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Journal of Oral Rehabilitation 2006 33; 313–315

Implant-retained overdenture following hemiglossectomy: a 10-year clinical case report
Y . T A I R A * , J . S E K I N E †, T . S A W A S E * & M . A T S U T A *

*Division of Fixed Prosthodontics and Oral

Rehabilitation and Division of Oral and Maxillofacial Surgical Reconstruction and Functional Restoration, Nagasaki University, Nagasaki, Japan

SUMMARY

A clinical evaluation of an implant-supported overdenture placed in the edentulous mandible after hemiglossectomy is described. The deltopectoral flap covering the mandibular ridge ˚ was replaced with a free mucosal graft. Four Branemark system implants were inserted into the anterior part of the mandible, but one of the four fixtures did not show osseointegration. The superstructure was designed as a spaced round bar-attachment supported by three implants so as to retain the complete overdenture. In addition to the metal clip,

a silicone-based soft denture liner material was applied in the female portion of the attachment so as to prevent the attachment from making a clattering noise upon mastication. Although the overdenture required adjustment at regular intervals, the treatment was successful both aesthetically and functionally for up to at least 10 years. KEYWORDS: dental implant, overdenture, attachment, tongue carcinoma Accepted for publication 20 August 2005

Introduction
When a patient has a compromised residual ridge anatomy as a result of pre-prosthodontic surgery, it is sometimes difficult to achieve comfortable function and aesthetics (1, 2). This challenge has been addressed to a certain extent in oral tumour patients after jaw resection and following rehabilitation with dental implants (3–6). In such cases, the implant-supported overdenture has the advantage of improved function associated with minimum movement, when compared with the conventional complete denture (7, 8). The movement of the overdenture also depends on the shape of the bar-attachment and the number of implants that are splinted (9). Various osseointegrated implant systems are applicable to the fabrication of implant-supported overden˚ ture, and the cumulative survival rates for Branemark and ITI systems supporting overdentures have been reported to be 94Æ5% for 5 years (10) and 95Æ7% for 7 years (11) respectively. Some patients prefer removable implant-supported prostheses to fixed
ª 2006 Blackwell Publishing Ltd

implant-supported prostheses because of ease of cleaning and improved aesthetics (12). It is essential to maximize the quality of prosthetic components so as to satisfy the expectations of patients. Previously, we reported a 2-year case of oral reha˚ bilitation by means of Branemark system* for a patient with tongue carcinoma (13). The present report describes the longer term follow-up of this patient.

Case report
A 52-year-old male with the chief complaint of a tongue ulcer was referred to our hospital. Based on the diagnosis of squamous cell carcinoma on the righthand side of the tongue, radiation therapy (Linac X-ray†) of 40 Gy and hemiglossectomy were selected as a course of treatment. Following the excision of the carcinoma, the defect in the tongue, oral floor and mandible was reconstructed using the deltopectoral
*Nobel Biocare, Goteborg, Sweden. ¨ † Siemens AG, Munich, Germany. doi: 10.1111/j.1365-2842.2006.01633.x

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Y . T A I R A et al.
flap. Eleven years later, a lesion resulting from inflammatory hypertrophic change of the deltopectoral flap was surgically removed. When the patient was seen in the prosthodontic division of our hospital, he requested treatment to restore occlusal function. Thereby, a treatment plan using dental implants was developed. Fifteen months before surgical placement of the implant, the deltopectoral flap was replaced with free palatal mucosa. Four months before implant surgery, hyperbaric oxygen therapy was employed on 15 occasions so as to prevent osteoradionecrosis of the irradiated mandible. A total of four implant fixtures ˚ (Branemark system*) were inserted into the interforaminal region of the mandible. This treatment was performed 13 years after the last radiation therapy. The fixtures were 4Æ1 mm in diameter and 13–15 mm in length. Six months post-implant placement, abutment connection was performed. However, one fixture did not show osseointegration, and was removed to allow bone healing. While the overdenture was being constructed, a temporary denture with an underlying tissue conditioner‡ was worn. Following the second implant surgery, a bar-attachment was fabricated using a round-shaped dolder bar with two clips* (Fig. 1). While using the completed overdenture, the patient complained of a clattering noise made by the barattachment upon mastication. A silicon-based soft denture liner (Sofreliner Medium Soft or Sofreliner Tough Medium§ was, therefore, applied into the space between the attachment-bar and metal clip. This resolved the patient’s concern. At 6-monthly checkups, the overdenture was adjusted and the soft denture liner material was renewed. Neither drug nor radiotherapy was used during the follow-up period. Based on published criteria (14), implants are considered successful if (i) radiographic evaluation reveals no more than 1Æ0 mm of marginal bone loss during the first year of loading and no more than 0Æ2 mm resorption per year in subsequent years; (ii) no peri-implant pathosis or radiolucency is observed; and (iii) severe soft tissue infections, persistent pain, paraesthesia and discomfort are absent. According to these criteria, the implant-supported overdenture in the present case was considered successful over the 10 years of follow-up;
‡ §

Fig. 1. Intraoral view 1 year after completion of the superstructure. The fat and skin of the deltopectoral flap were replaced with free palatal mucosa. The superstructure was designed as an overdenture retained with a bar-attachment.

˚ Fig. 2. Radiographs of the Branemark system* implant and the superstructure 10 years after the completion of the superstructure.

there was no excessive loss of the marginal bone level (Fig. 2), and the overdenture functioned well.

Discussion
This report describes a case of oral rehabilitation using an implant-supported overdenture. The surgically induced defect had initially been reconstructed using a deltopectoral flap. However, when a fixture is installed through a deltopectoral flap, the soft tissue around the implant is movable (15), and hair grows and keratinous tissue derived from the deltopectoral flap make the tissue difficult to clean. Therefore, so as to prevent peri-implantitis, we removed the fat and skin of the deltopectoral flap, and replaced the tissue with a free gingival graft (16). To decrease the likelihood of

Shofu Inc., Kyoto, Japan. Tokuyama Dental, Corp., Tokyo, Japan.

ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 313–315

IMPLANT FOLLOWING HEMIGLOSSECTOMY
infection around the implant, the two-phase implant system was employed. Failure of one of the four implants in this clinical case may have been due to the previous radiation that was applied to the tongue carcinoma (17–20). The spaced round bars fixed onto three implants allow minimum movement of the overdenture on mastication. Moreover, the use of soft denture liner decreased the clattering noise associated with the barattachment. The gap observed between the resin and the soft denture liner material may have been due to the deterioration of the soft denture liner and the limitation of the adhesive bonding. The present report suggests that a favourable prognosis and aesthetics can be achieved using an implantsupported overdenture, even in patients that have undergone irradiation therapy for tongue carcinoma in addition to reconstructive surgery using a deltopectoral flap.
9. Wright PS, Watson RM. Effect of prefabricated bar design with implant-stabilized prostheses on ridge resorption: a clinical report. Int J Oral Maxillofac Implants. 1998;13:77–81. 10. Jemt T, Chai J, Harnett J et al. A 5-year prospective multicenter follow-up report on overdentures supported by osseointegrated implants. Int J Oral Maxillofac Implants. 1996;11:291–298. 11. Romeo E, Lops D, Margutti E, Ghisolfi M, Chiapasco M, Vogel G. Long-term survival and success of oral implants in the treatment of full and partial arches: a 7-year prospective study with the ITI dental implant system. Int J Oral Maxillofac Implants. 2004;19:247–259. 12. Feine JS, de Grandmont P, Boudrias P et al. Within-subject comparisons of implant-supported mandibular prostheses: choice of prosthesis. J Dent Res. 1994;73:1105–1111. 13. Sekine J, Inokuchi T, Yoshida S et al. Mucosal graft replacement of the deltopectoral (DP) flap covering the mandibular alveolus for endosseous implant placement in the mandible – report of a case. J Jpn Soc Oral Implant. 1997;10:328–331. 14. Roos J, Sennerby L, Lekholm U, Jemt T, Grondahl K, ¨ Albrektsson T. A qualitative and quantitative method for evaluating implant success: a 5-year retrospective analysis of ˚ the Branemark implant. Int J Oral Maxillofac Implants. 1997;12:504–514. 15. Haers PEJ, van Straaten PJW, Stoelinga PJ, de Koomen HA, Blydorp PA. Reconstruction of the severely resorbed mandible prior to vestibuloplasty or placement of endosseous implants: a 2 to 5 year follow-up. Int J Oral Maxillofac Surg. 1991;20: 149–154. 16. Simons AM, Darany DG, Giordano JR. The use of free gingival grafts in the treatment of peri-implant soft tissue complications: clinical report. Implant Dent. 1993;2:27–30. ˚ 17. Granstrom G, Tjellstrom A, Branemark PI. Osseointegrated ¨ ¨ implants in irradiated bone: a case-controlled study using adjunctive hyperbaric oxygen therapy. J Oral Maxillofac Surg. 1999;57:493–499. 18. Mayer R, Hamilton-Farrell MR, van der Kleij AJ et al. Hyperbaric oxygen and radiotherapy. Strahlenther Onkol. 2005;181:113–123. 19. Granstrom G. Osseointegration in irradiated cancer patients: ¨ an analysis with respect to implant failures. J Oral Maxillofac Surg. 2005;63:579–585. 20. Oechslin CK, Zimmermann AP, Gratz KW, Sailer HF. Histo¨ logic evidence of osseointegration in the irradiated and reconstructed mandible: a case report. Int J Oral Maxillofac Implants. 1999;14:113–117.

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Correspondence: Yohsuke Taira, Division of Fixed Prosthodontics and Oral Rehabilitation, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki 852-8588, Japan. E-mail: yohsuke@net.nagasaki-u.ac.jp

ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 313–315

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