Rehabilitation of a patient with gunshot injury through the iliac graft and implant-retained restorations with a 3-year follow-up: a brief clinical study.

The Journal of Craniofacial Surgery

& Volume 25, Number 2, March 2014

8. Goiato MC, Zucolotti BC, Mancuso DN, et al. Care and cleaning of maxillofacial prostheses. J Craniofac Surg 2010;21:1270Y1273 9. Karayazgan-Saracoglu B, Zulfikar H, Atay A, et al. Treatment outcome of extraoral implants in the craniofacial region. J Craniofac Surg 2010;21:751Y758 10. Roumanas ED, Freymiller EG, Chang TL, et al. Implant-retained prostheses for facial defects: an up to 14-year follow-up report on the survival rates of implants at UCLA. Int J Prosthodont 2002;15:325Y332 11. Wolfaardt JF, Wilkes GH, Parel SM, et al. Craniofacial osseointegration: the Canadian experience. Int J Oral Maxillofac Implants 1993;8:197Y204 12. Karakoca Nemli S, Aydin C, Yilmaz H, et al. Retrospective study of implant-retained orbital prostheses: implant survival and patient satisfaction. J Craniofac Surg 2010;21:1178Y1183 13. Leonardi A, Buonaccorsi S, Pellacchia V, et al. Maxillofacial prosthetic rehabilitation using extraoral implants. J Craniofac Surg 2008;19:398Y405 14. Hooper SM, Westcott T, Evans PL, et al. Implant-supported facial prostheses provided by a maxillofacial unit in a U.K. regional hospital: longevity and patient opinions. J Prosthodont 2005;14:32Y38 15. Chang TL, Garrett N, Roumanas E, et al. Treatment satisfaction with facial prostheses. J Prosthet Dent 2005;94:275Y280

Rehabilitation of a Patient With Gunshot Injury Through the Iliac Graft and Implant-Retained Restorations With a 3-Year Follow-up: A Brief Clinical Study Sudhindra Kulkarni, MDS,* Sujatha Kamath, MDS,Þ Roopak Nayak, MDS,þ Sampath Kumar, MDS,Þ Anil Desai, MDS,§ Gopal Krishnan, MDS, FDSRCS,§ Sanjay Ganeshkar, MDS,þ Srinath Thakur, MDS, FDSRCS||

Brief Clinical Studies

ridge deficiency was augmented with iliac bone graft, and 3 months later, implants were placed. Five months later, hybrid prosthesis was delivered. At 3-year follow-up visit, the hybrid prosthesis was replaced with porcelain fused to a metal bridge. The bone levels on all the implants were stable. Key Words: Gunshot injury, iliac bone graft, implants, hybrid prosthesis, porcelain fused to metal bridge

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njuries to the head and neck region of the body are common occurrences in road traffic accidents, falls, or fights. Gunshot injuries, although uncommon, usually involve the facial area1 and result in aesthetic disfigurement, functional loss, and psychologic trauma.2Y4 Trauma and gunshot injuries are treated on a priority basis and surgically managed using either single-stage3 or multistage protocols. In a single-stage approach, both wound debridement and surgical reconstructions are performed simultaneously.5,6 However, the multistage method involves stabilization of the patient at the time of presentation and subsequent management of any fractures and soft tissue injuries. This initial phase is followed by hard and soft tissue reconstructions and a subsequent restorative therapy. Reconstruction of the bone and soft tissue lost due to trauma is required before the missing teeth can be replaced with implants. This osseous reconstruction is followed by implant placement and prosthetic rehabilitation.3,6Y8 The following report describes the case of a 24-year-old man with gunshot wounds to the jaw and tongue; he was treated with an iliac graft and implant-retained restorations.

CLINICAL REPORT A 24-year-old man was referred to the Department of Implantology for replacement of missing teeth. He had his teeth extracted owing to the trauma he experienced from 2 gunshots to his face. One of the 2 bullets was removed, and the other one, which had lodged in the lateral aspect of the spine, was left in situ (Fig. 1A). Examination showed that the tongue was disfigured (Fig. 1B) and that the residual ridge was deficient. Tooth 22 was fractured, and

Abstract: Trauma is one of the most common causes of teeth loss. Assault with a gunshot and bullet shot is life threatening, and for patients who survive the injury, it results in hard and soft tissue loss in the tissues and organs crossed by the bullet. The tissue loss results in the loss of structure and function. Rehabilitation of these patients to function and aesthetics requires surgical and prosthodontic procedures over time. This report is of a 24-year-old male patient who had a bullet injury resulting in hard and soft tissue deficiency. The

From the Departments of *Implantology and Periodontics, †Implantology and Prosthodontics, ‡Orthodontics and Dentofacial Orthopedics, §Oral and Maxillofacial Surgery, and ||Implantology and Periodontics, SDM College of Dental Sciences and Hospital, Karnataka, India. Received March 25, 2013. Accepted for publication June 16, 2013. Address correspondence and reprint requests to Sudhindra Kulkarni, MDS, Department of Implantology and Periodontics, SDM College of Dental Sciences and Hospital, Sattur, Dharwad: 580009, Karnataka, India; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e3182a2ecc4

FIGURE 1. A, Radiograph showing a bullet lodged in the lateral aspect of the spine. B, Disfigured tongue.

FIGURE 2. A. Deficient ridge in the 22 to 27 area. B, Iliac block graft placed at the defect as an onlay graft

* 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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FIGURE 6. Hybrid prosthesis in situ.

FIGURE 3. A, At 3 months after grafting, implants placed in the 22 to 26 area. B, Implants placed in the 34 to 37 areas in the mandible.

FIGURE 7. Radiograph of the hybrid restoration.

FIGURE 4. A, Four months after the operation, there is a lack of keratinised tissue. B, The keratinized tissues form the palate is displaced buccally.

teeth 23 to 27 and 34 to 36 were missing. The patient had a natural edge-to-edge bite.

Diagnostics and Treatment Articulated models of the jaws were made, and the magnitude of vertical deficiency and interocclusal space was evaluated. The deficiency necessitated a block graft to augment the defect. The patient’s consent was obtained for the following treatment plan: orthodontic therapy and iliac graft for reconstruction, followed by implant placement and restorations.

Surgery Full-thickness flaps were reflected. The vertical and horizontal bone deficiencies were approximately 6 to 7 mm in height, 6 mm in width, and 35 mm in length (anteroposterior extent). Bone blocks were harvested from the iliac crest and secured at the donor sites with fixation screws (Figs. 2A, B). Particulated autogenous bone was used to fill in the remaining spaces. Polytetrafluoroethylene (Teflon; Tefgen FD, Lifecore Dental, MN) guided tissue regeneration membranes were used to cover the grafts. The flaps were released further with periosteal scoring, and tension-free, primary closure was attained using 3-0 resorbable sutures (Vicryl, Ethicon, Johnson and Johnson, Aurangabad, India) (Fig. 4). The disfigured tongue was incised along the midline and along the borders of the enlarged portion medially and laterally in a Y shape and dissected in layers. The deeper portion was sutured in layers, and the shape was recontoured and corrected. Three months later, when the patient reported back, the guided tissue regeneration membranes were exposed in 2 areas in the maxilla. As the radiograph revealed a well-adapted graft, implant placement was planned. Full-thickness flaps were reflected; the membranes were

FIGURE 5. A. Palatal tissues have been sutured buccally. B, Well-formed keratinized tissues on the buccal aspect of the implants.

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subsequently retrieved. A 10% to 15% resorption of the graft in the buccolingual direction was observed; however, the amount of bone was adequate to receive the implants. The fixation screws were removed, and the implant sites were designated with a round bur. When initial drilling was performed using a 2.0-mm drill, the bone felt soft, and therefore, osteotomes were used to enlarge the implant sites to the planned dimensions. In the maxilla, a 3.5 12-mm implant was placed in the tooth 22 area, and 4.3 12-mm implants (Nobel Replace Select Tapered, Nobel Biocare AB, Goteborg, Sweden) were placed in the other areas at 20 Ncm2 torque. In the mandible, a 3.5 12-mm implant was placed in the tooth 34 area, and 4.3 12-mm implants were placed in the 35 and 36 areas (Figs. 3A, B). The flaps were approximated, and primary closure was attained. At the conclusion of the orthodontic treatment 4 months after implant placement, the second stage was performed. During the second stage procedure in the tooth 22 to the tooth 27 area, the palatal tissues were transposed buccally to create a band of keratinized tissue. Abutments were placed and covered with abutment caps, and the flaps were sutured (Figs. 4A, B and 5A, B).

Prosthetic Phase Three weeks after the second stage procedure, final impressions were made in vinyl polysiloxane (Aquasil, Dentsply DeTrey GmbH, Konstanz, Germany), and the jaw relations were recorded. Screw-retained prosthesis and cement-retained prosthesis were fabricated for the maxilla and mandible, respectively (Figs. 6 and 7). The tongue had well healed and was in an acceptable shape. The patient expressed happiness at the outcome (Figs. 8A, B). The patient reported 3 years after the initial therapy; the hybrid prosthesis had fractured. The hybrid prosthesis was then removed, and porcelain fused to metal (PFM) restorations were fabricated for the maxillary implants (Fig. 9).

FIGURE 8. A, Well-healed tongue. B, Our smiling patient.






REFERENCES

FIGURE 9. Final PFM restorations at 3-year follow-up.

The patient was satisfied with the outcome of the therapy. The bone levels around the implants have remained stable over a 3-year follow-up (Fig. 10).

DISCUSSION Patients surviving gunshot injuries have severe anatomic disfigurement of the structures in the path of the bullet. Treatment of these cases requires not only management of the teeth but also efforts to keep the patient motivated and cooperative through the multiple surgical and prosthetic phases. The present case was managed in a multistage manner, wherein initial bone augmentation was followed by implant placement and a subsequent restorative phase. The volume of the defect in this case necessitated use of large-size graft. Iliac grafts, although nonvascularized, provide adequatevolume, are easier to shape, and have less donor site morbidity compared with vascularized grafts.3,9Y13 The iliac bone undergoes reduction in volume owing to resorption to the range of 2% to 60%10; this resorption was countered by using over sized corticocancellous grafts and covering the grafts with membrane.7Y9,14Y18 Teflon membranes were used in this case because they have success rates comparable with those of collagen membranes17Y20 and are easier to maintain if they get exposed, which was anticipated in this case owing to the volume of the graft and flap advancement that was performed. Implant placement was performed at 3 months because waiting longer may have led to further resorption of the graft.17 Osteotome technique was used to prepare the implant sites owing to the softness of the grafted bone. This condensed the bone, aiding in achieving primary stability for the implants.21 To achieve a zone of keratinized tissue and to provide thicker tissues on the buccal sides of the implants, the soft tissue was transposed from the palatal to the buccal during second stage. This created a healthy soft tissue barrier and provided a thicker attached tissue that was less likely to recede.22,23 Screw-retained prosthesis using acrylic teeth with a metal substructure (hybrid) was fabricated for the maxillary implants so as to splint them and also to reduce the amount of forces that would get transmitted to the grafted bone. The mandibular implants were restored with a PFM bridge. At the third-year recall, the bone and soft tissue levels were found to be stable. Because of the fracture of the acrylic teeth on hybrid prosthesis, the maxillary prosthesis was replaced with a PFM bridge. The final prosthesis fulfilled the functions of mastication, speech, and aesthetics for the patient.

FIGURE 10. Radioraph of the final PFM restorations.

1. Cunningham LL, Haug RH, Ford J. Firearm injuries to the maxillofacial region: an overview of current thoughts regarding demographics, pathophysiology, and management. J Oral Maxillofac Surg 2003;61:932Y942 2. Hollier L, Grantcharova EP, Kattash M. Facial gunshot wounds: a four year experience. J Oral Maxillofac Surg 2001;59:277Y282 3. Bidra AS, Veeranki AN. Surgical and prosthodontic reconstruction of a gunshot injury of the mandible using dental implants and an acrylic resin fixed prosthesis: a clinical report. J Prosthet Dent 2010;104:142Y148 4. Mc Lean JN, Moore CE, Yellin SA. Gunshot wounds to the faceVacute management. Facial Plast Surg 2005;21:191Y198 5. Vayvada H, Menderes A, Yilmaz M, et al. Management of close-range, high energy shotgun and rifle wounds to the face. J Craniofac Surg 2005;16:794Y804 6. Cheung LK, Leung AC. Dental implants in reconstructed jaws: implant longevity and peri implant tissue outcomes. J Oral Maxillofac Surg 2003;61:1263Y1274 7. Cakan U, Anil U, Aslan Y. Prosthetic rehabilitation of mandibular gun shot defect with an implant supported fixed partial denture. J Prosthet Dent 2006;95:274Y279 8. Go¨k0en-Ro¨hlig B, Atalay B, Baca E, et al. Prosthetic rehabilitation of a patient with a mandibular defect caused by a gunshot wound. J Craniofac Surg 2009;20:1614Y1617 9. Misch CE, Dietsh F. Endosteal implants and iliac crest grafts to restore severely resorbed totally edentulous maxillaeVa retrospective study. J Oral Implantol 1994;20:100Y110 10. Chiapasco M, Casentini P, Zaniboni M. Bone augmentation procedures in implant dentistry. Int J Oral Maxillofac Implants 2009;24:237Y259 11. van Gemert JT, van Es RJ, Van Cann EM, et al. Non-vascularized bone grafts for segmental reconstruction of the mandibleVa reappraisal. J Oral Maxillofac Surg 2009;67:1446Y1452 12. Chiapasco M, Colletti G, Romeo E, et al. Long-term results of mandibular reconstruction with autogenous bone grafts and oral implants after tumor resection. Clin Oral Implants Res 2008;19:1074Y1080 13. Sjo¨stro¨m M, Sennerby L, Nilson H, et al. Reconstruction of the atrophic edentulous maxilla with free iliac crest grafts and implants: a 3-year report of a prospective clinical study. Clin Implant Dent Relat Res 2007;9:46Y59 14. Clayman L. Implant reconstruction of the bone-grafted maxilla: review of the literature and presentation of 8 cases. J Oral Maxillofac Surg 2006;64:674Y682 15. Barone A, Covani U. Maxillary alveolar ridge reconstruction with non-vascularized autogenous block bone: clinical results. J Oral Maxillofac Surg 2007;65:2039Y2046 16. Nelson K, Ozyuvaci H, Bilgic B, et al. Histomorphometric evaluation and clinical assessment of endosseous implants in iliac bone grafts with shortened healing periods. Int J Oral Maxillofac Implants 2006;21:392Y398 17. Donos N, Kostopoulos L, Karring T. Alveolar ridge augmentation by combining autogenous mandibular bone grafts and non-resorbable membranes. Clin Oral Implants Res 2002;13:185Y191 18. Verardi S, Simion M. Management of the exposure of e-PTFE membranes in guided bone regeneration. Pract Proced Aesthet Dent 2007;19:111Y117 19. da Silva Pereira SL, Sallum AW, Casati MZ, et al. Comparison of bioabsorbable and non-resorbable membranes in the treatment of dehiscence-type defects. A histomorphometric study in dogs. J Periodontol 2000;71:1306Y1314 20. Fotek PD, Neiva RF, Wang HL. Comparison of dermal matrix and polytetrafluoroethylene membrane for socket bone augmentation: a clinical and histologic study. J Periodontol 2009;80:776Y785 21. Markovi( A, 'alasan D, Cˇoli( S, et al. Implant stability in posterior maxilla: bone-condensing versus bone-drilling. A clinical study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:557Y563 22. Zigdon H, Machtei EE. The dimensions of keratinized mucosa around implants affect clinical and immunological parameters. Clin Oral Implants Res 2008;19:387Y392



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23. Bengazi F, Wennstro¨m JL, Lekholm U. Recession of the soft tissue margin at oral implants. A 2-year longitudinal prospective study. Clin Oral Implants Res 1996;7:303Y310

Current Concepts on Complications Associated With Sinus Augmentation Procedures Paolo Boffano, MD, Tymour Forouzanfar, MD, DDS Abstract: The sinus augmentation, or sinus lift procedure, is an internal augmentation of the maxillary sinus, which is intended to increase the vertical bony dimension in the lateral maxilla to make the placement of dental implants possible. Complication rate associated with maxillary sinus augmentation procedures in the literature is quite low. Typically, perforation of the Schneiderian membrane, hemorrhage, infection, and rhinosinusitis are more frequently encountered. Therefore, the aim of this article was to briefly review and resume the more common complications associated with sinus augmentation procedures. Key Words: Complications, maxillary sinus, sinus augmentation, sinus lift

T

he sinus augmentation, or sinus lift procedure, is an internal augmentation of the maxillary sinus, which is intended to increase the vertical bony dimension in the lateral maxilla to make the placement of dental implants possible. During the sinus augmentation via a lateral window approach, a bony window is performed on the lateral sinus wall, and a space is created between the Schneiderian membrane and the sinus walls, where a grafting material was placed. One key advantage of this approach is gaining direct access to the sinus. However, despite the high success rate, complications do occur. Complication rate associated with maxillary sinus augmentation procedures in the literature is quite low. Typically, perforation of the Schneiderian membrane, hemorrhage, infection, and rhinosinusitis are more frequently encountered.1 Therefore, the aim of this article was to briefly review and resume the more common complications associated with sinus augmentation procedures.

PERFORATION OF THE SCHNEIDERIAN MEMBRANE Maxillary sinus membrane perforation is the most common complication arising during sinus augmentation; its prevalence is between 7% and 44%.1Y17 From the Department of Oral and Maxillofacial Surgery/Oral Pathology, Vrije Universiteit University Medical Center/Academic Center for Dentistry Amsterdam, Amsterdam, the Netherlands. Received July 3, 2013. Accepted for publication August 27, 2013. Address correspondence and reprint requests to Paolo Boffano, MD, San Giovanni Battista Hospital, University of Turin, Corso Dogliotti 14, 10126, Torino, Italy; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000438

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The integrity of the sinus membrane is essential in maintaining the healthy, normal function of the maxillary sinus. The mucociliary apparatus protects the sinus against infection by removing organisms trapped in mucus through the ostium. The membrane also acts as a biologic barrier, and an increased chance of infection results if the biologic barrier (the membrane) perforates because a greater number of bacteria can invade the graft.18 Possible causes include septa, pathologic conditions, or very thin membranes.10 Perforation of the Schneiderian membrane often results when the lateral wall is being in-fractured, but it can also happen when the membrane is being elevated off the inferior and anterior bony aspect of the sinus and can occur because of irregularities of the sinus floor.1 The Schneiderian membrane consists of pseudociliated stratified respiratory epithelium, and it plays a fundamental role in the protection and constitution of the maxillary sinus. During the surgical intervention of sinus elevation, a small tear in the membrane determines a direct communication between the graft material and the contaminated sinus cavity. Perforation of the membrane always threatens the coverage of the graft materials. This may provoke infection and chronic sinusitis, with an eventual loss of graft volume.19 Fugazzotto and Vlassis20 classified sinus membrane damage based on location of the perforation (Table 1). The authors indicated that membrane perforations are not a reason to abort sinus augmentation procedures but should be addressed by properly repairing it.17,19 Many methods have been advocated for treatment of perforation of the Schneiderian membrane during the sinus floor elevation and augmentation.1 Perforations have most commonly been repaired with the use of collagen membranes between the graft material and the Schneiderian membrane. Repair could include folding the membrane on itself, covering the perforation with collagen tape, resorbable membrane, or freezedried human lamellar bone sheets, and, with larger perforations, careful suturing. As an alternative, use of fibrin adhesive for repair of perforations has been advocated.1Y21 However, there are no guidelines for the treatment of these complications.1,22

BLEEDING AND HEMORRHAGE The facial antral wall is populated with anastomosing vessels between the posterior superior alveolar artery and the infraorbital artery. The mean height from the alveolar ridge of these vessels is 18.9 to 19.6 mm; thus, they are in close proximity to the lateral window osteotomy. The surgical severance of one of the vessels during sinus augmentation may complicate the procedure because of the more difficult visualization of the Schneiderian membrane.18,19 Three arteries supply the maxillary sinus: the posterior superior alveolar, infraorbital, and posterior lateral nasal arteries. They are all ultimate branches of the maxillary artery. The posterior superior alveolar artery supplies the lining of the antrum, posterior teeth, and superficial branches to supply the maxillary gingivae and mucoperiosteum. The dental branch of this artery courses intraosseously, halfway up the lateral sinus wall, and forms a horizontal anastomosis with the infraorbital artery. The infraorbital artery runs through the infraorbital canal, and before emerging from the infraorbital foramen, it gives off 1 or 2 branches that course caudally along the anterior antral wall.18 Treatment for such complication includes firm pressure, direct ligation, bone wax, burnish with burs, and electrocautery.19 Intraoperative bleeding may happen readily during sinus augmentation because of highly vascular environment supported by the maxillary sinus.19 An abnormal increase in intraoperative bleeding may arise from a hypertensive state of the patient and can be * 2014 Mutaz B. Habal, MD


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