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The mandibular orthopedic bone staple in the treatment of the atrophic mandible
MAXILLOFACIAL SECTION
PROSTHETICS
. DENTAL
IMPLANTS
EDITORS
I. KENNETH
ADISMAN
RONALD
I’. DESJARDINS
The mandibular orthopedic bone staple in the treatment of the atrophic mandible John P. O’Malley, Charlotte,
D.M.D.,
and Alan B. Gordon, D.D.S.
N.C.
1 he mandibular orthopedic bone staple, an implantable, transosseousdevice, was first used clinically in 1968.’ The staple, which is made of an alloy of titanium, aluminum, and vanadium, has met with much clinical successover the past 13 years (Fig. 1). A follow-up study reported a 97% successrate achieved by dentistswho had inserted them in the past 10 years.2 The staple fulfills many of the requirements of an ideal, implantable device to augment the ability of the atrophic, edentulous residual mandible to function in chewing and speech.It is biocompatible, nonallergenic, noncorrosive, nononeogenic, nonmutogenic, and not technically difficult to insert in the mandible.’ A stress-broken attachment denture is attached to the staple in order to provide retention and stability for the denture. PATIENT
SELECTION
One indication for use of the staple is an atrophic mandible with a minimum of 9 mm in alveolar height to a maximum of approximately 25 mm, as measured just anterior to the mental foramen. (With a mandibular bone height greater than 25 mm, a staple is not necessary.) The mandibular height measurement is made from a lateral chin view radiograph. An occlusal film is used with a wire 10 mm in length taped to the patient’s chin (Fig. 2). This radiographic technique is more accurate and reproducible than a panoramic or cephalometric film. For the patient with less than 9 mm of mandibular height, an augmentation bone graft is necessary.A mandibular buccal and lingual vestibuloplasty with palatal mucosalgraft may be sufficient to provide adequate retention of the denture. Patients should have no acute endocrine or metabolic disorders. A diabetic patient who is well controlled with insulin
Presented at the Clinical Congress on Preprosthetic Surgery, sponsored by the Southeastern Society of Oral and Maxillofacial Surgeons, Richmond, Va.
432
OCTOBER
Fig. 1. Anterior view of mandibukr bone staple in dry mandible.
1982
VOLUME
48
NUMBER
4
Fig. 2. Lateral chin view of mandib.e for measuring alveolar height. (Note reference wires taped to patient’s chin.)
would be acceptable for this procedure, whereas an uncontrolled diabetic patient would I ot. Many debilitated and chronically ill patients can be safely treated with the staple technique. The typical patient cannot retain t le lower denture during mastication or speechwith a h story of multiple
OWL-3913/82/l
00432
+ OSSOO.50/0
@ 198 ! The C. V. .Mosby
Co.
MANDIBULAR
ORTHOPEDIC
BONE
STAPLE
Fig. 3. Intraoral view of patient with ridge or attached gingiva.
little residual
Fig. 5. Working bilization stent.
cast for construction
of surgical sta-
Fig. 4. One-month postoperative view of mandibular buccal vestibuloplasty with palatal mucosal graft.
Fig. 6. Thirty-month tal incision.
unsuccessful dentures. There is a minimum of clinically detectable residual ridge and attached gingiva (Fig. 3). In some situations, the patients are initially referred to a prosthodontist. The findings reported in this article are a brief summation of the authors’ experiences in the joint treatment of the patient with an atrophic, edentulous mandibule using a mandibular orthopedic bone staple.
sion and graft, the prosthodontist makes preliminary impressions for construction of the working cast. The mental neurovascular bundles are palpated bilaterally and marked on the oral mucosa and on the working cast. A surgical stent is constructed on the working cast to provide the intraoral stabilization of the drilling device during surgery (Fig. 5). An extraoral submental incision is made approximately 5 cm in length. This incision is 1 cm longer than the width of the submandibular drilling device to allow for adequate placement of the device at the inferior border of the mandible without creating undue tension on the soft tissues. The five or seven parallel holes are then drilled into the inferior border of the mandible. The two most lateral holes go completely through the alveolar crest to allow the transosteal pins to penetrate fixed oral mucosa near the crest of the residual ridge. The orthopedic staple is tapped to place and excess
TECHNIQUE Four weeks prior to the staple procedure, a mandibular buccal vestibuloplasty with palatal graft is routinely performed (Fig. 4). This procedure is conducive to the long-term success of the staple because the paracrestal, attached gingiva creates an appropriate matrix for successful insertion and use of the mandibular staple. Approximately 3 weeks after the vestibular exten-
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
postoperative
view of submen-
433
O’MA
.LEY
AND
GORDON
Fig. 8. Insertion of cast-gold bar 1:,ridge with Ceka attachments.
Fig. 7. Intraoral view of mandibular staple.
Table I. Postoperative results Months postPatient
Age/sex
operative
30 26 23 14
1
2 3 4 5 6 7
61/F 65/F 44/F 48/M
11
68/F
4 3
65/F 36/F
ASA No. 3 3 1
1 2 1 1
Pre-
Post-
operative height
operative height
Perioprobe
(mm)
(mm)
(mm) 14
14
2
18 12
18 12
1.5
22 16
22 16
1.2 1 1
10
10
1
20
20
1
Table II. Postoperative results
Patient 1
2 3 4 5 6 7
Operative time (minutes) 65 55 loo 80 60 65 75
Estimated blood loss kc) < 50 < 50 75 75 100
50 100
intraoral length of the threaded, transosteal pins is reduced. At this time, the lock nuts are placed intraorally. The prosthodontist, who also serves as the surgical assistant,givesfinal approval asto whether the transosteal pin position is acceptablefor prosthodontic reconstruction. The external incision is then sutured. Postoperative scarring is minimal, as seen in the 30-month postoperative view shown in Fig. 6. Two days after surgery, the patient is discharged
434
Stability and function
Radiographic changes
-
+ + + + + + +
-
and returns to the prosthodontist’soflice (Fig. 7). The old denture is hollowed out, and a solt denture liner is placed to allow the patient to wear the denture over the recently inserted staple. This permits immediate function with the staple. The patient is emouraged to begin chewing a soft diet and advance to 11ore challenging foods as they are tolerated. Approxmately 8 weeks after the insertion of the staple, tht prosthodontist beginsmaking impressionsand record: for construction
OCTOBER
1982
VOLUh
:E 48
NUMBER
4
MANDIBULAR
ORTHOPEDIC
BONE
Fig. 9. View of mandibular
STAPLE
denture with Ceka attach-
construction, Ceka attachments (J. F. Jelenko & Co, Armonk, N.Y.) are placed in the bridge and in the denture. The permanent lower denture is then inserted, as is the bar bridge (Figs. 8 and 9).
‘Z.&:: : ;;;gg
RESULTS
The range of postoperative follow-up in these seven patients extended from 3 to 30 months and consisted of clinical and radiographic examination and a patient questionnaire. As noted from the American Society of Anesthesiologists (ASA) number, the patients ranged from being very healthy to having compromised physiologic conditions. The ASA number refers to the patient’s physiologic ability to withstand the procedures planned and assigns a degree of risk to that patient. The higher the ASA number, the higher the risk. Patients selected for the procedure ranged from 36 to 68 years of age. Six of the seven patients were women. Preoperative and postoperative mandibular heights as measured with the lateral chin view remained the same regardless of postoperative duration. Periodontal probing of the parastaple sulcus depth was stable, ranging from 1 to 2 mm. Clinical evaluation of the gingival condition around the staple was negative. The average operative time for insertion of the orthopedic staple was approximately 70 minutes. Intraoperative blood loss was minimal, ranging from 25 to 100 cc (Table II). The procedure requiring 100 minutes was one in which the prosthodontist was dissatisfied with initial staple position; the staple was removed and reinserted in a satisfactory position. All
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
Fig. 10. Lateral chin view of 30-month postoperative staple. (Note wire index taped to patient’s chin.)
Fig. 11. Panorex staple.
view
of 30-month
postoperative
seven patients remained afebrile in the 48-hour postoperative period. Analgesics required to maintain patient comfort postoperatively ranged from none to three doses. Stability and function were assessed to be excellent in all patients by several dentists. Ail patients could function without pain during both the immediate and long-term postoperative periods. On radiographic
435
O‘MA:
follow-up, osteolytic changes were not seen either around the threaded transosteal posts or in the denturebearing areas. Thirty-month follow-up of the staple with lateral chin and panoramic radiographs demonstrates the minimal osseous changes that were observed (Figs. 10 and 11). A questionnaire was given to all patients postoperatively to ascertain the degree of patient satisfaction and acceptance with their treatment. The data revealed that all patients were very satisfied with their functional result. More important, all patients would undergo the procedure again if removal of the staple were indicated. By their own accounts, all patients had minimal pain postoperatively and would recommend this technique. Thus, the technique seems to exhibit a high degree of patient acceptance, minimal morbidity, and excellent function.
DISCUSSION It is critical that an attached gingival band of 8 mm minimum width be placed paracrestally, prior to staple insertion. This allows for a minimum of periodontic and soft tissue irritation problems and for good denture border seal. It also creates good tissue acceptance of the transosteal pins and enables the patient to maintain excellent oral hygiene around the transosteal pins. In the presurgical planning period, the patient should be classified as to skeletal Class I, II, or III, at the desired postoperative vertical dimension of occlusion. This allows for establishment of (1) an appropriate ridge relationship between the mandibular orthopedic bone staple and (2) the maxillary residual ridge. Failure to make this determination can lead to compromised occlusal and esthetic results due to a poor functional relationship of these two structures. It is essential that the prosthodontist work closely with the surgeon in all phases of planning and treatment, accompanying him to the operating room and sharing total authority and responsibility for the patient’s care. A breakdown of this joint treatment partnership is the likely source of many of the failures with the technique. We have made it a practice not to permanently cement the bar bridge to the staple for a minimum of 6 months postoperatively. In several patients, poor oral hygiene in the immediate postoperative period has led
436
.LEY AND
GORDON
to accumulation of plaque, irritation of the soft tissues, and hyperplasia around the staple. I is much easier to monitor and quickly correct patient hygiene deficiencies without the bar bridge in place. Stabilization and retention of the lower denture wit n the bar bridge temporarily cemented inside the dent Ire has not been a problem. Also, if esthetic changes ill the denture are necessary, they can be made much e isier with the bar bridge not cemented permanently :n place. Finally, placement of the transosteal pins on .he lingual side of the ridge creates gingival, esthetic, al id retentive problems that are not easily solved. Plac:ment of the pins through or slightly buccal to the aheolar crest of the mandible causes none of these probl :ms.
SUMMARY Postoperative clinical findings 01 the mandibular orthopedic bone staple have been essentially positive, from both the dentist’s and the patien ‘s viewpoint. The mandibular bone staple is a technica ly feasible procedure with a minimal morbidity, an : cceptable operating time, excellent stability, good rl:tention, minimal physiological insult, and a high (egree of patient acceptance. Postoperative alveolar ridge height seems to be stabilized by the technique. It should be considered in the rehabilitation of the atr jphic, edentulous mandible, especially for those patien; s with significant systemic diseases who might not be s1dtable candidates for more extensive procedures such as mandibular bone graft augmentation or visor osteotamy. In addition, another attractive advantage of this :echnique for the nutritionally deficient patient, is that within 4 weeks of the initiation of treatment the patimt can function successfully with a mandibular denture. This can be compared with a minimum 4- to S-month waiting period described for the patient who had either mandibular bone graft augmentation or 1 isor osteotomy. REFERENCES 1. 2.
Small, I. A.: Metal implants and the m; ndibular staple bone plate. J Oral Surg 33~571, 1975. Small, I. A.: Surgery of experiences with he mandibular staple bone plate. J Oral Surg 36:604, 1978.
Refwint requests to: DR. JOHN P. O’MALLEY 2007 RANWLPH RD. CHARLOTTE, NC 28207
OCTOBER
1982
VOLUA
[E 48
NUMBER
4
PROSTHETICS
. DENTAL
IMPLANTS
EDITORS
I. KENNETH
ADISMAN
RONALD
I’. DESJARDINS
The mandibular orthopedic bone staple in the treatment of the atrophic mandible John P. O’Malley, Charlotte,
D.M.D.,
and Alan B. Gordon, D.D.S.
N.C.
1 he mandibular orthopedic bone staple, an implantable, transosseousdevice, was first used clinically in 1968.’ The staple, which is made of an alloy of titanium, aluminum, and vanadium, has met with much clinical successover the past 13 years (Fig. 1). A follow-up study reported a 97% successrate achieved by dentistswho had inserted them in the past 10 years.2 The staple fulfills many of the requirements of an ideal, implantable device to augment the ability of the atrophic, edentulous residual mandible to function in chewing and speech.It is biocompatible, nonallergenic, noncorrosive, nononeogenic, nonmutogenic, and not technically difficult to insert in the mandible.’ A stress-broken attachment denture is attached to the staple in order to provide retention and stability for the denture. PATIENT
SELECTION
One indication for use of the staple is an atrophic mandible with a minimum of 9 mm in alveolar height to a maximum of approximately 25 mm, as measured just anterior to the mental foramen. (With a mandibular bone height greater than 25 mm, a staple is not necessary.) The mandibular height measurement is made from a lateral chin view radiograph. An occlusal film is used with a wire 10 mm in length taped to the patient’s chin (Fig. 2). This radiographic technique is more accurate and reproducible than a panoramic or cephalometric film. For the patient with less than 9 mm of mandibular height, an augmentation bone graft is necessary.A mandibular buccal and lingual vestibuloplasty with palatal mucosalgraft may be sufficient to provide adequate retention of the denture. Patients should have no acute endocrine or metabolic disorders. A diabetic patient who is well controlled with insulin
Presented at the Clinical Congress on Preprosthetic Surgery, sponsored by the Southeastern Society of Oral and Maxillofacial Surgeons, Richmond, Va.
432
OCTOBER
Fig. 1. Anterior view of mandibukr bone staple in dry mandible.
1982
VOLUME
48
NUMBER
4
Fig. 2. Lateral chin view of mandib.e for measuring alveolar height. (Note reference wires taped to patient’s chin.)
would be acceptable for this procedure, whereas an uncontrolled diabetic patient would I ot. Many debilitated and chronically ill patients can be safely treated with the staple technique. The typical patient cannot retain t le lower denture during mastication or speechwith a h story of multiple
OWL-3913/82/l
00432
+ OSSOO.50/0
@ 198 ! The C. V. .Mosby
Co.
MANDIBULAR
ORTHOPEDIC
BONE
STAPLE
Fig. 3. Intraoral view of patient with ridge or attached gingiva.
little residual
Fig. 5. Working bilization stent.
cast for construction
of surgical sta-
Fig. 4. One-month postoperative view of mandibular buccal vestibuloplasty with palatal mucosal graft.
Fig. 6. Thirty-month tal incision.
unsuccessful dentures. There is a minimum of clinically detectable residual ridge and attached gingiva (Fig. 3). In some situations, the patients are initially referred to a prosthodontist. The findings reported in this article are a brief summation of the authors’ experiences in the joint treatment of the patient with an atrophic, edentulous mandibule using a mandibular orthopedic bone staple.
sion and graft, the prosthodontist makes preliminary impressions for construction of the working cast. The mental neurovascular bundles are palpated bilaterally and marked on the oral mucosa and on the working cast. A surgical stent is constructed on the working cast to provide the intraoral stabilization of the drilling device during surgery (Fig. 5). An extraoral submental incision is made approximately 5 cm in length. This incision is 1 cm longer than the width of the submandibular drilling device to allow for adequate placement of the device at the inferior border of the mandible without creating undue tension on the soft tissues. The five or seven parallel holes are then drilled into the inferior border of the mandible. The two most lateral holes go completely through the alveolar crest to allow the transosteal pins to penetrate fixed oral mucosa near the crest of the residual ridge. The orthopedic staple is tapped to place and excess
TECHNIQUE Four weeks prior to the staple procedure, a mandibular buccal vestibuloplasty with palatal graft is routinely performed (Fig. 4). This procedure is conducive to the long-term success of the staple because the paracrestal, attached gingiva creates an appropriate matrix for successful insertion and use of the mandibular staple. Approximately 3 weeks after the vestibular exten-
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
postoperative
view of submen-
433
O’MA
.LEY
AND
GORDON
Fig. 8. Insertion of cast-gold bar 1:,ridge with Ceka attachments.
Fig. 7. Intraoral view of mandibular staple.
Table I. Postoperative results Months postPatient
Age/sex
operative
30 26 23 14
1
2 3 4 5 6 7
61/F 65/F 44/F 48/M
11
68/F
4 3
65/F 36/F
ASA No. 3 3 1
1 2 1 1
Pre-
Post-
operative height
operative height
Perioprobe
(mm)
(mm)
(mm) 14
14
2
18 12
18 12
1.5
22 16
22 16
1.2 1 1
10
10
1
20
20
1
Table II. Postoperative results
Patient 1
2 3 4 5 6 7
Operative time (minutes) 65 55 loo 80 60 65 75
Estimated blood loss kc) < 50 < 50 75 75 100
50 100
intraoral length of the threaded, transosteal pins is reduced. At this time, the lock nuts are placed intraorally. The prosthodontist, who also serves as the surgical assistant,givesfinal approval asto whether the transosteal pin position is acceptablefor prosthodontic reconstruction. The external incision is then sutured. Postoperative scarring is minimal, as seen in the 30-month postoperative view shown in Fig. 6. Two days after surgery, the patient is discharged
434
Stability and function
Radiographic changes
-
+ + + + + + +
-
and returns to the prosthodontist’soflice (Fig. 7). The old denture is hollowed out, and a solt denture liner is placed to allow the patient to wear the denture over the recently inserted staple. This permits immediate function with the staple. The patient is emouraged to begin chewing a soft diet and advance to 11ore challenging foods as they are tolerated. Approxmately 8 weeks after the insertion of the staple, tht prosthodontist beginsmaking impressionsand record: for construction
OCTOBER
1982
VOLUh
:E 48
NUMBER
4
MANDIBULAR
ORTHOPEDIC
BONE
Fig. 9. View of mandibular
STAPLE
denture with Ceka attach-
construction, Ceka attachments (J. F. Jelenko & Co, Armonk, N.Y.) are placed in the bridge and in the denture. The permanent lower denture is then inserted, as is the bar bridge (Figs. 8 and 9).
‘Z.&:: : ;;;gg
RESULTS
The range of postoperative follow-up in these seven patients extended from 3 to 30 months and consisted of clinical and radiographic examination and a patient questionnaire. As noted from the American Society of Anesthesiologists (ASA) number, the patients ranged from being very healthy to having compromised physiologic conditions. The ASA number refers to the patient’s physiologic ability to withstand the procedures planned and assigns a degree of risk to that patient. The higher the ASA number, the higher the risk. Patients selected for the procedure ranged from 36 to 68 years of age. Six of the seven patients were women. Preoperative and postoperative mandibular heights as measured with the lateral chin view remained the same regardless of postoperative duration. Periodontal probing of the parastaple sulcus depth was stable, ranging from 1 to 2 mm. Clinical evaluation of the gingival condition around the staple was negative. The average operative time for insertion of the orthopedic staple was approximately 70 minutes. Intraoperative blood loss was minimal, ranging from 25 to 100 cc (Table II). The procedure requiring 100 minutes was one in which the prosthodontist was dissatisfied with initial staple position; the staple was removed and reinserted in a satisfactory position. All
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
Fig. 10. Lateral chin view of 30-month postoperative staple. (Note wire index taped to patient’s chin.)
Fig. 11. Panorex staple.
view
of 30-month
postoperative
seven patients remained afebrile in the 48-hour postoperative period. Analgesics required to maintain patient comfort postoperatively ranged from none to three doses. Stability and function were assessed to be excellent in all patients by several dentists. Ail patients could function without pain during both the immediate and long-term postoperative periods. On radiographic
435
O‘MA:
follow-up, osteolytic changes were not seen either around the threaded transosteal posts or in the denturebearing areas. Thirty-month follow-up of the staple with lateral chin and panoramic radiographs demonstrates the minimal osseous changes that were observed (Figs. 10 and 11). A questionnaire was given to all patients postoperatively to ascertain the degree of patient satisfaction and acceptance with their treatment. The data revealed that all patients were very satisfied with their functional result. More important, all patients would undergo the procedure again if removal of the staple were indicated. By their own accounts, all patients had minimal pain postoperatively and would recommend this technique. Thus, the technique seems to exhibit a high degree of patient acceptance, minimal morbidity, and excellent function.
DISCUSSION It is critical that an attached gingival band of 8 mm minimum width be placed paracrestally, prior to staple insertion. This allows for a minimum of periodontic and soft tissue irritation problems and for good denture border seal. It also creates good tissue acceptance of the transosteal pins and enables the patient to maintain excellent oral hygiene around the transosteal pins. In the presurgical planning period, the patient should be classified as to skeletal Class I, II, or III, at the desired postoperative vertical dimension of occlusion. This allows for establishment of (1) an appropriate ridge relationship between the mandibular orthopedic bone staple and (2) the maxillary residual ridge. Failure to make this determination can lead to compromised occlusal and esthetic results due to a poor functional relationship of these two structures. It is essential that the prosthodontist work closely with the surgeon in all phases of planning and treatment, accompanying him to the operating room and sharing total authority and responsibility for the patient’s care. A breakdown of this joint treatment partnership is the likely source of many of the failures with the technique. We have made it a practice not to permanently cement the bar bridge to the staple for a minimum of 6 months postoperatively. In several patients, poor oral hygiene in the immediate postoperative period has led
436
.LEY AND
GORDON
to accumulation of plaque, irritation of the soft tissues, and hyperplasia around the staple. I is much easier to monitor and quickly correct patient hygiene deficiencies without the bar bridge in place. Stabilization and retention of the lower denture wit n the bar bridge temporarily cemented inside the dent Ire has not been a problem. Also, if esthetic changes ill the denture are necessary, they can be made much e isier with the bar bridge not cemented permanently :n place. Finally, placement of the transosteal pins on .he lingual side of the ridge creates gingival, esthetic, al id retentive problems that are not easily solved. Plac:ment of the pins through or slightly buccal to the aheolar crest of the mandible causes none of these probl :ms.
SUMMARY Postoperative clinical findings 01 the mandibular orthopedic bone staple have been essentially positive, from both the dentist’s and the patien ‘s viewpoint. The mandibular bone staple is a technica ly feasible procedure with a minimal morbidity, an : cceptable operating time, excellent stability, good rl:tention, minimal physiological insult, and a high (egree of patient acceptance. Postoperative alveolar ridge height seems to be stabilized by the technique. It should be considered in the rehabilitation of the atr jphic, edentulous mandible, especially for those patien; s with significant systemic diseases who might not be s1dtable candidates for more extensive procedures such as mandibular bone graft augmentation or visor osteotamy. In addition, another attractive advantage of this :echnique for the nutritionally deficient patient, is that within 4 weeks of the initiation of treatment the patimt can function successfully with a mandibular denture. This can be compared with a minimum 4- to S-month waiting period described for the patient who had either mandibular bone graft augmentation or 1 isor osteotomy. REFERENCES 1. 2.
Small, I. A.: Metal implants and the m; ndibular staple bone plate. J Oral Surg 33~571, 1975. Small, I. A.: Surgery of experiences with he mandibular staple bone plate. J Oral Surg 36:604, 1978.
Refwint requests to: DR. JOHN P. O’MALLEY 2007 RANWLPH RD. CHARLOTTE, NC 28207
OCTOBER
1982
VOLUA
[E 48
NUMBER
4