Creation of supports for fixed prosthesis of the upper and lower jaw with advanced atrophy with the help of subperiosteal implants

Dr. Hristo Hristov, Sofia

Jaws with advanced atrophy of the alveolar bone are a problem for prosthetics in dentistry with both plaque prostheses and intraosseous (enosal) implants. In this article I describe the creation of supports for fixed prosthesis of the upper and lower jaw with the help of subperiosteal implants in completely and subtotally edentulous jaws. I used metal-ceramic bridge structures to restore the dentition. The result of the treatment of the patients shows a complete restoration of the function of the upper and lower jaw.

Through this restorative approach, I avoid complicated, expensive and lengthy bone augmentation surgeries to place enosal implants, as well as the high risk of mandibular fracture when using other methods (for example Trans mandibular implants).
Through subperiosteal implants, I created bridge supports for seven people / 5 men and 2 women /, aged 32 to 72 years. I placed 4 implants on the upper jaw, one on the lower jaw, and on one of the patients - on the upper and lower jaw. I used my own patent subperiosteal implants made of titachrome.

After a follow-up period of 8 months to 7 years, it became clear that patients were satisfied with the functional and aesthetic effect.
 



Patients with completely or subtotally edentulous jaws and advanced atrophy of the jawbones are particularly difficult for conventional prosthetics with plaque prostheses, no less difficult for fixed prostheses on implant supports. Such patients were toothless for five, ten, and in some cases more years. Their gingival mucosa is graceful, and the rest of the alveolar bone is sharp as a knife. There are almost no tubers on the upper jaw due to atrophy, the immobile mucosa is small and the sinuses are close to the alveolar ridge. On the lower jaw, n.mentails is just below the mucosa, due to which very unpleasant paraesthesias of the lower lip occur. Also important is the "high" capture of m.buccinator, m.mentails, m.genioglossus and m.mylohyoideus, by palpation I assess the configuration of the alveolar ridge, establish the attachment of gingivobuccal connections and frenulums. Finally yet importantly, I assess the patient's level of intelligence, as well as his hygiene habits.
On orthopantomography I check if there are any extracted roots, cysts, not healed alveoli, the condition of the remaining one or two teeth in subtotal edentulousness, the proximity of the ridge of the alveolar ridge with the sinuses and mandibular canals, etc. I determine if the middle line matches jaws, as well as the degree of sagging of the tissues around the mouth in view of the type of future prosthesis.

Manner of performing the operation

I perform subperiosteal implantation under local anesthesia with Ultracain DS, and in the recent past, I used Baycain. I perform the operation in the dental office in compliance with all the rules of asepsis and antiseptics. I use an "antibiotic umbrella", a broad-spectrum antibiotic, usually Rovamycine. Postoperatively I recommend sputtering with Biodent, and in case of pain, I give Saridon. The distance between the ridge of the gums of the upper and lower jaw is very large. Based on all this, the person receives the so-called "senile appearance - the characteristic sagging of the cheeks and lips and the relative protrusion of the chin. Wrinkles appear around the mouth. In this situation, it is difficult to talk about any stability of the plaque prostheses to provide chewing function. Moreover, practicing certain professions related to speaking and constant social contacts is practically impossible. It is clear that the way of prosthetics and hence of eating and communicating must be radically different.



We create supports by placing implants, but in practice, there are a large number of implantation methods, respectively different in design implants for the treatment of defects of the dentition, characterized by such a large loss of hard and soft tissues. For example:
1. Placing several (usually 4 in number) root implants 3,4 in the area of ​​the symphysis (also applies to the upper jaw), which we connect to the traverse and place a prosthesis on it.
2. Implant placement - bracket in the area of ​​the symphysis of the lower jaw.
3. Bosker Trans mandibular implant placement.
4. Placement of bone grafts, which we position above, below or insert in the middle by osteotomy or hydroxyapatite for reconstructive surgery of the sinus maxillaris. The donor bone we usually take from the os iliaca. After bone grafting or hydroxyapatites, we can place intraosseous implants on the upper and lower jaw or Trans mandibular implants on the lower jaw.
5. Subperiosteal implant placement.
 


The listed possible ways of treatment approach to item 4 are complex, lengthy and expensive, in addition, they have a high risk of failure or postoperative complications. Placing a subperiosteal implant is perhaps the biggest challenge for the dentist; I would call it the "weapon" capable of dealing with such cases.
That is why it is the most commonly chosen method for tooth restoration. The prosthesis (bridge) lying on top is supported by 4 to 6 stumps.

Clinical approach
It includes a thorough examination of the patient, a history of systemic diseases, contraindications of a general nature for any surgical intervention, if necessary; we appointed laboratory para-clinical examinations, as well as analysis of orthopantomography. During the examination, we pay attention to the type and thickness of the mucosa.


Stage 1 - preliminary laboratory.
Taking an imprint. We take fingerprints from the jaws, cast plaster models and make bite patterns on them. After removing the bite, we arrange the teeth as for a prosthesis. This allows us to position the places of the stumps during the operation, which should usually coincide with the third, fifth and seventh teeth. We remove these teeth and drill holes in the base plate. Then we remove all the arranged teeth, and the base plate serves as an individual spoon for the bone.

Stage 2 - preliminary surgical intervention.



We place the individual spoon on the jaw and with a round drill through the holes; we mark the places of the future stumps. We make an incision along the ridge of the gum from the end to the end of the jaw. On the lower jaw, we make additional vertical incisions on the sides of the place of the future stump and so as not to affect the n.mentails and the corresponding blood vessels. We make the same incisions linguistically. On the upper jaw, palatally we make oblique incisions around the papilla incisiva so as not to affect the trunk of n. incisivus, respectively the corresponding blood vessels. Then we prepare on mucoperiosteal lambo, which we sew to the mucous membrane of the cheeks and tongue, and the palatal lambo remains hanging freely. Then with a fissure drill № 8 we make transverse grooves in the bone / Fig. 1 /. The arches of the implant subsequently lie there, which gives it stability and prevents tension from the inside out to the surgical wound, preventing opening between the sutures. Thus prepared, the operative field is very convenient for taking a bone impression. We adjust the individual spoon on the bone and take the impression only with "solid", which is enough for its accuracy. If we use correction, it can enter the pores of the bone, due to its viscosity and after hardening and removal of the impression, the pieces of it remain included in the bone. This leads to a violent reaction with suppuration and fistulization. After pressing the spoon to the bone on it, we add solid and invite the patient to bite. I use Kondisil for a print. I suture the surgical wound with sparse sutures with silk threads № 000. I recommend gargling with Biodent - solutio.

Stage 3 - real laboratory

In the dental laboratory, we cast a model from hard gypsum, we duplicate it with silicone, we cast a new model from a packing table, on which I paint the construction. The dental technician models the implant with profile waxes, wraps it and casts it by the method of model casting. The casting is sandblasted and electro-polished.
We strictly follow the parallelism of the stumps and their length, as this subsequently facilitates prosthetics. We sterilize the implant in an autoclave and it is ready for...


Stage 4 - actual surgery

We perform it 3-4 weeks after the preliminary one. We make the incisions in the same tracks. We cure the chutes and test the implant to see if it "fits" on the jawbone and in the chutes, which is usually the case, but in rare cases, we adjust. Once we find that the implant fits well in place, we make relieving incisions in the periosteum. In this way, we mobilize the lambo to adapt without tension. Then we cut the edge of the flap around the heads of the implant and sew with densely spaced seams, tightening tightly around the stumps. We invite the patient for a daily examination until the removal of the sutures to remove the plaque from the stumps, which ensures the smooth healing of the wound. We remove the sutures on the seventh day.

Stage 5 – orthopedic
 


Stage 6 - hygienic care and control examinations

We recommend that patients with implant prostheses follow stricter hygiene than usual. In addition to the standard toothbrush, the patient must use the brush shown in Fig. 3 to clean interdental spaces. It is good for patients to use chlorhexidine pastes or chlorhexidine solutions for rinsing their teeth after brushing. We appoint control examinations every 6 months in the first year and once a year in the following years. We monitor the observance of hygiene and the detachment of some of the fasteners. At the end of the first year, it is good to take a control X-ray to see if there is a "sinking" of the implant. We do the same at the end of each following year, if the patient appears for a follow-up examination and if he agrees to it. We instruct each of the patients that he should come immediately for a follow-up examination; outside these 6 months in case of an incident, that disturbs him personally. In older male patients and in postmenopausal women in connection with the onset of osteoporosis, we prescribe Osteogenon.

Results



With a total and subperiosteal implant we restored the jaws of 7 people, of which 5 men and 2 women. The age range was 32 to 72 years. We made 4 total subperiosteal implants on the upper jaw and 2 on the lower. One of the above implants - subtotal, and one of the total was deliberately divided into two halves, as the patient had an incredibly strong nausea reflex and after several unsuccessful attempts we took an imprint instead of the whole jaw - 2 halves. We made respectively 2 partial subperiosteal implants, which we implanted in the second operation and subsequently the bridge prosthetic structure united them. By a tragic coincidence, two of the patients had a serious accident, which led to a hospital stay in the neurosurgical ward. In one, we found a fracture of the implant in the area of one of the arches, but without complaints. There was no objective finding. In the other, the inlays of some of the teeth broke off. The breakage was great and this necessitated the removal of the bridge and the construction of a new one.  There was no damage to the implant. We followed the cases from 8 months to 7 years. Patients generally feel well. In terms of hygiene, everyone is strict.

Complications

To date, we know of 4 cases of complications that have received adequate treatment and we have overcome them.



Case 1 - In one of the patients the ceramics of 13 and 23 teeth were broken. We made a correction according to Kisov's method.
Case 2 - Another patient, for 2 years in a row, during a flu epidemic received a palatal abscess near one of the stumps. Under antibiotic protection, we made an incision and the abscess passed.
Case 3 - Another patient developed a jaw pain similar to rheumatic fever. After treatment with Feloran, the pain subsided.
Case 4 - Due to the impossibility of preservation, we cut the n.mentalis bilaterally during the fingerprinting operation. The patient received anesthesia on the lower lip, which gradually turned into paresthesia and eventually resolved spontaneously.

Conclusion

The use of total and subtotal subperiosteal implants in many cases is the most acceptable, fastest, associated with the low operative risk and the cheapest alternative for the dentist and for the patient who does not want or cannot wear removable dentures. The dentist must show a creative sense and a fine aesthetic sense in order to anticipate the necessary functional and aesthetic effect. In his hands is the possibility to combine a subperiosteal implant and natural teeth, as well as to combine a subperiosteal implant with a bridge or joint connecting prosthetic structure. The presented cases emphasize the advantage of the complete attachment of the prosthetic structure on implants and inspire confidence for a relatively long-lasting effect and minimal risk of complications.