Rehabilitation of a mandibulotomy/

onlay/graft-reconstructed mandible
using a milled bar and a tooth- and
implant-supported removable dental
prosthesis: A clinical report
T. L. Wong, BDS, MDS,a Peter Y. P. Wat, BDS,b Edmond H. N.
Pow, BDS, MDS, PhD,c and Anne S. McMillan, BDS, PhDd
Faculty of Dentistry, University of Hong Kong, Hong Kong SAR,
Peoples Republic of China
Prosthodontic rehabilitation of a surgically resected/reconstructed jaw with a conventional tissue-borne dental pros-
thesis is often challenging, if not impossible, because of the suboptimal conditions of the soft and hard tissue topog-
raphy/architecture of the reconstructed site. Placing dental implants in grafted bone to provide appropriate support,
stability, and retention for prosthodontic rehabilitation offers the potential for improved oral function. There are,
however, some clinical conditions for which an implant-supported removable prosthesis may be preferred to a fixed
implant prosthesis. This clinical report describes the design and fabrication of a milled bar and a tooth- and implant-
supported removable dental prosthesis for oral rehabilitation of a reconstructed mandible, which considers patient
factors associated with oral and financial conditions, ease of oral hygiene procedures, and long-term maintenance. (J
Prosthet Dent 2010;104:1-5)

Rehabilitation of mandibular de-
fects associated with tumor resec-
tion presents a significant challenge
for prosthodontic rehabilitation. De-
pending on the location and extent
of the lesion, jaw resection often cre-
ates varying degrees of impairment
in appearance, mastication, speech,
deglutition, and self-image, impact-
ing the quality of life of patients so af-
flicted.1,2 To minimize the functional
and psychological impact to the pa-
tients after jaw resection, jaw recon-
struction can be used to reestablish
continuity of the jaw and provide an
optimal supporting tissue bed for
prosthetic rehabilitation.3,4 The goals
for oral rehabilitation after mandibu-
lar reconstruction are to restore func-
tion and esthetics, preserve the asso-
ciated structures, and contribute to
the patients perception of improved
quality of life.5 Osseointegrated im-
plants placed in grafted bone can
make a significant contribution to
assist in addressing problems related
to denture retention, support, and
stability.6,7 It has been reported that
a
Postgraduate student, Oral Rehabilitation.
b
Honorary Associate Professor, Oral Rehabilitation.
c
Associate Professor, Oral Rehabilitation.
d
Professor, Oral Rehabilitation.
Wong et al
rehabilitation with implants after jaw
reconstruction improves not only the
oral function but also the patients
psychosocial well being.8
Selection of the design of the im-
plant prosthesis depends on the inter-
ridge relation, interridge space condi-
tion, oral access for implant/prosthesis
placement, required amount of soft
tissue support, aftercare regarding
oral hygiene procedures and prosthesis
maintenance,9,10 financial resources,11
and patient preference.5,12 The pros-
thesis can be fixed,13 fixed with a re-
movable component, or an overden-
ture retained by attachments.12,14-20
The overdenture can be: (1) primar-
ily mucosa supported, (2) combined
mucosa/implant supported, or (3)
completely implant supported, de-
pending on the number and location
of the implants. The implant-sup-
ported removable dental prosthesis
with a milled bar, which is entirely
implant supported, provides patients
with comfort, security, and mastica-
tory ability similar to a fixed implant
prosthesis, in addition to providing
the advantages of a removable im-
plant prosthesis. This clinical report
demonstrates the use of a tooth- and
implant-supported removable dental
prosthesis to meet the challenge in
restoring a reconstructed mandible
and highlights the advantages of this
treatment option.
CLINICAL REPORT
A 66-year-old Chinese man pre-
sented in 2001 to the department of
Oral and Maxillofacial Surgery, Fac-
ulty of Dentistry, University of Hong
Kong, with an asymptomatic but
gradually enlarging swelling in the an-
terior mandible of at least 9 months
duration. Clinical examination re-
vealed a hard bony mass extending
buccally from the right canine to the
left premolar region of the mandible.
There was a corresponding radiolu-
cency with a honeycomb appear-
ance and ill-defined margins (Fig. 1,
A). Histopathological examination
confirmed the diagnosis of multicys-
tic ameloblastoma.
2 Volume 104 Issue 1
1 A, Preoperative panoramic radiograph. B, Reconstructed mandible with 2 distractors after osteotomies were
completed.
2 Four dental implants placed in reconstructed mandible. 3 Trial insertion of mandibular prosthesis.
Marginal mandibulotomy from
the right first molar to the left sec-
ond premolar region was performed,
followed by immediate reconstruc-
tion using a custom-made titanium
mesh tray (Leibinger Dynamic Mesh;
Stryker Leibinger GmbH & Co KG,
Freiburg, Germany) with a particulate
cortico and cancellous autogenous
iliac crest bone graft.4
Implant rehabilitation was planned
after 24 months of graft consolidation
with no signs of recurrence. Following
removal of the superior and labial part
of the titanium mesh tray, vertical dis-
traction osteogenesis (Alveolar Dis-
tractor; Synthes GmbH, Solothurn,
Switzerland) was performed over 3
weeks, in early 2004, to increase the
bone height of the grafted bone by
approximately 10 mm (Fig. 1, B). Six
months after completion of the dis-
traction procedures, the distractors
were removed, followed by the im-
The Journal of Prosthetic Dentistry
A B
mediate insertion of 4 implants (Mk
IV, 4 x 18 mm, external hex implants;
Nobel Biocare AB, Gteborg, Swe-
den). The second-stage surgery was
performed 6 months later (Fig. 2). In
the same operation, vestibuloplasty
was performed with a split thickness
mucosal graft harvested from the pal-
ate to deepen the labial sulcus.
Resonance frequency analysis (Os-
stell Mentor; Osstell AB, Gteborg,
Sweden) showed that the implant
stability quotients of the implants
ranged from 65 to 79, which is within
the normal range recommended.21 An
implant level impression was made
with square impression copings (No-
bel Biocare AB), polyether impres-
sion material (Impregum; 3M ESPE,
Seefeld, Germany) using a custom-
made acrylic impression tray, and
the open tray technique to obtain a
preliminary cast to assist in the se-
lection of collar height and angula-
tion of the transmucosal abutments.
A screw-retained cast gold (Esteticor
Cosmor H; Cendres & Mtaux SA,
Bienne, Switzerland) milled bar was
planned to support the prosthesis.
A 17-degree abutment (Multi-unit
Abutments; Nobel Biocare AB) was
selected and placed at the implant in
the right mandibular premolar region,
while straight abutments were used
for the other implants. A definitive im-
pression was recorded using the same
impression material and technique
described. Since the existing maxillary
removable prosthesis was assessed to
be satisfactory with the prosthesis in
place, a maxillomandibular jaw rela-
tion record was made on 3 temporary
titanium copings (Nobel Biocare AB)
with wax (Truwax; Dentsply Intl, York,
Pa). A wax trial tooth arrangement
was then evaluated intraorally to en-
sure correct tooth positioning, as-
sessment of lip support, speech, and
Wong et al
July 2010 3

4 Silicone index as guide for waxing gold bar. 5 Mandibular overdenture in situ.

6 Optimal thickness of acrylic resin around bar and 7 Good plaque control and periimplant health at 3-year
magnets. recall.

A B
8 A, Panoramic radiograph at time of prosthesis placement. B, No marginal bone loss around implants at 3-year recall.

to obtain the patients approval of the
esthetics (Fig. 3). A silicone (Coltne
Rapid; Coltne/Whaledent AG, Alt-
sttten, Switzerland) matrix was then
made to assist the dental laboratory
technician in design and fabrication
of the cast gold bar (Fig. 4).
Since it was planned that the im-
Wong et al
plant overdenture would be retained
by 3 neodymium-iron-boron magnets
(Magfit EX600W; Aichi Steel Corp,
Aichi, Japan), the magnetic keepers
were cast into the top of the milled
cast gold bar. This gold implant sub-
structure was evaluated intraorally
by the methods described previously
to assess whether or not the cast-
ing had a passive fit.22 It was then
milled (Metalor Technologies SA,
Neuchtel, Switzerland) according
to the planned path of insertion of
the removable magnet-retained over-
denture prosthesis. A cobalt chrome
metal housing with a lingual exten-
4 Volume 104 Issue 1
sion (Chromodur; Elephant Dental
BV, Hoorn, the Netherlands) 2 mm
thick was cast, and prosthetic teeth
(Trubyte Bioblend IPN; Dentsply Intl)
were arranged on the metal housing
and evaluated intraorally. At the in-
sertion appointment, in mid 2006,
the milled bar was secured to the im-
plant abutments with the prosthetic
screws tightened to 15 Ncm, in ac-
cordance with the manufacturers
recommendations. Chairside transfer
of the magnets was accomplished
using autopolymerizing acrylic resin
(Unifast; GC Corp, Tokyo, Japan) at
another appointment when no fur-
ther adjustment of the prosthesis was
required (Figs. 5 and 6). The patient
was evaluated once each year and,
thus far, has been followed for 3 years
with no complications (Figs. 7 and 8).
DISCUSSION
A conventional removable prosthe-
sis was considered for rehabilitating this
patient. However, considering the long-
term prognosis of the augmented bone,
an implant-supported prosthesis was
recommended instead. The long-term
survival and success rates of implants
placed in reconstructed jaws (96.7%
and 93.3%, respectively) indicate an
excellent potential prognosis for im-
plant-supported prostheses.3 Cheung
and Leung6 reported that endosseous
implants can be successfully placed
in jaws reconstructed with custom-
made titanium mesh tray and particu-
late bone graft. The implant-support-
ed fixed prosthesis is often considered
the treatment of choice for patients
following jaw resection/reconstruc-
tion.13 However, its fabrication re-
quires more implants, and the initial
treatment cost is much higher than
the implant overdenture option.11,12
Although implant splinting may
not be necessary for long-term im-
plant survival,15 the milled bar, in the
presented scenario, supported by 4
implants widely distributed antero-
posteriorly, could minimize movement
of the prosthesis during function. This
patients treatment was planned such
The Journal of Prosthetic Dentistry
that the prosthesis would be primarily
implant supported. This can greatly
reduce or eliminate the load on the
soft tissues and is helpful in situations
with friable or sensitive mucosa in
which a mucosa-supported prosthe-
sis is often not well tolerated by the
patient. However, this bar design re-
quires more interocclusal space than
a design using simple attachments. In
the present scenario, the distraction
osteogenesis was carefully planned to
provide sufficient interocclusal space
for rehabilitation.
Cast metal reinforcement is rec-
ommended for an implant-supported
overdenture to enhance its mechani-
cal properties.15 For the patient pre-
sented, the metal substructure was
designed at the lingual region so as
to reduce the lingual flange thickness
and to avoid encroaching on tongue
space, while a labial acrylic resin
flange was contoured to provide lip
and soft tissue support. A matrix of
the established tooth position was
used to guide the design and fabrica-
tion of the cast gold milled bar so that
the space for the denture around the
bar could be developed to accommo-
date the previously noted design con-
siderations (Fig. 6). The cast gold bar
was milled to provide a single path
of insertion for the prosthesis.17 This
path was selected to be parallel to the
mesial surface of the distal abutment
molar teeth on each side, and the
tooth surfaces were prepared prior to
making the definitive impression so as
to optimize this design feature. The
guiding planes greatly reduced the
reliance on retainers and the embra-
sure spaces between the denture and
the adjacent teeth and were designed
with a view toward minimizing food
impaction at this interface. Chrome
was used as the overcasting because
of its rigidity in thin sections.
There may be a concern regarding
differential wear between dissimilar
metals. However, no observable wear
was detected over the 3-year period,
and that might partly be due to mini-
mal movements of the prosthesis dur-
ing function. Although 3 magnets
were initially planned, the guiding
planes provided by the milled gold
bar and tooth surfaces for the defini-
tive prosthesis proved to be so effec-
tive that 2 magnets (600-g force per
magnet) were found to be sufficient
clinically.
It has been reported that the in-
cidence of technical complications
related to implant components and
suprastructures was higher in over-
dentures than in fixed prostheses,9
and there is concern about the long-
term maintenance cost of an implant
overdenture which may outweigh the
benefit of the relatively lower initial
cost compared with a fixed implant
prosthesis. However, no such studies
were identified by the authors for sur-
gically manipulated jaws. In the pres-
ent scenario, no adjustment has been
necessary, thus far, for the magnet at-
tachments, and there has been no ob-
servable wear or reduction in denture
retention noticed for up to 3 years
following prosthesis insertion. The
implant-supported design described
in this report eliminates or greatly re-
duces the need for regular relines of
the denture base over time, which has
been a noted maintenance issue for
tissue-borne implant overdentures.
Compared with single attach-
ments, this cast gold milled bar design
can provide even support over a great-
er surface area for the prosthesis. It
has been suggested that rigid anchor-
age using milled bars and a metal-re-
inforced denture framework requires
less prosthodontic maintenance for
clip activation/fracture than nonrigid
attachments such as round bars.20
The even thickness of the acrylic resin
in this implant-retained overdenture
prosthesis may also account for the
fact that there have been no mechani-
cal complications occurring after 3
years of function.
A removable implant-supported
prosthesis is easier for the patient to
clean.14 This is particularly important
in reconstructed sites where there is
often a lack of keratinized mucosa,
coupled with reduced labial sulcus
depth and limited oral access that
Wong et al
July 2010
may hinder the patients oral hygiene
procedures. In the present scenario,
vestibuloplasty with a palatal muco-
sal graft provides a zone of keratin-
ized mucosa around the implants and
deepens the sulcus, hence facilitating
the patients oral hygiene procedures.
Throughout the follow-up period of
3 years following prosthesis inser-
tion, this patient was able to main-
tain good periimplant plaque control
and has shown excellent periimplant
health (Fig. 7). There has been no ra-
diographic evidence of periimplant
bone loss (Fig. 8). The encouraging
treatment outcomes for this patient
are in agreement with the findings of
another study which reported a low
incidence of biological and prosth-
odontic complications associated with
implant-supported mandibular over-
dentures that are rigidly retained by
a milled bar.19 As a result, long-term
treatment costs for this prosthesis de-
sign might be lower than costs associ-
ated with the fixed implant-supported
prosthesis option.11
SUMMARY
The milled bar and tooth- and
implant-supported prosthesis de-
scribed was used to rehabilitate the
reconstructed mandible after resec-
tion/particulate graft reconstruction
followed by distraction osteogenesis
and implant placement.
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Corresponding author:
Dr T. L. Wong
Oral Rehabilitation
Faculty of Dentistry
University of Hong Kong
34 Hospital Road
HONG KONG
Fax: 852-2858 6114
E-mail: mwongtl@yahoo.com.hk
Acknowledgements
The authors thank L. K. Cheung, Professor of
Oral and Maxillofacial Surgery, Faculty of Den-
tistry, University of Hong Kong, for performing
the reconstructive surgery, as well as his staff
for their assistance, and Ms Canny Fung for
the dental laboratory work.
Copyright 2010 by the Editorial Council for
The Journal of Prosthetic Dentistry.