implants in mandibles
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Mandibular defects
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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
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Acquired
defect
of mandible
Partially edentulous Edentulous patients
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Acquired
defect
of mandible
Lateral discontinuitydefects
Anterior borderdefects
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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
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Zest anchor stud
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Attachements
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Bar attachement\ Hedar bar
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Patient partially edentulous
1. Lateral discontinuity defects------RPD
2. Anterior discontinuity defects--
-----RPD
3. Implant-retained prosthesis
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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.
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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
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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)
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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.
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Implant retainer prosthesis in lateral
defects
Conventional RPD
Conventional RPD will not meet the support of
the prosthesis alone.
Implant supported prosthesis
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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
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For edentulous patients
1. Mastication is difficult
2. Compromised denture bearing surface
3. Deviation of mandible4. Impaired tongue function
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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
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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
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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
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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.
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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:
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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.
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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.
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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 .
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Treatment of recurrent mandibularmyxoma by curettage and
cryotherapy after thirty years
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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."
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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.
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There were no tooth
displacements or rotationsand no related sensory
).2Figuredisturbances (
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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
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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 (
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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
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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(
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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.
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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
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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
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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.
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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.
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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 )
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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.
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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.
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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).
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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).
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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
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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.
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radio\Patients receiving chemo
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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
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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.
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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.
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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.
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* Overall, implants in radiated patients
experienced a very high success rate
that is slightly lessthan the successachieved in patients that had no
radiation.
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Condylar implant
HOFFMAN-PAPPAS
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TEMPOROMANDIBULAR JOINT
REPLACEMENT SYSTEM*
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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.
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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
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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
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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
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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.
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FLAT INTERFACE
CUSTOM INTERFACE
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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.
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David C. Hoffman
DDS
256 Mason AvenueC-bldg, 3rd floor
Staten Island,
NY 10305
http://www.siuh.edu/oral.html