Long-term results of mandibular bone grafting operations
48-year-old male who had undergone multiple surgical attempts to augment mandibular bone for implant placement ('pins'). The patient received the opinion of a spesialist who spotted severe atrophy in the right mandibular posterolateral area. He reported on the condition of the mucosa with high insertion of frenii in the level of the alveolar ridge. Also the report related to occlusion problem and temporo mandibular dysfunction. In 2007, the patient received a report following a neurophysiological examination of the masseter muscle showing a change in sensation from the lower alveolus.
1) Do you think that the described situation could have a solution?
2) In the event of affirmative answer to the above question, what kind of surgical operation would you suggest?
3) Which maxillofacial surgeons and/or centers of excellence could you indicate in Italy outside the Milan area and its province?
48 years old, male, Italian
In 2003 the patient underwent a dental visit to heal some cavities and to assess the prosthetics surgery of a right mandibular edentulous space (3 teeth lacking). Having little bone to insert the pins, on May 2004 he therefore underwent autologous bone graft surgery to take from the mounting mandibular branch. After a little while an infection occurred in the area undergone to surgery and, therefore, all the bone grafts were removed.
On July 2004 another surgery was carried out by the same dentist with the insertion of a synthetic bone. During post-surgery the patient reported sharp pain and the repeated detachment of stitches that led the dentist to make new sutures in two occasions. During the next follow-up visit the dentist decided the patient to be examined, on July 2004, by a maxillofacial surgeon who decided for the immediate removal of the grafts explaining to the patient that he could not undergo implantations anymore. In the following days the algic symptomatology improved until it completely receded. At that point the patient decided to interrupt all the treatments.
Following the opinion of another specialist the patient underwent a CT scan of the mandibular arch on April 2005 (to attach) with the following report: “In the edentulous spaces of the two hemi-arches, atrophy of moderate importance in the vertical direction of the alveolar processes with good horizontal integrity, good vestibular and lingual cortical condition, as well as the alveolar ridge. The bone thickness appears moderately uncompromised with related prevalence of osteosclerotic lesion in the distal areas. Moderate marginal periapical paradontitis at 37 bridge abutment (Scan 52 - 56) and mixed form of parodontopathy to the remaining elements. The edentulous distal areas of the two arches show, moreover, moderate lingual undercut.”
On June 2005 examination at Prof. S. (odontostomatologist) consulting room who gave the following medical report:“today (June 2005) I visited the patient and I could notice a severe atrophy in the right mandibular posterolateral region. The corresponding mucosa shows signs of cicatricial retraction due to previous attempts of reconstructive operations. The patient reports a feeling of muscular tension and frequent mastication traumas at the level of the corresponding cheek and of the mouth pavement. This symptomatology is to trace back to the decrease of the fornix depth and of the insertion of the muscle near the alveolar crest.
Further operations of graft and bone reconstruction in the area are not advisable as they would determine a worsening of the mucosa situation. In the future there could be indications for a deepening fornix operation by means of free gingival autograft. The patient shows, moreover, algic-dysfunctional pathology on the temporomandibular articulations to be traced back to a bad occlusion.”
Later, on March 2007, the patient also underwent a neurophysiologic examination (to attach) with the following medical report: “The reflex of esteroceptive suppression of the right masseter muscle has been investigated, with a needle electrode placed in it, with electromyographic control of the muscular contraction, with repeated stimulations of the left/right sides of the genian region at variable intensities from 20 to 35mA.
For left stimulations appearance of both asymptomatic times ES1 showing a probable change of the trigeminal sensibility afferent through the lower alveolus.”
At present the patient reports a persisting clinical picture with: strong jaw pains, above all when the patient speaks a lot and chews. The lower part of the jaw has begun to move to the right also puffing up part of the throat; he feels a constant tingling sensation where the operation has been carried out and when he opens and closes his mouth, everything moves jerkily.
Following the presented report, without examination of an updated x-ray and CT, it may diagnosed as a case with unilateral lack of support which may affect the Temporo Mandibular Joint. A periodontal problem along with a decrease in support in the left side, may further worsen the stomatognathic system status and its ability to withstand occlusal loads (mastication forces).
After a full mouth evaluation of the periodontal status that must be performed, a suitable periodontal treatment plan has to be set for the patient. Following that stage of treatment, the first step of treatment must come in the form of a removable partial denture to decrease the load on the right joint. The status of the left lower fixed bridge is in question as teeth 34 and 37 look in questionable prognosis. If the bridge has to be disassembled, the stability of the removable appliance may be improved using the support of the left lower edentulous ridge. A CT scan must be performed of the lower jaw in 1 mm segments to learn the quality and quality of bone.
If tooth 34 will be extracted, that will open space probably for an implant to support a removable partial denture and increase retention and stability.
The existence of a well designed removable partial denture will assist in improving the function of the stomatognathic system. This solution includes minimum surgical interventions and might be a good relief to the right problem.
A CT scan and good x-ray survey in the long cone technique may assist in designing a more sophisticated treatment plan, not necessarily with complex surgical procedures. The only surgical procedure that is most probably needed, is a soft tissue correction of the Masseteric muscular insertions (muco gingival surgery) .
Dr. M. maybe a good surgeon advised for this treatment and he may reccommend on a prosthodontist for this treatment.
Further detailed response will be given upon receiving the requested CT and X-ray periapical survey.