Ideas and Innovations

Craniofacial/Pediatric
Patient-specific Implants for Treating
Atrophic Mandibles
Dekel Shilo, DMD, PhD*† Summary: Extremely atrophic mandibles are difficult to treat. Most patients choose
Tal Capucha, DMD, PhD* to live with removable dentures. However, what if the atrophy is so extreme that
Ori Blanc, DMD* spontaneous fractures occur? The objective of this report is to offer a single-stage
Dafna Shilo Yaacobi, MD‡ augmentation method, which uses patient-specific crib-shaped implants (PSI) com-
Omri Emodi, DMD*† bined with autogenous free bone grafts. PSI were planned using three-dimensional
Adi Rachmiel, DMD, PhD*† (3D) segmentation and 3D virtual-planning software. Implants were designed
according to the patient’s mandible with a mesh-like structure and included large
holes for allowing blood supply recovery. During surgery, the PSI fitted perfectly.
In cases exhibiting malposition of the mandibular fragments, repositioning was
performed using 3D virtual planning. When repositioning mandibular segments,
the PSI served as a guide for the correct positioning. Iliac-crest bone graft was
harvested and fixed as an onlay over the residual mandibular basal bone. External
approach was used to avoid contamination. Six months following surgery, fixation
wires were removed, and dental implants were positioned in the newly formed
bone. The PSI allowed for rigid fixation, thus leading to optimal incorporation of
the iliac-crest bone graft. No further augmentation was required. Bony continu-
ity for future stability and secession of the spontaneous fractures was achieved.
Dental implants were placed effortlessly. Treating extremely atrophic mandibles is
an entity of its own and is considered one of the most challenging in craniofacial
reconstruction. It mostly requires multiple operations with high rates of failure.
We offer a novel method of 3D mandibular reconstruction, both vertically and
horizontally, showing promising results and achieving enough bone for further
dental rehabilitation. (Plast Reconstr Surg Glob Open 2022;10:e4359; doi: 10.1097/
GOX.0000000000004359; Published online 6 June 2022.)

INTRODUCTION Rate of resorption usually increases during the first year

As life expectancy increases, there is an increase in following tooth loss and then decreases.4 In some indi-
the prevalence of atrophic mandibles following tooth viduals, bone resorption continues until extreme atrophy
loss.1 The mechanical effect of teeth and dental implants is observed. These patients are prone to spontaneous
on bone preservation was previously established. Missing fractures.5 Luhr et al6 classified atrophic mandibles into
teeth results in the lack of bone stimulation, which facili- three categories: class I, moderate atrophy in which the
tates resorption.2 The rate of resorption is influenced by height of the mandible is between 16 and 20 mm; class II,
various factors and is variable among different individuals.3 significant atrophy with a height of 11–15 mm; and class
III, extreme atrophy with a height of 10 mm or less.
Treatment of fractured atrophic mandibles is complex.
From the *Department of Oral and Maxillofacial Surgery, Rambam The remaining bone should be supported by a reconstruc-
Health Care Campus, Haifa, Israel; †Bruce Rappaport Faculty of tion plate.7 Decreased blood supply, lower mandibular
Medicine, Technion-Israel Institute of Technology, Haifa, Israel; height, and poor healing capacity increase the rates of
and ‡Department of Plastic Surgery and Burns, Rabin Medical complications.8,9 In the era of dental implants, the stan-
Center, Petah Tikva, Israel. dard of care includes a full fixed rehabilitation, a demand
Received for publication January 17, 2020; accepted April 15, difficult to achieve in patients with extreme atrophy of
2022. the mandible. There are two major reasons for this often-
Drs. Shilo and Capucha contributed equally to this work. unequivocal request. The first is the embarrassment and
Copyright © 2022 The Authors. Published by Wolters Kluwer Health,
Inc. on behalf of The American Society of Plastic Surgeons. This Disclosure: The authors have no financial interests to
is an open-access article distributed under the terms of the Creative declare in relation to the content of this article.
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the
work provided it is properly cited. The work cannot be changed in Related Digital Media are available in the full-text ver-
any way or used commercially without permission from the journal. sion of the article on www.PRSGlobalOpen.com.
DOI: 10.1097/GOX.0000000000004359

www.PRSGlobalOpen.com 1
 PRS Global Open • 2022

discomfort, which accompanies the need to remove den-

tures at night. The second is the difficulty in achieving a Takeaways
stable removable full mandibular denture. During func- Question: How to reconstruct a severely atrophic lower
tion, such as talking and eating, the intrinsic muscles of jaw?
the tongue and the floor of the mouth cause instability Findings: We present a novel method for reconstructing
and displacement of the denture. One of the challenges in an atrophic lower jaw using a crib-shaped patient-specific
rehabilitating an atrophic mandible is the superior posi- titanium implant concomitantly with an iliac crest bone
tion of the inferior alveolar nerve. This nerve supplies sen- graft. 3D planning was used for reduction of malunion or
sation to the chin and lower lip. Its superior position is a nonunion lower jaws and creation of crib-shaped titanium
major limitation for placing future dental implants. implant fitting perfectly to the lower border of the lower
In cases of moderate resorption, several options for jaw. Free bone graft was connected to the existing bone
rehabilitation exist10: onlay and interpositional bone graft, for 6 months. Following that period, dental implants were
distraction-osteogenesis, guided bone regeneration, and easily placed and reconstructed.
inferior alveolar nerve lateralization. The above-men-
Meaning: A new treatment option for surgeons encoun-
tioned techniques except for the latter require minimal
tering severely atrophic lower jaws.
bone above the inferior alveolar nerve or are limited in
the possible vertical gain achieved and thus are contra-
indicated in severe cases of Luhr class III mandibles.10 performed and exported (Fig. 1). Planning of the cases
Nerve lateralization is a one-stage technique, including included two computer-assisted design software: one for
dental implant placement, yet no vertical augmentation segmentation (D2P; 3D systems, Ore.) and the other for
is performed, thus resulting in unfavorable crown-implant designing the PSI (Geomagic-Freeform; 3D systems).
ratio. In addition, in this technique, high rates of inferior The process included segmenting the mandible and cre-
alveolar nerve dysesthesia are observed, and there is a con- ating a stereolithography file using the D2P software. In
cern for a fracture during or following implant placement. case there was a fracture in need of repositioning, the
In cases with Luhr class III, the mandible is prone mandible was segmented into two segments. The stereo-
to spontaneous fractures, and augmentation is required lithography file was then exported into the Geomagic-
for bone continuity and not only for rehabilitation. Freeform software for further manipulation, and the
We describe a novel method for using patient-specific segments were repositioned in the correct form. A crib-
implants (PSI) in combination with an onlay bone graft shaped mesh-like PSI was created, fitting perfectly to
for augmentation and rehabilitation of extreme atrophic the patient’s mandible (Fig. 2). The process of 3D plan-
mandibles prone to spontaneous fractures. ning is detailed in a previous report (See Video [online],
which displays a step by step video presenting the 3D
TECHNIQUE virtual planning of the patient-specific implant).11 The
Two cases of Luhr III mandibles6 were treated using PSI was sent for 3D printing in selective laser sinter-
a novel crib-shaped PSI with simultaneous iliac-crest ing technology (3D Systems, S.C.), and a model of the
free bone graft. Computed tomography imaging was mandible was printed in-house using a fused deposition
modeling printer for confirming the passive fitting of
the PSI. The operation included an extra oral approach

Fig. 1. Radiographic evaluation. Anterior aspect of a 3D reconstruc- Fig. 2. 3D manipulation and designing the PSI. Following segmen-
tion from a CT demonstrating the severe mandibular atrophy. A pre- tation of the mandible, the left segment was repositioned to cre-
vious fracture showing fibrous healing can be observed in the right ate an aligned mandible. A crib-shaped mesh-like PSI was designed
mandibular body. according to the final location of the segments.

2
Shilo et al. • PSI for Treating Atrophic Mandibles

aspect of the mandible.12 These solutions have several dis-

advantages. First, this focuses the forces of mastication on
the reconstruction plate rather than sharing the load with
the bone, thus increasing the chance of failure due to loss
of bony anchorage around the screws or plate fracture.
Second, the forces of mastication are concentrated on
dental implants placed on the anterior segment, poten-
tially leading to their failure. Finally, this method only
allows for the placement of removable dentures and does
not allow for a fixed solution.
Our solution includes a PSI for stabilization combined
with an autogenous bone graft for continuity and reha-
bilitation. It allows for anterior as well as posterior dental
implant placement for a fixed dental rehabilitation. The
disadvantages include an external submandibular scar
Fig. 3. Evaluating the results. CT evaluation 6 months after surgery and a two-stage approach. We offer a novel method of
was performed, exhibiting abundant bone augmentation in all bony reconstruction showing promising results, allowing
aspects of the mandible. for full reconstruction of the mandible in both the vertical
and horizontal aspects. Bony continuity for future stability
and secession of the spontaneous fractures was achieved,
and abundant bone for further dental rehabilitation was
observed.
Dekel Shilo, DMD, PhD
Rambam Health Care Campus
8 Ha’Aliyah Street
Haifa 35254, Israel
E-mail: [email protected]

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