The Importance of Multidisciplinary Treatment Planning: Revision Treatment for Maxillary and Mandibular Arches Following Catastrophic Failure of Initial Implant Reconstruction
Sadesh Kumar, DMD, BDS; Thomas J. Balshi, DDS, PhD; Ramzey Tursun, DDS; Martinos K. Gavathas, BS; and Joanne M. Balshi, BA
Abstract: The high success rate of current dental implant protocols makes studies of catastrophic failures a rarity; however, this article presents a case study in which faulty medical intervention was the direct cause of traumatic implant failure. The patient, who had been treated with implants that successfully osseointegrated, ultimately experienced a life-threatening medical incident due to an ill-fitting definitive prosthesis. This case report includes a detailed narrative of how this patient, who began his dental journey with compromised and missing teeth, became edentulous and then, following an arduous recovery, was restored to full function with a meticulously planned revision treatment. Today, after enduring radical and perhaps unnecessary treatment and physical and mental trauma, the patient is tolerating osseointegrated implants with both maxillary and mandibular prostheses that are comfortable and well-functioning.
This case report describes the restoration of an edentulous patient via a complex revision treatment. In order to establish a comprehensive portrait of this patient's history, it is beneficial to draw on the significant narrative that demonstrates the efficacy of early Brånemark concepts, which urge meticulous attention to implant placement that is functionally adequate for the definitive prosthetic solution.1 The evolution of extensive digital implant planning tools along with enormous advances in tissue-integrated prostheses have made it possible to predesign definitive prosthetic dentitions based on an individual patient's ideal anatomy.2 Thus, as demonstrated herein, a prosthetically driven plan can emerge as a natural guide for implant placement to achieve the desired result.
Previous Flawed Treatment
In this case, a 40-year-old male patient, who was a trained operating room technician in pursuit of a nursing career and a veteran of the US Armed Forces, presented edentulous with an alarming clinical back story. Prior to his initial treatment he had limited function with anterior teeth, missing posterior teeth, and tongue enlargement into the molar space bilaterally (Figure 1 through Figure 4).
Previously, the patient had committed to a full-mouth reconstruction and was treatment planned for a fixed maxillary and mandibular prosthetic restoration based on four standard implants and two zygomatic implants in the maxilla and four standard implants in the mandible. The implants were placed by an oral surgeon, and interim prostheses were immediately placed by a prosthodontist in a dental treatment center.
According to the patient's testimony, the acrylic provisional screw-retained prostheses were uncomfortable for the duration of the osseointegration process, but he tolerated them in anticipation of a better-fitting definitive prosthesis (Figure 5). While the original implant placement may have been within normal limits, poor anatomical construction of the provisional was the likely source of the patient's primary dissatisfaction; however, the zirconium-opposing-zirconium final prosthesis created even more severe discomfiture, and despite the laboratory's multiple efforts to recontour the prosthetic teeth, the patient grew continually more anxious about what he described as obstruction of his tongue movement and teeth that was considerably different from his customary jaw relationship (Figure 6 and Figure 7).
According to Balshi et al, the zirconium maxillary and mandibular prosthetics have an inherent fracture potential that can alter occlusal integrity and even contribute to the development of an overbite.3 Although the patient's dental records from this period of treatment indicated no complications, the patient reported suffering difficulty initially with mastication, then impaired speech as well as lip, cheek, and tongue biting, eventually reaching the point where his oral trauma severely affected his sleep. The final breaking point for the patient was the severity of pain he endured when he bilaterally traumatized his tongue by repeatedly biting it.
The patient then sought care in a different facility, hopeful for a consultation and possible retreatment. Upon clinical examination, a severe laceration was noted, having entirely pierced the dorsal surface bilaterally on the tongue (Figure 8 and Figure 9). He was treated with palliative laser biostimulation, given amoxicillin (500 mg) and chlorhexidine mouthrinse, and was provided a nightguard. (The model/brand of laser and how it was used, as well as the brand of chlorhexidine mouthrinse, was unavailable to the authors.)
The patient was then scheduled for a follow-up visit that would involve debridement and suturing of the tongue. At this return visit, upon evaluation, the patient was found to have multiple oral lacerations that fomented severe swelling of the tongue. His condition indicated a fluid deterioration of the airway's ability to function effectively. He appeared to be suffering from rapid onset angioedema, a subdermal swelling that releases histamines and other chemicals into the bloodstream.4 Therefore, it was recommended that the patient promptly present to a hospital emergency center to alleviate the immediate breathing issues.
Unfortunately, the patient's ordeal, brought on by a defective execution of a dental implant treatment plan with implants that despite being placed in the center of available bone had poor angulation resulting in an ill-fitting, incorrectly sized prosthesis, would continue at the hospital emergency center. The tongue swelling increased, further constricting the airway; thus, a decision was made to intubate and sedate the patient. The intubation continued for 22 days as the chronic biting had resulted in an infection that spread to the patient's lungs, causing acute respiratory distress syndrome, pneumonia, and sepsis. Cultures indicated the presence of both Escherichia coli and Klebsiella. The treatment regime consisted of intravenous therapy antibiotics and steroids; however, at this point the hospital treating team determined that in addition to the lungs, the dental implants were also grossly infected.
The hospital records reflect that an oral surgeon was called in to remove the implants, thereby arresting the chronic tongue biting so that the source of the pulmonary issues could be treated. The surgeon opted to remove both the maxillary and mandibular prostheses but his lack of familiarity with prosthetic drivers prevented a simple unscrewing of the zirconium prostheses. The oral surgeon aggressively explanted all 10 implants (even though they had fully osseointegrated) in order to create ample space for the tongue and restore adequate airway function. This unnecessarily radical surgical intervention removed not only the implants and implant prosthodontics, but also a substantial amount of healthy bone into which the original fixtures were well-integrated (Figure 10 and Figure 11). The patient was then left with a severely atrophic maxilla and mandible.
Revision Treatment
Therein begins the revision treatment for the patient, whose oral, pulmonary, and psychological health had suffered a long-term catastrophic impact that required months of physical, occupational, and speech therapy before he could even consider a methodology to restore his mouth. He felt hopeless because of the massive amount of bone loss he experienced with the removal of his original implants. However, having a medical background, the patient engaged in multiple consultations discussing restorative options until a revision treatment plan with collaborative protocols solidified. He underlined the early Stig Blomberg conclusions that edentulism is a serious psychological handicap even when compensated with dentures, and that the very nature of the fixed restoration breeds wholeness and security.5 This was the level of oral wellness that the patient felt he required and deserved.
The initial step was guided by a hospital oral surgery team. The treatment plan was strategically constructed using the Sadowsky and Bedrossian guidelines,6 giving exceptional consideration to the patient's recent dental history, current systemic condition, affinity for infection, and tolerance of surgical exposure. In a 6-hour procedure in the operating suite, a portion of the patient's fibula was removed from his left leg and grafted in sections to the edentulous maxilla, connecting the vascularity to preserve bone vitality and promote both healing and the osseous maturation process (Figure 12).
The fibula is the most common donor site for maxillofacial rehabilitation, as studies show the increasing effectiveness of the graft accelerating osseointegration.7 In addition, donor site morbidity is minimal with an anticipated return to normal ambulation 4 weeks after surgery.8 The mandible was reconstructed with a tissue engineering concept mixing bone morphogenetic protein (BMP) and applying allografts obtained from fibula fragments.
During this same surgery, the remaining apical pieces of the original zygomatic implants were removed.9 Postoperatively, the patient remained in the intensive care unit for an entire week, but the surgical procedure was highly successful. Both the maxilla and mandible healed solidly over a period of 4 months, allowing the next phase of the revision treatment to commence guided by an experienced implant/restorative clinician.
Given the oral trauma previously experienced by this patient, his candidacy for revision treatment was scientifically scrutinized at length. The treatment plan was designed using a two-stage protocol to allow for optimum healing. In the initial phase, five implants were placed in the maxilla and four in the mandible. Zygomatic implants were no longer required because the fibula graft provided sufficient bone height and width to support standard-sized implants. The implants were placed submucosally with no contraindications (Figure 13 through Figure 16), and the patient, who remained closely monitored for infection and complications, healed successfully over an extended period of 6 months. During this time he wore a maxillary and mandibular complete removable denture, which established the vertical dimension for the construction of the conversion prosthesis. During the osseointegration period, vestibuloplasty in the mandible was necessary to control the mucosal tissue position, thereby creating complementary soft-tissue healing that was anatomically receptive to the installation of abutments on the new implants.10
Primary tension-free closure to all soft-tissue flaps over the grafted site was necessary to ensure simultaneous healing of bone and soft tissue with no wound dehiscence.11
Provisional and Definitive Prostheses
Two months after the screw-retained abutment installation, final impressions were taken using the PIC (Precise Implants Capture, picdental.com) method for accuracy,12,13 and the estimated occlusal vertical dimension was recorded. Because of this patient's history, extreme diligence was given to the construction of the provisional implant-supported screw-retained prosthesis, ensuring no potential impingements of the tongue or intraoral mucosa would result. According to Bidra, prosthetic space needs to be fully determined in the planning stage of a case to ensure the patient's oral cavity is adequate for the dimensions of the fixed or removable prosthesis.14
A fully milled monolithic polymethyl methacrylate (PMMA) prosthesis was then fabricated. The jaw relationships indicated a class III position was most advantageous. The patient tolerated the first conversion prosthesis for several months with only minute incursions on his tongue space; a second conversion prosthesis, however, was milled to provide the patient with even more lateral tongue space, widening the position of the posterior teeth in both arches (Figure 17).
Before the eventual placement of the definitive prostheses and the choosing of the most appropriate restorative materials, the treatment team, comprised of an oral and maxillofacial/orthopedic surgeon who performed the fibula grafting, a prosthetically trained implant clinician who placed the implants, an advisor in implant surgery, dental assistants, and a digital dental laboratory, engaged in a multifaceted analysis of the patient's physical and psychological ability to tolerate a long-term fixed prosthodontic solution. In addition to Albrektsson's traditional principles for predicting implant survival,15 the patient's skeletal and natural dental occlusion, resting tongue position, and history of seizures were factored. The teeth were set forward and wider than the initial narrow prosthesis, based on the neutral zone with consideration given to the number of years the patient had missing posterior teeth, which may have contributed to the original catastrophic intolerance of implant therapy.
The definitive screw-retained prostheses were constructed with multiple materials, utilizing a titanium framework splinted to the implants and individual zirconia crowns with a layer of polyetheretherketone (PEEK) over the titanium and a pink resin replicating gingiva (Figure 18 through Figure 21).16
The patient today enjoys uncompromised oral health, comfort, and esthetics.
Discussion
This case study discusses a critical dental case in which initial implant procedures led to severe complications for a 40-year-old patient with compromised dentition. Despite proper osseointegration, the implants caused traumatic failure manifested as physical discomfort, impaired speech, and acute medical emergencies, including tongue lacerations and airway blockage. The flawed zirconium prostheses induced chronic injuries, eventually leading to pneumonia and sepsis. Subsequent emergency treatments included antibiotic therapy and the aggressive removal of the implants, causing significant bone loss.
The patient then underwent extensive multidisciplinary revision treatment, which included a fibula graft for maxillary reconstruction, careful implant placement, and personalized prosthodontic adjustments. The successful restoration emphasized the importance of detailed planning and consideration of the patient's anatomical and psychological needs in complex implant therapies.
Conclusion
Complicated dental implant reconstructions/revisions are best accomplished with multidisciplinary consideration of anatomical structure, comprehensive medical, dental, and psychological history, and analysis of oral habits and tongue usage. The digital treatment plan should be prosthetically driven with all facets scientifically incorporated into the plan so that "prosthetic space" is sacredly achieved for each individual patient.
About the Authors
Sadesh Kumar, DMD, BDS
Private Practice, Melbourne, Florida; Membership of the Faculty of Dental Surgery (MFDS), Royal College of Surgeons of England; Diplomate, International Congress of Oral Implantologists
Thomas J. Balshi, DDS, PhD
Prosthodontist Emeritus, Founder, Pi Dental Center, Fort Washington, Pennsylvania; Diplomate, American Board of Prosthodontics; Fellow, American College of Prosthodontists
Ramzey Tursun, DDS
Associate Professor, Clinical Surgery, Department of Dental and Maxillofacial Surgery, Jackson Memorial Hospital, Miami, Florida; Fellow, American College of Surgeons
Martinos K. Gavathas, BS
Dental Assistant, Melbourne, Florida
Joanne M. Balshi, BA
Medical Writer and Practice Coach, Vero Beach, Florida
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