Implant Prosthetic Rehabilitation of Posterior Mandible After Tumor Ablation With Inferior Alveolar...

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Oral Maxillofac Surg7:1104-1112, 2009

Implant Prosthetic Rehabilitation ofPosterior Mandible After Tumor AblationWith Inferior Alveolar Nerve Mobilizationand Inlay Bone Grafting: A Case Report

Pietro Felice, MD, DDS,* Giuseppe Corinaldesi, MD, DDS,†

Giuseppe Lizio, DDS,‡ Adriano Piattelli, MD, DDS,§

Giovanna Iezzi, DDS, PhD,¶ and Claudio Marchetti, MD, DDS�

Purpose: To report a successful clinical case of dental implant provisionalization of a posteriormandible resected for tumor ablation and subsequently reconstructed with interpositional bone graftingafter mobilization of the inferior alveolar nerve.

Materials and Methods: A 47-year-old woman with a severe posterior mandibular defect due to ablationof a squamous cell carcinoma was treated with transposition of the inferior alveolar nerve and inlay iliac bonegraft. Four months later, 4 dental implants were inserted and immediately provisionalized. Bone core biopsieswere taken during implant insertion. After an additional 3 months, a definitive fixed bridge was inserted.

Results: At the 24-month follow-up visit, all implants appeared to have osseointegrated. The histologicexamination showed that the grafted bone was lined by newly formed bone without gaps at the interface.

Conclusions: Inlay bone grafting can allow implant provisonalization of the posterior mandible evenwith a remarkable bone alveolar deficit after tumor ablation.© 2009 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 67:1104-1112, 2009
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evere atrophy (Class V/VI, according to the Ca-ood/Howell classification1) of posterior mandi-les poses a great challenge for implant-supportedxed dental rehabilitation. Mandibular atrophy haseen treated by a variety of surgical procedures,

*Resident, Department of Oral and Dental Sciences, University of

ologna, Bologna, Italy.

†Researcher, Department of Oral and Dental Sciences, University

f Bologna, Bologna, Italy.

‡Scholar, Department of Oral and Dental Sciences University of

ologna, Bologna, Italy.

§Professor of Oral Medicine and Pathology, Dean and Director of

tudies and Research, Dental School, University of Chieti-Pescara,

hieti-Pescara, Italy.

¶Research Fellow, Dental School, University of Chieti-Pescara,

hieti-Pescara, Italy.

�Professor of Maxillofacial Surgery, Department of Oral and Den-

al Sciences, University of Bologna, Bologna, Italy.

Address correspondence and reprint requests to Dr Felice: De-

artment of Oral and Dental Sciences, University of Bologna, Via

an Vitale 59, Bologna 40125 Italy; e-mail: [email protected]

2009 American Association of Oral and Maxillofacial Surgeons

278-2391/09/6705-0027$36.00/0

noi:10.1016/j.joms.2008.12.010

1104

uch as transpositioning of the mandibular nerve,2,3

he use of short implants,4 alveolar ridge augmen-ation procedures, with or without grafting (onlay,5

nlay,6 guided bone regeneration,7 and distractionsteogenesis8,9). However, very few reports haveescribed alveolar tumor resection of the posteriorandible, subsequently reconstructed for implantrosthetic rehabilitation.9-12

Inferior alveolar nerve (IAN) transposition, first de-cribed by Alling2 in 1977 and subsequently modifiedy Jensen and Nock13 in 1987, may fail to correctcclusal interarch discrepancies and can damage theerve bundle.2,3

The inlay bone graft technique, first described bychettler and Holtermann14 in 1976 for the recon-truction of the edentulous severely atrophic mandi-le, has great potential for bone graft incorpora-ion,15,16 but few studies have reported positiveutcomes in the posterior mandible.6,17

The present clinical and histologic case reportescribes an implant prosthetic rehabilitation of aosterior mandible resected for squamous cell car-inoma and reconstructed with an inlay augmenta-ion procedure associated with inferior alveolar
erve transposition.
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FELICE ET AL 1105

ase Report

A 47-year-old systemically healthy woman was re-erred to the Oral and Maxillofacial Surgery Unit of S.rsola/Malpighi Hospital, Bologna, Italy, for fixedrosthetic rehabilitation of the left posterior mandi-le. The patient underwent resection of the alveolarone process with the covering soft tissues maintain-

ng mandibular arch continuity. No evidence of recur-ent or metastatic disease was present at admission;o chemotherapy or radiotherapy was performed.After 2 years, 8 months, an inlay procedure was

erformed for mandible reconstruction. Clinical ex-mination, preliminary radiographic evaluation (pan-ramic radiograph [Fig 1A], profile radiographs, andomputed tomography [Fig 1B]) and dental casts con-rmed a Class V/VI (according to the Cawood/Howelllassification1) mandibular deficit. The preoperativeesidual bone height above the mandibular canal was5 mm distal to the mental nerve foramen (4.14 mm,

.47 mm, and 5.61 mm) and 6, 12, and 18 mm,espectively, from the mental nerve foramen, mea-ured with Autocad/Autodesk software from the mostoronal point of the mandibular canal to the interme-iate point of the crestal ridge (Fig 1C and Table 1).We decided to perform an inlay bone grafting pro-

edure after lateralization of an IAN, to provide suffi-ient bone volume for the upper transport segment.ritten informed consent, approved by the local eth-

IGURE 1. A, Preoperative panoramic evaluation. B, Preoperativeanal measured with Autocad/Autodesk software on CT scans at

elice et al. Implant Prosthetic Rehabilitation. J Oral Maxillofac

cal committee, was given by the patient.FS

SURGICAL PROCEDURE

The patient underwent general anesthesia. Theechnique started with a paracrestal incision in theuccal vestibule with respect to the lingual perios-eum and the emergence of the mental nerve to ex-ose the alveolar ridge and buccal bone. No mucope-iosteal dissection was performed toward the alveolarrest or on the lingual side to preserve an adequatelood supply to the bone segment to be osteoto-ized. The osteotomies were done with a piezosur-

ery device (Mectron Piezosurgery Device; Mectron,arasco, Italy). A monocortical lateral osteotomy wasone posteriorly to the mental foramen, and the cor-ical bone was removed with a chisel. The neurovas-

aluation. C, Preoperative residual bone height above mandibularand 18 mm.

009.

Table 1. BONE HEIGHT VALUES ABOVEMANDIBULAR CANAL MEASURED ON CT SCANS AT6, 12, AND 18 MM DISTAL TO MENTAL FORAMEN

Location of CTMeasurementSlide Distally

to MentalForamen (mm)

Preoperative(mm)

ImmediatelyAfter

Inlay Procedure(mm)

ImplantInsertion

Time(mm)

6 4.1 11.8 11.112 5.5 11.7 11.518 5.6 11.3 11.2

bbreviation: CT, computed tomography.

CT ev6, 12,

elice et al. Implant Prosthetic Rehabilitation. J Oral Maxillofacurg 2009.

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1106 IMPLANT PROSTHETIC REHABILITATION

ular bundle was visualized from the surroundingarrow bone, then the osteotomy was extended an-

eriorly to the mental foramen, following the hypo-hetical course of the alveolar nerve loop. Once theortex had been removed, the incisive branch wasisualized and cut with a scalpel to move the mentalerve from the bone canal (Fig 2). The bundle was

solated and carefully lifted from its location in theandible. The nerve was then fixed to the vestibular

ap with Vicryl 4-0 (Ethicon FS-2, St-Stevens-Woluwe,elgium), and the inlay grafting procedure wastarted.

A horizontal osteotomy and 2 oblique cuts wereade using piezosurgery to obtain a neater osteotomy

ine and thereby reducing the risk of transport seg-ent fracture. The horizontal osteotomy was 2 to 4m above the mandibular canal, the mesial oblique

ut was 2 mm distal to the last tooth in the arch, andhe distal oblique cut was relative to the implant–graft

IGURE 3. Osteotomy of coronal bone segment and its elevationor graft positioning.

IGURE 2. Visualization and cut of incisive branch of alveolarerve.



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reatment plane (Fig 3). The osteotomized segmentas then raised in the coronal direction, sparing the

ingual periosteum. The bone removed from the me-ial surface of the iliac crest was interposed betweenhe raised fragment and the mandibular basal bonend then fixed with titanium miniplates and minis-rews (Martin, Tuttlingen, Germany) (Fig 4). Aftereleasing the vestibular periosteum, the flap waslosed with 4-0 Vicryl sutures (Ethicon FS-2). The iliacrest had a 3-layer suture and drainage for 3 days.ntibiotic therapy with ceftriaxone (Ceftriaxon, Tyrolharma, Bordon, UK) was administered intravenouslyn induction at a loading dose of 2 g, with 2 g/d fromhe day after surgery, together with a nonsteroidalnalgesic drug (Ketoprofen, Orudis, Aventis, Pharma,ridgewater, NJ) for 10 days. The postoperative in-tructions included a soft food diet for 2 weeks andppropriate oral hygiene with twice daily rinsing with0.2% chlorhexidine digluconate mouthwash (Corso-yl; GlaxoSmithKline, Middlesex, UK). The suturesere removed 7 to 10 days after the surgical proce-ure. Her postoperative recovery was uneventful.As far as donor site recovery is concerned, the

atient reported temporary pain and discomfort in

FIGURE 5. Immediate postoperative panoramic evaluation.

FIGURE 4. Iliac graft positioned and fixed.



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FELICE ET AL 1107

eambulation lasting 5 weeks. The sutures were re-oved at 10 days postoperatively, both intraorally

nd at the donor site. The patient was followed withclinical examination at 1 week after surgery, twice

n the first month, and once in the subsequent 3onths. Radiographic assessment was performed im-ediately after surgery (panoramic) (Fig 5) and 1eek and 3 months thereafter (computed tomogra-hy [CT]). Neurosensory function was tested onach occasion. A subjective evaluation was per-ormed by asking the patient if she had any areas iner lip or chin region of hypoesthesia, numbness,ingling, or pain. An objective evaluation was doneith a 2-point discrimination test using a sharp

aliper and with a static light touch test with aotton-tipped applicator. The patient reported hy-oesthesia from the first week postoperatively iner left half-lip and half-chin region, associated withumbness and tingling progressively increasing inhe subsequent month. After 5 weeks, the hypoes-hesia was completely resolved with no furtherumbness or tingling sensations. The response tohe objective tests was normal from the secondeek after surgery. The patient was not allowed toear removable dentures before implant place-ent. The healing process proved successful.The vertical bone height augmentation obtainedith the surgical procedure was determined by com-aring the preoperative CT scans on the paraxial-mm-thin slices acquired at surgery with the imme-iate postoperative CT scans. Measurements were

IGURE 6. Immediate postoperative evaluation of bone gainbove mandibular canal measured with Autocad/Autodesk soft-are on CT scans at 6, 12, and 18 mm.


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aken at 6, 12, and 18 mm posterior to the left mentaloramen with the Autocad/Autodesk software fromhe most coronal point of the mandibular canal to thentermediate point of crestal ridge (Fig 6 and Table 1).

IMPLANT INSERTION ANDPROSTHETIC REHABILITATION

Four months later, after creation of the diagnosticax-up and radiographic template, CT scans werebtained to plan the implant placement procedure.ertical bone resorption of the graft before implant

nsertion was determined by comparing the CT scans.easurements were taken at 6, 12, and 18 mm pos-

erior to the left mental foramen with the Autocad/

IGURE 7. Postoperative evaluation at 3 months showing boneain above mandibular canal measured with Autocad/Autodeskoftware on CT scans at 6, 12, and 18 mm.


FIGURE 8. Insertion of 4 XiVE plus implants.


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utodesk software (Fig 7 and Table 1). Implant inser-ion was performed with the patient under localnesthesia.

A full-thickness crestal incision was made, and theoft tissues overlying the reconstructed mandiblesere elevated. The fixation screws used for stabiliza-

ion of the bone graft were removed, and the dentalmplants were placed according to a prefabricatedesin template. A bone trephine with an internal di-meter of 2 mm (Dentsply-Friadent, Mannheim, Ger-any) was used as the second dental drill to take a

one core biopsy. The length and diameter of themplants were selected to engage the cortical bone ofhe residual mandibular basal bone, to optimize theirrimary stability. Four XiVE plus implants (Dentsply-riadent) were inserted: 3 were 15 mm long with aiameter of 3.8 mm, and 1 was 13 mm long with aiameter of 3.4 mm (Fig 8). The insertion torque forll implants was �40 N-cm. Intraoperative periapicaladiographs were taken to verify the implant position.

Provisional abutments were immediately con-ected to the implants, and the flap was tightly su-ured around them. Transfer copings were mountedn the provisional abutments, and an impression wasaken with a polyether material (Impregum F, ESPEental AG, Seefeld, Germany). An acrylic resin provi-

ional fixed prosthesis was made in the laboratory andnally screwed in place to the fixtures with a 30 N-cmorque 4 hours after implant placement (Fig 9). Theurfaces of the prosthetic teeth were in occlusal cen-ric contact. An antibiotic (amoxicillin with clavulaniccid, Augmentin; GlaxoSmithKline), 1 g twice daily,as administered for 7 days, and an analgesic drug

ketoprofen, Orudis, Aventis Pharmaceutical, Bridge-ater, NJ) was prescribed to be taken as needed. A

old/soft diet was recommended for 7 days with

FIGURE 9. Application of provisional fixed prosthesis.


wice-daily rinsing with a 0.2% chlorhexidine diglu-FS

onate mouthwash (Corsodyl). The patient was in-tructed to avoid brushing and trauma to the surgicalite. The sutures were removed after 1 week. Herostoperative recovery was uneventful. The provi-ional prosthesis was removed from the oral cavity 3onths later, when the definitive gold alloy/ceramicrosthetic fixed bridge was screwed to the implants.he occlusion setting provided a centric occlusal con-

act between the 2 dental arches.The patient was followed with clinical examina-

ion, every week in the first month, twice a month forhe subsequent 3 months, and once at 6, 8, 12, 15, 20,nd 24 months after implant placement and the startf prosthetic loading. Intraoral periapical radiographsere taken immediately after implant placement, 4ours after provisional loading, and 6, 12, and 24onths after the start of prosthetic loading.

Processing of SpecimensThe bone core biopsies were stored immediately

n 10% buffered formalin and processed to obtainhin ground sections with the Precise 1 Automatedystem (Assing, Rome, Italy). The specimens wereehydrated in an ascending series of alcohol rinsesnd embedded in a glycolmethacrylate resin (Tech-ovit 7200 VLC, Kulzer, Wehrheim, Germany). Af-er polymerization, the specimens were sectionedongitudinally along the major axis with a high-recision diamond disc at about 150 �m andround down to about 30 �m. Three slides werebtained. The slides were stained with acid fuchsinnd toluidine blue.

esults

CLINICAL RESULTS

The vertical bone gain after grafting was 7.7, 6.2,nd 5.7 mm at 6, 12, and 18 mm, respectively, distalo the mental foramen, with a mean value of 6.5 mm

Table 2. BONE GAIN AND BONE RESORPTIONVALUES ABOVE MANDIBULAR CANAL MEASUREDON CT SCAN AT 6, 12, AND 18 MM DISTAL TOMENTAL FORAMEN

Location of CTMeasurementSlide Distally

to MentalForamen (mm)

Bone Gain(mm)

BoneResorption

(mm)

BoneResorption

(%)

6 7.7 0.7 5.912 6.2 0.2 1.718 5.7 0.1 0.9

Mean 6.5 0.3 2.8

bbreviation: CT, computed tomography.


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Table 2). The vertical resorption rate before implantnsertion time (consolidation period) was 0.7, 0.2,nd 0.1 mm at 6, 12, and 18 mm, respectively, distalo the mental foramen, with a mean value of 0.3 mm2.8%) (Table 2). At each follow-up visit, no patho-ogic symptoms or signs were recorded (no implant

obility, no peri-implant probing depth, no peri-im-lant bleeding on probing). Only mild bleeding onrobing from the lingual sulcus of 3.5 and 3.6 location

mplants (score 2 in both sites according to the mod-fied sulcus bleeding index MBI—modified bleedingndex—by Mombelli and Lang18) was assessed at 12

onths that was due to mild plaque retention causedy poor oral hygiene. No inflammatory signs wereecorded at the end of the follow-up period (24onths) (Fig 10A), nor was any implant failure re-

orded, with no radiographic signs of peri-implantitisFig 10B). No prosthetic damage (such as unscrewingr fracture of the implant-abutment connectioncrews or fracture of prosthetic bridge) was recorded

IGURE 10. A, Clinical and B, radiographic findings at end ofollow-up.


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HISTOLOGIC RESULTS AT IMPLANT PLACEMENT

At low-power magnification, a clear demarcationas seen between the grafted bone and the newly

ormed bone. New bone presented with a greatertaining affinity. Trabecular bone with wide marrowpaces was present. The bone trabeculae were con-tituted by grafted bone lined with newly formedone. At higher magnification, newly formed boneurrounded the grafted bone trabeculae. No gaps oronnective tissue were present at the interface (Figs1A-C).

iscussion

Few published reports have described posteriorandible resection owing to tumor ablation, followed

y reconstruction and rehabilitation with an implant-orne fixed prosthesis.9-11,13 Different techniques cane used in posterior mandibular ridge augmentationnd can be distinguished by the graft procedure (on-ay, inlay, guided bone regeneration) and no graftrocedure (distraction osteogenesis, mandibular nerveranspositioning, short implants placement).

Onlay bone grafting is prone to unpredictable boneesorption, with the potential for total graft loss.19

uided bone regeneration with polytetrafluoroethyl-ne titanium-reinforced membrane and titanium mi-romesh is often affected by dehiscence and subse-uent membrane exposure and infection; it is anperator-dependent technique and is better indicatedor limited vertical bone reconstruction.20-22

Distraction osteogenesis overcomes the drawbacksf bone grafting and obtains �15 mm of bone height,ut it is prone to remarkable complications and isery difficult to manage.15,20 Transpositioning of theandibular nerve alone and implant placement3,13

esults in an excessive length of prosthetic crownsith an unfavorable crown/implant ratio.The inlay augmentation procedure associated with

AN lateralization was used to rehabilitate the presentase.Our patient had been treated for cancer by box-

haped alveolar resection alone, with oral conditionsuitable to undergo implant prosthetic rehabilitation.

The few applications of the inlay grafting techniquen the posterior atrophic mandible have yielded aertical bone gain of 4 to 8 mm,6,17,23,24 with minimalone resorption rates (14% resorption in 5 cases24)nd minor complications.6,17,20 An implant successate of 90%6 at 1 to 4 years and 95.2% rate24 atostloading follow-up of 22.5 months have been re-orted. Nevertheless, this procedure requires �4 to 6m of residual bone above the mandibular canal toerform the transport segment osteotomy.6,23 Thisone volume is unavailable in the surgically resected
andible, which requires IAN transposition for inlay

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rafting. The association of these techniques offershe great advantages of obtaining not only adequateone volume for implant insertion in one surgicalession, but also correcting interarch occlusal dis-repancies, avoiding an unfavorable crown/implantatio.

This case presented particular technical problemsecause of the anatomic conditions: the reducedeight of the residual resected mandible and the riskf nerve bundle damage. To prevent mandibular re-idual corpus from fracture after the IAN lateraliza-ion, we performed with piezoelectric instrumentshe horizontal part of osteotomy as far as possiblerom the inferior border, 2 to 4 mm above the man-ibular canal.Published studies have reported the inlay tech-

ique for posterior mandible augmentation with these of a “smile-shape” osteotomy.6 In this technique,nteriorly, a step osteotomy is made vertically to therest of the ridge, and, posteriorly, the osteotomyapers to the crest in a smile-shaped cut terminating

IGURE 11. A, Left, vestibular side; Right, lingual side. Low-powerrafted bone (G) lined by newly formed bone (B). Toluidine blue-arafted bone (G) lined with newly formed bone (B) with wide ostuchsin stain, original magnification �40. C, Newly formed bonerafted bone (G). No gaps or connective, fibrous tissue presentlue-acid fuchsin stain, original magnification �200.

elice et al. Implant Prosthetic Rehabilitation. J Oral Maxillofac

ear the retromolar pad. w

In our case, it was preferred to perform a squaredsteotomy, 2 to 4 mm above the mandibular canal, toefine a rectangular-shaped transport segment, withn adequate thickness, and to obtain a proper fittingf the iliac graft.Even if the IAN lateralization procedure might dam-

ge the nerve bundle,2,3 piezosurgery instruments en-bled the surgeon to cut the bone without soft tissuesnjury,25,26 with no complications and transient sen-ory impairments, which had completely resolvedithin 2 months.Implant placement, in conjunction with the graft-

ng procedure, to shorten the surgical and prostheticreatment times5,27 presents with a great risk ofound dehiscence with infection/necrosis of theone graft, the risk of implant osteointegration fail-re, and prevention of a correct implant insertionesult from a prosthetic viewpoint.28-30 For these rea-ons, we waited for the completion of graft consoli-ation before performing implant placement tohorten the recovery of the patient’s oral function

fication disclosing trabecular bone with wide marrow spaces (MS).hsin stain, original magnification �6. B, At higher magnification,lacunae. Wide marrow spaces present (MS). Toluidine blue-acidth wide osteocyte lacunae (black arrows) is in close contact withinterface (white arrows). Marrow spaces (MS) present. Toluidine

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FELICE ET AL 1111

A recent literature review31 concluded that imme-iate provisionalization or immediate loading canchieve predictable results only in the anterior man-ible. Nevertheless, many studies have investigatedhe application of immediate provisionalization oroading in the posterior mandible, reporting high im-lant success rates (about 95%)32,33 and good histo-

ogic results.34 Hitherto, a paucity of data has beenvailable on the immediate provisionalization or load-ng protocol of implants placed in severely atrophicaws reconstructed with autogenous bone grafts,35,36

nd no reports, to our knowledge, have been pub-ished of immediate loading in the grafted posterior

andible.In our patient, the histologic outcomes at implant

nsertion revealed complete incorporation of the iliacraft in the surgical site, encouraging the applicationf an immediate provisonalization protocol. A provi-ional rigid acrylic fixed bridge was screwed to allxtures 4 hours after implant insertion, obtaining aplinting of fixtures and functional centric loadingith no lateral contacts. The implant success ob-

ained was consistent not only with those related tommediately provisionalized/loaded implants placedn native, nonreconstructed bone, but also with thoseelated to delayed loading.36

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