Use of the mandibular staple bone plate with augmentation bone grafts

TIPPS AND LANDIS

implant could be used as an alternative method should the Silastic implants fail to function adequately.

9. Topazian RG, Costich ER: Management of protracted dislocation of the mandible. J Trauma 7:257. 1%7 10. McKelvey LE: Sclerosing solution in the treatment of chronic subluxation of the temporomandibular joint. J Oral Surg 8:225, 1950 11. Hayward JR: Prolonged dislocation of the mandible. J Oral Surg 23:585, 1%5 12. Gottlieb 0: Long-standing dislocation of the jaw. J Oral Surg 10:25, 1952 13. Litzow TM, Royer RQ: Treatment of longstanding dislocation of the mandible. Proc Mayo Clin 37:399, 1962 14. Harpman JA: Treatment of old unreduced forward dislocation of the temporomandibular joints. J Oral Surg 10~250, 1952 15. Rawls HC, Brani A, Hamilton MK: Surgical correction of the permanently dislocated mandible. J Oral Surg 31:386, 1973 16. Irby WB: Surgical correction of chronic dislocation of the temporomandibular joint not responsive to conservative therapy. J Oral Surg 15:308, 1957 17. Warren RE, Weinberg S, VandeMark TB: Prolonged traumatic dislocation of the mandible. J Oral Surg 32:535, 1974 18. Hale RH: Treatment of recurrent dislocation of the mandible: Review of literature and report of cases. J Oral Surg 30:528, 1972 19. Westwood RM, Fox GL, Tilson HB: Eminectomy for the treatment of recurrent temporomandibular joint dislocation. J Oral Surg 33:774, 1975 20. Baumstark RJ, Harrington WS, Markowitz NR: A simple method of eminoplasty for correction of recurrent dislocation of the mandible. J Oral Surg 35:75, 1977 21. Cherry CQ, Frew AL: Bilateral reductions of articular eminence for chronic dislocation: Review of eight cases. J Oral Surg 35:598, 1977 22. Dingman RO, Constant E: A fifteen year experience with temporomandibular joint disorders. J Oral Surg 44: 123, 1969 23. Boudreaux RE, Spire ED: Plication of the capsular ligament of the temporomandibular joint: A surgical approach to recurrent dislocation or chronic subluxation. J Oral Surg 26:330, 1968 24. Howe AG et al: Implant of articular eminence for recurrent dislocation of the temporomandibular joint. J Oral Surg 361523, 1978 25. Maw RB, McKean TW: Scarification of the temporal for treatment of chronic subluxation of the temporomandibular joint. J Oral Surg 31:22. 1973

Summary A brief review of the pathogenesis and treatment of chronic or prolonged dislocations and a case of bilateral mandibular dislocation of 13 months duration have been presented. The reduction was accomplished via bilateral eminectomy, lateral pterygoid myotomy. condylectomy, and placement of Silastic blocks to maintain ramus height. The structural changes that occurred in the condyles and articular eminences were demonstrated by tomography. References 1. Van Der Kwast WAM: Surgical management of habitual luxation of the mandible. Int J Oral Surg 7:329, 1978 2. Miller GA, Murphy EJ: External pterygoid myotomy for recurrent mandibular dislocation: Review of the literature and report of a case. Oral Surg 42:705, 1976 3. Adekeye EO, Shamia RI, Cove P: Inverted L-shaped ramus osteotomy for prolonged bilateral dislocation of the temporomandibular joint. Oral Surg 41:568, 1976 4. Sanders B, Newman R: Surgical treatment for recurrent dislocation or chronic subluxation of the temporomandibular joint. Int J Oral Surg 4:179, 1975 5. Tasanen A, Lamberg MA: Closed condylotomy in the treatment of recurrent dislocation of the mandibular condyle. Int J Oral Surg 7: 1, 1978 6. Rowe PF, Caldwell JB: Correction of permanent temnoromandibular ioint dislocation. J Oral Surg 28:222 1970 7. La’skin DM: Myotomy for the management of recurrent and protracted mandibular dislocations. Fourth International Conference on Oral Surgery, Amsterdam, Holland, May 1971, pp 264-267 8. Hueston JT: The surgical exposure of the dislocated mandibular condyle. Br J Plast Surg 12:275, 1959

J Oral Maxillofac 40527-531,

Surg

1982

Use of the Mandibular with Augmentation

Staple Bone Plate Bone Grafts

RICHARD B. LIPOSKY, The treatment of advanced mandibular atrophy may be greatly enhanced by the insertion of the mandibular staple bone plate. When moderate bone loss is present, this may be the only treatment re-

DMD

quired to stabilize the lower denture. However, when the remaining bone is less than 0.9 cm, bone grafts must be used. The mandibular staple bone plate will enhance the overall results of the auementation procedure by stabilizing the denture on the grafted alveolus. The following cases show the use of the mandibular staple bone plate in conjunc-

Address correspondence and reprint requests to Dr. Liposky: Suite 409, Mellon Pavillion, 4815 Liberty Avenue, Pittsburgh, Pennsylvania 15224.

0278-2391/82/0800/0527 $01 .OO@ American Association

527

of Oral and Maxillofacial Surgeons

528

MANDIBULAR STAPLE BONE PLATE

showed remodeling and reorganization with approximately 40% bone loss (Fig. 4). Six months after the graft, a mandibular vestibuloplasty was performed, using a lingually based pedicle flap (Fig. 5). Recontouring of the bone and repositioning of the tissue to re-establish the vestibule were the main objectives. Extensive vascularity of the bone graft was noticed. On the fourth week after vestibuloplasty. a denture was constructed with flanges extending into the depth of the labial and buccal vestibules. The patient had minimal difficulty with her denture but on occasion she experienced tenderness in the area of the wires that had been placed to stabilize the graft. As these wires surfaced from continued bone loss, they were removed (Fig. 4). In the posterior mandibular vestibule, a small portion of the cortical plate of the iliac crest graft perforated the mucosa in the area of a denture sore. After a course of

FIGURE 2. Below,, Preoperative radiograph of atrophic mandible. Notice that the neurovascular bundles are close to the surface

of the alveolar

ridge in the premolar

tion with augmentation

region.

bone grafts with and without

vestibuloplasty. Report of Two Cases Patient No. I. A 53-year-old white woman had a chief complaint of chronic mandibular pain and denture sores from very loose, ill-fitting dentures. She had been edentulous for 18 years and had had several sets of complete dentures. Moderate facial changes occurred because of autorotation of the mandible and decreased vertical dimension. Oral examination showed shallow labial and buccal vestibules with muscle attachments at the alveolar crest (Fig. 1). Minimal attached gingiva was present. The denture was easily dislodged with minimal movements of the lips, cheek, or tongue. The patient wanted to be able to chew food without pain and discomfort and to be able to speak without the teeth clicking or being dislodged from her mouth. Radiographic examination showed atrophic changes of the mandible (Fig. 2). The height of the horizontal ramus was 1.1 cm, and the neurovascular bundles were close to the alveolar crest, particularly on the right side. An augmentation bone graft with a subsequent vestibuloplasty approximately six months later was planned. On October 25, 1977, by use of an extraoral approach, an iliac crest bone graft was recontoured and inserted on the alveolar crest bilaterally, extending across the anterior alveolus (Fig. 3). Postoperative radiographs at six months

FIGURE 3. Above. Patient No. I, one month after augmentation bone graft. Notice that the bone grafts extend about 0.7 cm above

the suspension

wires.

FIGURE 4. Center, Ten months after the bone loss. Notice the level of bone in relation wires. The left wire has been removed. FIGURE 5. tibuloplasty.

Below. After

augmentation

graft, there is 40% to the suspension

bone

graft

and

ves-

LIPOSKY

antibiotics was given, a piece of cortical bone graft, 0.5 x 0.7 x 0.1 cm, exfoliated. On subsequent occasions, the patient continued to lose small portions of the graft. An attempt to debride and close the area was successful, but it was thought that the patient would lose a significant amount of the graft because of the loading forces of her denture. On this basis, a mandibular staple bone plate to stabilize the denture was suggested. On May 2, 1979 (19 months after the bone graft), the mandibular staple bone plate was inserted. The patient completed her prosthetic treatment by the 12th postoperative week. To date, she has had no further evidence of remodeling or bone loss in the graft sites. The patient is

FIGURE 6. Above. staple bone plate.

Patient No. 1, after insertion of mandibular

FIGURE 7. Center. Final dentures in position. Notice the extension of the labial and buccal denture flange. FIGURE 8. Below, Twenty-seven months after the graft and six months after insertion of the mandibular staple bone plate.

FIGURE 9. Patient No. 2, preoperative view. Notice the decreased anterior facial height associated with autorotation of the mandible. There is also lack of sup port for the lower facial musculature.

able to eat, speak, and enjoy all the functions of her dentures. (Figs. 6, 7. and 8). Patient No. 2. A 53-year-old white woman was seen for evaluation of right temporomandibular joint pain and ill-fitting dentures. She had been edentulous in the maxilla for 33 years and in the mandible for 23 years. Ten years before this visit, the patient had been treated for right temporomandibular joint dysfunction by an increase in the vertical dimension with new dentures. She had experienced improvement, but the symptoms had gradually recurred. The patient also had episodes of labial anesthesia following meals. Her chief complaint was the temporomandibular joint pain. Examination showed facial changes consistent with autorotation of the mandible and decreased vertical dimension (Fig. 9). Oral examination showed extensive alveolar bone loss with complete obliteration of the buccal and labial vestibules (Fig. 10). She had crepitus over both temporomandibular joints and marked pain in the right temporomandibular joint. Radiographic examination revealed degenerative changes in the temporomandibular joint and extreme mandibular atrophy with exposure of the neurovascular bundles bilaterally on the crest of the alveolus (Fig. 11). The treatment plan was to re-establish the vertical dimension using a treatment denture to see if the TMJ symptoms would subside. If they subsided, then a mandibular staple bone plate would be inserted to stabilize the denture and thus treat the temporomandibular joint dysfunction. The temporary denture was inserted, and the patient’s progress appeared to be quite good. After approximately three months, more acute symptoms developed in the temporomandibular joint. TMJ arthrography reveaied a perforation of the right meniscus and condylar degeneration bilaterally. A right arthroplasty revealed total degeneration and perforation of the meniscus. The condyle was eroded and required recontouring. A Proplast Teflon sheet was placed to reconstruct the temporomandibular joint. The patient’s postoperative progress was quite satisfactory, and her symptoms completely subsided. Crepitus without pain occurred in the left joint but did not require treatment. Because it was important to stabilize the lower denture and maintain the vertical dimension, a lower denture was planned. Advanced mandibular atrophy precluded use of a conventional denture. Therefore, on March 20, 1980, an iliac crest graft was placed on the posterior mandible, and

MANDIBULAR

STAPLE BONE PLATE

mandible as is needed. In each case, resorption has occurred in the first six months, resulting in approximately 40 to 50% loss of the original graft. The rate of bone loss decreases substantially after the six-month postoperative period, and only an additional 5 to 10% is lost over the subsequent five years.2*5 The Baker study reported that even though most grafts did resorb, function was greatly improved.13 Clinically, the ridge form was more receptive to the denture. Fazili reported “almost complete” resorption, but generally good clinical improvement, after 39 months.‘” Although the patient will have a greatly improved denture base and denture function, much greater improvement can be achieved with the addition of the mandibular staple bone plate. If it is true that a mobile denture contributes to bone loss, then the

FIGURE 10. Above, Patient No. 2, preoperative view of alveolar ridge. Notice the shallow vestibule and minimal amount of attached gingiva. FIGURE 11. B&W. Preoperative radiograph. There is advanced mandibular atrophy with exposure of the neurovascular canal bilaterally.

a mandibular staple bone plate was inserted in the anterior mandible (Fig. 12). Because the mandibular staple bone plate was inserted at the time of the augmentation bone graft it was possible to construct a temporary denture to maintain the vertical dimension. This denture did not extend over the graft area but established occlusion only in the anterior region. Care was taken to distribute vertical forces to the anterior ridge. At the 12th postoperative month, after the use of several temporary dentures, final prosthetic rehabilitation was completed. The patient’s postoperative progress has been quite satisfactory; minimal bone loss has been noticed (Figs. 13, 14, and 15).

Discussion When severe atrophy bone grafts are often tibuloplasty procedure.

has occurred, augmentation required prior to the vesThe bone graft is usually

taken from the iliac crest or a rib. There are several variations in the bone graft techniques, but most, if not all, augmentation grafts undergo remodeling and resorption in the early postoperative period.‘-12 Most of this author’s experience has been with iliac crest grafts and an extraoral approach. In these cases, nearly twice as much bone is added to the

FIGURE 12. Above, Patient No. 2, one month after grafting and insertion of staple bone plate. FIGURE 13. Crntar. Twelve months after bone grafting and insertion of staple. FIGURE 14. B&W. Staple bone plate in position.

531

LIPOSKY

Summary The mandibular staple bone plate is a helpful adjunct to the treatment of advanced mandibular atrophy when augmentation bone grafts are required. The vestibuloplasty procedure can often be eliminated or modified. The patient can be prosthetically rehabilitated sooner and experiences much greater stability than with the conventional denture. If instability contributes to bone loss, then the mandibular staple bone plate should decrease the rate of bone loss in these more vulnerable denture patients and subsequently improve the long term results of the augmentation procedures.

FIGC IRE 15. Patient No. 2, Postoperative view: dentures in place.

References

more

effective

the

stabilization

of the

denture,

the

bone loss should occur.15*‘6 When the mandibular staple bone plate is included in the treatment plan, the postgraft vestibuloplasty can be limited to the bone plate area only. In some cases, palatal grafting over the area where the transosteal pins enter the oral cavity is the only vestibuloplasty procedure required. When the mandibular staple bone plate is used, it can be inserted as soon as the gross remodeling of the graft has occurred. In some cases where the grafts do not extend to the anterior alveolar area, the staple can be placed early in the post-graft period or at the same time as the insertion of the graft (Case 2). Care must be taken, however, to prevent communication between the staple and the graft. The staple should in these cases be completely supported by mandibular bone. In cases where severe atrophy is limited to the posterior mandibular area, the insertion of the mandibular staple bone plate in the anterior region may be all that is needed for the patient to function with the denture. However, if the patient is under 40 years of age or if there is involvement of the inferior alveolar nerve, grafting of the posterior area and/or repositioning the neurovascular bundles is indicated. less

1. Kethley JL Jr et al: The lipswitch: A modification of Kazanjian’s labial vestibuloplasty. J Oral Surg 36:701, 1978 2. de Kooman HA et al: Interposed bone graft augmentation of the atrophic mandible. J Maxillofac Surg 7:129, 1979 3. Stoelinga PJ et al: Interpositional bone graft augmentation of the atrophic mandible: A preliminary report. J Oral Surg 36~30, 1978 4. Peterson LJ et al: Mandibular ridge augmentation by a modified visor osteotomy: Preliminary report. J Oral Surg 351999, 1977 5. Ridley MT et al: Resorption of rib graft to inferior border of the mandible. J Oral Surg 36546, 1978 6. Danielson PA et al: Subcortical bone grafting for ridge augmentation. J Oral Surg 34:887, 1976 7. Sanders B et al: Inferior-border rib grafting for augmentation of the atrophic edentulous mandible. J Oral Surg 34:897, 1976 8. Reitman MJ et al: Augmentation of the deficient mandible by bone grafting to the inferior border. J Oral Surg 34:916, 1976 9. Bell W et al: Surgical correction of the alveolar ridge: A preliminary report on a new concept of treatment. Oral Surg 431485, 1977 10. Schettler D et al: Clinical and experimental results of a sandwich-technique for mandibular alveolar ridge augmentation. J Maxillofac Surg 5:199, 1977 11. Curtis TA et al: Autogenous bone graft procedures for atrophic edentulous mandibles. J Prosthet Dent 38:366,1977 12. Davis WH et al: Transoral bone graft for atrophy of the mandible. J Oral Surg 28:760, 1979 13. Baker RD et al: Long-term results of alveolar ridge auementation. J Oral Shg 37:486, 1979 14. Fazili M et al: Follow up investigation of reconstruction of the alveolar process in the atrophic mandible. Int J Oral Surg 7:400, 1978 15. Canzona JE et al: Autogenous bone grafts in augmentation of the edentulous canine mandible. J Oral Surg 34:879, 1976 16. Atwood DA: Reduction of residual ridges: A major oral disease entity. J Prosthet Dent 26:266 I

I