THIEME

e38 Original Article

Current Therapeutic Options for Implant-Supported

Rehabilitation of Severely Atrophic Mandibles
Paulo Domingos Ribeiro-Júnior, DDS, MS, PhD1 Rafael Zetehaku Araujo, DDS, MS2
Gabriel Cury Mendes, DDS, MS, PhD1 Luis Eduardo Padovan, DDS, MS, PhD3

1 Department of Oral and Maxillofacial Surgery, Universidade Sagrado
Curacao, Bauru, São Paulo, Brazil
2 Department of Oral Implantology, Universidade Federal de
Uberlandia, Campus Umuarama, Uberlandia, Minas Gerais, Brazil
3 Department of Oral Implantology, Instituto Latino Americano de
Pesquisa e Ensino Odontologico, Curitiba, Paraná, Brazil
Address for correspondence Rafael Zetehaku Araujo, DDS, MS,
Department of Oral Implantology, Universidade Federal de
Uberlandia, Campus Umuarama, Uberlandia, Minas Gerais 38400-902,
Brazil (e-mail: rafaelzaraujo@hotmail.com).

Craniomaxillofac Trauma Reconstruction Open 2018;2:e38–e48.

Abstract
Keywords
► dental implants
► atrophic mandible
► bone atrophy
► oral rehabilitation
The implant-supported rehabilitation of atrophic mandibles (AM) with severe bone
resorption is challenging for both surgical and prosthetic procedures due to the high
risk of mandible fracture during implant surgery and postoperatively due to the
masticatory load. The aim of case presentations was to demonstrate treatment
alternatives for patients with AM who required oral rehabilitation with osseointegrated
implants (OIs) according to the residual mandibular bone volume. When bone is 9 mm
in height, the ideal treatment is the use of narrow, short OIs. When the bone height is 5
to < 9 mm, mandibular reinforcement with reconstruction plates using the intraoral
approach and simultaneous placement of osseointegrated implants are proposed. In
cases where bone height is < 5 mm, the choice of treatment is mandibular recon-
structive surgery with an autogenous bone graft and biomaterials. The fundamental
principles of this protocol are to reduce the morbidity and complications associated
with the surgical procedure, which would reduce both the time and cost of full dental
rehabilitation. The choice of the technique for mandibular reconstruction should be
indicated according to the magnitude of the atrophy.

Patients with mandibular atrophy often have problems using
full removable dentures, resulting in a lack of stability, intol-
erance to loading by the mucosa, pain, feeding and diction
difficulties, loss of adjacent soft tissue support, and abnormal
facial appearance.1 Therefore, many of these patients should be
perceived as having an oral disability, as oral rehabilitation will
often result in maxillofacial recovery.
The rehabilitation of complete edentulous mandibles with
osseointegrated dental implants was first performed by
Brånemark et al.2 They reported great success, predictability,
and effectiveness; this form of rehabilitation treatment is
now well grounded in the literature, with more than 40 years
of follow-up and proven successes. However, in cases where
the patient presents severe mandibular bone atrophy, dental
rehabilitation with osseointegrated implants (OIs) becomes
less predictable and has an increased complication rate.1,3
Mandibular fracture is one of the most severe complications;
these fractures have been widely described in the literature
along with cases of osteomyelitis, permanent paresthesia,
and poor longevity of osseointegrated implants.3
In 1996, Luhr et al4 proposed a classification of mandibular
atrophy according to the height of the bone base. They con-
sidered the mandibles to be atrophic when the bone height
was  20 mm. Mandibles 16 to 20 mm in height were classi-
fied as class I atrophy, those 11 to 15 mm as class II atrophy,
and those  10 mm as extremely atrophic or class III atrophy.4

received DOI https://doi.org/ Copyright © 2018 by Thieme Medical

February 6, 2018 10.1055/s-0038-1669466. Publishers, Inc., 333 Seventh Avenue,
accepted after revision ISSN 2472-7512. New York, NY 10001, USA.
June 26, 2018 Tel: +1(212) 584-4662.
 Available Therapeutic Options for Implant-Supported Rehabilitation of Severely Atrophic Mandibles Ribeiro-Júnior et al. e39

The functional rehabilitation of severely resorbed mandibles
remains a prosthetic and surgical challenge due to the extreme
reduction in the supporting bone structure and due to the
progressive nature of the resorption process.5
Many alternatives for the treatment of atrophic mandibles
(AM) are found in the literature, including transmandibular
implant,6,7 short implants,8–10 distraction osteogenesis,11–13
and bone substitutes followed by implant installation,14
reconstructive techniques such as autogenous grafts to the
mandible base, segmental osteotomies with interposition of
grafts, the sandwich technique and inverted sandwich tech-
nique,1,5,14–16 and, most recently, reinforcement of the
atrophic mandible with reconstruction plates concomitant
with dental implant surgery.17–20
None of these alternatives is considered the gold standard
for rehabilitation of an atrophic mandible. Each has its own
specific advantages and disadvantages, including different
morbidity and associated time and treatment costs. Most of
the surgical techniques described in the literature have high
complication rates, especially distraction osteogenesis and
the reconstructive techniques.3,6,11,21,22 Blackburn et al23
reviewed the literature to evaluate the level of evidence in
published studies for the outcomes of bone augmentation
before implant surgery for atrophic jaws; they concluded
that the level of evidence was of a low order. No meta-
analysis of outcomes was possible due to the degree of
heterogeneity found in the articles reviewed, and future
studies with a higher level of evidence are needed.23
This case presentation aims to present alternatives to the
implant-supported rehabilitation of class III mandibles
according to the type and magnitude of bone atrophy. We
propose a protocol for the complete rehabilitation of AM
based on the remaining bone height and width (►Table 1).
We must also remember that the greatest number of patients
with this pathological condition are elderly. The fundamental
principles of this protocol are to reduce the morbidity and
complications associated with the surgical procedure, thus
reducing the time and cost of full dental rehabilitation.
Rehabilitation of Atrophic Mandibles
Type I Atrophic Mandible Rehabilitation: Mandibles
with a Minimum Width of 5 mm and Height of 9 mm
The Type I protocol for the rehabilitation of an atrophic
mandible is the use of short implants. Currently, this
treatment option is associated with technological advances
of modern implantology, as it uses implants that are both
short and have a reduced diameter—the so-called narrow
platform. Following this advance, the possibilities of the
Morse taper connection should be emphasized due to its
improved biomechanics; it allows rehabilitation resistance
very similar to rehabilitation with regular platform
implants. New titanium–zirconium alloy implants permit
rehabilitation with narrower implants because they allow
greater resistance and have higher strength compared with
conventional implants.24,25

Table 1 Proposed treatments for severe atrophic mandibles according to bone availability

Classification Proposed treatment Bone height Bone width Advantages

of atrophy
Type I Short (6, 7, 8, or 9 mm) and
narrow (3.3 or 3.5 mm)
implants
Type II Short and narrow implants
plus 2.0-mm reconstruction
plate
Type III Autogenous bone graft
reconstructive surgery in the
anterior mandible prior to
implant placement surgery
> 9 mm Minimum 5 mm - Low cost and reduced
treatment time
- Low morbidity
- Local anesthesia
- Predictable results.
< 9 mm and > 6 mm Minimum 5 mm - Reduced treatment time,
especially when immediate
loading is possible
- No need for donor site
morbidity
(without autogenous graft)
- Intraoral approach
- Low morbidity.
< 5 mm - Intraoral approach
- Autogenous bone graft
associated with biomaterials
reducing donor site bone
volume needed
- Possibility for removable
temporary prosthesis during
bone grafts incorporation
period
- Dental implants platform is
placed in the residual
mandibular bone, reducing
peri-implant bone loss over
time.

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e40 Available Therapeutic Options for Implant-Supported Rehabilitation of Severely Atrophic Mandibles
Fig. 1 (A) Panoramic radiograph and (B) lateral cephalometric radiograph showing a patient with Type I mandibular atrophy; the bone height is
9 mm.
The use of this technique can be observed in ►Figs. 1 and 2,
which show a clinical case of mandibular atrophy of a patient
classified by Luhr as class III, with 9 mm of bone height in the
anterior mandible (►Fig. 1). The patient was treated using
osseointegrated dental implants with Morse taper connections
3.5 mm in diameter and 8 mm in length. Abutments were
installed at the same time as the implant surgery installation;
transfer molding for immediate loading system rehabilitation,
with installation of a definitive full-arch implant-supported
hybrid prostheses, was also performed (►Fig. 2).
Some of the problems posed by this technique involve cases
where the mandibular atrophy is more pronounced in the
horizontal direction (width < 5 mm), which can lead to
increased bone fragility while installing the OIs. This can
induce a mandibular fracture. The use of narrow implants
can minimize this type of complication, but cannot prevent it.
Type II Atrophic Mandible Rehabilitation: Mandibles with
a Minimum Width of 5 mm and a Height of 6 to 9 mm
The Type II protocol for rehabilitation of AM is used for
mandibles 6 to < 9 mm in height. This technique uses a
mandibular reconstruction plate simultaneously with OIs
installation and minimizes the chances of mandibular fracture
(►Fig. 3). Furthermore, due to the reinforcement provided by
Fig. 2 Type I protocol. A panoramic radiograph showing short,
narrow, osseointegrated dental implants installed in the interforamen
region for a full-arch prosthesis.
Craniomaxillofacial Trauma & Reconstruction Open Vol. 2 No. 1/2018
Ribeiro-Júnior et al.
the titanium plate, immediate loading rehabilitation can be
achieved as long as the OIs achieve adequate initial stability.
This rehabilitative sequence may be observed in ►Figs. 4–6.
A 68-year-old patient with upper and lower edentulism
and severe mandibular atrophy, with a lower bone height
of < 9 mm (►Fig. 4) was rehabilitated using implant-sup-
ported prostheses. The rehabilitative sequence was based on
the principle of concurrent reinforcement of the mandible with
a 2.0-mm locking system reconstruction plate and installation
of the osseointegrated implants, thereby preventing mandibu-
lar fracture of the weakened atrophic mandible. The reconstruc-
tion plate should preferably be prefolded or prebent using a
biomodel made from the patient’s computerized tomography
(CT) scan to reduce the surgical time and ensure more accurate
adaptation (►Fig. 5). An acrylic implant surgical guide can be
manufactured to determine correct implant placement that
does not interfere with the screws used for the reconstruction
plate (►Fig. 6).
The surgical procedure must be performed while the
patient is under general anesthesia. The surgical approaches
used in this case were intraoral access to install the plate and
implants (►Fig. 7) and bilateral transcutaneous accesses to
fix the distal plate screws. The integrity of the mental
neurovascular bundle was maintained during surgery. In
Fig. 3 Panoramic radiograph showing the use of a reconstruction
plate in an atrophic mandible for reinforcement to prevent fractures
due to implant installation (Type II protocol).
 Available Therapeutic Options for Implant-Supported Rehabilitation of Severely Atrophic Mandibles Ribeiro-Júnior et al. e41

this technique, the inferior alveolar bundle is displaced
because in most cases of extensive bone atrophy, the mental
nerve tends to be positioned more superficially above the
alveolar ridge.
After positioning the reconstruction plate using intraoral
and transcutaneous surgical access, with a surgical guide
preconstructed on a patient’s biomodel, four titanium implants
are installed, as described in a Branemark protocol. Often,
despite bone atrophy, bone quality and quantity are adequate
for immediate prosthetic transfer of the OIs and immediate
loading. After administration of anesthesia discharge, the
patient underwent transfer molding, followed by the prosthe-
tic procedures necessary for immediate loading rehabilitation.
Three days after surgery, a Branemark protocol-type with a
metal bar and acrylic aesthetics was installed (►Fig. 8).
Type III Atrophic Mandible Rehabilitation:
Mandibles < 5 mm in Height
The Type III protocol for rehabilitation of an atrophic mandible
is indicated when the patient’s atrophy prevents rehabilitation

Fig. 4 (A–C) CT scans showing a Type II severely atrophic mandible with < 9 mm of vertical bone height. CT, computed tomography.

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e42 Available Therapeutic Options for Implant-Supported Rehabilitation of Severely Atrophic Mandibles
Fig. 4 (Continued)
using OIs, such as in medical conditions in which the remnant
mandibular bone is < 5 mm in height (►Fig. 9). In such cases,
it is prudent to perform bone reconstruction prior to implant
placement. The use of biological and/or synthetic biomaterials
is indicated for more predictable results and less overall
morbidity associated with the reconstructive surgery.
The surgical procedure was performed using an autoge-
nous bone graft from the iliac crest for reconstruction of the
anterior mandible in association with a xenograft (Bio-Oss,
Craniomaxillofacial Trauma & Reconstruction Open Vol. 2 No. 1/2018
Ribeiro-Júnior et al.
Geistlich Pharma) and morphogenetic protein rhBMP-2
(Infuse Bone Graft, Medtronic) (►Figs. 10–12).
In this clinical situation, it is necessary to allow incorpora-
tion of the bone into the graft site for at least 6 months.
Imaging examinations permit the evaluation of the recon-
structed bone for implant surgery planning (►Fig. 11).
At that time, reverse prosthetic planning and the produc-
tion of surgical guides are performed, and OIs with Morse
taper connections are installed. In most cases, good initial
 Available Therapeutic Options for Implant-Supported Rehabilitation of Severely Atrophic Mandibles Ribeiro-Júnior et al. e43

Fig. 8 Three days after surgery, a Branemark protocol-type pros-

thesis can be installed. This is a control panoramic radiograph taken
12 months after surgery.

Fig. 5 The reconstruction plate can be preadapted to a biomodel

made using the patient’s CT scan, reducing the surgical time and
enabling surgery to be performed using an intraoral approach. CT,
computed tomography.
stability of the implants is achieved, and prosthetic abut-
ments can be installed for rehabilitation with an immediate
loading system. Full-arch metal-acrylic implant-supported
prosthesis are fabricated and installed 72 hours after surgery
(►Fig. 12).
Discussion
Transmandibular implants for the treatment of an atrophic
mandible without reconstructive procedures were described
by Bosker and van Dijk7 in 1989. Studies show complication
rates ranging from 7.8 to 22.2%, including loss of osseointe-
gration, mandibular base bone inflammation and/or fistula,
postoperative infections, and fractures.6 These fractures
have a high occurrence rate when this system is used for

Fig. 6 (A) Acrylic implant surgical guide to direct correct implant placement that does not interfere with the screws of the reconstruction plate.
(B) Lateral view of the surgical guide and the prefolded plate.

Fig. 7 (A and B) Two different patients who underwent the Type II protocol. The reconstruction plate and implants were installed using the
intraoral approach. (B) Note the integrity of the mental neurovascular bundle. Due to optimal implant stability, in both cases, abutments were
installed for immediate loading rehabilitation.

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e44 Available Therapeutic Options for Implant-Supported Rehabilitation of Severely Atrophic Mandibles Ribeiro-Júnior et al.

severely resorbed mandibles.14 This technique also recom-
mends extra oral access for proper execution.
In 1998, Perry16 described a technique for the treatment of
AM using osseointegrated subperiosteal implants and
implants associated with iliac crest grafts, with the aim of
extending the support of the prosthesis to the posterior region
of the mandible. The complications of this technique included
paresthesia of the inferior alveolar nerve followed by hyper-
esthesia, graft exposure, and a 50% loss of the graft. This
technique seems to have a few advantages due to the morbidity
of the procedure and the type of prosthesis proposed for the
patient’s rehabilitation. The patients were ultimately rehabi-
litated with removable dentures of the overdenture type.
In 1995, Keller8 described a technique in which implants of
the interforamen region in mandibles were installed that
extended through both cortices and elevated the periosteum
of the mandibular basal bone with the apex of the implant,
leading to clot stabilization and bone tissue formation after
wound closure. Complications including mandibular fracture
occurred during the wound closure period following the

Fig. 9 (A–C) CT scan showing a Type III severely atrophic mandible (< 5 mm). CT, computed tomography.

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 Available Therapeutic Options for Implant-Supported Rehabilitation of Severely Atrophic Mandibles Ribeiro-Júnior et al. e45

Fig. 9 (Continued)

procedure. The incidence of mandibular fractures in this type
of patients reported in the literature is yet to be determined. In
2012, Almasri and El-Hakim in a PubMed search revealed 13
cases of fractured atrophic mandible secondary to implant
placement.26
The technique of distraction osteogenesis has advantages
compared with grafting procedures, as it does not require a
donor area. This difference results in lower morbidity and the
presence of vital bone in the distraction area (and therefore
in the region that will receive the implant) in addition to an
increase in soft tissue. However, complications such as
mandibular fractures, infection, and necrosis of the upper
fragment have been described in AM.1,3 Complications are
also described by Perdijk et al11 who reported a complication
rate of 66% in AM, contraindicating that the procedure could
be performed on mandibles < 10 mm height.
In principle, the use of short implants is a very interesting
treatment, as the procedure is quite safe, relatively simple, and
has low morbidity.8 However, the risk in this isolated type of
treatment lies in the possibility of mandibular fractures,9 as the

Fig. 10 Surgical procedure for mandibular reconstruction. (A) Surgical access and exposure of the mandibular bone. (B) Fixation of the
autogenous bone block graft to the mandibular base. (C) Xenograft (Bio-Oss) and bone morphogenetic protein rhBMP-2 (Infuse Bone Graft)
were associated with the autogenous bone.

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e46 Available Therapeutic Options for Implant-Supported Rehabilitation of Severely Atrophic Mandibles
Fig. 11 Panoramic radiograph taken 6 months after surgery showing
adequate bone volume in the anterior mandible.
Fig. 12 Panoramic radiograph after rehabilitation with implant-
supported prostheses.
osteotomy for implant placement removes bone tissue from an
already weakened mandible.21 Although this is a rare compli-
cation,3 treatment is difficult22. The use of short implant
therapy is indicated for cases of moderate atrophy of the
mandible.10,17–20 Treatment of AM with only short implants
is usually associated with mandibular fractures during the
trans- or postoperative period, as described. To minimize the
risk of complications, the use of narrow diameter implants (3.5,
3.3, or 2.9 mm) should be emphasized. The recent credibility
attributed to narrow implants reinforced by zirconia, which
provides sufficient strength to withstand masticatory and
occlusal loads, encourages the use of these new technologies
in severe AM. The use of this type of implant leads to thicker
lateral and medial remnant bone, decreasing the risk of frac-
ture. However, as these implants require prosthetic rehabilita-
tion resistance, the use of OIs with Morse taper connections
seems to be an interesting option, as other types of narrow
implants may have inefficient prosthetic biomechanics.
In Type I AM, with less than 5 mm in width, it should be
decided, based on the remaining bone volume, whether to
perform the Type I protocol (with possible complications
such as mandibular fracture in mind), or to perform the
mandibular reinforcement with a reconstruction plate, as
proposed in Type II protocol. The decision must be planned
individually and in the remaining total bone height and
width. In cases where bone width is less than 5 mm, there
is an increased risk of mandibular fracture due to a lack of
residual bone around implants. To reinforce a severely
atrophic mandible, a reconstruction plate of the 2.0-mm
Craniomaxillofacial Trauma & Reconstruction Open Vol. 2 No. 1/2018
Ribeiro-Júnior et al.
locking system adjusted on the mandibular base can be used
with narrow implants.18–20 Prior to surgery, the plate should
be adapted on a biomodel of the patient, due to advantages
such as the opportunity to better study the case and reduce
the surgical time.27,28 Using the same biomodel, it is possible
to establish the positioning of the implants and the plate
screws before surgery so that the screws in the anterior
region do not interfere with the positioning of the implants.
The plate can be installed via intraoral access with pre-
servation of the mental neurovascular bundle, which requires
only two small transcutaneous accesses points for installation
of the most distal plate screws. We reinforced the need for
displacement of the inferior alveolar nerve by bilaterally
repositioning it more posteriorly, so that the reconstruction
plate could be installed via intraoral access. The type of
osteosynthesis indicated is the 2.0-mm locking system. With
this system, hardware with a smaller volume, plate, and screws
may be inserted, and the locking system permits increased
biomechanical resistance of the plate.29 The smaller volume
also facilitates an intraoral surgical approach and decreases
the chance of plate exposure in the intraoral environment
during the healing period. This material provides adequate
resistance to the mandible, allowing patients to return to their
routine quickly and with minimal morbidity. Thus, rehabilita-
tion is fast, safe, and predictable.20
The literature regarding atrophic mandible treatments
includes various bone reconstruction techniques, such as
onlay and interpositional grafts, which enable OIs placement
either during the same surgical procedure or after the graft
incorporation period. When implants are placed at the same
time as bone grafts, the difficulty in planning ideal implant
positioning may be a disadvantage. In addition, in these
cases, osseointegration into the grafted area can be unpre-
dictable.30 The two-stage techniques have the disadvantage
of requiring a second surgical procedure.5 Moreover, it is not
possible to predict how much the graft will be remodeled
around the implant. Bone graft resorption using the sand-
wich technique seems minor compared with onlay grafts.15
Complications associated with autogenous grafting techni-
ques include sensory disorders of the mental nerve, suture
dehiscence, infection of the grafted area, and major morbid-
ity.3 Most cases require extraoral incisions.
With the increasing development of modern implantol-
ogy, large reconstructive surgeries have become less fre-
quent in clinical practice. However, while treating severe
bone atrophy, implant therapy is often impossible without
previous reconstructive procedures. It would be impossible
to perform the Type III atrophic mandible reconstruction
protocol described in this work using the reconstruction
plate, as the extremely low bone height would prevent
placement of the robust screws of the 2.0-mm system and
the osseointegrated implants. Mandibular bone reconstruc-
tion is required in these situations.
Since bone remodeling of the onlay grafts for vertical bone
augmentation is unpredictable,15 it is a good option to
accommodate the graft at the mandibular base, allowing
the implant platforms to be placed in the patient’s original
bone instead of grafted bone. To compensate for possible
 Available Therapeutic Options for Implant-Supported Rehabilitation of Severely Atrophic Mandibles
graft resorption, the use of heterogeneous biomaterial with a
slow resorption rate seems to be a good alternative. In
addition, the use of a removable prosthesis is permitted
during incorporation, as it will not jeopardize the stability of
the bone graft.
Currently, the intraoral approach is recommended for
surgery. This technique has advantages: it allows for faster
postoperative recovery with no apparent extraoral scars,
and often results in a shorter hospital stay. However,
surgeons should pay special attention not to damage the
mental neurovascular bundle during incision and soft tissue
detachment, as this structure is often found on the man-
dibular edge due to extensive atrophy. In some cases, the
inferior alveolar neurovascular bundle is exposed for most
of its length along the mandibular edge. We consider that
the disadvantage of higher inferior alveolar bundle par-
esthesia due to nerve manipulation is of minor importance
when compared with an atrophic mandible fracture or the
morbidity of reconstructive surgery. Reinforcing the mand-
ible with a reconstruction plate not only prevents a man-
dibular fracture, but also enhances the possibility of
immediate prosthetic rehabilitation procedures, making it
unnecessary to use a removable prosthesis during osseoin-
tegration period and/or the bone healing period when bone
reconstruction is needed.
The age range of most of these patients should not be
disregarded. Elderly patients have a higher incidence of sys-
temic diseases, and treatment planning should be more con-
servative and as short as possible. That is a primary reason to
emphasize the importance and advantages of the Type I and
Type II protocols, eliminating long treatment planning and
reducing the morbidity of reconstructive procedures.
We must mention a technique recently published by
Gellrich et al which consists of the accomplishment of a
treatment strategy through the installation of subperiosteal
implants through a rigid fixation anchorage system.31,32
This type of treatment, known as IPS-Dental, aims at the
execution of customized connections for patients who go
against the characteristics of traditional implantology and
can be used in cases of AM and patients with a history of
extensive bone defects, such as post treatment of oral
cancer. Therefore, it is a promising technique for the mini-
mally invasive rehabilitation, with reduction in costs and
treatment time and in accordance with the concepts of
modern implantology. Although the technique may be
considered as a potential treatment plan for patients with
extremely AM, the authors of this paper are yet to become
familiar with the technique. Since few cases with a short
follow-up time have been published, in addition to not
having a specific protocol or indication for these types of
patients, this technique was not initially included in the
AM rehabilitation protocol.31,32 All clinical cases of severe
mandibular atrophy are currently addressed by all oral and
maxillofacial surgeons linked to our service for over
10 years, using the approaches suggested in this study.
We may now consider that our complications associated
with the therapeutic approaches employed in severely AM
are close to zero. More than 25 patients with severe
Ribeiro-Júnior et al. e47
mandibular atrophies have already been treated with the
techniques presented here, and the vast majority of them
had immediate loading implant prostheses, as these were
associated with the classifications I and II suggested by us.
The lower likelihood of complications, as well as the faster
and less invasive treatments with shorter periods of hospi-
talization, make these techniques attractive to patients.
Even more, because many of these patients are elders
with systemic fragility, which makes us think twice about
the issue of surgical invasiveness. In numbers, we currently
have 4 patients treated through Protocol III, 8 patients
treated through Protocol II, and 13 patients treated through
Protocol I.
Conclusion
Treatment of AM using short, narrow implants is good for
Type I cases. Treatment should preferably attempt to use
implants with Morse taper connections, as these provide a
better biomechanical implant–prosthesis system, even with
small-diameter implants. In Type II AM, the use of a
reconstruction plate and the installation of the implants
in the same surgery are effective; the material provides
adequate resistance for the mandible, preventing fractures
during the trans- and postoperative periods and allowing
immediate oral rehabilitation. In turn, in Type III cases, a
bone graft should be considered for mandibular recon-
struction prior to implant placement, and all modern
resources of bone tissue engineering should be pursued.
Therefore, it is possible for oral rehabilitation procedures to
reach all patients with mandibular atrophy and to rehabi-
litate these patients safely, predictably, and with minimal
morbidity.
Conflict of Interest
None.
References
1 Stellingsma C, Vissink A, Meijer HJA, Kuiper C, Raghoebar GM.
Implantology and the severely resorbed edentulous mandible.
Crit Rev Oral Biol Med 2004;15(04):240–248
2 Brånemark PI, Adell R, Albrektsson T, Lekholm U, Lundkvist S,
Rockler B. Osseointegrated titanium fixtures in the treatment of
edentulousness. Biomaterials 1983;4(01):25–28
3 Raghoebar GM, Stellingsma K, Batenburg RH, Vissink A. Etiology
and management of mandibular fractures associated with endo-
steal implants in the atrophic mandible. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2000;89(05):553–559
4 Luhr HG, Reidick T, Merten HA. Results of treatment of fractures of
the atrophic edentulous mandible by compression plating: a
retrospective evaluation of 84 consecutive cases. J Oral Maxillofac
Surg 1996;54(03):250–254, discussion 254–255
5 Bell RB, Blakey GH, White RP, Hillebrand DG, Molina A. Staged
reconstruction of the severely atrophic mandible with autoge-
nous bone graft and endosteal implants. J Oral Maxillofac Surg
2002;60(10):1135–1141
6 Betts NJ, Powers MP, Barber HD. Reconstruction of the severely
atrophic edentulous mandible with the transmandibular implant
system. J Oral Maxillofac Surg 1995;53(03):295–304
7 Bosker H, van Dijk L. The transmandibular implant: a 12-year
follow-up study. J Oral Maxillofac Surg 1989;47(05):442–450
Craniomaxillofacial Trauma & Reconstruction Open Vol. 2 No. 1/2018
e48 Available Therapeutic Options for Implant-Supported Rehabilitation of Severely Atrophic Mandibles
8 Keller EE. Reconstruction of the severely atrophic edentulous
mandible with endosseous implants: a 10-year longitudinal
study. J Oral Maxillofac Surg 1995;53(03):305–320
9 Mason ME, Triplett RG, Van Sickels JE, Parel SM. Mandibular
fractures through endosseous cylinder implants: report of cases
and review. J Oral Maxillofac Surg 1990;48(03):311–317
10 Stellingsma C, Meijer HJ, Raghoebar GM. Use of short endosseous
implants and an overdenture in the extremely resorbed mand-
ible: a five-year retrospective study. J Oral Maxillofac Surg 2000;
58(04):382–387, discussion 387–388
11 Perdijk FBT, Meijer GJ, Strijen PJ, Koole R. Complications in
alveolar distraction osteogenesis of the atrophic mandible. Int J
Oral Maxillofac Surg 2007;36(10):916–921
12 Enislidis G, Fock N, Ewers R. Distraction osteogenesis with sub-
periosteal devices in edentulous mandibles. Br J Oral Maxillofac
Surg 2005;43(05):399–403
13 Garcia AG, Martin MS, Vila PG, Maceiras JL. Minor complications
arising in alveolar distraction osteogenesis. J Oral Maxillofac Surg
2002;60(05):496–501
14 Marx RE, Shellenberger T, Wimsatt J, Correa P. Severely resorbed
mandible: predictable reconstruction with soft tissue matrix
expansion (tent pole) grafts. J Oral Maxillofac Surg 2002;60
(08):878–888, discussion 888–889
15 Lew D, Hinkle RM, Unhold GP, Shroyer JV III, Stutes RD. Reconstruc-
tion of the severely atrophic edentulous mandible by means of
autogenous bone grafts and simultaneous placement of osseointe-
grated implants. J Oral Maxillofac Surg 1991;49(03):228–233
16 Perry RT. Reconstruction of advanced mandibular resorption with
both subperiosteal and root-form implants. Implant Dent 1998;7
(02):94–102
17 Alvarenga RL, Akaki E, Souza ACRA, Souza LN. Reabilitação de
mandíbula atrófica com implantes curtos e placa de titânio:
apresentação de um caso clínico. Rev Port Estomatol Med Dent
Cir Maxilofac 2013;5:217–221
18 Lopes N, Oliveira DM, Vajgel A, Pita I, Bezerra T, Vasconcellos RJH.
A new approach for reconstruction of a severely atrophic mand-
ible. J Oral Maxillofac Surg 2009;67(11):2455–2459
19 Batista Mendes GC, Padovan LEM, da Silva WS, Ribeiro-Junior PD.
Immediate oral rehabilitation of atrophic mandible. Int J Den-
tistry Oral Sci 2016;3:288–290
20 Ribeiro-Junior PD, Mendes GCB, Senko RAG, Momesso NR,
Padovan LEM. Current therapeutic possibilities for implant-
Craniomaxillofacial Trauma & Reconstruction Open Vol. 2 No. 1/2018
Ribeiro-Júnior et al.
supported rehabilitations in atrophic mandibles. Full Dent Sci
2016;7:11–18
21 Chrcanovic BR, Custódio ALN. Mandibular fractures associated with
endosteal implants. Oral Maxillofac Surg 2009;13(04):231–238
22 Tolman DE, Keller EE. Management of mandibular fractures in
patients with endosseous implants. Int J Oral Maxillofac Implants
1991;6(04):427–436
23 Blackburn TK, Cawood JI, Stoelinga PJW, Lowe D. What is the
quality of the evidence base for pre-implant surgery of the
atrophic jaw? Int J Oral Maxillofac Surg 2008;37(12):1073–1079
24 Chiapasco M, Casentini P, Zaniboni M, Corsi E, Anello T. Titanium-
zirconium alloy narrow-diameter implants (Straumann Roxolid(®))
for the rehabilitation of horizontally deficient edentulous ridges:
prospective study on 18 consecutive patients. Clin Oral Implants Res
2012;23(10):1136–1141
25 Grandin MH, Berner S, Darde M. A review of titanium zirconium
(TiZr) alloys for use in endosseous dental implants. Materials
2012;5:1348–1360
26 Almasri M, El-Hakim M. Fracture of the anterior segment of the
atrophic mandible related to dental implants. Int J Oral Maxillofac
Surg 2012;41(05):646–649
27 Arvier JF, Barker TM, Yau YY, D’Urso PS, Atkinson RL, McDermant
GR. Maxillofacial biomodelling. Br J Oral Maxillofac Surg 1994;32
(05):276–283
28 D’Urso PS, Atkinson RL, Lanigan MW, et al. Stereolithographic (SL)
biomodelling in craniofacial surgery. Br J Plast Surg 1998;51(07):
522–530
29 Ellis E III, Price C. Treatment protocol for fractures of the atrophic
mandible. J Oral Maxillofac Surg 2008;66(03):421–435
30 Lundgren S, Rasmusson L, Sjöström M, Sennerby L. Simultaneous
or delayed placement of titanium implants in free autogenous
iliac bone grafts. Histological analysis of the bone graft-titanium
interface in 10 consecutive patients. Int J Oral Maxillofac Surg
1999;28(01):31–37
31 Gellrich N-C, Zimmerer RM, Spalthoff S, et al. A customised digitally
engineered solution for fixed dental rehabilitation in severe bone
deficiency: A new innovative line extension in implant dentistry.
J Craniomaxillofac Surg 2017;45(10):1632–1638
32 Gellrich N-C, Rahlf B, Zimmerer R, Pott P-C, Rana M. A new
concept for implant-borne dental rehabilitation; how to over-
come the biological weak-spot of conventional dental implants?
Head Face Med 2017;13(01):17