The use of computer-aided manufacturing during the treatment of the edentulous mandible in an oral radiation therapy patient: clinical

report
Madelyn L. Fletcher-Stark, DDS, MSD,a Jeffrey E. Rubenstein, DMD, MS,b and Ariel J. Raigrodski, DMD, MSc Loma Linda University, Loma Linda, Calif; University of Washington, Seattle, Wash
This clinical report describes the treatment of an edentulous patient with previous radiation therapy to the base of the tongue. A computer-aided manufactured titanium framework was used to fabricate the implant-supported fixed complete denture and meet the functional and psychosocial needs of the patient. (J Prosthet Dent 2011;105:154-157) Brnemark and his colleagues met the challenge of restoring the edentulous mandible with the endosteal dental implant and the implantsupported fixed complete denture.1 A protocol for this acrylic resin veneered prosthesis was established using a cast gold alloy framework with transmucosal abutments.2 Long term follow-up demonstrated excellent implant prosthesis survival and led the way to modern implant reconstruction.3,4 Since the process of casting large metal frameworks is technique sensitive, time consuming and expensive, other methods of fabricating the framework evolved. At first, titanium frameworks were fabricated by combining blocks with stereo laser welding with promising results.5 Recently, a milled titanium framework was introduced as a result of computer-aided design and manufacturing (CADCAM). In a 5-year study, the milled titanium framework was shown to be a viable alternative to the gold cast framework with 98% survival rate.6 Using computer-aided manufacturing, an excellent interface between the framework and the implant can be established without potential errors from casting and soldering. Passive fit of the implant framework is significant, since misfit may result in mechanical failures of the prostheses as well as biological complications.7 When a patient has undergone radiation therapy in the head and neck region, special precautions must be taken during treatment. The dosage of radiation, location, manner of delivery, and time elapsed since treatment should be considered. While short-term side effects such as mucositis dissipate in a few months after radiotherapy, time only increases the lack of blood perfusion and risk for osteoradionecrosis of the jaw.8 Marx describes a protocol of hyperbaric oxygen therapy to reduce the risk of osteoradionecrosis by stimulation of angiogenesis in irradiated tissue with regrowth of capillaries previously destroyed by radiation and subsequent supportive healing.9 While limited evidence is available, there appears to be a decrease in post-surgical sequelae when using hyperbaric oxygen treatment for patients treated with osseointegrated implants that have a history of receiving head and neck radiation treatment.10 The purpose of this clinical report is to illustrate the use of advanced technology in the treatment of the edentulous mandible in an oral radiation therapy patient.

CLINICAL REPORT
A 62-year-old edentulous woman with a number of co-morbidities presented with no exiting prostheses. The patient reported discomfort in social settings and an inability to partake in a normal diet. Her chief concern was to have her dentition restored. The dental history revealed oral cancer in the base of the tongue 7 years prior with concomitant chemoradiation therapy. The information provided from the treating radiation oncologist was limited. Since treatment was provided 7 years ago, radiation was most likely administered by parallel opposed field treatment. While the field of radiation was not specified, the base of the tongue was treated, so most likely the anterior mandible received the lowest dosage. The parotid glands compromised by the treatment to manage her oral cancer resulted in radiation induced xerosto-

Presented at the Pacific Coast Society for Prosthodontists annual meeting, Bend, Oregon, June 2009. Assistant Professor, Department of Restorative Dentistry, School of Dentistry, Loma Linda University. Professor, Division of Prosthodontics, Director-Maxillofacial Prosthetic Service, University of Washington School of Dentistry. c Professor, Director Graduate Prosthodontics, Department of Restorative Dentistry, School of Dentistry, University of Washington.
a b

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mia and caries. Fourteen months prior, the patient underwent hyperbaric treatment and extraction of the remaining dentition. A clinical exam was performed and a panoramic radiograph recorded and evaluated. Preliminary examination revealed minimal resorption of the maxilla and mandible with sufficient attached keratinized tissue and normal anatomy. There was radiographic and intraoral evidence of poor healing in the extraction sites of the first molars in the mandible. Since persistent irritation of irradiated tissues can result in ulcers and possible osteoradionecrosis, a treatment plan was chosen to limit tissue contact in the posterior mandible: a maxillary complete denture and a mandibular implant-supported fixed complete denture with 5 endosseous dental implants placed in the anterior mandible. Given the patient already received 20 pre- and 10 post-extraction dives, the patient underwent an additional post implant placement course of 10 hyperbaric oxygen dives according to the Marx protocol.11 Diagnostic impressions were made with irreversible hydrocolloid (Jeltrate Alginate Regular; Caulk, Dentsply Int, York, Pa) and diagnostic casts (Microstone; WhipMix, Louisville, Ky) were articulated in a semi-adjustable articulator (Magnetic Model PCH Articulator; Panadent, Colton, Calif ) using wax-rims placed on record bases (Triad Denture Base Material; Dentsply Int), a vinyl polysiloxane centric relation record (Regisil PB; Dentsply Caulk, Milford, Del) and a facial analyzer (Kois Dento-Facial Analyzer; Panadent, Colton, Calif ). The wax trial dentures with acrylic resin denture teeth (Enigma; Dillon Products, Cranston, UK) were evaluated for esthetics, phonetics, vertical dimension of occlusion and centric relation. A radiographic and surgical guide was fabricated by duplicating the mandibular wax trial denture using a 1:3 ratio of barium sulfate powder (Hypaque Sodium; Amersham Health, Princeton, NJ) and autopolymerized acrylic resin (Dentsply Trubyte; Dentsply Trubyte, York, Pa). A cone beam radiograph (CBCT Hitachi system serial #DX 12015; Hitachi Medical Systems America, Inc, Twinsburg, Ohio) was recorded with the radiographic guide in place stabilized with the maxillary wax trial denture. Five regular platform 13 mm dental implants (Brnemark; Nobel Biocare, Zurich, Switzerland) were placed in the anterior mandible followed by 10 post implant placement dives in the hyperbaric chamber. After 3 months of healing, the definitive impression for the implantsupported fixed complete denture was made with an acrylic resin block and custom tray technique described by Ivanhoe et al.12 A preliminary irreversible hydrocolloid impression (Jeltrate Alginate Regular; Caulk, Dentsply Int, York, Pa) was recorded using a stock metal tray (Rimlock; Caulk Dentsply Int) and impression copings (Impression Coping Implant Level Open Tray; Nobel Biocare) secured to each implant site at 15 Ncm. The impression copings were removed from the mouth, secured to the implant level replicas (Implant Replica; Nobel Biocare) and repositioned in the impression. A type 4 stone cast (Microstone; WhipMix) was poured using soft tissue replication (Softissue Moulage, KerrLab, Orange, Calif ) surrounding the implant replicas. The resultant preliminary cast with the impression copings in place was then used to fabricate an acrylic resin custom open impression tray (Triad Custom Tray Material; Dentsply Int). The impression copings were splinted with light polymerized acrylic resin (Triad Custom Tray Material; Dentsply Int). A separating disk (Serrated Saw, 8964; Brasseler USA, Savannah, Ga) was used to vertically section between each impression coping and each were numbered to their respective implant sites. The impression copings with their acrylic resin addition were place intraorally and attached to the implants with guide pins secured at 35 Ncm (Fig. 1). Care was taken to assure no binding between the acrylic resin blocks when set in place and an amalgam matrix band was used as a gap spacer when securing the acrylic resin blocks. The blocks were luted together with a light polymerized modeling acrylic resin (Palavit GLC; Heraes Kulzer LLC, South Bend, Ind) and a final impression was made using an acrylic resin custom open impression tray (Triad Custom Tray Material, Denstply Int), border molded with modeling plastic impression compound (Green Stick Impression Compound; KerrLab) and recorded with polyether impression material (Impregum; 3M ESPE, St. Paul, Minn) (Fig. 2). Implant replicas were attached to the impression copings by securing them to 35 Ncm stabilized at the apical end with a he-

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1 Light polymerized acrylic resin blocks on implant impression copings which were luted together and transferred to definitive impression.

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2 Definitive impression.

3 Light polymerized acrylic resin index used to orient denture teeth to definitive cast.

4 Acrylic resin pattern of the mandibular framework on definitive cast. mostat while applying the aforementioned pre-load and the definitive cast was poured in improved dental stone (Fujirock EP; GC America, Inc, Alsip, Ill) with silicone soft tissue replication (KerrLab). On the mandibular definitive cast, a record base was formed with light polymerized tray acrylic resin (Triad Custom Tray Material, Denstply Int), surrounding 2 temporary polymeric abutments (Plastic Temporary Abutment; Nobel Biocare) and a wax rim was added. The mandibular definitive cast was articulated against the existing maxillary wax trial denture using a vinyl polysiloxane centric relation record (Regisil PB; Dentsply Int) and a wax trial mandibular denture was developed. After a clinical trial insertion, the position of the mandibular teeth was indexed using light polymerized

5 Digital rendering of scanned acrylic resin pattern of mandibular framework. ticles (Rocatec-pre; 3M Dental ISR, ESPE, St. Paul, Minn) under 5 kg/ cm2 of pressure, embedded with glass particles (Rocatec-plus; 3M Dental ISR, ESPE and covered with pink opaque light polymerized resin (ESPE Sinfony; 3M ESPE, St. Paul, Minn) Subsequently, the denture teeth were reapplied to the framework using the acrylic resin index and base plate wax. Using a lingualized occlusion scheme,13 the maxillary and mandibular tooth arrangement was finalized and evaluated intraorally. Since the patient was pleased with the original maxillary teeth arrangement, the base was border molded, washed with tissue conditioning material (Lynol; Caulk, Dentsply Int) and poured in type 4 stone (Microstone; WhipMix). The maxillary and mandibular prostheses were processed with injection

tray material (Triad Custom Tray Material, Denstply Int) and related to the cast (Fig. 3). The teeth were removed from the wax rim, positioned in the index and the amount of space between the teeth and the implant replicas was assessed. A pattern of the proposed framework was fabricated using auto-polymerizing acrylic resin (Pattern Resin; GC America, Inc) applied to temporary polymeric abutments (Fig. 4). The acrylic resin pattern of the mandibular framework was scanned using tactile scanning (Procera Forte; Nobel Biocare) (Fig. 5) and milled in titanium (Procera; Nobel Biocare). The framework was evaluated clinically to assess its fit (Fig. 6). In the laboratory, the titanium milled framework was airborne-particle-abraded with 110 m aluminum oxide par-

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6 CAD titanium framework assessed intraorally.

7 Frontal view of definitive prostheses.

molding (Success Injection System; Dentsply Int). The definitive prostheses were placed (Fig. 7) and the abutment screws were tightened with a torque wrench (Manual Torque Wrench Prosthetic; Nobel Biocare) to 35 Ncm. The access holes were sealed with silicone (Fit Checker; GC America, Inc,) and a composite resin (Fermit N; Ivoclar Vivadent, Schaan, Liechtenstein). The occlusion and screw tightness were evaluated during the follow-up visits and a one-year recall was scheduled. The patient demonstrated a dramatic improvement in socialization, self-esteem and improved oral function.

logical advances in the titanium milled framework reduced the quantity and duration of treatment visits.

REFERENCES
1. Brnemark PI. Osseointegration and its experimental background. J Prosthet Dent 1983;50:399-410. 2. Jemt T. Failures and complications in 391 consecutively inserted fixed prostheses supported by Brnemark implants in edentulous jaws: a study of treatment from the time of prosthesis placement to the first annual checkup. Int J Oral Maxillofac Implants 1991;6:270-6. 3. Adell R, Eriksson B, Lekholm U, Brnemark PI, Jemt T. Long-term follow-up study of oseointegrated implants in the treatment of totally edentulous jaws. Int J Oral Maxillofac Implants 1990;5:347-59. 4. Astrand P, Ahlqvist J, Gunne J, Nilson H. Implant treatment of patients with edentulous jaws: a 20-year follow-up. Clin Implant Dent Relat Res 2008;10:207-17. 5. Rubenstein JE. Stereo laser-welded titanium implant frameworks: clinical and laboratory procedures with a summary of 1-year clinical trials. J Prosthet Dent 1995;74:284-93. 6. Ortorp A, Jemt T. Clinical experiences of computer numeric control-milled titanium frameworks supported by implants in the edentulous jaw: a 5-year prospective study. Clin Implant Dent Relat Res 2004;6:199-209. 7. Kan JY, Rungcharassaeng K, Bohsali K, Goodacre CJ, Lang BR. Clinical methods for evaluating implant framework fit. J Prosthet Dent 1999;81:7-13.

SUMMARY
The treatment of the esthetic, social and functional needs of an edentulous patient with a maxillary complete denture and a mandibular implantsupported fixed complete denture is described. Not only did this mode of treatment address the physical challenges imposed by the previously irradiated tissues and xerostomia, but it also greatly impacted the patients self image and social comfort. Techno-

8. Rayatt SS, Mureau MA, Hofer SO. Osteoradionecrosis of the mandible: Etiology, prevention, diagnosis and treatment. Indian J Plast Surg 2007;40:65-71 9. Marx RE, Johnson RP, Kline SN. Prevention of osteoradionecrosis: a randomized prospective clinical trial of hyperbaric oxygen versus penicillin. J Am Dent Assoc 1985;111:49-54. 10.Chavez JA, Adkinson CD. Adjunctive Hyperbaric Oxygen in Irradiated Patients Requiring Dental Extractions: Outcomes and Complications. J Oral Maxillofac Surg 59:518-522, 2001. 11.Marx RE, Ames JR. The use of hyperbaric oxygen therapy in bony reconstruction of the irradiated and tissue deficient patient. J Oral Maxillofac Surg 1982;40:412-20. 12.Ivanhoe JR, Adrian ED, Krantz WA, Edge MJ. An impression technique for osseointegrated implants. J Prosthet Dent 1991;66:410-1. 13.Becker CM, Swoope CC, Guckes AD. Lingualized occlusion for removable prosthodontics. J Prosthet Dent 1977;38:601-8. Corresponding author: Dr Madelyn L. Fletcher-Stark Loma Linda University, School of Dentistry Department of Restorative Dentistry 10922 Anderson Street Loma Linda, CA 92354 Fax: 909-558-0253 E-mail: mlfletcher@llu.edu Copyright 2011 by the Editorial Council for The Journal of Prosthetic Dentistry.

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