implants in mandibles

8/10/2019 Implants in Mandibles

1/81

Mandibular defects


2/81

Mandible Cantor and Curtisclassified mandibular defects into

6 different categories based on extent of the defectand the method of restoration in edentulous patients.

Class I - Radical alveolectomy with preservation of mandibular continuity

Class II - Lateral resection of the mandible distal to the cuspid area

Class III - Lateral resection of the mandible to the midline

Class IV - Lateral bone graft and surgical reconstruction

Class V - Anterior bone graft and surgical reconstruction

Class VI - Anterior mandibular resection without surgical reconstruction


3/81

Acquired

defect

of mandible

Partially edentulous Edentulous patients


4/81

Acquired

defect

of mandible

Lateral discontinuitydefects

Anterior borderdefects


5/81

Treatment plan of hemi-

mandilectomy as well as total

mandiblectomy

RPD \ CD with attachment

RPD \ CD with no attachment RPD \ CD supported by implants

Implant supported over denture


6/81


7/81

Zest anchor stud


8/81


9/81

Attachements


10/81

Bar attachement\ Hedar bar


11/81

Patient partially edentulous

1. Lateral discontinuity defects------RPD

2. Anterior discontinuity defects--

-----RPD

3. Implant-retained prosthesis


12/81

Implant retained prosthesis in

anterior defect

Implants placed in the anterior region of mandible,

with remaining posterior teeth.

These Osseo integrated implants provide support

anteriorly and enable most anterior resection patientsto masticate effectively.

In patients who have undergone a marginal resection

of the mandible, at least 10 mm of vertical bone is

advisable before implants are considered, A similar

bulk of bone is required for grafted mandible.


13/81

Implant retained prosthesis in

anterior defect

The major challenge encountered when

placing implants into ant mandibular resection

, patient is to creat thin, attached,keratinized

tissues arund the implant (skin or palatal graft)

Removable overlying prosthesis is performed

for restoring this defect


14/81

Implant properties and location

Only 2 implants (13 mm in length) arerequired to restore most defect

if shorter implants are required----4 or more

implants may be needed If an implant supported prosthesis is preferred

and if edentulous space extends into the molar

region, a minimum of 4 or 5 implants must beplaced( proper arrangement of implant iscritical)


15/81

If fixed restoration is planned implants should

be placed in the sites to be occupied by the

teeth as opposed by the teeth as opposed to

inter proximal areas

During RPD construction the metal frame

work to be divided in to segments (to insure a

passive fit.


16/81

Implant retainer prosthesis in lateral

defects

Conventional RPD

Conventional RPD will not meet the support of

the prosthesis alone.

Implant supported prosthesis


17/81

In large defects osseointegration implants

significantly improve the retention, support

and stability (support most important)

The purpose of the portion of the prosthesis

that extends into the defect in to support the lip

and cheek and to to prevent over-eruption of

opposing dentition

2 or more implants should be placed


18/81

For edentulous patients

1. Mastication is difficult

2. Compromised denture bearing surface

3. Deviation of mandible4. Impaired tongue function


19/81

Implant in complete edentulous pts

with lateral defect

Best choice is implant supported prosthesis

In many pts, there will usually be 2 implant

sites on the normal side and 1 on the resected

site.

It is advisable to use a bar attachment

Pts with implants should be followed to ensurecompliance with proper oral hygiene


20/81

Implant in complete edentulous pts

with anterior defect

If anterior mandibular teeth are to be replaced

care should be taken.

Careful placement of flange contour

If opposing is an edentulous maxilla, 2

implants are sufficient.

If opposing is a dentulous maxilla, 4 implantsor more are recomended


21/81


22/81

Consultation between the surgeon

and maxillofacial prosthodontist in

total mandiblectomy ORHemimandiblectomy

Evaluation of anticipated remaining oral and

facial structures needed to provide support,

retention, and stability of prosthesis

immediately after surgery and in the future.

Extent of disease

Anticipated post-operative defects

Anticipated post-operative healing time

course


23/81

Case presention

For the Maxilla :

Patient refused sinus lift procedure or any other ancillary graftsfor restoring the atrophic and highly pneumatised maxilla.

Teeth present were extracted .BrnemarkZygomatic

Implantswere placed: 50 mmon the right side and 52.5mmin the left zygoma, along with Nobel Replace implants inthe maxillary anterior region. One Replace Implant wasinserted in the left tuberosity and left as a sleeping implant to

be used in case required. The surgical pictures are available inthe earlier post on this blog.


24/81

For the Mandible:

Remaining teeth were extracted. All on Four

technique was chosen to replace the mandibular

dentition. Nobel Replace implants with lengths of 13mm in the anterior region and 16mm in the premolar

region were placed as per the laid protocol. Surgical

pictures are posted below:


25/81
http://4.bp.blogspot.com/_mvKKBhLcSoc/Sb7AgCEXORI/AAAAAAAAAGo/91Ljlc2ur_4/s1600-h/immediate+ext+copy.jpghttp://4.bp.blogspot.com/_mvKKBhLcSoc/Sb7AgCEXORI/AAAAAAAAAGo/91Ljlc2ur_4/s1600-h/immediate+ext+copy.jpg


26/81
http://4.bp.blogspot.com/_mvKKBhLcSoc/Sb7AgHCbjdI/AAAAAAAAAGw/SgHakOay7ek/s1600-h/Template+copy.jpg


27/81
http://4.bp.blogspot.com/_mvKKBhLcSoc/Sb7AgtzxbHI/AAAAAAAAAG4/VvMgYMhm2O0/s1600-h/drill+copy.jpg


28/81
http://1.bp.blogspot.com/_mvKKBhLcSoc/Sb7Agley9EI/AAAAAAAAAHA/3OTDvx6q5XE/s1600-h/Imp+final+copy.jpghttp://1.bp.blogspot.com/_mvKKBhLcSoc/Sb7Agley9EI/AAAAAAAAAHA/3OTDvx6q5XE/s1600-h/Imp+final+copy.jpg


29/81


30/81
http://1.bp.blogspot.com/_mvKKBhLcSoc/Sb6ggXLDlWI/AAAAAAAAAFw/H0czXvYRWk4/s1600-h/DSC03284.jpghttp://1.bp.blogspot.com/_mvKKBhLcSoc/Sb6ggXLDlWI/AAAAAAAAAFw/H0czXvYRWk4/s1600-h/DSC03284.jpg


31/81
http://1.bp.blogspot.com/_mvKKBhLcSoc/Sb6ggZCTYHI/AAAAAAAAAF4/Nqk_6z4es1Y/s1600-h/DSC03287.jpghttp://1.bp.blogspot.com/_mvKKBhLcSoc/Sb6ggZCTYHI/AAAAAAAAAF4/Nqk_6z4es1Y/s1600-h/DSC03287.jpg


32/81
http://4.bp.blogspot.com/_mvKKBhLcSoc/Sb6gg5TET7I/AAAAAAAAAGA/d550t4xKnb4/s1600-h/DSC03297.jpghttp://4.bp.blogspot.com/_mvKKBhLcSoc/Sb6gg5TET7I/AAAAAAAAAGA/d550t4xKnb4/s1600-h/DSC03297.jpg


33/81
http://4.bp.blogspot.com/_mvKKBhLcSoc/Sb6gg_FUE-I/AAAAAAAAAGI/0z-UtbIyNa4/s1600-h/DSC03300.jpghttp://4.bp.blogspot.com/_mvKKBhLcSoc/Sb6gg_FUE-I/AAAAAAAAAGI/0z-UtbIyNa4/s1600-h/DSC03300.jpg


34/81
http://1.bp.blogspot.com/_mvKKBhLcSoc/Sb6usv061YI/AAAAAAAAAGg/M7uJHS9w5FA/s1600-h/DSC03291.jpghttp://1.bp.blogspot.com/_mvKKBhLcSoc/Sb6usv061YI/AAAAAAAAAGg/M7uJHS9w5FA/s1600-h/DSC03291.jpg


35/81
http://1.bp.blogspot.com/_mvKKBhLcSoc/Sb6htbkDkEI/AAAAAAAAAGY/Knun6qOtD1c/s1600-h/Post-op+OPG+copy.jpghttp://1.bp.blogspot.com/_mvKKBhLcSoc/Sb6htbkDkEI/AAAAAAAAAGY/Knun6qOtD1c/s1600-h/Post-op+OPG+copy.jpg


36/81


37/81

Difficulty in Hemi-mandiblectomy

If mandibular resection involves the lower border ofthe mandible, the remaining segments deviate towardthe defect side, backward, and upward. Usingintermaxillary fixation for 5-7 weeks following the

resection can reduce the deviation.

So

The placement of a resection guidance appliance canalso help minimize the deviation. These appliancesare temporary and are removed once acceptableocclusal relationship and proper proprioception areattained.


38/81

Solution for deviation

An occlusal rampmay be added to the palatal side of

the maxillary teeth on the non-resected side.

Uses of ramp:

1.helps guide the mandible to the desired occlusionduring closure.

2. In both edentulous and dentulous patients, attempt

to close the bite as far as possible in order to facilitate

insertion of a food bolus and to minimize stress

transmitted to the remaining ridges.


39/81

Difficulties of mandibular defects

A large number of surgical procedures have

been advocated for mandibular reconstruction.

The management of patients with defects

secondary to resection of malignant tumors

associated with the tongue, mandible and

adjacent structures represents an especially

difficult challenge .


40/81


41/81

Treatment of recurrent mandibularmyxoma by curettage and

cryotherapy after thirty years


42/81

CASE REPORT

A 47-year-old Caucasian female patient was referred tothe Oral and Maxillofacial Trauma and SurgeryService (Brazil) in January, 1995. The patientcomplained of a symptomatic volume increase in theleft mandibular body that had existed for one month.

The patient reported that she underwent a surgical

intervention for the removal of a tumor in the samearea 30 years before. The histopathological diagnosisof the biopsy performed in 1965 was "edematous

fibroma."


43/81

On extraoral clinical examination, aslight crowning was observed in the

Figurebody region (mandibularleft) and the patient described local1

pain. An intraoral clinicalexamination showed light swelling

that was firm on palpation. Therewas an overlying intact mucosa and

a discrete loss of definition of theleft inferior vestibular fornix.
http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322009000200013http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322009000200013http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322009000200013http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322009000200013


44/81

There were no tooth

displacements or rotationsand no related sensory

).2Figuredisturbances (


45/81

The panoramic radiograph

was not pathognomonic,

and revealed an extensiveradiolucent, multilocular

area with imprecise

borders that extendedfrom the left posterior

mandibular body to the

anterior contralateralmandibular body, and

exhibited a "soap bubble"

).3Figureappearance (

Computed axial tomography


46/81

Computed axial tomography

imaging showed an area of

infiltration in the medullar

bone with a discrete expansionof the external mandibular

cortical layer and a thin

trabecula along the entirelesion area. No cortical bone

or tooth root reabsorbtion were

seen. Thus, the lesion did notpenetrate the periosteum, and

was not contiguous with the

).4Figurealveolar mucosa (


47/81

An incisional biopsy wasmade and a histopathologicalexamination of the tissuesample exhibited rounded,spindled, and stellate cellsarranged in a loose, myxoidstroma with few collagenfibrils. These results

confirmed the clinicalhypothesis of odontogenic

).5Figure(myxoma


48/81

Lesion excision was

performed under general

anesthesia, followed by

vigorous curettage of the

bone lodge and three 1min liquid nitrogen

sprayings with a

defrosting intervalbetween applications

).6Figure(


49/81

The sequestrated bone was removed 6 months aftersurgery, and the mandibular fracture was treatedwith local care (irrigation) and a diet consisting ofsoft foods. Five years after the surgical procedure,

there were no radiographic or clinical signs ofrecurrence, and the patient's ultimaterehabilitation was completed by the insertion ofosteointegrated implants. Five titanium implants

with bicortical anchors were placed in themandible. After a four-month osteointegrationperiod, an implant-supported denture wasinstalled.


50/81


51/81

After 10 years of postoperative follow up, the

patient is rehabilitated with no clinical or

radiographic signs of lesion recurrence

).10-8Figures(

Consultation between the surgeon
http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322009000200013http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322009000200013http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322009000200013http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322009000200013http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322009000200013http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322009000200013http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322009000200013http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322009000200013


52/81

Consultation between the surgeonand maxillofacial prosthodontist in

total mandiblectomy a fibular flap was the first choice because:

1. this provides a bone segment of more than 20 cm for

transfer and has flexibility for replicating thecontour of the resected mandible in order in some

cases to make implants to support prosthesis

2. Plastic surgeons have suggested that vascularized

mandibular reconstruction is more advantageous and

stable than an autogenous bone graft and bridging

plates made of titanium


53/81

Limitations of use of dental implants

In patients that are receiving radiotherapy or

chemotherapy in any other remote site.

In severly elder patients that cannot tolerate

second stage surgery.

Patients with past failure history of implants.

In patients with fear of having implants.

Patients with oesteoporosis or bone not

sufficient to support prosthesis.


54/81

SO Treatment modalities should be

Using of maxillofacial prosthesis supported by

pins or any retentive undercuts present.

OR

Using of extra-oral implants to support themandibular prosthesis.


55/81

In the present patient, we had to consider a

number of difficult conditions

* a long mandibular defect involving the

symphysis region and an a vascular recipient

bed after heavy irradiation. The surgical

procedure was reconstruction using special

grafting materials as (a lateral thigh flap and afibular flap )


56/81

A Large Maxillofacial Prosthesis for Total

Mandibular Defect: a Case ReportJapanese Journal of Clinical OncologyPages 256-260

Figure1.Frontal view showing

the total defect of the mandible.

Figure2.Lateral view showing

the defect in the inferior portionof the face.
http://jjco.oxfordjournals.org/cgi/content/full/29/5/256http://jjco.oxfordjournals.org/cgi/content/full/29/5/256http://jjco.oxfordjournals.org/content/vol29/issue5/images/hyc06401.gifhttp://jjco.oxfordjournals.org/content/vol29/issue5/images/hyc06402.gifhttp://jjco.oxfordjournals.org/cgi/content/full/29/5/256http://jjco.oxfordjournals.org/cgi/content/full/29/5/256


57/81

After applying petrolatumaround the defect and

maintaining an airway,

a final impression of the

defect was made withhydrocolloid impression

material, using an individual

acrylic resin

impression tray (Fig. 3)

Impression with individual tray

holes drilled through.
http://jjco.oxfordjournals.org/cgi/content/full/29/5/256http://jjco.oxfordjournals.org/content/vol29/issue5/images/hyc06403.gifhttp://jjco.oxfordjournals.org/cgi/content/full/29/5/256


58/81

A stone cast was made from the

impression for the laboratory phase

of prosthesis fabrication.

The wax contours of the

facial prosthesis were formed

with the aid of a pre-surgical

photograph of the patient.

The wax prosthesis was evaluatedon the patient for esthetics

and marginal adaptation (Fig. 4).
http://jjco.oxfordjournals.org/cgi/content/full/29/5/256http://jjco.oxfordjournals.org/content/vol29/issue5/images/hyc06404.gifhttp://jjco.oxfordjournals.org/cgi/content/full/29/5/256


59/81

It was anticipated that the retention of this

facial prosthesis might be obtained by hanging

clear acrylic resin rods on the back of the

patient's bilateral auricles (Fig. 5).
http://jjco.oxfordjournals.org/cgi/content/full/29/5/256http://jjco.oxfordjournals.org/content/vol29/issue5/images/hyc06408.gifhttp://jjco.oxfordjournals.org/content/vol29/issue5/images/hyc06407.gifhttp://jjco.oxfordjournals.org/content/vol29/issue5/images/hyc06406.gifhttp://jjco.oxfordjournals.org/cgi/content/full/29/5/256


60/81

The inner part of the wax prosthesis was hollowed out to

reduce its weight and to provide space for rotation of the neck.

For support of the prosthesis interior, a basic framework was

made using a combination of a U-shaped piece of acrylic resin

and clear resin rods (Fig. 6).

Fig re 7 Attachment de ice placed on the interior of the
http://jjco.oxfordjournals.org/cgi/content/full/29/5/256http://jjco.oxfordjournals.org/content/vol29/issue5/images/hyc06408.gifhttp://jjco.oxfordjournals.org/cgi/content/full/29/5/256http://jjco.oxfordjournals.org/cgi/content/full/29/5/256http://jjco.oxfordjournals.org/cgi/content/full/29/5/256


61/81

Figure7.Attachment device placed on the interior of the

lower lip.

Figure8.Lateral view of the facial prosthesis with an

attachment device and clear rods for hanging.
http://jjco.oxfordjournals.org/cgi/content/full/29/5/256http://jjco.oxfordjournals.org/cgi/content/full/29/5/256http://jjco.oxfordjournals.org/content/vol29/issue5/images/hyc06410.gifhttp://jjco.oxfordjournals.org/content/vol29/issue5/images/hyc06410.gifhttp://jjco.oxfordjournals.org/content/vol29/issue5/images/hyc06409.gifhttp://jjco.oxfordjournals.org/cgi/content/full/29/5/256http://jjco.oxfordjournals.org/cgi/content/full/29/5/256


62/81

radio\Patients receiving chemo


63/81

radio\Patients receiving chemo

therapy

Chemotherapy kills cancer cells by taxing

some aspects of their life cycles more than ittaxes the life cycle of most normal cells.

However normal cells in the body can be

susceptible to the stress of chemotherapy.

Side effects resulted from


64/81

Side effects resulted from

radiotherapy Reduction in the blood supply to the irradiated tissues.

Mucositis.

loss of taste.

xerostomia

trismus.

Osteoradionecrosis.

Fungal infection.

Patients who have ill fitting dentures are instructed not to wear

their dentures during the course of radiation therapy. Fabrication of new denture should be delayed until the oral

soft tissue has adequately healed.


65/81


66/81


67/81


68/81


69/81

Hyperbaric oxygen treatment:

Objective :

*Improvement of osseointegration of implants placed in radiatedbone.

*Decrease all the complication resulted from radiotherapy.

The protocol:

It requires 20 preoperative and 10 postoperative sessions, inwhich the patient breathes 100% oxygen for 90 minutes at 2.4atmospheres.

Effect:The HBO therapy causes an increase in the microvascular blood

supply to the irradiated tissues.


70/81

The use of dental implants has been studied by

several authors. Some authors recommended

the use if hyperbaric oxygen treatment (HBO)hyperbaric oxygen treatment (HBO)prior to

implant placement. Others dont recommend

the use of HBO.Literatures seem to find equalimplant successand failure ratesregardless of

the use of HBO.

Overall, implants in radiated patientsexperienced a very high success rate that is

slightly lessthan the success achieved in

patients that had no radiation.


71/81

* Overall, implants in radiated patients

experienced a very high success rate

that is slightly lessthan the successachieved in patients that had no

radiation.


72/81

Condylar implant

HOFFMAN-PAPPAS


73/81

TEMPOROMANDIBULAR JOINT

REPLACEMENT SYSTEM*


74/81

Temporomandibular Joint Replacement.

The extensive orthopaedic experience of

Dr. Pappas in the area of design and product

development of various joint replacements is

evident in the H-P TMJ prosthesis.


75/81

Keys for TMJ implant successs

1.The proven design concepts that have been utilized

2.The use of materials that are biocompatable

3.The use of materials that are superior in wear

performance and abrasive resistance4.To always provide the lowest possible contact stress

via the articulating surface geometry

5.To allow for the natural motion required in the joint6. To allow for prosthetic misalignments while still

maintaining the maximum contact area.

Important criteria should be done


76/81

during diagnosis and choosing

implant

Custom CAD-CAM design allows precise fit for each patient

Custom fit titanium backed fossa adds stability

Two piece fossa allows for bearing exchange without removing well fixedcomponent

Custom ramus component allows for use in irregularly shaped or deformedmandibular anatomy

Condylar head design increases contact area, while allowing for variousmotions and misalignments

One piece titanium alloy condylar component with UltraCoat?providessuperior mechanical and biological compatibility.

Bearing materials (UltraCoat on UHMWPe) provide superior wearcharacteristics to current joint prosthesis

Locking screw fixation for ramus allows maximum fixation withoutmicromovement


77/81

Device Description

The Hoffman-Pappas

Temporomandibular joint replacement

system consists of:

1. a mandibular ramus component,

2. fossa component and3. interlying fossa bearing.

Mandibular Component


78/81

Mandibular Component

The mandibular component profile in the

sagittal plane is one which allows for bony

coverage of the mandible in order to allow for

appropriate holes for screw fixation. Thebone/prosthesis interface is usually flat;

however, a custom surface can be constructed

in certain situations where the surgeon deemsnecessary.


79/81

FLAT INTERFACE

CUSTOM INTERFACE


80/81

1. The mandibular component is constructed from a

single piece of titanium bar stock and is used to

replace the condylar head while being secured to

the lateral side of the ramus, and is coated with

UltraCoat, a proprietary thin film titanium nitride

ceramic. The fossa is composed of a titanium alloy

fixturing cup and a ultra-high molecular weight

polyethylene (UHMWPe) bearing insert to replacethe glenoid fossa and articulate with the ramus

prosthetic condylar head.


81/81

David C. Hoffman

DDS

256 Mason AvenueC-bldg, 3rd floor

Staten Island,

NY 10305
http://www.siuh.edu/oral.html

implants in mandibles

Documents