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CASE REPORT
Year : 2020  |  Volume : 23  |  Issue : 12  |  Page : 1767-1771

Prosthetic and Surgical Reconstruction of the Atrophic Anterior Maxilla with Iliac Bone Grafting and Malo Bridge Design: A Case Report


1 Department of Prosthodontics, Faculty of Dentistry, Karadeniz Teknik University, Trabzon, Turkey
2 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Karadeniz Teknik University, Trabzon, Turkey
3 Private Practice, Trabzon, Turkey

Date of Submission08-May-2020
Date of Acceptance29-Jun-2020
Date of Web Publication23-Dec-2020

Correspondence Address:
Dr. R G Kocak
Department of Prosthodontics, Faculty of Dentistry, Karadeniz Technical University - 61080, Trabzon
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_237_20

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   Abstract 


Alveolar bone loss subsequent to long-term edentulism and trauma may be severe and treatment plan is always an esthetic and functional challenge. Implant supported hybrid prosthesis is widely regarded as an effective treatment option for patients with excessive and irregular bone loss. However, implant placement is occasionally impossible without surgical procedures in such cases. This case report presents rehabilitation of 19-year-old maxillary anterior edentulous male patient with maxillary anterior bone defect and excessive cross-bite anterior closure with multidisciplinary approach. The patient was rehabilitated with implant supported hybrid prosthesis with Malo Bridge design following autogeneous iliac bone augmentation, teeth leveling with orthodontic treatment, and surgical placement of three implants. Esthetics, pleasing phonetics and function were achieved as desired with this treatment option and no complications were observed.

Keywords: Atrophic maxilla, dental implant, iliac bone graft, immediate loading, Malo Bridge


How to cite this article:
Kocak R G, Gulnar A, Altintas N Y, Altintas S H, Nalcaci R. Prosthetic and Surgical Reconstruction of the Atrophic Anterior Maxilla with Iliac Bone Grafting and Malo Bridge Design: A Case Report. Niger J Clin Pract 2020;23:1767-71

How to cite this URL:
Kocak R G, Gulnar A, Altintas N Y, Altintas S H, Nalcaci R. Prosthetic and Surgical Reconstruction of the Atrophic Anterior Maxilla with Iliac Bone Grafting and Malo Bridge Design: A Case Report. Niger J Clin Pract [serial online] 2020 [cited 2023 Jan 29];23:1767-71. Available from: https://www.njcponline.com/text.asp?2020/23/12/1767/304421




   Introduction Top


Tooth loss due to trauma, especially in the anterior region, results in esthetic and functional issues. Implant supported prostheses give the possibility to improve the patients' quality of life.[1] However, atrophic and defective alveolar ridges are serious obstacle in dental implantation.[2] Iliac bone graft is a gold standard for bone reconstruction in such cases.[3],[4]

The Malo Bridge is one of the hybrid screw-retained and cement-retained implant prosthesis. In this technique, the substructure consists of a screw-retained titanium framework and crowns fabricated separately with computer-aided design (CAD) and computer-aided manufacturing system (CAM).[5]

The aim of this clinical report is to describe the multidisciplinary treatment of a patient with maxillary anterior defect.


   Case Report Top


A 19-year-old male patient with no systemic disease was referred to the clinic with a history of trauma in 2017. The patient's principal symptoms were poor esthetics and function. Intraoral and extraoral findings revealed an anterior maxillary alveolar bone defect, lack of lip support, and excessive anterior cross-bite closure. Panoramic radiography (OPTG) and cone beam computerized tomography (CBCT) revealed insufficient, crest volume and height for implant placement in the anterior maxillary region, and significant augmentation was required [Figure 1]. The proposed treatment plan involved reconstruction of the maxillary anterior defect with an implant supported Malo Bridge design prosthesis following iliac bone augmentation and orthodontic treatment.
Figure 1: Preoperative intraoral view (a), lateral cephalometric radiograph (b) and panoramic radiograph (c) showing maxillary anterior bone defect and excessive anterior cross-bite closure

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An autogenous corticocancellous iliac bone graft was harvested under general anesthesia and placed in the defect area [Figure 2]. Bone formation was completed in 4 months, and no complications were observed during the healing period.
Figure 2: Panoramic radiograph and intraoral views 4 months after iliac bone grafting

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Although the teeth were leveled with orthodontic treatment, the extreme anterior cross-bite closure was not completely resolved, and prosthetic treatment was required. Three intraosseous implants (Nobel Biocare, Göteburg, Sweden), 3.5 mm in diameter and 13 mm in length, were inserted. An acrylic temporary fixed prosthesis for non-functional immediate loading was screwed onto the multiunit abutments during surgery to provide a satisfactory esthetic appearance and reshape the soft tissue [Figure 3].
Figure 3: (a) Surgical implant placement (b) Panoramic radiograph of three endosteal implants with multiunit abutments (c, d) Intraoral views of the immediate acrylic temporary prosthesis

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Following an 8-month healing period, open-tray impression transfer copings were splinted to each other with pattern resin (GC Pattern Resin, GC Dental Industrial Corp., Tokyo, Japan), and an open-tray impression was taken using a type silicone polyvinlysiloxane (Variotime Dynamix Heavy Tray, Light Body Set, Heraeus Kulzer GmbH, Germany) [Figure 4].
Figure 4: Open tray implant impression

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In the second session, a stone verification jig was placed onto the abutments, and passive fit of the cast framework was confirmed using the Sheffield test and periapical radiography. The artificial teeth were then tested in the mouth for esthetic and phonetic controls [Figure 5].
Figure 5: Confirming passive fit with stone verification jig and try in of the tooth arrangement

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The titanium framework and zirconia crowns (Gc initial, GC Europe, Leuven, Belgium) were produced with CAD/CAM system (Aadva IOS, GC, Tokyo, Japan) [Figure 6]. Copings on the titanium framework were prepared in line with the tooth preparation criteria. Zirconium crowns were fabricated separately from the framework and were layered with lithium disilicate glass ceramic. The titanium substructure was covered with pink composite resin (Gradia GC, Tokyo, Japan) to provide a good esthetic appearance and match with the soft tissue [Figure 7]. The substructure was screwed to the abutments with a torque value of 15 N in line with the manufacturer's instructions.
Figure 6: Producing the titanium framework and zirconia crowns with CAD/CAM system

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Figure 7: Extraoral views of the titanium framework and zirconium crowns

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The screw access holes were closed with composite resin, and the zirconium crowns were cemented individually with dual cure resin cement (Panavia V5, Kuraray Noritake Dental, Tokyo, Japan) [Figure 8]. The patient was highly satisfied with the result, and no complications were observed at 6-month follow-up visits.
Figure 8: Intraoral views of the final restoration

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   Discussion Top


Anterior esthetics is a very important psychological impact on patients' lives. Therefore replacement of the missing teeth, the smile pattern, and lip support should all be considered in the treatment planning of anterior maxillary tooth loss.[6],[7] High success rates are observed in implant placement with autogenous iliac bone grafts in terms of such parameters as good quality bone formation, robust amount of bone graft and low donor morbidity.[8] However, some major and minor risks, such as loss of nerve sensation, superficial infections, hematomas, and neuropathy have also been reported.[9] No complications were observed in our patient at postoperative controls.

In the present case, patient had excessive anterior cross-bite closure, we were not even able to fully treat with orthodontic treatment. Due to the excessive bone defect and advanced anterior cross bite we had to maintain soft tissue support. Non-functional immediate fixed prosthesis reshaped and prepared surrounding soft tissue for final result and gave comfort to the patient while healing period. Ideal rehabilitation in dental components, and lip and soft tissue support are provided with Malo Bridge design prosthesis. Increased crown inclination and lengthening are avoided.[10] This design has also several advantages over conventional fixed hybrid prostheses such as easy crown repair and better esthetic result by tolerating undesirable screw access hole positions.[5]

Production of a titanium framework with the CAD/CAM system allows proper adaptation to the abutment system.[5] Pink composite resin was laid over the framework to achieve a natural appearance on the gum. However, despite these advantages, the process is laborious and expensive, since adapting the contact points of the individual crowns makes the technical stage particularly difficult.[10]

Maxillary anterior reconstruction with an autogenous iliac bone graft and Malo Bridge design prosthesis can be a useful therapeutic option in patients with advanced alveolar ridge atrophy. In the present case, the patient was highly satisfied with the esthetic outcome, phonation and function, although long-term follow-up is now required.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgments

We would like to express our particular gratitude to Universal Dental Studio and Haluk Demir Taşdemir.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
1. Pennington J, Parker S. Improving quality of life using removable and fixed implant prostheses. Compend Contin Educ Dent 2012;33:268-70.  Back to cited text no. 1
    
2.
2. Kang YH, Kim HM, Byun JH, Kim UK, Sung IY, Cho YC, et al. Stability of simultaneously placed dental implants with autologous bone grafts harvested from the iliac crest or intraoral jaw bone. BMC Oral Health 2015;15:172.  Back to cited text no. 2
    
3.
3. Schaaf H, Lendeckel S, Howaldt HP, Streckbein P. Donor site morbidity after bone harvesting from the anterior iliac crest. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:52-8.  Back to cited text no. 3
    
4.
4. Almaiman M, Al-Bargi HH, Manson P. Complication of anterior iliac bone graft harvesting in 372 adult patients from may 2006 to may 2011 and a literature review. Craniomaxillofac Trauma Reconstr 2013;6:257-66.  Back to cited text no. 4
    
5.
5. Kodama T. Implant-supported full-mouth reconstruction Malo Implant Bridge. J Calif Dent Assoc 2012;40:497-508.  Back to cited text no. 5
    
6.
6. Cetintas S, Tokar E, Guzelce E, Karacaer O. Prosthetic rehabilitation after complicated surgical procedures in the anterior region. J Dent Res 2018;1:1-5.  Back to cited text no. 6
    
7.
7. Egilmez F, Ergun G, Cekic-Nagas I, Bozkaya S. Implant-supported hybrid prosthesis: Conventional treatment method for borderline cases. Eur J Dent 2015;9:442-8.  Back to cited text no. 7
    
8.
8. Shirani G, Hasheminasab M, Bashiri S. Implant survival in atrophic maxilla and mandible reconstructed with free iliac graft: A literatur review. Ann Dental Specialty 2018;6:197.  Back to cited text no. 8
    
9.
9. Goulet JA, Senunas LE, DeSilva GL, Greenfield ML. Autogenous iliac crest bone graft: Complications and functional assessment. Clin Orthop Relat Res 1997;339:76-81.  Back to cited text no. 9
    
10.
10. Montero J, de Paula CM, Albaladejo A. The “Toronto prosthesis”, an appealing method for restoring patients candidates for hybrid overdentures: A case report. J Clin Exp Dent 2012;4:e309.  Back to cited text no. 10
    


    Figures

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



 

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