Received: 30 April 2019 Revised: 2 July 2019 Accepted: 5 July 2019

DOI: 10.1111/scd.12407

CA S E H I ST O RY R E P O RT

Use of osseointegrated implants in the intermaxillary suture in a

patient with microstomia: Case report with a 2-year follow-up

Rodrigo Lorenzi Poluha DDS1 João Matheus Scherbaum Eidt DDS1

Carolina Ferrairo Danieletto-Zanna DDS1 Gustavo Zanna Ferreira DDS1
Osmar Kenji Takizawa DDS2 Gustavo Jacobucci Farah PhD1

1 State University of Maringá, Maringá,

Abstract
Brazil
2 Private Clinic, Maringá, Brazil
Aim: To report the rehabilitation of a female patient, 40 years old, with a microstomia.

Correspondence
Rodrigo Lorenzi Poluha, Dentistry Depart-
ment, State University of Maringá, Mandacaru
Avenue, 1550, 87080-000 Maringá, Paraná,
Brazil.
Email: rodrigopoluha@gmail.com
Case Report: The Z-plasty surgery was performed in the region of the labial com-
missure to increase the mouth opening. In the mandible, two implants were installed
in the interforaminal region and an overdenture with bar/clip attachment system was
made. The maxilla was atrophic, with the presence of two bone sites in the intermax-
illary suture region: the first one anterior to the incisive foramen and the second one
in the middle of the hard palate. Two implants were placed without a graft in those
sites. The conventional maxillary denture was converted into an overdenture with ball
attachments system.

Conclusion: Based on the presented case, with a 2-year follow-up, it can be con-
cluded the validity of the use of the techniques of surgeries to increase the mouth
opening, implants in intermaxillary suture and overdentures as rehabilitation therapy
for patients with microstomia.

KEYWORDS
dental prosthesis, implants, microstomia

1 I N T RO D U C T I O N and flexible prostheses.7 However, some edentulous patients

Microstomia is defined as an abnormally small oral ori-
fice and impairs speech, feeding, oral hygiene, and dental
treatment.1,2 This condition may be the result of genetic dis-
orders, surgical treatments of orofacial neoplasia, lip fissures,
burn, radiotherapy, or scleroderma.3 In 80% of patients with
scleroderma, there is the presence of microstomia.4
Different surgical procedures have been presented to
reconstruct microstomia. Commissuroplasty, such as Z-plasty
present good results and rapid recovery.2
For the rehabilitation of patients with microstomia, the lit-
erature reports modalities such as segmented prostheses5,6
may face difficulties in adapting to conventional complete
denture due to poor adaptation and failure of retention.8
In this scenario, the use of osseointegrated dental implants
allows the preparation of treatments that overcome these
limitations.9
The discussion of different approaches to oral rehabilita-
tion can improve the literature and clinical practice. Thus, the
aim of this paper is to report the rehabilitation of a patient
with a microstomia. It was used as a combination of surgeries
to increase the mouth opening, implants in the intermaxillary
suture and overdentures.

© 2019 Special Care Dentistry Association and Wiley Periodicals, Inc.

Spec Care Dentist. 2019;1–5. wileyonlinelibrary.com/journal/scd 1

2 POLUHA ET AL.
FIGURE 1 A, Initial mouth opening. B, Initial panoramic
radiograph
2 CA SE REPORT
A 40-year-old female patient with scleroderma and micros-
tomia sought care. She complained of functional aesthetic
impairment, limitation of mouth opening, as well as mobil-
ity and pain in several teeth, which reflected the difficulty of
feeding and social seclusion. In the clinical and radiographic
examination, the remaining teeth presented extrusion, caries,
and extensive periodontal support impairment (Figure 1). The
patient asked for a quick functional and aesthetic rehabilita-
tion. The proposed treatment included surgery to increase the
mouth opening, extraction of condemned teeth, and installa-
tion of implant supported overdentures in the mandible and
maxilla. The patient signed the written informed consent form
for the present case report.
The first surgical step was performed under general anes-
thesia, together with a plastic surgeon. A preoperative full
medical evaluation was required for general anesthesia; no
relevant alteration was observed. A bilateral Z-plasty was
performed at the labial commissure. Z-plasty involves the
creation of two triangular flaps of equal dimension that are
then transposed. Afterward, all teeth were extracted and two
implants (3.5/10 mm, Alvim CM Acqua Neodent, Curitiba,
Brazil) were installed in the mandible in the interforaminal
region (Figure 2). After 120 days, a good healing state and sat-
isfactory mouth opening were observed. At this moment, the
construction of a maxillary denture and a mandibular over-
denture with bar/clip attachment system began.
The maxilla was atrophic, making it impossible to put
implants in the conventional positioning. Reconstructive surg-
eries (bone graft, sinus lift and zygomatic implants) were
ruled out due to the reduced mouth opening, high morbid-
ity, and extensive postoperative period for implant activa-
tion. Cone beam computed tomography (CBCT) showed the
presence of two bone sites in the intermaxillary suture region,
FIGURE 2 A, Mouth opening after Z-plasty surgery. B,
Panoramic radiograph 120 days after mandibular implants
FIGURE 3 Initial CBCT scan, sagittal reconstruction
the first one anterior to the incisive foramen and the second
one in the middle of the hard palate (both 5-mm high and 5-
mm wide) (Figure 3).
Two implants were installed (3.5/6.5 mm, Ankylos Implant
Driver C/X, Petrópolis, Brazil). In the surgery, local anesthe-
sia was applied to the nasopalatine and bilateral major pala-
tine nerves. The drillings were performed without incision,
with depth and inclination planned according to bone avail-
ability and following the sequence of drills of the implant sys-
tem. About 1.5 mm of the neck region of the implants was
not intraosseous. The resonance frequency analysis device
(Osstell ISQ, Gothenburg, Sweden) showed implant stabil-
ity quotient (ISQ) values of 65 for primary stability of both
implants (Figures 4 and 5).
After 45 days, both implants presented ISQ of 70 show-
ing high stability. Two ball attachments (3.5 mm in length
and 2.7 mm of diameter) (Ankylos Snap Attachment, Petrópo-
lis, Brazil) were installed. The conventional maxillary den-
ture was perforated at the implant regions and placed in the
mouth, verifying the complete settling. The matrices (4.0 mm
in length and 3.5 mm of diameter) for Snap Attachment were
captured with self-curing polymethylmethacrylate (Dencor,
São Paulo, Brazil). At the end of the polymerization, out of
the mouth, the finishing and polishing of the acrylic were
POLUHA ET AL.
FIGURE 4 A, Hard palate before surgery. B, First drilling. C, Second drilling. D, Implants in the intermaxillary suture
FIGURE 5 CBCT scan after implants in the intermaxillary
suture, sagittal reconstruction
performed, taking care not to leave any overhang on the exter-
nal surface of the denture (Figure 6).
The patient received instruction and training about the cor-
rect way to perform insertion, removal, and hygiene of the
prostheses (Figure 7). During the 2-year follow-up, there were
no complaints from the patient, reporting satisfaction with
the treatment results; the implants presented without bleed-
ing on probing, mobility, or any sign of significant bone loss
(Figure 8); the overdentures remained stable, with good reten-
tion and adaptation. The patient made regular returns every
6 months for 2 years; in the returns, only a simple tightening
of the matrices of the Snap Attachment was performed with a
specific instrument of the system. No relining of the prosthe-
sis was necessary.
3 DIS CUSSI O N
Adequate mouth opening is essential for speech, nutrition,
oral hygiene, facial harmony, and social life.10 To provide
patients with microstomia an adequate mouth opening, labial
3
Z-plasty surgery is an appropriate method with good results.11
In addition to the microstomia, patients with scleroderma usu-
ally present with deformities on the fingers, which also makes
intrabuccal hygiene difficult.6 In this scenario, overdentures
are an interesting oral rehabilitation alternative as they present
adequate retention and stability for speech and chewing func-
tions besides allowing extrabuccal hygiene.12,13 Among the
overdenture attachment systems in the mandible, the bar-clip
system was chosen to provide a better quality-of-life indexes
to the patients and lower maintenance in relation to other
systems.14,15
The use of osseointegrated implants in the intermax-
illary suture is one of the options for atrophic maxilla,
presenting low morbidity and costs, besides allowing the
use of overdenture.16 In the presented case, there was
only bone availability for two maxillary implants. CBCT
imaging is recommended to accurately identify palate bone
thickness for implant placement.17 Although there is no con-
sensus on the optimal number of implants that should support
an overdenture,18 the two-implant or one-implant maxillary
overdenture is a successful treatment option and may not be
limited only to exceptional circumstances.19
The selected implant system for maxilla (Ankylos)
was chosen because of rapid osseointegration (on average
45 days), and the high survival rate (93.3% after 204 months),
even in poor bone quality (95.5% after 204 months).20
According to literature, the midsagittal area of the palate lends
sufficient bone support for implants with an intraosseous
length of 4-6 mm and a diameter of 3.5 mm, without the
need for grafting.21 Although the available bone sites of the
patient reported had a height of 5 mm and the implants
selected 6.5 mm in length, the surface of the implant without
4 POLUHA ET AL.

FIGURE 6 A, Installation of Snap Attachment. B, Installation of matrices for Snap Attachment. C, Capturing the matrices. D, Maxillary
overdenture, internal view

and maintenance.24 The care in capturing the matrices with

the base of the denture completely seated on the palate is crit-
ical to prevent the build-up of food beneath the overdenture, in
addition to enhancing the prosthesis stability and optimization
of forces dissipation over the maxilla.25 The bone availability
did not allow the parallel arrangement of the implants. How-
ever, this divergence of inclination was partially compensated
in the simultaneous capture of the matrices and did not cause
FIGURE 7 Final smile
damage in the settlement or in the retention of the maxillary
overdenture.
Based on the presented case, with a 2-year follow-up, it
can be concluded the validity of the use of the techniques
of surgeries to increase the mouth opening, implants in inter-
maxillary suture and overdentures as rehabilitation therapy for
patients with microstomia. Analysis and planning of the par-
ticularities of each case are fundamental to adjust the treat-
ment and achieve clinical success and patient satisfaction.
FIGURE 8 CBCT scan with 2-year follow-up, sagittal
reconstruction CO N F L I C T O F I N T E R E ST

The authors declare no conflict of interest.

bone contact did not significantly impair the stability of the
implants, as evidenced in the resonance frequency analysis
that showed results of 65 ISQ in primary stability and 70 AU T H O R CO N T R I B U T I O N S
ISQ in secondary stability, values indicating excellent implant
stability.22 Although the 1.5 mm of the neck region of the All authors were involved in the work leading to the publica-
implants that were not intraosseous did not influence the ISQ, tion of the paper, which was read and approved by all of them.
so far; this value (1.5 mm) can be considered as an early bone
loss and professional follow-up is necessary to implants con-
O RC I D
tinuing to present a satisfactory survival.23
Were selected ball attachments for maxillary overdenture Rodrigo Lorenzi Poluha DDS
due to the simplicity in design, good retention, ease of use, https://orcid.org/0000-0001-7180-6448
POLUHA ET AL.
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How to cite this article: Poluha RL, Eidt JMS,
Danieletto-Zanna CF, Ferreira GZ, Takizawa OK,
Farah GJ. Use of osseointegrated implants in the inter-
maxillary suture in a patient with microstomia: Case
report with a 2-year follow-up. Spec Care Dentist.
2019;1–5. https://doi.org/10.1111/scd.12407