 12-year-old girl presented slight tumefaction in the posterior region of the left mandible. The panoramic radiograph (Fig. 1A) showed a multilocular radiolucent lesion with extension from the left ramus of the mandible up to the region of the second premolar. Histopathologic examination of the incisional biopsy showed an
FIGURE 1. A, Diagnostic panoramic radiograph exhibiting multiloculated radiolucent lesion with well-defined margins in the region of the left mandibular molars, with clinical radiographic diagnosis of multilocular ameloblastoma. B, Histopathologic examination of the incisional biopsy with diagnosis of ameloblastoma follicular. One notes islands of columnar cells with inverted polarity forming follicles with central region presenting myxoid degeneration similar to stellate reticule of the enamel organ (400, hematoxylin-eosin).
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FIGURE 2. Excisional biopsy with diagnosis of ameloblastic fibrodentinoma showing (A) a stroma rich in fusiform cells with cords of 1 or 2 layers of odontogenic epithelium, presence of calcified material similar to dentin, and cement (B) and dentinoid material (C) intimately associated with the odontogenic epithelium (200, hematoxylin-eosin).
ameloblastoma of the follicular type (Fig. 1B). Conservative surgical excision of the lesion was performed. Despite the thinness of the remaining tissue, the basilar region of the mandible was maintained. With the aid of the prototyping biomodel, a titanium plate was previously adjusted to the affected region. The complete surgical specimen was sent for histopathologic examination. It was observed a proliferation of fusiform and stellate (star-shaped) cells in a fibromyxoid stroma presenting numerous islands and narrow cords lined with columnar epithelium with peripheral cells with inverted polarity (Fig. 2A). In addition, the following were visualized: dentin matrix (Fig. 2B) and dentinoid material (Fig. 2C) deposited in association with epithelial tissue. The final diagnosis was AFD. After 3 years of follow-up, the patient was shown to be free of recurrence (Fig. 3A), and at the end of 5 years of follow-up (17 years old), orthodontic adjustment was performed in association to osseointegrated implant placement (Fig. 3B) and rehabilitation by means of implant-supported dentures (Fig. 3C). The AFD is a rare lesion with a benign biologic behavior. This benign biologic behavior associated with slow growth does not justify aggressive and mutilating treatments,1,5 which must be reserved for suspicions of possible processes of malignant transformation into an ameloblastic fibrodentinosarcoma.5 Presently, the diagnosis was made because of the retarded eruption of the 2 impacted mandibular molars, directly associated with the tumor. These 2 teeth in addition to 1 adjacent molar and 2 adjacent premolars were lost in the process of excision of the tumoral mass, because of its large extension. The option was taken to perform rehabilitation by means of osseointegrated implants, because the use of removable dentures might interfere in the growth and development of the bony bases.3 Despite the advantage of implants, they behave as ankylosed teeth, interfering in the development of the alveolar process, which may lead to a unilateral posterior crossbite and significant facial asymmetry. For this reason, the option was taken to place implants when the patient reached the age of 17 years, a time when bone growth in girls tends to stop.3 After 6 years of follow-up, the patient is currently free of tumor recurrence, and the implants are in ideal occlusion and have adequate stability after 1 year of follow-up. Therefore, the importance of a multidisciplinary approach is pointed out in the face of the need for early diagnosis and intervention in children and adolescents with
FIGURE 3. Three (A) and 5 (B) years postoperatively exhibiting complete healing of the mandibular bone and rehabilitation with implants with osseointegration in the posterior region of the left mandible. C, Implantsupported dentures placed in the oral cavity after osseointegration.
#
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Correspondence
FIGURE 2. A, Teeth impacted in the symphysis region during surgery. B, Bone defects after teeth impaction. C, Microgranular bovine bone graft to guide bone regeneration. D, Mandibular premolars being removed. E, Supernumerary tooth of the left maxillary region bring removed. F, Maxillary premolar and supernumerary tooth in the right maxillary region being extracted.
suture was performed with 4-0 nylon (Figs. 2D–F). One year postoperatively, complete bone regeneration was verified, with great healing aspect and significant improvement in patient’s occlusion, who is still under orthodontic treatment (Figs. 1E, F). The surgical procedure was performed in some stages because there were many teeth to be extracted. As bone defect created by the procedure was great, it was established to perform bone grafting with lyophilized bovine bone and guide bone regeneration. Therefore, despite considering the genetic theory of etiology, it is still quite unclear. It is known that genetics does not follow a simple Mendelian pattern, and environment can have such an important influence; therefore, cases have been reported in nonsyndromic patients with no family history of dental anomalies.1,2,6,7,10 Pedro Henrique Silva Gomes-Ferreira, DDS Beneficent Portuguese Hospital Bauru, Sa˜o Paulo Brazil Gabriel Ramalho-Ferreira, DDS, MSc Gustavo Antonio Correa Momesso Matheus da Silva Brasilino Sabrina Ferreira, DDS, MSc Aracatuba Dental School Univ Estadual Paulista (UNESP) Sa˜o Paulo, Brazil Joa˜o Lopes Toledo-Filho, DDS, PhD Gustavo Lopes Toledo, DDS, PhD Beneficent Portuguese Hospital Bauru, Sa˜o Paulo Brazil Leonardo Perez Faverani, DDS, PhD Aracatuba Dental School Univ Estadual Paulista (UNESP) Sa˜o Paulo, Brazil [email protected]
REFERENCES 1. Gu¨ndu¨z K, Mug˘lali M. Non-syndrome multiple supernumerary teeth: a case report. J Contemp Dent Pract 2007;8:81–87
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2. Leco Berrocal MI, Martı´n Morales JF, Martı´nez Gonza´lez JM. An observational study of the frequency of supernumerary teeth in a population of 2000 patients. Med Oral Patol Oral Cir Bucal 2007;12:E134–E138 3. Yagu¨e-Garcı´a J, Berini-Ayte´s L, Gay-Escoda C. Multiple supernumerary teeth not associated with complex syndromes: a retrospective study. Med Oral Patol Oral Cir Bucal 2009;14:E331–E336 4. Cobourne MT, Sharpe PT. Making up the numbers: the molecular control of mammalian dental formula. Semin Cell Dev Biol 2010;21:314–324 5. Fleming PS, Xavier GM, DiBiase AT, et al. Revisiting the supernumerary: the epidemiological and molecular basis of extra teeth. Br Dent J 2010;208:25–30 6. Scheiner MA, Sampson WJ. Supernumerary teeth: a review of the literature and four case reports. Aust Dent J 1997;42:160–165 7. Holzhausen M, Gonc¸alves D, CorreˆaFde O, et al. A case of Zimmermann-Laband syndrome with supernumerary teeth. J Periodontol 2003;74:1225–1230 8. Richardson A, Deussen FF. Facial and dental anomalies in cleidocranial dysplasia: a study of 17 cases. Int J Paediatr Dent 1994;4:225–231 9. Duncan BR, Dohner VA, Priest JH. The Gardner syndrome: need for early diagnosis. J Pediatr 1968;72:497–505 10. Dı´az A, Orozco J, Fonseca M. Multiple hyperodontia: report of a case with 17 supernumerary teeth with non syndromic association. Med Oral Patol Oral Cir Bucal 2009;14:E229–E231
Prosthetic Rehabilitation Using Short Dental Implants Associated With Homogenous Bone Graft To the Editor: At present, oral rehabilitation with the use of osseointegratable implants is a highly successful treatment modality1–3 that is well accepted by patients.4 However, there are some factors, such as unsatisfactory quality and quantity of bone, implant length and location, denture type and location, that may be considered risk factors of the treatment.2 Therefore, various studies have sought alternative that favors the success of implants, making them a feasible treatment even in less favorable conditions. One of the main challenges to face in implant dentistry is the placement of implants in areas with deficient bone tissue, without causing damage to important anatomic structures. In the maxilla, the most frequent concern to the face is related to the proximity of the maxillary sinus to the crest of the alveolar ridge in posterior implants, and in the anterior region, its proximity to the floor of the nasal fossa and palatine canal. In the mandible, the mandibular canal is the main structure to be preserved. Therefore, in order to rehabilitate areas with an insufficient quantity of bone with implants, considering the anatomic structures, it is necessary to perform previous treatment of the area. The placement of short implants, that is, less than 10 mm long,5–7 may, in certain cases, eliminate or minimize this treatment. That is why, for these areas, this treatment is considered less complex, invasive, and traumatic.8,9 Moreover, more recent studies have suggested the use of these implants for oral rehabilitation in situations of limited vertical bone height.7 Therefore, the purpose of this article was to relate a clinical case of rehabilitation with short implants associated with homogeneous bone graft in the posterior region of the mandible. #
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 3, May 2015
Correspondence
CLINICAL CASE The patient, a 46-year-old, partially edentulous woman, sought rehabilitative treatment to replace teeth 34, 36, 37, 45, and 46, in order to achieve better masticatory quality. By means of tomographic analysis, it was verified that the posterior region of the patient’s mandible presented significant limitation in bone height (approximately 3 mm measured from the rest of the ridge to the external cortical of the mandibular canal) and thickness, making it unfeasible to perform rehabilitation with implants, including the short type (Fig. 1). Therefore, bearing in mind the insufficient availability of bone tissue in intraoral donor areas, and the patient’s refusal to remove bone from extraoral sites, the option was taken for bone reconstruction of these areas with the use of homogeneous bone (Unimar–Universidade da Cidade de Marı´lia, SP, ‘‘UNIOSS–Banco de Ossos’’). Before the bone reconstruction surgery, the fabrication of a tridimensional prototype model of the patient’s mandible was requested for preparation and adaptation of the homogenous bone blocks (Fig. 2), with the aim of reducing the surgical time and consequent morbidity of the procedure. The patient received preventive antibiotic therapy (2 capsules of 500 g of amoxicillin 1 hour before the surgical procedure). After this, anesthetic nerve block of the inferior alveolar, oral, and lingual nerves was performed by means of the direct pterygomandibular technique using 4% articaine with adrenaline 1:100,000 (DFL, Rio de Janeiro, Brazil), bilaterally. After incision and mucoperiostal detachment on both sides, preparation of the receptor bed was performed with tapered-trunk cutters (701) to promote grooves and consequent tissue bleeding in the homogenous bone receptor areas (Figs. 3 and 4). After this, each block preadapted to the prototype model was removed, transferred to the mandibular posterior region, and fixed according to the predetermined position (Figs. 3 and 4). In the molars areas, the blocks were adapted to the bone crest bilaterally, in the shape of a saddle, to allow restoration of the bone framework in the 2 dimensions. After a period of 8 months for bone regeneration (Fig. 5), it was observed that although the graft had not provided a gain in width and height, because of the preexistent reduced bone height (3 mm), the placement of 2 short implants on both sides was planned and 1 long implant in the region of the left first premolar (Connect AR, 3.75 11.5 mm; Conexa˜o Sistemas de Pro´tese Aruja´, Sa˜o Paulo, Brazil). A supracrestal incision, full-thickness flap, and preparation of the surgical bed were performed, followed by the placement of 4
FIGURE 1. Initial computed tomographic scan and panoramic radiograph. Note the reduced alveolar bone height in the edentulous areas corresponding to teeth 34, 36, 37, 45, and 46.
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2015 Mutaz B. Habal, MD
FIGURE 2. A, Homogeneous bone tissue block. B, Prototype three-dimensional model of the patient’s mandible for preparation and adaptation of the homogeneous bone blocks. C, Right-side view of the block adapted to the model. D, Left-side view of the block adapted to the model.
short implants (these being in the region of teeth 36, 37 and 46: 5.0 6.0 mm (Bicon Dental Implants, Boston, MA); of tooth 45: Connect AR, 3.75 8.5 mm; Conexa˜o Sistemas de Pro´tese Aruja´, Sa˜o Paulo, Brazil). The implant presented primary stability of 50 N cm (Figs. 6–8). Four months postoperatively, transfer molding was performed for fabrication of the implant supported dentures (Fig. 9). Special attention was paid to occlusal adjustment. The clinical case, which has been followed for 5 years, has been shown to be satisfactory (Fig. 10).
DISCUSSION Rehabilitation by means of osseointegrated implants was indicated in this clinical cause because it was an excellent strategy for replacing the lost natural teeth and provided adequate masticatory quality, predictability, and high success rates of the procedure.1 –3,10 The rehabilitated area in the current clinical case presented limited bone availability. For this reason, the option was taken for an
FIGURE 3. A, Mucoperiostal displacement showing evidence of the receptor bed with grooves in the region of teeth 45 and 46. B, Positioning and fixation of the bone block for the receptor region preadapted to the model. C, Smoothing the bone tissue block, using a multibladed cutter at low speed. D, Block fixed and adapted to the receptor bed.
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Correspondence
The Journal of Craniofacial Surgery
FIGURE 4. Mucoperiostal displacement showing evidence of the receptor bed with grooves in the region of teeth 34, 36, and 37. B, Mucoperiostal flap released to promote approximation of the edger after the bone graft. C, Positioning and fixation of the bone block for the receptor region preadapted to the model. D, Suture with nylon thread.
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FIGURE 7. A, Mucoperiostal displacement 8 months after the homogeneous bone graft. Placement of 2 implants in the region of tooth 34. B, Receptor bed of the implant in the region of tooth 34. C, Suture with nylon thread after placement of implants in the region of teeth 34, 36, and 37. D, Radiograph showing the position of implants in relation to the adjacent structures.
FIGURE 8. Panoramic radiograph of the implants placed.
FIGURE 5. A, Mucoperiostal displacement 8 months after the homogeneous bone graft. B, Positioning parallel pins to guide implant positioning.
approach with the association of homogeneous bone grafting and the use of short implants to favor successful treatment. The aim of bone reconstruction by means of homogeneous bone tissue graft was to diminish the lack of bone height in the implant receptor area. The proximity to the mandibular canal would have compromised even the placement of short implants. Other
FIGURE 6. A, Placement of 2 short implants in the region of teeth 45 and 46. B, Adaptation of the autogenous bone tissue scrapings during osteotomy for covering the cervical spirals of the implants. D, Radiograph showing the position of short implants in relation to the adjacent structures.
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alternatives such as lateralization of the inferior alveolar nerve11 and osteogenic distraction12 could have been considered with the same objective but were not, because they presented greater morbidity to the patient. The use of short implants alone, in some cases, may be sufficient to overcome the lack of bone height. In this clinical case, however, the proximity of the mandibular canal to the bone crest was critical (3 mm), and even with reducing the implant length, it would not have been possible to use it. The most indicated option in these cases is the use of an adjunct therapy, and the use of
FIGURE 9. A, Right-side view of the abutments for the fabrication of metalceramic dentures. B, Left-side view of the abutments for the fabrication of metalceramic dentures. C, Metal-ceramic dentures cemented in the region of teeth 45 and 46. D, Metal-ceramic dentures cemented in the region of teeth 34, 36, and 37.
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2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 3, May 2015
Correspondence
alternative that may favor the rehabilitation of areas with lack of bone tissue. Nevertheless, to minimize the risk of failures, careful periodic follow-up is indicated. Roge´rio Margonar, DDS, PhD Thallita Pereira Queiroz, DDS, PhD Department of Health Sciences, Implantology Post Graduation Course, Dental School, University Center of Araraquara–UNIARA, Sa˜o Paulo, Brazil
FIGURE 10. A, Periapical radiograph of short implants in the region of teeth 45 and 46. B, Periapical radiograph of the implant in the region of tooth 34. C, Periapical radiograph of the implant in the region of teeth 36 and 37. Five years of follow-up.
short implants associated with it would result in a reduction in the degree of invasiveness of the procedure.13 As regards the material used for bone reconstruction, autogenous bone is the type that presents the most favorable qualities. However, to obtain it requires greater technical skill and causes more surgical morbidity.14 In this rehabilitation, the availability of bone tissue in the intraoral donor areas was insufficient, and the patient did not agree to removing bone from extraoral areas. Therefore, homogeneous grafts were indicated to the patient and accepted by her as an alternative. Moreover, with regard to longterm osseointegration, the homogenous material presented a satisfactory result, similar to that of autogenous bone.15 Previously, according to some authors, short implants presented greater risk of failures when compared with the long type. However, more recent studies have related that the use of short implants alone presents a success rate of 84% to 98.7%.7,16,17 This fact may be related to the modifications in the design and microstructure on the implant surfaces, which have occurred in the last decade and that probably enabled the length of implants to be diminished.18 These changes have favored osseointegration and the distribution of forces, which justified the high degree of success and feasibility of short implants, because the same crown-root proportion in natural dentition predisposes to failures. Therefore, the contemporary short implants similarly present success and longevity to the percentages obtained for long implants. Apart from this, the use of short implants simplifies treatment in maxillary and mandibular posterior regions and reduces the number of situations in which an adjunct therapy is required13; they present less surgical morbidity and lower risk of complications, diminish the time without the use of a stable denture, and require less technical skill in the approach to areas with insufficient bone tissue.19 Adequate surgical prosthetic planning, considering the position and quality of fixations, appropriate selection and use of implants, suitable longitudinal follow-up and observation of the biomechanical principles with the use of texturized surface implants,20 optimization of initial stability, adequate anchorage of the implants with a reduction in the incidence of nonaxial forces and reduced stresses and occlusal overloads are determinant factors for the success of short implants. Implant failures, in turn, appear to be related to bone quality rather than to the length of implants.6,7
CONCLUSIONS From the results obtained, one observes that the use of short implants associated with homogeneous bone grafting is a feasible #
2015 Mutaz B. Habal, MD
Ce´lia Tomiko Matida Hamata Saito, DDS, PhD Eloa´ Rodrigues Luvizuto, DDS, PhD Department of Surgery and Integrated Clinic, UNESP–Univ Estadual Paulista, Arac¸atuba Dental School Sa˜o Paulo, Brazil [email protected] Walter Betoni-Ju´nior, DDS, PhD Department of Oral Surgery, Dental School, University of Cuiaba´ –UNIC, Mato Grosso, Brazil Ju´lio Ce´sar Silva de Oliveira, DDS, MS Department of Surgery and Integrated Clinic, UNESP–Univ Estadual Paulista, Arac¸atuba Dental School, Sa˜o Paulo, Brazil E´lcio Marcantonio, DDS, PhD Department of Diagnosis and Surgery, UNESP–Univ Estadual Paulista, Araraquara Dental School, Araraquara, Sa˜o Paulo, Brazil
REFERENCES 1. Simonis P, Dufour T, Tenenbaum H. Long-term implant survival and success: a 10–16-year follow-up of non-submerged dental implants. Clin Oral Implants Res 2010;21:772–777 2. Jang HW, Kang JK, Lee K, Lee YS, et al. A retrospective study on related factors affecting the survival rate of dental implants. J Adv Prosthodont 2011;3:204–215 3. Jung RE, Fenner N, Hammerle CH, et al. Long-term outcome of implants placed with guided bone regeneration (GBR) using resorbable and non-resorbable membranes after 12–14 years. Clin Oral Implants Res 2013;24:1065–1073 4. Johannsen A, Wikesjo U, Tellefsen G, et al. Patient attitudes and expectations of dental implant treatment—a questionnaire study. Swed Dent J 2012;36:7–14 5. Deporter DA, Caudry S, Kermalli J, et al. Further data on the predictability of the indirect sinus elevation procedure used with short, sintered, porous-surfaced dental implants. Int J Periodontics Restorative Dent 2005;25:585–593 6. Misch CE, Steignga J, Barboza E, et al. Short dental implants in posterior partial edentulism: a multicenter retrospective 6-year case series study. J Periodontol 2006;77:1340–1347 7. Annibali S, Cristalli MP, Dell’Aquila D, et al. Short dental implants: a systematic review. J Dent Res 2012;91:25–32 8. Arlin ML. Short dental implants as a treatment option: results from an observational study in a single private practice. Int J Oral Maxillofac Implants 2006;21:769–776 9. de Santis D, Cucchi A, Longhi C, et al. Short threaded implants with an oxidized surface to restore posterior teeth: 1- to 3-year results of a prospective study. Int J Oral Maxillofac Implants 2011;26:393–403 10. Rodriguez AM, Orenstein IH, Morris HF, et al. Survival of various implant-supported prosthesis designs following 36 months of clinical function. Ann Periodontol 2000;5:101–108 11. Vasco MA, Hecke MB, Bezzon OL. Analysis of short implants and lateralization of the inferior alveolar nerve with 2-stage dental implants by finite element method. J Craniofac Surg 2011;22:2064–2071 12. Marcantonio E, dela Coleta R, Spin-Neto R, et al. Use of a tooth-implant supported bone distractor in oral rehabilitation: description of a personalized technique. J Oral Maxillofac Surg 2008;66:2339–2344
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Correspondence
The Journal of Craniofacial Surgery
13. Ferrigno N, Laureti M, Fanali S. Dental implants placement in conjunction with osteotome sinus floor elevation: a 12-year life-table analysis from a prospective study on 588 ITI implants. Clin Oral Implants Res 2006;17:194–205 14. Aghabeigi B, Bousdras VA. Rehabilitation of severe maxillary atrophy with zygomatic implants. Clinical report of four cases. Br Dent J 2007;202:669–675 15. Pelegrine AA, Sorgi da Costa CE, Sendyk WR, et al. The comparative analysis of homologous fresh frozen bone and autogenous bone graft, associated or not with autogenous bone marrow, in rabbit calvaria: a clinical and histomorphometric study. Cell Tissue Bank 2011;12: 171–184 16. Renouard F, Nisand D. Short implants in the severely resorbed maxilla: a 2-year retrospective clinical study. Clin Implant Dent Relat Res 2005;7 (suppl 1):S104–S110 17. das Neves FD, Fones D, Bernardes SR, et al. Short implants—an analysis of longitudinal studies. Int J Oral Maxillofac Implants 2006;21:86–93 18. Goene R, Bianchesi C, Huerzeler M, et al. Performance of short implants in partial restorations: 3-year follow-up of Osseotite implants. Implant Dent 2005;14:274–280 19. Pommer B, Frantal S, Willer J, et al. Impact of dental implant length on early failure rates: a meta-analysis of observational studies. J Clin Periodontol 2011;38:856–863 20. Sohrabi K, Mushantat A, Esfandiari S, et al. How successful are small-diameter implants? A literature review. Clin Oral Implants Res 2012;23:515–525
Surgical Approach in a Large Ameloblastic Fibrodentinoma To the Editor: The ameloblastic fibrodentinoma (AFD) is a rare odontogenic tumor of epithelial origin, associated with the odontogenic ectomesenchyme, and presents the formation of calcified material.1 Because of the peak of prevalence in the first 2 decades of life,2 there is a treatment direction and planning based on the growth process.3 The AFD is an extremely rare lesion in pediatric epidemiologic4 surveys, and the knowledge about their biologic characteristics is due to case reports and literature reviews.1 –3 This study aimed to discuss the conservative approach and oral rehabilitation in a young patient with AFD. A 12-year-old girl presented slight tumefaction in the posterior region of the left mandible. The panoramic radiograph (Fig. 1A) showed a multilocular radiolucent lesion with extension from the left ramus of the mandible up to the region of the second premolar. Histopathologic examination of the incisional biopsy showed an
FIGURE 1. A, Diagnostic panoramic radiograph exhibiting multiloculated radiolucent lesion with well-defined margins in the region of the left mandibular molars, with clinical radiographic diagnosis of multilocular ameloblastoma. B, Histopathologic examination of the incisional biopsy with diagnosis of ameloblastoma follicular. One notes islands of columnar cells with inverted polarity forming follicles with central region presenting myxoid degeneration similar to stellate reticule of the enamel organ (400, hematoxylin-eosin).
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FIGURE 2. Excisional biopsy with diagnosis of ameloblastic fibrodentinoma showing (A) a stroma rich in fusiform cells with cords of 1 or 2 layers of odontogenic epithelium, presence of calcified material similar to dentin, and cement (B) and dentinoid material (C) intimately associated with the odontogenic epithelium (200, hematoxylin-eosin).
ameloblastoma of the follicular type (Fig. 1B). Conservative surgical excision of the lesion was performed. Despite the thinness of the remaining tissue, the basilar region of the mandible was maintained. With the aid of the prototyping biomodel, a titanium plate was previously adjusted to the affected region. The complete surgical specimen was sent for histopathologic examination. It was observed a proliferation of fusiform and stellate (star-shaped) cells in a fibromyxoid stroma presenting numerous islands and narrow cords lined with columnar epithelium with peripheral cells with inverted polarity (Fig. 2A). In addition, the following were visualized: dentin matrix (Fig. 2B) and dentinoid material (Fig. 2C) deposited in association with epithelial tissue. The final diagnosis was AFD. After 3 years of follow-up, the patient was shown to be free of recurrence (Fig. 3A), and at the end of 5 years of follow-up (17 years old), orthodontic adjustment was performed in association to osseointegrated implant placement (Fig. 3B) and rehabilitation by means of implant-supported dentures (Fig. 3C). The AFD is a rare lesion with a benign biologic behavior. This benign biologic behavior associated with slow growth does not justify aggressive and mutilating treatments,1,5 which must be reserved for suspicions of possible processes of malignant transformation into an ameloblastic fibrodentinosarcoma.5 Presently, the diagnosis was made because of the retarded eruption of the 2 impacted mandibular molars, directly associated with the tumor. These 2 teeth in addition to 1 adjacent molar and 2 adjacent premolars were lost in the process of excision of the tumoral mass, because of its large extension. The option was taken to perform rehabilitation by means of osseointegrated implants, because the use of removable dentures might interfere in the growth and development of the bony bases.3 Despite the advantage of implants, they behave as ankylosed teeth, interfering in the development of the alveolar process, which may lead to a unilateral posterior crossbite and significant facial asymmetry. For this reason, the option was taken to place implants when the patient reached the age of 17 years, a time when bone growth in girls tends to stop.3 After 6 years of follow-up, the patient is currently free of tumor recurrence, and the implants are in ideal occlusion and have adequate stability after 1 year of follow-up. Therefore, the importance of a multidisciplinary approach is pointed out in the face of the need for early diagnosis and intervention in children and adolescents with
FIGURE 3. Three (A) and 5 (B) years postoperatively exhibiting complete healing of the mandibular bone and rehabilitation with implants with osseointegration in the posterior region of the left mandible. C, Implantsupported dentures placed in the oral cavity after osseointegration.
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2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
