Journal of Oral Implantology Rehabilitation of a severely atrophic mandible using soft tissue matrix expansion technique, implants, and fixed dental prosthesis: A clinical report --Manuscript Draft-Manuscript Number:
aaid-joi-D-14-00162R2
Full Title:
Rehabilitation of a severely atrophic mandible using soft tissue matrix expansion technique, implants, and fixed dental prosthesis: A clinical report
Short Title:
implant treatment soft tissue matrix expansion
Article Type:
Clinical Case Letter
Keywords:
Implant; graft; tent-pole; Prosthesis; mandible
Corresponding Author:
ilser turkyilmaz, DDS, PhD University of Texas, Dental School, Health Science Center at San Antonio, Texas san antonio, tx UNITED STATES
Corresponding Author Secondary Information: Corresponding Author's Institution:
University of Texas, Dental School, Health Science Center at San Antonio, Texas
Corresponding Author's Secondary Institution: First Author:
ilser turkyilmaz, DDS, PhD
First Author Secondary Information: Order of Authors:
ilser turkyilmaz, DDS, PhD
Order of Authors Secondary Information: Abstract:
It is a demanding process to restore edentulous patients with a severely resorbed mandible. These patients using complete dentures may have many problems such as poor retention, soreness of the soft tissues, and difficulties with eating and speech. Implant-supported restorations are a known solution for them. However, there are some edentulous patients with extreme resorption of the mandibular alveolar bone in whom the bone volume is so minimal, and it is impossible to place implants without performing bone grafting procedures. Soft tissue matrix expansion technique using dental implants as tent-poles has been presented to increase bone height. This clinical report explains how to perform soft tissue matrix expansion technique step by step and describes the rehabilitation of a patient with soft tissue matrix expansion approach, implants and a mandibular implant-supported fixed dental prosthesis.
Response to Reviewers:
Reviewers' comments: Reviewer #2: Thanks for making the suggested revisions! Nice case. Response: Thank you.
Reviewer #3: 1. Is the title of the manuscript clear, concise, and descriptive? If not, please suggest an appropriate title? The title is not concise, but is descriptive. Maybe a shorter title may be: Severely atrophic mandible: a "tent-pole" technique report. Response: The title suggested by the Reviewer has been used. 2. Does the abstract accurately summarize the content of the investigation? N/A (clinical case letter) 3. Can the Abstract stand-alone? N/A (clinical case letter) 4. Does the abstract provide a succinct and accurate summary of the manuscript? N/A (clinical case letter) Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation
5. Has the author completed a comprehensive and critical discussion of recent literature? Yes, in an adequate extent for a clinical case letter. 6. Has the author stated a clear and concise purpose for his/her manuscript? Yes 7. Are the procedures described in enough detail to permit a reader to understand them? Yes 8. Are the data presented appropriately? N/A (clinical case letter) 9. Does the case report section contain only pertinent information describing the patient's condition and treatment? Yes 10. Does the case report section begin with a description of how the patient presented for treatment, the patient's chief complaint, and history? The case report missed a description of any contributory health history and the participation of patient on the decision-making for this treatment. Response: The chief complaints of the patient have already been presented in the 1st paragraph of the clinical report on Page 2. Other treatment options discussed with the patient were mentioned, which she declined all of them. She was only interested in a fixed mandibular prosthesis. She was taking medication for high blood pressure which was under control. This was added to the text. The patient made the final decision about her treatment. She also signed for the consent form. No treatments which are not approved by patients are provided in our clinic. 11. Are all diagnostic procedures, treatment, and results of treatment adequately described? At some extent. The CBCT was only cited, and no images or details were provided. Maybe a CBCT image will be more valuable than the orthopantomography for the initial case presentation (Fig 1). Response: CBCT scans were taken before the treatment. We would not be attempting to a major surgery and advanced restoration before CBCT scan, which is also our school’s policy for all implant patients. The CD including DICOM images keeps giving error now so we will not be able to provide any CBCT image. In addition. We think that the clinic photos and radiographs that we already provided clearly/directly show the status of the mandibular bone. CBCT scan image would not significantly contribute to this case report. 12. If a technique is described in the manuscript, is it accurately described? Yes. 13. Are the study limitations described? N/A (clinical case letter) 14. Has the author acknowledged important alternative points of view? No. No discussions was made regarding alternative treatments and its pros and cons. Nor possible complication and its management were discussed. Response: Alternative options were provided to the patient but she refused all of them. She was only interested in a fixed restoration. No other treatment such as a new mandibular complete denture would not provide greater benefits than the treatment provided to her. This is the reason why she came to us in the first place. No complications were observed during the treatment. There is no better method to provide a fixed prosthesis. Cons are considered as having a surgery under general anesthesia, waiting period for bone healing and osseointegration and restorations and relatively high cost, which were added in the discussion section. 15. Is the interpretation of data consistent with results? N/A (clinical case letter) Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation
16. Are the results compared with other relevant and similar Investigations? N/A (clinical case letter) 17. Do the author's conclusions and generalizations logically follow the text? Yes 18. Are the conclusions reflective of the data and data analysis? N/A (clinical case letter) 19. Are the conclusions succinct? Yes 20. Are the references current and pertinent? Yes 21. Are the references adequate in number? Yes 22. Are the references accurately cited? Yes 23. Are tables and figures adequately described with legends? Yes 24. Should any or all of the illustrations be printed in color? Yes. 25. Are there tables or figures that should be eliminated? No. 26. Should some sections of the manuscript be expanded, condensed, or omitted? No. 27. Does the manuscript present original material? At some extent. The technique is not new, so it is case report of an established technique, what did not add much to the knowledge in the field. Although, it may be interesting for some of the Journal's readers. Response: If you check the literature, you may find only few case reports/case series (4-5), and they did not describe/illustrate the procedures step by step the way we did. As you mention, we think the dentists who are interested in implants and especially oral surgery, periodontics and prosthodontics residents may benefit from this case report.
Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation
Article File
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
1 Rehabilitation of a severely atrophic mandible using soft tissue matrix expansion (tent-pole) technique, implants, and a fixed dental prosthesis: A clinical report
Jeremy Leland, DDS, MD,a Ilser Turkyilmaz, DDS, PhD,b Conception Barboza Arguello, DDS c and Daniel Perez, DDSd
a
Private practice, Austin, Texas; former resident, Department of Oral and Maxillofacial Surgery,
The University of Texas Health Science Center, San Antonio, Texas, USA
b
Assistant Professor, Department of Comprehensive Dentistry, The University of Texas Health
Science Center, San Antonio, Texas, USA
c
Assistant Professor, Department of Oral and Maxillofacial Surgery, The University of Texas
Health Science Center, San Antonio, Texas, USA
d
Assistant Professor, Department of Oral and Maxillofacial Surgery, The University of Texas
Health Science Center, San Antonio, Texas, USA
Corresponding author: Dr Ilser Turkyilmaz The University of Texas Health Science Center 7703 Floyd Curl Drive, MSC 7914, San Antonio, Texas 78229-3900 E-mail: [email protected]
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
2 Severely atrophic mandible: A "tent-pole" technique report INTRODUCTION In the last 30 years, dental implants supporting prosthetic rehabilitations of edentulous jaws have become one of the most significant breakthroughs in dentistry, 1-8 and several clinical studies have showed high implant survival rates. 5-8 Now, dental implants provide a successful and predictable means of support and retention for edentulous patients and implant-supported restorations have enhanced quality of life for millions of patients.1-4 However, there are some edentulous patients with severely resorbed mandible in whom the bone volume is so insufficient, which makes implant placement impossible. Mandibles with bone height no greater than 6 mm usually do not allow implant placement without considerable bone grafts.9-11 In 2002, Marx et al.,9 presented a technique, soft tissue matrix expansion, in which dental implants were used as ‘‘tent poles”. The novel strategy of this approach was to allow iliac bone grafts to consolidate and maintain their volume with dental implants that create a tenting effect. During the same operation, the surgical procedure using autogenous bone grafts from the iliac crest and implant placement was performed with extra-oral approach underneath the tip of the mandible at the chin.9 The reported osseointegration success rate was 99.5%, and the mean bone height gain was 10.2 mm for the 64 cases in the study by Marx et al. 9 Only few clinical reports9-12 using soft tissue matrix expansion technique have been published. This report aimed to describe the rehabilitation of an extremely resorbed mandible using soft tissue matrix expansion technique, implants, and an implant-supported screw-retained fixed dental prosthesis (FDP).
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
3 CLINICAL REPORT A 79-year-old woman with an edentulous maxilla and mandible presented to the Implant Clinic. The patient has been using complete dentures for about 40 years. The patient’s chief complaints were that her dentures were worn, created sore spots, and the mandibular denture lacked retention. The patient indicated a desire for a fixed implant-supported prosthesis. She was was taking medication for high blood pressure, which was under control. She did not have any other major health problems. Clinical examination of the patient revealed a maxilla with adequate retention, support, and stability for a complete denture, and a mandibular residual ridge with significant resorption (Fig. 1). However, her cone-beam computerized tomography (CBCT) scan (Master 3-D CBCT machine, Geeing-Do, Republic of Korea) indicated about 6-7mm vertical bone height in the anterior mandible, which does not allow any implant placement without extensive bone grafting. After other options such as maxillary and mandibular complete dentures, and mandibular implant-retained overdenture were discussed, the patient accepted the proposed treatment plan which included a new maxillary complete denture and an implantsupported screw-retained FDP in the mandible after soft tissue matrix expansion using autograft from iliac crest. The patient signed an informed consent before the treatment. Surgical Procedure
After general anesthesia was achived, a scalpel was used to make a 10 cm anterior, low submental incision through skin and subcutanous tissue in an existing skin fold (Fig. 2). Using monopolar electrocautery, hemostasis was obtained and blunt dissection in all directions was performed in the subcutaneous plane with scissors. Superior sharp dissection then ensued until the anterior inferior mandibular border was identified (Fig. 3). The crest of the atrophic
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
4 mandibular ridge was dissected and the mental neurovascular bundles identified bilaterally at the alveolar crest superior border.
The mandible was severely atrophic, measuring 6 mm in vertical height. Under copious normal saline irrigation, the implant osteotomies were prepared (Fig. 4). Tapping was performed not to generate excessive pressure during implant placement. Five 13 mm-long implants (4.3×13 mm (3), 3.5×13 mm (2), Nobel Replace Tapered Groovy; Nobel Biocare, Yorba Linda, CA) were then placed extraorally with a tent-pole technique (Fig. 5). All healing abutments (3 mmlong, Nobel Biocare, Yorba Linda, CA) were placed on the implants.
The left hip was isolated and the landmarks were identified for a standard anterior iliac crest bone graft harvest. The anterior superior iliac spine was palpated and marked with a surgical marker. After administering local anesthetics (2% lidocaine with 1:100000 epinephrine; Dentsply Pharmaceutical, York, PA), a 4 cm incision 2 cm lateral to the iliac crest and 2 cm superior to the anterior superior iliac spine using a scalpel was made. A periosteal incision was made and the abdominal oblique, transverus abdominus, and iliacus muscles medially were dissected, exposing the medial ilium. A 4×5 cm corticocancellous block was harvested with a reciprocating saw under copious irrigation. Then cancellous bone was harvested. An absorbable gelatin compressed sponge (Gelfoam; Pfizer Inc., New York, NY) was placed to the site after copiously irrigating and placing bone wax and hemostasis was confirmed. The surgical incision was closed in layers with the deep tissue approximation using sutures (3.0 vicryl suture; Ethicon Inc., Somerville, NJ). The subcutaneous tissues and skin were then closed using sutures and staples.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
5 The autogenous bone graft was prepared by using the bone mill and mixed with a bone growth stimulator (OsteoGen, Biomet Inc., Warsaw, IN) and an alloplastic material (CaSO4; ACE Surgical Supply Co., Brockton, MA). Then the anterior mandible was grafted to submerge the implants in the bone graft (Figs. 6,7). Approximately 7-8 mm of each implant remained out of native bone prior to grafting. The oral cavity was inspected and no perforations were observed. The patient was extubated and then transferred to the recovery room. Five months later, The patient presented for phase 2 implant surgery under local anesthesia. Preoperative panoramic radiograph was reviewed and excellent bone levels (15 mm 18 mm gain in vertical bone height) was maintained in the anterior mandible (Figs. 8,9). All implants remained submerged without intraoral mucosal perforation. A mandibular midcrestal incision was made with a scalpel. The grafted mandible was exposed, an alveoloplasty was performed, reducing the bone height to uncover all implants with an acrylic bur. All healing abutments were removed uneventfully (Fig. 10). Then a strip of a regenerative tissue matrix (Alloderm; BioHorizons Inc., Birmingham, AL) was placed and contoured to the surgical site. The margins of the regenerative tissue matrix (Alloderm; BioHorizons Inc., Birmingham, AL) was sutured to the remaining buccal and lingual tissues and to immobilize the graft. The implants were then exposed through the regenerative tissue matrix with a tissue punch and new healing abutments were placed (5mm-long, Nobel Biocare) (Fig 11). A thermoplastic splint was then contoured to the surgical site as a stent and a resilient lining material (Coe-soft; GC America Inc., Alsip, IL) was used to reline the intaglio surface. Two holes were drilled and then the screws were used to immobilize the splint. Restorative Procedure
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
6 The following steps were followed to fabricate the implant-supported screw-retained FDP. The healing abutments were unscrewed. The impression copings were screwed on the implants and splinted to each other with autopolymerizing acrylic resin (GC America Inc., Alsip, IL). An implant-level impression using impression copings, and polyether impression material (Impregum Penta soft medium body; 3M ESPE, St. Paul, MN) was made. After implant replicas were connected to the impression copings, the definitive cast using Type IV dental stone (ResinRock; Whip Mix Corp., Louisville, KY) was poured. Maxillary and mandibular trial dentures (Ivoclar, Vivadent Inc., Amherst, NY) were fabricated using traditional prosthetic methods. A trial denture insertion was performed, and centric occlusion, esthetics, phonetics, and occlusal vertical dimension were confirmed. A titanium metal framework using CAD/CAM technology was fabricated. After confirming the fit of framework on the definitive cast, it was intraorally verified using radiographs. The denture teeth were transferred from the previously fabricated trial denture to the framework. The implant-supported, screw-retained FDP was processed, finished, and polished in the laboratory. Then the prosthesis was screwed on the implants. Screw access holes were covered using cotton pellets and composite resin (Fig. 12). DISCUSSION Although dental implant treatment has been one of the most predictable option to restore edentulous mandibles, this option may not be possible for some edentulous patients with severely resorbed mandible in whom the bone volume is so insufficient. The soft tissue matrix expansion, in which dental implants were used as tent-poles, has been an alternative to increase bone height before implant placement for these patients.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
7 Korpi et al.,12 investigated the outcomes of patients with severely resorbed fractured mandibles who were managed with a modified tent-pole procedure. 4 edentulous patients with a severely atrophic fractured mandible and less than 10 mm of vertical height of the body of the mandible were treated with an immediate or a delayed protocol. Implant were were loaded at 3 months as the patients were fitted with healing caps, and the dental implants were loaded using provisional screw-retained acrylic resin prostheses and bar-retained overdentures afterward. The average alveolar augmentation was 7.5±1.17 mm. In the present case report, over 15mm vertical bone height was gained. The extra oral approach used in this case has been one of the most crucial parts of this treatment and has contributed to this succesful bone gain. Because there was not any communication between the surgical site (implants and graft) and the intra oral environment during the osseointegration and bone healing processes. If we used an intra oral approach, it would have been almost impossible to keep the graft material in place and have an uncompromised osseointegration process. The disadvantages of this method can be considered as having a surgery under general anesthesia, waiting period for bone healing and osseointegration and restorations, and relatively high cost. However, the benefits of this technique outweigh the possible disadvantages mentioned above. Because this type of cases are seen rarely, each person (surgeon, restorative doctor, laboratory technician) involved in this process should possess the knowledge, which requires advanced training and experience. Otherwise, failures would be inevitable and costly. Although each step was explained and illustrated in this report, the readers need to make to sure that they have proper knowledge, armemantarium, and experience before attempting to this type of treatment.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
8 CONCLUSION This clinical report describes the rehabilitation of a patient with a mandibular implantsupported fixed dental prosthesis after soft tissue matrix expansion approach.
REFERENCES 1. Allen PF, McMillan AS. A longitudinal study of quality of life outcomes in older adults requesting implant prostheses and complete removable dentures. Clin Oral Implants Res. 2003;14:173-9. 2. Awad MA, Lund JP, Shapiro SH, Locker D, Klemetti E, Chehade A, Savard A, Feine JS. Oral health status and treatment satisfaction with mandibular implant overdentures and conventional dentures: a randomized clinical trial in a senior population. Int J Prosthodont 2003;16:390-6. 3. Lindquist LW, Carlsson GE, Hedegard B. Changes in bite force and chewing efficiency after denture treatment in edentulous patients with denture adaptation difficulties. J Oral Rehabil. 1986;13:21-9. 4. Turkyilmaz I, Company AM, McGlumphy EA. Should edentulous patients be constrained to removable complete dentures? The use of dental implants to improve the quality of life for edentulous patients. Gerodontology. 2010;27:3-10. 5. Behneke A, Behneke N, d'Hoedt B. A 5-year longitudinal study of the clinical effectiveness of ITI solid-screw implants in the treatment of mandibular edentulism. Int J Oral Maxillofac Implants. 2002;17:799-810.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
9 6. Turkyilmaz I, Tozum TF, Fuhrmann DM, Tumer C. Seven-year follow-up results of TiUnite implants supporting mandibular overdentures: early versus delayed loading. Clin Implant Dent Relat Res. 2012;14 Suppl 1:e83-90 7. Harel N, Piek D, Livne S, Palti A, Ormianer Z. A 10-year retrospective clinical evaluation of immediately loaded tapered maxillary implants. Int J Prosthodont. 2013;26:244-9. 8. Turkyilmaz I. 26-year follow-up of screw-retained fixed dental prostheses supported by machined-surface Branemark implants: a case report. Tex Dent J. 2011;128:15-9. 9. Marx RE, Shellenberger T, Wimsatt J, Correa P. Severely resorbed mandible: predictable reconstruction with soft tissue matrix expansion (tent pole) grafts. J Oral Maxillofac Surg. 2002;60:878-88. 10. Manfro R, Batassini F, Bortoluzzi MC. Severely resorbed mandible treated by soft tissue matrix expansion (tent pole) grafts: case report. Implant Dent. 2008;17:408-13. 11. Le B, Rohrer MD, Prasad HS. Screw "tent-pole" grafting technique for reconstruction of large vertical alveolar ridge defects using human mineralized allograft for implant site preparation. J Oral Maxillofac Surg. 2010;68:428-35. 12. Korpi JT, Kainulainen VT, Sandor GK, Oikarinen KS. Tent-pole approach to treat severely atrophic fractured mandibles using immediate or delayed protocols: preliminary case series. J Oral Maxillofac Surg. 2013;71:83-9.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
10 FIGURE LEGENDS Fig. 1. Panoramic radiograph before treatment. Fig. 2. Extraoral view of surgical area determined by blue markings. Fig. 3. Low submental incision through skin and subcutanous tissues was made to access mandible. Fig. 4. Mental neurovascular bundles were identified bilaterally and implant osteotomies were prepared.
Fig. 5. Five implants were placed without any complications.
Fig. 6. Anterior mandible was grafted to submerge implants in the bone graft. Fig. 7. Alloplastic material was used over graft material to promote wound healing. Fig. 8. Panoramic radiograph 5 months after implant placement. Fig. 9. New bone formation 5 months after implant placement. Fig. 10. Alveoloplasty was performed to uncover all implants with acrylic bur. Fig. 11. Implants were exposed through regenerative tissue matrix with tissue punch and healing abutments were placed. Fig. 12. Panoramic radiograph of restoration at insertion.
Figure 1 Click here to download high resolution image
Figure 2 Click here to download high resolution image
Figure 3 Click here to download high resolution image
Figure 4 Click here to download high resolution image
Figure 5 Click here to download high resolution image
Figure 6 Click here to download high resolution image
Figure 7 Click here to download high resolution image
Figure 8 Click here to download high resolution image
Figure 9 Click here to download high resolution image
Figure 10 Click here to download high resolution image
Figure 11 Click here to download high resolution image
Figure 12 Click here to download high resolution image
Copyright Form1 Click here to download Copyright Form: copyright form1.jpg
Copyright Form2 Click here to download Copyright Form: copyright form2.jpg
Cover Letter Click here to download Cover Letter: JOI-submission letter2.doc
aaid-joi-D-14-00162R2
Full Title:
Rehabilitation of a severely atrophic mandible using soft tissue matrix expansion technique, implants, and fixed dental prosthesis: A clinical report
Short Title:
implant treatment soft tissue matrix expansion
Article Type:
Clinical Case Letter
Keywords:
Implant; graft; tent-pole; Prosthesis; mandible
Corresponding Author:
ilser turkyilmaz, DDS, PhD University of Texas, Dental School, Health Science Center at San Antonio, Texas san antonio, tx UNITED STATES
Corresponding Author Secondary Information: Corresponding Author's Institution:
University of Texas, Dental School, Health Science Center at San Antonio, Texas
Corresponding Author's Secondary Institution: First Author:
ilser turkyilmaz, DDS, PhD
First Author Secondary Information: Order of Authors:
ilser turkyilmaz, DDS, PhD
Order of Authors Secondary Information: Abstract:
It is a demanding process to restore edentulous patients with a severely resorbed mandible. These patients using complete dentures may have many problems such as poor retention, soreness of the soft tissues, and difficulties with eating and speech. Implant-supported restorations are a known solution for them. However, there are some edentulous patients with extreme resorption of the mandibular alveolar bone in whom the bone volume is so minimal, and it is impossible to place implants without performing bone grafting procedures. Soft tissue matrix expansion technique using dental implants as tent-poles has been presented to increase bone height. This clinical report explains how to perform soft tissue matrix expansion technique step by step and describes the rehabilitation of a patient with soft tissue matrix expansion approach, implants and a mandibular implant-supported fixed dental prosthesis.
Response to Reviewers:
Reviewers' comments: Reviewer #2: Thanks for making the suggested revisions! Nice case. Response: Thank you.
Reviewer #3: 1. Is the title of the manuscript clear, concise, and descriptive? If not, please suggest an appropriate title? The title is not concise, but is descriptive. Maybe a shorter title may be: Severely atrophic mandible: a "tent-pole" technique report. Response: The title suggested by the Reviewer has been used. 2. Does the abstract accurately summarize the content of the investigation? N/A (clinical case letter) 3. Can the Abstract stand-alone? N/A (clinical case letter) 4. Does the abstract provide a succinct and accurate summary of the manuscript? N/A (clinical case letter) Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation
5. Has the author completed a comprehensive and critical discussion of recent literature? Yes, in an adequate extent for a clinical case letter. 6. Has the author stated a clear and concise purpose for his/her manuscript? Yes 7. Are the procedures described in enough detail to permit a reader to understand them? Yes 8. Are the data presented appropriately? N/A (clinical case letter) 9. Does the case report section contain only pertinent information describing the patient's condition and treatment? Yes 10. Does the case report section begin with a description of how the patient presented for treatment, the patient's chief complaint, and history? The case report missed a description of any contributory health history and the participation of patient on the decision-making for this treatment. Response: The chief complaints of the patient have already been presented in the 1st paragraph of the clinical report on Page 2. Other treatment options discussed with the patient were mentioned, which she declined all of them. She was only interested in a fixed mandibular prosthesis. She was taking medication for high blood pressure which was under control. This was added to the text. The patient made the final decision about her treatment. She also signed for the consent form. No treatments which are not approved by patients are provided in our clinic. 11. Are all diagnostic procedures, treatment, and results of treatment adequately described? At some extent. The CBCT was only cited, and no images or details were provided. Maybe a CBCT image will be more valuable than the orthopantomography for the initial case presentation (Fig 1). Response: CBCT scans were taken before the treatment. We would not be attempting to a major surgery and advanced restoration before CBCT scan, which is also our school’s policy for all implant patients. The CD including DICOM images keeps giving error now so we will not be able to provide any CBCT image. In addition. We think that the clinic photos and radiographs that we already provided clearly/directly show the status of the mandibular bone. CBCT scan image would not significantly contribute to this case report. 12. If a technique is described in the manuscript, is it accurately described? Yes. 13. Are the study limitations described? N/A (clinical case letter) 14. Has the author acknowledged important alternative points of view? No. No discussions was made regarding alternative treatments and its pros and cons. Nor possible complication and its management were discussed. Response: Alternative options were provided to the patient but she refused all of them. She was only interested in a fixed restoration. No other treatment such as a new mandibular complete denture would not provide greater benefits than the treatment provided to her. This is the reason why she came to us in the first place. No complications were observed during the treatment. There is no better method to provide a fixed prosthesis. Cons are considered as having a surgery under general anesthesia, waiting period for bone healing and osseointegration and restorations and relatively high cost, which were added in the discussion section. 15. Is the interpretation of data consistent with results? N/A (clinical case letter) Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation
16. Are the results compared with other relevant and similar Investigations? N/A (clinical case letter) 17. Do the author's conclusions and generalizations logically follow the text? Yes 18. Are the conclusions reflective of the data and data analysis? N/A (clinical case letter) 19. Are the conclusions succinct? Yes 20. Are the references current and pertinent? Yes 21. Are the references adequate in number? Yes 22. Are the references accurately cited? Yes 23. Are tables and figures adequately described with legends? Yes 24. Should any or all of the illustrations be printed in color? Yes. 25. Are there tables or figures that should be eliminated? No. 26. Should some sections of the manuscript be expanded, condensed, or omitted? No. 27. Does the manuscript present original material? At some extent. The technique is not new, so it is case report of an established technique, what did not add much to the knowledge in the field. Although, it may be interesting for some of the Journal's readers. Response: If you check the literature, you may find only few case reports/case series (4-5), and they did not describe/illustrate the procedures step by step the way we did. As you mention, we think the dentists who are interested in implants and especially oral surgery, periodontics and prosthodontics residents may benefit from this case report.
Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation
Article File
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
1 Rehabilitation of a severely atrophic mandible using soft tissue matrix expansion (tent-pole) technique, implants, and a fixed dental prosthesis: A clinical report
Jeremy Leland, DDS, MD,a Ilser Turkyilmaz, DDS, PhD,b Conception Barboza Arguello, DDS c and Daniel Perez, DDSd
a
Private practice, Austin, Texas; former resident, Department of Oral and Maxillofacial Surgery,
The University of Texas Health Science Center, San Antonio, Texas, USA
b
Assistant Professor, Department of Comprehensive Dentistry, The University of Texas Health
Science Center, San Antonio, Texas, USA
c
Assistant Professor, Department of Oral and Maxillofacial Surgery, The University of Texas
Health Science Center, San Antonio, Texas, USA
d
Assistant Professor, Department of Oral and Maxillofacial Surgery, The University of Texas
Health Science Center, San Antonio, Texas, USA
Corresponding author: Dr Ilser Turkyilmaz The University of Texas Health Science Center 7703 Floyd Curl Drive, MSC 7914, San Antonio, Texas 78229-3900 E-mail: [email protected]
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
2 Severely atrophic mandible: A "tent-pole" technique report INTRODUCTION In the last 30 years, dental implants supporting prosthetic rehabilitations of edentulous jaws have become one of the most significant breakthroughs in dentistry, 1-8 and several clinical studies have showed high implant survival rates. 5-8 Now, dental implants provide a successful and predictable means of support and retention for edentulous patients and implant-supported restorations have enhanced quality of life for millions of patients.1-4 However, there are some edentulous patients with severely resorbed mandible in whom the bone volume is so insufficient, which makes implant placement impossible. Mandibles with bone height no greater than 6 mm usually do not allow implant placement without considerable bone grafts.9-11 In 2002, Marx et al.,9 presented a technique, soft tissue matrix expansion, in which dental implants were used as ‘‘tent poles”. The novel strategy of this approach was to allow iliac bone grafts to consolidate and maintain their volume with dental implants that create a tenting effect. During the same operation, the surgical procedure using autogenous bone grafts from the iliac crest and implant placement was performed with extra-oral approach underneath the tip of the mandible at the chin.9 The reported osseointegration success rate was 99.5%, and the mean bone height gain was 10.2 mm for the 64 cases in the study by Marx et al. 9 Only few clinical reports9-12 using soft tissue matrix expansion technique have been published. This report aimed to describe the rehabilitation of an extremely resorbed mandible using soft tissue matrix expansion technique, implants, and an implant-supported screw-retained fixed dental prosthesis (FDP).
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
3 CLINICAL REPORT A 79-year-old woman with an edentulous maxilla and mandible presented to the Implant Clinic. The patient has been using complete dentures for about 40 years. The patient’s chief complaints were that her dentures were worn, created sore spots, and the mandibular denture lacked retention. The patient indicated a desire for a fixed implant-supported prosthesis. She was was taking medication for high blood pressure, which was under control. She did not have any other major health problems. Clinical examination of the patient revealed a maxilla with adequate retention, support, and stability for a complete denture, and a mandibular residual ridge with significant resorption (Fig. 1). However, her cone-beam computerized tomography (CBCT) scan (Master 3-D CBCT machine, Geeing-Do, Republic of Korea) indicated about 6-7mm vertical bone height in the anterior mandible, which does not allow any implant placement without extensive bone grafting. After other options such as maxillary and mandibular complete dentures, and mandibular implant-retained overdenture were discussed, the patient accepted the proposed treatment plan which included a new maxillary complete denture and an implantsupported screw-retained FDP in the mandible after soft tissue matrix expansion using autograft from iliac crest. The patient signed an informed consent before the treatment. Surgical Procedure
After general anesthesia was achived, a scalpel was used to make a 10 cm anterior, low submental incision through skin and subcutanous tissue in an existing skin fold (Fig. 2). Using monopolar electrocautery, hemostasis was obtained and blunt dissection in all directions was performed in the subcutaneous plane with scissors. Superior sharp dissection then ensued until the anterior inferior mandibular border was identified (Fig. 3). The crest of the atrophic
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
4 mandibular ridge was dissected and the mental neurovascular bundles identified bilaterally at the alveolar crest superior border.
The mandible was severely atrophic, measuring 6 mm in vertical height. Under copious normal saline irrigation, the implant osteotomies were prepared (Fig. 4). Tapping was performed not to generate excessive pressure during implant placement. Five 13 mm-long implants (4.3×13 mm (3), 3.5×13 mm (2), Nobel Replace Tapered Groovy; Nobel Biocare, Yorba Linda, CA) were then placed extraorally with a tent-pole technique (Fig. 5). All healing abutments (3 mmlong, Nobel Biocare, Yorba Linda, CA) were placed on the implants.
The left hip was isolated and the landmarks were identified for a standard anterior iliac crest bone graft harvest. The anterior superior iliac spine was palpated and marked with a surgical marker. After administering local anesthetics (2% lidocaine with 1:100000 epinephrine; Dentsply Pharmaceutical, York, PA), a 4 cm incision 2 cm lateral to the iliac crest and 2 cm superior to the anterior superior iliac spine using a scalpel was made. A periosteal incision was made and the abdominal oblique, transverus abdominus, and iliacus muscles medially were dissected, exposing the medial ilium. A 4×5 cm corticocancellous block was harvested with a reciprocating saw under copious irrigation. Then cancellous bone was harvested. An absorbable gelatin compressed sponge (Gelfoam; Pfizer Inc., New York, NY) was placed to the site after copiously irrigating and placing bone wax and hemostasis was confirmed. The surgical incision was closed in layers with the deep tissue approximation using sutures (3.0 vicryl suture; Ethicon Inc., Somerville, NJ). The subcutaneous tissues and skin were then closed using sutures and staples.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
5 The autogenous bone graft was prepared by using the bone mill and mixed with a bone growth stimulator (OsteoGen, Biomet Inc., Warsaw, IN) and an alloplastic material (CaSO4; ACE Surgical Supply Co., Brockton, MA). Then the anterior mandible was grafted to submerge the implants in the bone graft (Figs. 6,7). Approximately 7-8 mm of each implant remained out of native bone prior to grafting. The oral cavity was inspected and no perforations were observed. The patient was extubated and then transferred to the recovery room. Five months later, The patient presented for phase 2 implant surgery under local anesthesia. Preoperative panoramic radiograph was reviewed and excellent bone levels (15 mm 18 mm gain in vertical bone height) was maintained in the anterior mandible (Figs. 8,9). All implants remained submerged without intraoral mucosal perforation. A mandibular midcrestal incision was made with a scalpel. The grafted mandible was exposed, an alveoloplasty was performed, reducing the bone height to uncover all implants with an acrylic bur. All healing abutments were removed uneventfully (Fig. 10). Then a strip of a regenerative tissue matrix (Alloderm; BioHorizons Inc., Birmingham, AL) was placed and contoured to the surgical site. The margins of the regenerative tissue matrix (Alloderm; BioHorizons Inc., Birmingham, AL) was sutured to the remaining buccal and lingual tissues and to immobilize the graft. The implants were then exposed through the regenerative tissue matrix with a tissue punch and new healing abutments were placed (5mm-long, Nobel Biocare) (Fig 11). A thermoplastic splint was then contoured to the surgical site as a stent and a resilient lining material (Coe-soft; GC America Inc., Alsip, IL) was used to reline the intaglio surface. Two holes were drilled and then the screws were used to immobilize the splint. Restorative Procedure
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
6 The following steps were followed to fabricate the implant-supported screw-retained FDP. The healing abutments were unscrewed. The impression copings were screwed on the implants and splinted to each other with autopolymerizing acrylic resin (GC America Inc., Alsip, IL). An implant-level impression using impression copings, and polyether impression material (Impregum Penta soft medium body; 3M ESPE, St. Paul, MN) was made. After implant replicas were connected to the impression copings, the definitive cast using Type IV dental stone (ResinRock; Whip Mix Corp., Louisville, KY) was poured. Maxillary and mandibular trial dentures (Ivoclar, Vivadent Inc., Amherst, NY) were fabricated using traditional prosthetic methods. A trial denture insertion was performed, and centric occlusion, esthetics, phonetics, and occlusal vertical dimension were confirmed. A titanium metal framework using CAD/CAM technology was fabricated. After confirming the fit of framework on the definitive cast, it was intraorally verified using radiographs. The denture teeth were transferred from the previously fabricated trial denture to the framework. The implant-supported, screw-retained FDP was processed, finished, and polished in the laboratory. Then the prosthesis was screwed on the implants. Screw access holes were covered using cotton pellets and composite resin (Fig. 12). DISCUSSION Although dental implant treatment has been one of the most predictable option to restore edentulous mandibles, this option may not be possible for some edentulous patients with severely resorbed mandible in whom the bone volume is so insufficient. The soft tissue matrix expansion, in which dental implants were used as tent-poles, has been an alternative to increase bone height before implant placement for these patients.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
7 Korpi et al.,12 investigated the outcomes of patients with severely resorbed fractured mandibles who were managed with a modified tent-pole procedure. 4 edentulous patients with a severely atrophic fractured mandible and less than 10 mm of vertical height of the body of the mandible were treated with an immediate or a delayed protocol. Implant were were loaded at 3 months as the patients were fitted with healing caps, and the dental implants were loaded using provisional screw-retained acrylic resin prostheses and bar-retained overdentures afterward. The average alveolar augmentation was 7.5±1.17 mm. In the present case report, over 15mm vertical bone height was gained. The extra oral approach used in this case has been one of the most crucial parts of this treatment and has contributed to this succesful bone gain. Because there was not any communication between the surgical site (implants and graft) and the intra oral environment during the osseointegration and bone healing processes. If we used an intra oral approach, it would have been almost impossible to keep the graft material in place and have an uncompromised osseointegration process. The disadvantages of this method can be considered as having a surgery under general anesthesia, waiting period for bone healing and osseointegration and restorations, and relatively high cost. However, the benefits of this technique outweigh the possible disadvantages mentioned above. Because this type of cases are seen rarely, each person (surgeon, restorative doctor, laboratory technician) involved in this process should possess the knowledge, which requires advanced training and experience. Otherwise, failures would be inevitable and costly. Although each step was explained and illustrated in this report, the readers need to make to sure that they have proper knowledge, armemantarium, and experience before attempting to this type of treatment.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
8 CONCLUSION This clinical report describes the rehabilitation of a patient with a mandibular implantsupported fixed dental prosthesis after soft tissue matrix expansion approach.
REFERENCES 1. Allen PF, McMillan AS. A longitudinal study of quality of life outcomes in older adults requesting implant prostheses and complete removable dentures. Clin Oral Implants Res. 2003;14:173-9. 2. Awad MA, Lund JP, Shapiro SH, Locker D, Klemetti E, Chehade A, Savard A, Feine JS. Oral health status and treatment satisfaction with mandibular implant overdentures and conventional dentures: a randomized clinical trial in a senior population. Int J Prosthodont 2003;16:390-6. 3. Lindquist LW, Carlsson GE, Hedegard B. Changes in bite force and chewing efficiency after denture treatment in edentulous patients with denture adaptation difficulties. J Oral Rehabil. 1986;13:21-9. 4. Turkyilmaz I, Company AM, McGlumphy EA. Should edentulous patients be constrained to removable complete dentures? The use of dental implants to improve the quality of life for edentulous patients. Gerodontology. 2010;27:3-10. 5. Behneke A, Behneke N, d'Hoedt B. A 5-year longitudinal study of the clinical effectiveness of ITI solid-screw implants in the treatment of mandibular edentulism. Int J Oral Maxillofac Implants. 2002;17:799-810.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
9 6. Turkyilmaz I, Tozum TF, Fuhrmann DM, Tumer C. Seven-year follow-up results of TiUnite implants supporting mandibular overdentures: early versus delayed loading. Clin Implant Dent Relat Res. 2012;14 Suppl 1:e83-90 7. Harel N, Piek D, Livne S, Palti A, Ormianer Z. A 10-year retrospective clinical evaluation of immediately loaded tapered maxillary implants. Int J Prosthodont. 2013;26:244-9. 8. Turkyilmaz I. 26-year follow-up of screw-retained fixed dental prostheses supported by machined-surface Branemark implants: a case report. Tex Dent J. 2011;128:15-9. 9. Marx RE, Shellenberger T, Wimsatt J, Correa P. Severely resorbed mandible: predictable reconstruction with soft tissue matrix expansion (tent pole) grafts. J Oral Maxillofac Surg. 2002;60:878-88. 10. Manfro R, Batassini F, Bortoluzzi MC. Severely resorbed mandible treated by soft tissue matrix expansion (tent pole) grafts: case report. Implant Dent. 2008;17:408-13. 11. Le B, Rohrer MD, Prasad HS. Screw "tent-pole" grafting technique for reconstruction of large vertical alveolar ridge defects using human mineralized allograft for implant site preparation. J Oral Maxillofac Surg. 2010;68:428-35. 12. Korpi JT, Kainulainen VT, Sandor GK, Oikarinen KS. Tent-pole approach to treat severely atrophic fractured mandibles using immediate or delayed protocols: preliminary case series. J Oral Maxillofac Surg. 2013;71:83-9.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
10 FIGURE LEGENDS Fig. 1. Panoramic radiograph before treatment. Fig. 2. Extraoral view of surgical area determined by blue markings. Fig. 3. Low submental incision through skin and subcutanous tissues was made to access mandible. Fig. 4. Mental neurovascular bundles were identified bilaterally and implant osteotomies were prepared.
Fig. 5. Five implants were placed without any complications.
Fig. 6. Anterior mandible was grafted to submerge implants in the bone graft. Fig. 7. Alloplastic material was used over graft material to promote wound healing. Fig. 8. Panoramic radiograph 5 months after implant placement. Fig. 9. New bone formation 5 months after implant placement. Fig. 10. Alveoloplasty was performed to uncover all implants with acrylic bur. Fig. 11. Implants were exposed through regenerative tissue matrix with tissue punch and healing abutments were placed. Fig. 12. Panoramic radiograph of restoration at insertion.
Figure 1 Click here to download high resolution image
Figure 2 Click here to download high resolution image
Figure 3 Click here to download high resolution image
Figure 4 Click here to download high resolution image
Figure 5 Click here to download high resolution image
Figure 6 Click here to download high resolution image
Figure 7 Click here to download high resolution image
Figure 8 Click here to download high resolution image
Figure 9 Click here to download high resolution image
Figure 10 Click here to download high resolution image
Figure 11 Click here to download high resolution image
Figure 12 Click here to download high resolution image
Copyright Form1 Click here to download Copyright Form: copyright form1.jpg
Copyright Form2 Click here to download Copyright Form: copyright form2.jpg
Cover Letter Click here to download Cover Letter: JOI-submission letter2.doc
