Longitudinal treatment of a severely atrophic mandible: A clinical report
Christopher Whitmyer, DDS,a Salvatore J. Esposito, DMD,b and Scott Alperin, DDSc
The Cleveland Clinic Foundation, Cleveland, Ohio
This clinical report presents the treatment of a patient with a severely atrophic mandible. The report
details the clinical successes and failures over nearly a 20-year period. Clinical and surgical procedures
are presented in a longitudinal fashion, as well as the rationale at the time to support each procedure.
(J Prosthet Dent 2003;90:116-20.)
T he atrophy or resorption of alveolar bone is most
dramatic during the first year after the loss of teeth.1
Alveolar atrophy is also accelerated during the first year
and perhaps beyond by the use of tissue-borne complete
dentures with poor adaptation to the alveolar ridge and
improper occlusal scheme.1-5 The sequelae of mandib-
ular atrophy include, among others, difficulties with
prosthetic retention and comfort. This, in turn, may
negatively affects functional abilities such as speech and
mastication. These functional deficits are amplified in
the mandibular arch.
The reconstructive challenges of an atrophic mandi-
ble are considerable. Previous surgical treatment of
mandibular atrophy was concentrated on the replace-
ment of bone where it was lost, or efforts to further use
the existing residual ridge through procedures aimed at
lowering the floor of the mouth or deepening the vesti-
bules.6-10 Osseous grafting was most commonly accom-
plished with a superior border onlay graft.11-13 This ap-
proach, although logical, is commonly less than ideal.
Surgical complications may include infection, paresthe-
sias, broad unretentive residual ridges, and rapid loss of
the graft to resorption.6 Because of the nature of the
surgery, patients also experienced a lengthy recovery pe-
riod of at least 6 months during which they were unable
to wear their mandibular denture. This posed a signifi-
cant hardship for most patients who found it impossible
to leave their prostheses out for that period of time.
The introduction of dental implants to the surgeons
armamentarium has dramatically reduced the need to
consider preprosthetic soft and hard tissue surgical pro-
cedures.14 There was, however, during this time, a steep
learning curve for most surgeons and prosthodontists,
many of whom were treating patients with implants for
the first time. Many diagnostic and clinical errors were
made during this learning curve. Much has been written
since then concerning bone-to-metal interface, implant
surfaces, biomechanics, biomaterials, and number and
distribution of implants for success.15 In addition, many
reports have been published on the subject of occlusal
a
General & Sports Dentistry, Director, General Practice Residency,
Department of Dentistry.
b
Chairman, Department of Dentistry.
c
Consultant, Oral & Maxillofacial Surgery.
116 THE JOURNAL OF PROSTHETIC DENTISTRY
load and overload. Although most of this has been clin-
ical opinion and anecdotal in nature, there have been
several studies that have implicated occlusal load or
overload in implant and prosthetic failure.16-20
Even with the many advances noted, there are still
situations when there is minimal mandibular alveolar
bone in which to place implants. In these situations bone
grafting procedures are necessary if the patient desires
the implant treatment approach. Since the 1970s, sev-
eral studies have discussed various modifications of an
inferior border graft for an atrophic mandible.11,21-25
Quinn et al21 presented a technique with a cadaver man-
dible tray filled with autogenous marrow from the iliac
crest. A 16-year clinical report for a young patient with a
severely atrophic mandible with the aforementioned
surgical technique is presented.
CLINICAL REPORT
A 37-year old white woman was initially seen for
evaluation for dental implants at the Cleveland Clinic
Foundation, Department of Dentistry in 1986. She gave
a history of 23 years of complete edentulism, extraction
of all her teeth at age 14, and placement of immediate
dentures. Subsequent to that, she had several complete
dentures constructed, but by age 27 had difficulty with
her mandibular prosthesis. A skin graft vestibuloplasty
and superiorly onlayed rib graft procedure were done
after which she was modestly successful with her man-
dibular denture. She complained, however, of her facial
appearance, pseudoprognathism, and the loss of the
mental labial fold (Fig. 1).
A radiographic examination revealed a very atrophic
mandible with little, if any, evidence of the previously
placed bone graft (Fig. 2). The labial skin graft vestibu-
loplasty was now contiguous with the crest of the resid-
ual alveolus with no labial vestibule present. The height
of the mandible measured approximately 8 mm on pan-
oramic and cephalometric radiographs. A computed to-
mography scan was subsequently obtained and revealed
approximately the same amount of bone available for
implant placement.
Because the patients existing complete dentures
were ill-fitting and esthetically compromising, new com-
plete maxillary and mandibular dentures were fabri-
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WHITMYER, ESPOSITIO, AND ALPERIN
Fig. 1. Preoperative photograph demonstrates prognathic
chin associated with loss of labiomental fold and collapse of
lower third of face.
cated. This was done to improve the overall esthetic
appearance of the face by changing vertical face height
and support of the midface. In addition, the better-
fitting mandibular prosthesis could then be worn during
the 3-month healing phase after stage I osseointegration
surgery.
The limited height and width of the mandible neces-
sitated the use of 7 mm/3.75 mm implants (Branemark;
Nobel Biocare, Gothenberg, Sweden). Six implants
numbered 1 to 6 (starting at the distal left side to the
right) were surgically placed by use of standard protocol
with the prosthetic goal of a screw-retained, implant-
supported prosthesis.26 Because of the excessive alveolar
bone resorption and the loss of the previously placed rib
graft, there was little anterior-posterior curvature of the
anterior mandible. This situation necessitated placement
of the implants in a straight linear fashion from right to
left. The surgery was uneventful, and the patient recov-
ered well. Ten days after the surgery, the mandibular
prosthesis was replaced. The denture was lined with a
resilient liner (Coe Soft; GC America, Alsip, Ill), which
was replaced every 7 to 10 days to minimize trauma to
the implants. At the time of abutment placement, one
implant (number 2) was mobile (not integrated) and
thus was removed (Fig. 3).
AUGUST 2003
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 2. Panoramic and cephalometric radiograph reveal se-
verely atrophic mandible. There is no evidence of previous
bone graft.
The decision to proceed with 5 implants for the man-
dibular prosthesis was made based on the clinical and
radiographic evidence of integration. However, the au-
thors planned to place another implant in the lost site
once adequate bone fill was observed. The prosthodon-
tic phase of the treatment was completed using standard
protocol. A Noble metal (Ultima Gold; Ney Dentsply/
Ceramco, Burlington, NJ) was used for the superstruc-
ture casting. The fit was evaluated both in the laboratory
under a microscope and clinically. The casting had a
passive fit with no pressure on the implants as evaluated
by the patient during placement. The prosthesis was
completed as described in the literature.1,26 Four
months later the lost implant was replaced in the afore-
mentioned site (number 2).
One year after the initial placement of the implants, the
patient had development of symptoms with implant num-
ber 1. Unfortunately this implant was lost because of infec-
tion and a lack of integration. This left the patient with 4 of
the original implants and 1 new one in space number 2.
Before completion of a new mandibular prosthesis, im-
plant 6 was lost to a lack of integration, leaving the patient
with 4 seemingly integrated implants.
Within the next 18 months, implants 3 and 5 were
lost, and another implant was placed in area 6. By year 4,
117
THE JOURNAL OF PROSTHETIC DENTISTRY WHITMYER, ESPOSITIO, AND ALPERIN

Fig. 3. A, Location of implant 2, which was lost first, is evident on panoramic radiograph. Note: long lever arm distal to short
7-mm implants. B, Only surviving implants of original 6 used to support overdenture for 6 years.

after the original surgery, only 2 implants remained in-

tegrated; the original 4 and the second in area 6. The
final count at this time was 8 implants placed, 6 lost, 2
remaining. Ball attachments (Branemark; Nobel Bio-
care) were placed, and an implant-retained overdenture
was fabricated on the remaining 2 implants (Fig. 3, B).
This prosthesis served the patient well for 6 years, at
which time she questioned the possibility of the place-
ment of additional implants for a fixed prosthesis.
In an effort to provide the patient with a mandibular
screw-retained, implant-supported prosthesis, an infe-
rior border graft with secondary placement of longer
implants (Branemark; Nobel Biocare) was planned. Sev-
eral modifications of this inferior approach have been
published, and ultimately the authors decision was to Fig. 4. Cadaver mandible is sutured in place and packed
use the technique described by Quinn et al.11,21-25 The with autologous cancellous bone from iliac crest.
inferior border of the mandible was approached through
a supralaryngeal incision stretching from 1 mandibular
angle to the other. Special care was used to place this premolar, canine, lateral incisor, and the right mandib-
incision between skin folds to minimize visualization of ular first and second premolar. All 5 implants integrated
the scar. Once the inferior border was exposed, a tray successfully.
prepared from a cadaver mandible was secured with 4 With the previously described technique, a new man-
trans-mandibular sutures and packed with autogenous dibular screw-retained, implant-supported prosthesis
cancellous bone harvested from the iliac crest (Fig. 4). was fabricated on the 2 remaining 7-mm implants and
The surgical sites were closed in layers, and both healed the 5 new 15-mm implants (Fig. 5). The prosthesis has
uneventfully. After allowing the graft 6 months of heal- now been in service for 6 years without loss of graft,
ing, 5 new 15-mm implants (Branemark; Nobel Bio- superior ridge heights, or implant. In addition, there has
care) were placed in the areas of the mandibular left first been no periimplant bone loss at the superior ridge crest.

118 VOLUME 90 NUMBER 2

WHITMYER, ESPOSITIO, AND ALPERIN THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 5. Six-year follow-up radiograph in which mature bone graft is evident. Note significant difference in implant lengths
before and after graft.

Fig. 6. Intraoral view of completed maxillary denture and

mandibular hybrid prosthesis.

Improved esthetics and reestablishment of the correct

vertical face height was accomplished (Figs. 6 and 7).

DISCUSSION
If the initial treatment provided for this patient is
retrospectively evaluated, the appropriateness of the
treatment plan would have to be questioned. The resid-
ual alveolar ridge between the mental foramina had lit-
tle, if any, anterior-posterior curvature, which would
Fig. 7. Postoperative photograph demonstrates correction of
only allow for a linear placement of the 6 implants. This preoperative deficiencies.
would have to be considered a relative contraindication
for a screw-retained, implant-supported prosthesis with
distal cantilevers. In addition, the presence of only 8 mm
of bone height and placement of 7-mm implants to re- thetics and occlusion may have placed excessive tensile
tain a screw-retained, implant-supported prosthesis and compressive loading on the implants. Another fac-
would, at this time, be reconsidered. The implant length tor to be considered is that the treatment was rendered
to prosthesis ratio (1:3) was very unfavorable, consider- in 1986, only 4 years after the Toronto Conference on
ing the amount of bone loss and vertical dimension of Osseointegration in Clinical Dentistry in May 1982
occlusion that needed restoration. Also, the presence of and during a steep learning curve for most surgeons and
both anterior and distal cantilevers to provide both es- prosthodontists.

AUGUST 2003 119

THE JOURNAL OF PROSTHETIC DENTISTRY
With respect to the inferior border graft, several issues
regarding its choice warrant comment: first, the desire to
avoid the relative unpredictability of a superior onlay
graft and, second, unpredictability from the standpoint
of greater infection risk with an intraoral procedure, as
well as the potential for complete loss of the grafted
bone within a few years. Additionally, the use of an
inferior border graft permits the continued comfortable
hygienic use of an existing prosthesis during the healing
phase which, in this situation, lasted several months.
Other benefits of the inferior graft are reduced risks of
paresthesias and no need for intraoral skin grafting that
can be both painful and often poorly tolerated.
The ability to place 15-mm implants after the graft-
ing procedures allowed for a dramatically improved
implant-to-prosthesis ratio. In addition, the graft pro-
vided for a curved assembly of implants around the arch,
thus improving long-term prognosis.
SUMMARY
A grafting procedure such as the use of an inferior
border graft to enlarge the residual mandible, thereby
allowing the placement of longer implants, may be an
option when restoring the severely atrophic mandible.
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Reprint requests to:
DR SALVATORE J. ESPOSITO
DEPARTMENT OF DENTISTRY
THE CLEVELAND CLINIC FOUNDATION
9500 EUCLID AVE (A-70)
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FAX: 216-445-8570
E-MAIL: Esposis@ccf.org
Copyright 2003 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2003/$30.00 0
doi:10.1016/S0022-3913(03)00265-8
VOLUME 90 NUMBER 2