CLINICAL REPORT aDoctoral stu bDoctoral stu cDoctoral stu dAssistant Pr eAssistant Pr fFull Professo THE JOURNA Multidisciplinary approach to oral rehabilitation with dental implants after gunshot injury: A clinical report Lélis Gustavo Nícoli, MSc,a Suzane Cristina Pigossi, MSc,b Raphael Ferreira de Souza Bezerra Araújo, MSc,c Cláudio Marcantonio, PhD,d Élcio Marcantonio, PhD,e and Élcio Marcantonio, Jr, PhDf ABSTRACT This clinical report describes a multidisciplinary approach to treat a patient with edentulism and a severe anatomic defect in the mandible caused by a gunshot injury by using an implant-fixed complete dental prosthesis. An immediate loading interim implant-fixed complete dental pros- thesis in the mandible associated with a maxillary removable complete denture prosthesis was initially provided to restore the intermaxillary relation. Nasal floor elevation and maxillary sinus augmentation were subsequently performed to increase the maxillary bone volume. Definitive implant-fixed complete dental prostheses were placed in both arches in order to rehabilitate this initially compromised anatomic condition, which ensured patient satisfaction and improvement in masticatory function and esthetics. (J Prosthet Dent 2018;119:329-33) Gunshot injuries can have de- vastating consequences, inclu- ding extensive bone and soft tissue destruction in the oral and maxillofacial region,1 cre- ating difficulties for rehabilita- tion with endosseous dental implants.2 Dental implants have been used to retain and support fixed complete dental prosthe- ses, improving the retention and stability of the prosthetic rehabilitation. Implant-supported restorations bring func- tional and psychological advantages for the patients, enhancing their comfort and self-confidence.3 Delayed, early, and immediate loading of implant-fixed complete dental prostheses have been described.4,5 In immediate loading, the prosthesis is placed as soon as the implant is inserted, which has some advantages, including more rapid prosthetic replacement and reduced morbidity, treatment time, and number of surgical procedures.6-8 A review of 15 randomized controlled trials found no clinically important differences in prosthesis and implant failure or bone loss among the loading protocol types.9 Bone height in the maxilla is usually limited by the extended nasal cavity and maxillary sinus pneumatiza- tion, which hinders the ideal 3-dimensional position of the implants.10 Several techniques have been used to increase bone volume in the maxilla, including nasal floor elevation and maxillary sinus augmentation.11,12 In these dent, Department of Diagnosis and Surgery, São Paulo State University, A dent, Department of Diagnosis and Surgery, São Paulo State University, A dent, Department of Dental Materials and Prosthesis, São Paulo State Uni ofessor, Dental Graduate Program, University Centre of Araraquara, Araraq ofessor, Dental Graduate Program, University Centre of Araraquara, Araraq r, Department of Diagnosis and Surgery, São Paulo State University, Arara L OF PROSTHETIC DENTISTRY procedures, the nasal mucosa and/or the maxillary sinus membrane are carefully elevated, and the cavity is filled with bone graft material. Recent studies have shown that both techniques are effective in maxillary bone reconstruction, and their implant success rates were similar.13-16 This clinical report describes a multidisciplinary approach for the treatment of a patient with edentulism and severe atrophy of both arches because of a gunshot injury by using implant-fixed complete dental prosthesis. CLINICAL REPORT A 63-year-old man, a heavy smoker (more than 20 cig- arettes/day for 45 years), in good general health, was admitted to the School of Dentistry at Araraquara for oral rehabilitation with dental implants (Fig. 1). The patient had experienced a gunshot injury affecting his mandible raraquara, Brazil. raraquara, Brazil. versity, Araraquara, Brazil. uara, Brazil. uara, Brazil. quara, Brazil. 329 http://crossmark.crossref.org/dialog/?doi=10.1016/j.prosdent.2017.03.020&domain=pdf Figure 1. Pretreatment. A, Extraoral view. B, Panoramic radiograph shows extensive bone defect in mandibular right side associated with reconstruction plate and vertical bone resorption on left side of maxilla. C, Intraoral view. 330 Volume 119 Issue 3 23 years previously and had received a reconstruction plate for mandibular fixation at that time. After the reconstruction, the patient’s oral rehabilitation involved a removable dental prosthesis in both arches. However, the mandibular atrophy impaired the performance of the prosthesis because of insufficient retention, limiting the patient’s mastication and speech. THE JOURNAL OF PROSTHETIC DENTISTRY A clinical examination revealed an edentulous maxilla and some residual roots in the mandible. An extensive bone defect associated with the reconstruction plate used for the mandibular fixation after the gunshot injury was observed in the right side of the mandibular arch. In the maxilla, vertical bone resorption was extensive on the left side because of the masticatory forces exerted over more than 2 decades between the edentulous maxillary alveolar ridge and the remaining antagonist teeth (Fig. 1). First, presurgical prosthetic planning for fabricating an implant-fixed complete dental prosthesis was executed, following conventional clinical steps. The vertical dimension was adaptively restored because of the patient’s anatomic limitations, which included an altered condylar hinge position, limited mouth opening, and tissue loss on the right side of the lower lip. An immediately loaded implant-fixed complete dental prosthesis in the mandible associated with a complete denture prosthesis in the maxilla was proposed to restore the occlusal vertical dimension before providing definitive maxillary and mandibular implant-supported prostheses. The mandibular rehabilitation at this stage was limited to the right mandibular second premolar only to avoid excessive masticatory force on the atrophic side of the mandible. The right mandibular second premolar was maintained in infraocclusion, and the masticatory forces were distributed from the right mandibular first premolar to the left mandibular first molar. The reconstruction plate was not removed before placement of the dental implants. This was to avoid the surgery necessary for this procedure, as implants could not be installed in this region because of limited bone availability. After the clinical evaluation, a transparent autopolymerizing acrylic resin multifunctional guide was made by duplicating the mandibular wax base and tooth arrangement. The height, diameter, and distribution of the dental implants were planned from cone beam computerized tomography (CBCT) images. Local anesthesia was induced using a 4% articaine solution with epinephrine (1:100 000 dilution; articaine 100; Nova DFL). An intraoral crestal incision was initiated in the left molar area and extended to the second premolar area on the opposite side. Subperiosteal dissection was performed to expose the mental foramina, and the remaining teeth were extracted. Prior to implant site preparation, the residual ridge crest of the mandible was flattened with a rotating bur under sterile saline solution irrigation to ensure sufficient space to accommodate the prosthetic requirements. The multifunctional guide was used to delimit the area to be implanted. The drilling sequence followed the manufacturer’s recommendation, and 5 external hexagon 3.75×1.5 mm implants (Conexão Nícoli et al Figure 2. Five dental implants with abutments installed in mandible (left side) to avoid excessive masticatory force on atrophic side. March 2018 331 Sistema de Próteses) were placed. The insertion torque for all implants was approximately 45 Ncm, which allowed the immediate loading approach. Sutures were made using 4-0 silk (4-0 silk; Ethicon). The abutments (Micro Unit; Conexão Sistema de Próteses) were installed (Fig. 2), and dental implant impressions were made using the multifunctional guide. The metal framework fabrication was made by waxing and con- ventional casting of Ni-Cr alloy. On the day after the surgery, the metal framework and teeth were evaluated, and the prosthetic adaptation and esthetic/functional parameters were found to be adequate. After 48 hours, the mandibular implant-fixed complete dental prosthesis and the maxillary removable complete denture prosthesis were delivered, and occlusal adjustment was made (Fig. 3). The patient was scheduled for a follow-up visit every 4 months for removal, evalu- ation, and cleaning of the prosthesis and examination of the implants. Two months after the mandibular surgery, a CBCT of the posterior maxilla revealed pneumatization of the left Figure 3. A, Mandibular implant-fixed complete dental prosthesis and maxilla complete dental prosthesis modification design. Nícoli et al maxillary sinus and severe crestal resorption on the left side of the maxilla, resulting in close proximity between the alveolar crest and nasal cavity (Fig. 4). A maxillary inlay bone graft using the nasal floor and maxillary sinus augmentation technique was thus proposed to allow dental implant placement in this region. The leukocytic-platelet rich fibrin (L-PRF) was pre- pared as described by Choukroun et al17 in fragment or membrane forms before the surgical procedure. Under infiltrative local anesthesia, a full-thickness mucoper- iosteal flap was raised to gain access to the lateral wall of the sinus. The lateral wall cortical bone was removed using diamond round burs with sterile saline irrigation. The sinus membrane was elevated with special curettes (Cureta para Levantamento de Seio; Neodent) and the medial maxillary sinus wall was removed, allowing nasal cavity access. Nasal mucosal elevation was then per- formed using the same curettes. The elevation extension was determined by the position of the most mesial/ distal dental implant. The L-PRF membrane was placed over both sinus and nasal membranes to prevent perforation by the particulate graft (Fig. 5). The sinus and nasal cavities were filled with deproteinized bovine bone material (DBBM) and L-PRF (0.25- to 1-mm particle size) using a 2:1 ratio.18,19 The L-PRF mem- brane also covered the access window before flap closure to improve soft tissue healing. Flap closure was completed using 4.0-nylon interrupted sutures (ETHI- LON Suture; Ethicon). Standard sinus lifting post- operative instructions were prescribed. The sutures were removed 10 days after the surgery. A healing time of 8 months was indicated to ensure adequate bone formation. However, before the patient’s healing time was complete, in situ oral squamous cell carcinoma was diagnosed in the patient, localized to the left retromolar area of the mandible. Because of the extensive oncolog- ical treatment, the dental treatment had to be ry denture installed in first treatment phase. B, Mandibular implant-fixed THE JOURNAL OF PROSTHETIC DENTISTRY Figure 4. Maxillary cone beam computerized tomography images. Pneumatization of left maxillary sinus associated with severe crestal resorption on maxilla left side. Figure 5. Internal view of the maxillary sinus and nasal cavity coated with leukocytic-platelet rich fibrin (L-PRF) membrane to prevent perforation by particulate graft. 332 Volume 119 Issue 3 interrupted. For the cancer treatment, the lesion was completely excised and chemotherapy without bisphosphonates was prescribed. Two years after the cancer diagnosis, following the same approach described in the first surgical phase, a total of 6 morse cone connection implants (Conexão Sistemas de Prótese) were placed, 3 (3.75×11.5 mm) on the left and 3 (3.5×10 mm) on the right side of the maxilla. Definitive impressions and abutment selections were made 6 months after implant healing. A maxillary metal framework was fabricated, and the tooth arrangements for maxillary and mandibular definitive fixed implant protocol prosthesis were fabricated to maintain the occlusal vertical dimension established and confirmed with the interim prosthesis. At the last follow-up visit (34 months from the implant-fixed prosthesis installa- tion in the mandible and 4 months from that in the maxilla), the patient reported improvement in his masticatory function, esthetics, and quality of life and expressed satisfaction with the definitive result of the treatment. No prosthesis failure or radiograph signs of peri-implant disease were found in this follow-up visit (Figs. 6, 7). THE JOURNAL OF PROSTHETIC DENTISTRY SUMMARY After 23 years of edentulism, the patient showed alter- ation in the intermaxillary relationship associated with bone/soft tissue atrophy in both arches. An immediate Nícoli et al Figure 6. Post-treatment images. A, Extraoral view. B, Intraoral view. Figure 7. Panoramic radiograph after 2 years and 10 months in mandible and 4 months in maxilla from implant-fixed prosthesis installation. March 2018 333 loading interim implant-fixed complete dental prosthesis in the mandible associated with a maxillary removable complete denture prosthesis was initially provided to restore the intermaxillary relation. Nasal floor elevation and maxillary sinus augmentation were subsequently performed. Definitive implant-fixed complete dental prostheses were placed in both arches. REFERENCES 1. Motamedi MH. 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Corresponding author: Dr Elcio Marcantonio Junior Department of Diagnosis and Surgery São Paulo State University (UNESP) Humaitá, 1680 Araraquara, SP -14801-903 BRAZIL Email: elciojr@foar.unesp.br Copyright © 2017 by the Editorial Council for The Journal of Prosthetic Dentistry. 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