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Table of Contents
CASE REPORT
Year : 2012  |  Volume : 2  |  Issue : 3  |  Page : 201-204

Implant prosthetic rehabilitation following reconstructive custom-made TMJ condyle and fossa prosthesis


Department of Periodontics, Manubhai Patel Dental College and Hospital, Vadodara, Gujarat, India

Date of Web Publication11-Jun-2013

Correspondence Address:
Sarath Chandran Srinivasan
Department of Periodontics, Manubhai Patel Dental College and Hospital, Vadodara, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5194.113261

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   Abstract 

Implant rehabilitation involving patients with facial deformities and temporomandibular joint (TMJ) ankylosis requires competence and expertise. It is important to understand that such patients present with minimal or restricted mouth opening, severe joint and facial pain, mandibular deviation, and facial deformities. The case reported here involved two-stage implant rehabilitation for a 54-year-old female patient who had undergone custom-made TMJ condyle and fossa reconstructive prosthesis due to severe facial deformity and ankylosis of the right TMJ following previous unsuccessful surgeries. Following the reflection of a mucoperiostel flap three implants corresponding to the missing maxillary canine, first and second premolars were placed. To achieve better distribution of occlusal load and optimal esthetics, the prosthesis was restored with 3-unit porcelain fused to metal crown and bridge.
Clinical Relevance to Interdisciplinary Dentistry

  • This case report signifies the multidisciplinary approach to complex implant dentistry through surgical and prosthodontic functional rehabilitation.
  • It also highlights the importance of restoring the dentition in situations of facial and mandibular reconstruction, whereby we achieve optimal and adequate function and esthetics.
  • This unique case report also will conclude the need for future rehabilitation of patients with TMJ condylar reconstruction, and the special care needed to improve occlusal balance.

Keywords: Condyle reconstruction, implant prosthesis, temporomandibular joint prosthesis


How to cite this article:
Srinivasan SC, Vishnoi SL, Singh PK. Implant prosthetic rehabilitation following reconstructive custom-made TMJ condyle and fossa prosthesis. J Interdiscip Dentistry 2012;2:201-4

How to cite this URL:
Srinivasan SC, Vishnoi SL, Singh PK. Implant prosthetic rehabilitation following reconstructive custom-made TMJ condyle and fossa prosthesis. J Interdiscip Dentistry [serial online] 2012 [cited 2019 Aug 17];2:201-4. Available from: http://www.jidonline.com/text.asp?2012/2/3/201/113261


   Introduction Top


Implant dentistry has become a vital part of reconstructive prosthodontics for the partially and completely edentulous patients. In India, it has now been incorporated both in the undergraduate as well as in the specialty programs, and duly accredited by the dental governing bodies. Dental implant restorations have the highest survival rate when compared to any other type of prosthesis to replace the missing teeth provided the recommended surgical and restorative protocols are followed. [1]

However, implant rehabilitation involving patients with facial deformities and temporomandibular joint (TMJ) ankylosis requires competence and expertise. It is important to understand that such patients present with minimal or restricted mouth opening, severe joint and facial pain, mandibular deviation and facial deformities. [2],[3],[4] Another undesirable but common outcome of these patients who have undergone repeated surgeries involving the TMJ is damage to the sensory and sympathetic neuronal fibers, known as reflex sympathetic dystrophy. In these situations, all neuronal signals such as thermal, pressure, touch, etc., are perceived as acute pain, the most difficult part to correct, and requires medications that help reduce neural inflammation. [3],[4],[5],[6] The other reason for pain is the structural damage to the masticatory musculature, which involves continuous physical therapy and sometimes the use of special jaw-stretching devices (Therabite Corporation, Newton Square, PA, USA), to aid in stretching the muscles and avoid spasm or trismus type of situations [Figure 1]. [4],[5],[6],[7],[8]
Figure 1: Therabite, jaw opening and measuring device

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The present case involves two-stage implant rehabilitation for a patient who had undergone custom-made TMJ condyle and fossa reconstructive prosthesis due to facial deformity and ankylosis of the right TMJ following previous unsuccessful surgeries [Figure 2]a and b.
Figure 2: (a) Front profile showing right side mandibular deformity, (b) side profile showing right mandibular condyle area deformity, (c) pre-operative radiograph showing the TMJ and condyle prosthesis

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   Case Report Top


A 54-year-old female patient presented for fixed implant prosthesis of the maxillary left canine, first and second premolars, following reconstruction of the right TMJ condyle and fossa with a custom made prosthesis [Figure 2]c. This surgery was done to restore the severe facial deformity and ankylosis of the right TMJ as a result of multiple unsuccessful TMJ surgeries. The procedure involved facial reconstruction, coronoidectomy and reconstruction of the right mandibular condyle and fossa with a custom-made prosthesis. The patient was placed on intermaxillary fixation to hold the jaw in proper alignment and position. The patient was advised to restrict mouth opening not beyond 3 cm (≥1.5 inches) for the first 6 months, and a semi-solid/soft diet. Routine dental prophylaxis with care was provided at 3-month intervals to help the patient maintain adequate oral hygiene. All other elective dental procedures were avoided for 1-2 years following the TMJ surgery. The patient was instructed regular physical therapy to improve the mouth opening and jaw movements and given anti-inflammatory drug to reduce the neuronal inflammation.

After 3 years there was a need for prosthesis in the maxillary left and mandibular region. A detailed clinical examination was carried out to explore the possibilities for dental implant prosthesis. The patient had mild facial deformity and limited mouth opening (1-1.5 inches) [Figure 3]a and b. An attempt to increase the mouth opening resulted in sharp lancinating type of pain in the right TMJ region. Intra-oral examination revealed the presence of 6-unit porcelain fused to metal crown and bridge in the maxillary right segment from the right central incisor to the maxillary right first molar, the premolars as pontics, and second and third molars missing. The maxillary left central and lateral incisors along with the left first molars were also restored with porcelain fused to metal crowns, and missing third molars. The patient was using a removable partial prosthesis in the region of maxillary left canine-premolars. The mandibular premolars also had porcelain fused to metal crowns with all molars missing, i.e., occlusion restricted to the premolars.
Figure 3: (a) Placement and positioning the therabite device, (b) Therabite depicting maximum mouth opening of the patient

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Routine intra-oral periapical and Orthopantomogram radiographic examination was carried out. Radiographs revealed the presence of root canal treatments in the maxillary right incisors and canine, left maxillary first molar, and both the mandibular right premolars with no other pathologies. The right temporomandibular prosthesis appeared normal with no signs of bone pathology [Figure 2]c.

Phase I - Planning the surgical implant placement

Appropriate consent was obtained from the patient and she was advised of the risks, benefits, complications, and alternative treatment options. Although restricted mouth opening was present the patient was extremely cooperative toward the entire treatment procedure. Alginate impressions for diagnostic casts were taken with utmost care to avoid and restrict wider mouth opening. The patient's existing removable partial denture was used as the surgical stent. We decided to place three implants corresponding to the missing canine, first and second premolars (3.5 × 10 mm Maestro external implant system; Biohorizons, Birmingham, AL, USA). Due to the narrower width of the bucco-palatal ridge, it was decided to reflect a mucoperiosteal flap for better visualization and implant placement [Figure 4]. Osteotomies using the surgical drills under copious saline irrigation to progressively widen the sites were performed in a sequential manner. The most distal implant (second premolar) was placed first, followed by the implant for the canine region to achieve parallelism between the implants [Figure 5], and [Figure 6]. This improved proper orientation and visualization for the placement of third implant corresponding to the second premolar [Figure 7]. The flap was approximated back to its position and interrupted sutures with 4-0 mersilk (Ethicon, Johnson and Johnson Ltd, Aurangabad, India) were placed to avoid undue tension. The patient was instructed about routine post-surgical instructions. She was also advised to avoid wearing the partial denture for the entire healing period of 4 months before stage II loading, to prevent premature loading and decrease microstrain at the bone-implant interface. The patient was recalled every month to assess implant healing and for oral hygiene evaluation and maintenance.
Figure 4: Mucoperiostel flap reflected and placement of distal implant

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Figure 5: Radiograph showing the placement of guiding pin and parallelism between the implants

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Figure 6: Surgical placement of all three implants

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Figure 7: Radiographic image after implants placement

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Phase II - Uncovering the implants, placement of healing abutments, and prosthetic loading

After an uneventful healing period of 4 months, the implants were uncovered and healing abutments placed. They were left undisturbed for 2 weeks to achieve an acceptable gingival collar. After this period the healing abutments were unscrewed and impression posts (3-in-1 abutments, Maestro external implant system; Biohorizons, Birmingham, USA) placed [Figure 8]a. A closed tray impression technique with an addition silicone material (Aquasil, Dentsply Caulk, Milford DE, USA) was used [Figure 8]b. To achieve better distribution of occlusal load and optimal esthetics, we decided to restore the prosthesis with 3-unit porcelain fused to metal crown and bridge [Figure 9]a and b. The final prosthesis was then restored into function with temporary luting cement (Relyx Temp NE, 3M ESPE Dental Products, St. Paul, MN, USA). The patient has been advised soft, non-sticky/chewy diet to minimize strain on the temporomandibular prosthesis and the masticatory musculature.
Figure 8: (a) Placement of impression posts, (b) addition silicone impression using closed tray technique

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Figure 9: (a) Clinical view of the porcelain fused to metal crown and bridge, (b) clinical view of the implant prosthesis in occlusion

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   Discussion Top


Dental implant restorations have the highest survival rate when compared to any other type of prosthesis to replace the missing teeth, provided the recommended surgical and restorative protocols are followed. [1]

However, implant rehabilitation involving patients with facial deformities and TMJ ankylosis requires competence and expertise. It is important to understand that such patients present with minimal or restricted mouth opening, severe joint and facial pain, mandibular deviation, and facial deformities. [6],]7],[8]

This case involved a female patient who had undergone previous surgeries for right side TMJ ankylosis, which were unsuccessful, and this resulted in further facial deformity and acute pain. She then had to undergo complete TMJ and condyle custom-made titanium prosthesis to restore the mandibular anatomy, function and improve the facial deformity. Although, this rehabilitation improved the function and deformity, it however rendered the patient with restricted mouth opening, difficulty in mastication and oral hygiene maintenance. The patient's desire for fixed implant prosthesis was thus fulfilled after considering the available options. All precautions were taken to prevent undue strain on the right side TMJ prosthesis as well as the masticatory musculature. With two-stage implant prosthesis, the left maxillary canine, first and second premolars were successfully restored. It is both our and the patient's desire also to have implant prosthesis for the missing mandibular first molars, thereby completing and complementing a normal functional occlusion. However, this would be a plan for the future, provided the patient's mouth opening increases and improves to allow implant placement.

 
   References Top

1.Misch CE. Rationale for dental implants. In: Dolan J, Editor. Text Book of Contemporary Implant Dentistry. 3 rd edn. New Delhi: Mosby, Elsevier Publishers; 2008. p. 3-25.  Back to cited text no. 1
    
2.Wolford LM. Factors to consider in joint prosthesis systems. Proc Bayl Univ Med Cent 2006;19:232-8.  Back to cited text no. 2
    
3.Mercuri LG, Wolford LM, Sanders B, White RD, Giobbie-Hurder A. Long-term follow-up of the CAD/CAM patient fitted total temporomandibular joint reconstruction system. J Oral Maxillofac Surg 2003;60:1440-8.  Back to cited text no. 3
    
4.Mercuri LG, Edibam NR, Giobbie-Hurder A. Fourteen-year follow-up of a patient-fitted total temoromadibular joint reconstruction system. J Oral Maxillofac Surg 2007;65:1140-8.  Back to cited text no. 4
    
5.Saeed NR, Kent JN. A retrospective study of the costochondral graft in TMJ reconstruction. 2003;32:606-9.  Back to cited text no. 5
    
6.Wolford LM, Pitta MC, Reiche-Fischel O, Franco PF. TMJ concepts/techmedica custom-made TMJ total joint prosthesis: 5-year follow-up study. Int J Oral Maxillofac Surg. 2003;32:268-74.  Back to cited text no. 6
    
7.Wolford LM, Dingwerth DJ, Talwar RM, Pitta MC. Comparison of 2 temporomandibular joint total joint prosthesis systems. J Oral Maxillofac Surg 2003;61:685-90.  Back to cited text no. 7
    
8.Guarda-Nardini L, Manfredini D, Ferronato G. Temporomandibular joint total replacement prosthesis: Current knowledge and considerations for the future. Int J Oral Maxillofac Surg 2008;37:103-10.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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