Mandibular Fracture in Conjunction with Bicortical Penetration,

Using Wide-Diameter Endosseous Dental Implants

Won-suk Oh, DDS, MS,1 Eleni D. Roumanas, DDS,2 & John Beumer III, DDS, MS2
1
Division of Prosthodontics, Department of Biologic and Materials Sciences, University of Michigan School of Dentistry, Ann Arbor, MI
2
Division of Advanced Prosthodontics, Biomaterials and Hospital Dentistry, UCLA School of Dentistry, Los Angeles, CA

Keywords Abstract
Prosthodontic rehabilitation; fracture of
atrophic edentulous mandible; thermal injury; Prosthodontic rehabilitation of a patient with an atrophic edentulous mandible presents
wide-diameter implant; bicortical penetration. a significant challenge in restoring esthetics and function. The purpose of this clinical
report is to describe fracture of an atrophic edentulous mandible opposing maxillary
Correspondence natural dentition in association with endosseous dental implants. The patient received
Won-suk Oh, Department of Biologic & two wide-diameter implants in the anterior mandible for an implant-assisted mandibu-
Materials Sciences, University of Michigan lar overdenture, in which the implants penetrated the inferior border of the mandible
School of Dentistry, 1011 N. University, Rm for bicortical stabilization. Three months following implant placement surgery, the
K1014A, Ann Arbor, MI 48109-1078. E-mail: patient experienced pain, swelling, and intraoral purulent drainage around the right
ohws@umich.edu implant. Panoramic radiograph revealed a fracture of the mandible through the right
implant site and signs of infection around the left implant. The implants were removed
This clinical report was presented at the surgically, and open reduction and fixation of the fracture site were undertaken using a
biennial session of the ICP in Fukuoka, titanium bone fixation plate. This clinical report demonstrates that placement of wide-
Japan, September 2007.
diameter implants in conjunction with bicortical penetration in a severely atrophic
edentulous mandible can risk fracture of the mandible.
Accepted December 2, 2009

doi: 10.1111/j.1532-849X.2010.00646.x

Osseointegrated dental implants are highly predictable for pros- healing period for this process is approximately 4 months for
thetic rehabilitation of the edentulous mandible,1-5 although machined surfaces, but currently available moderately rough
various biologic and mechanical complications have been re- surfaces may accelerate bone formation and enhance biome-
ported.6-9 Mandibular fracture is not a common problem en- chanical and biochemical bonding around the implant. Prior to
countered in conjunction with endosseous implants but recog- establishment of osseointegration, the implants are required to
nized as a serious potential complication. This is particularly maintain intimate contact with the bone by means of frictional
problematic in the highly resorbed, osteoporotic, or osteoscle- fit. Thus, stress distribution is not homogenous at the implant
rotic edentulous mandible.10-13 sites, which act as stress concentrators, in particular in the at-
In the normal human dentate mandible, the volume of cor- rophic edentulous mandible due to reduced bone volume.20-23
tical bone is approximately 3.5 times less than that of can- Fracture of the atrophic mandible can occur even under normal
cellous bone.14 Following the loss of teeth, the mandible function, in part due to flexure of the mandible by physiologic
experiences significant reduction in bone height and volume. forces generated by the muscles of mastication.24
Although both cortical and cancellous portions of the mandible Bicortical engagement is recommended and frequently used
are affected by resorption, the remaining portion of the at- in the atrophic edentulous mandible to enhance implant sta-
rophic mandible becomes denser with increased load applica- bility, permit placement of longer implants, and improve load
tions from the mandibular prosthesis. The resulting increase transfer characteristics;25-27 however, bicortical penetration of
in cortical wall thickness and bone density occurs simultane- the atrophic mandible may significantly reduce structural in-
ously with vertical bone resorption, beneath the functioning tegrity due to the loss of continuity at the inferior and lat-
prosthesis.15,16 The atrophic dense edentulous mandible subse- eral border.28,29 Implant site preparation for wide-diameter im-
quently becomes susceptible to fracture from external trauma plants may further increase the risk of thermal injury of the
or functional forces. bone and thin out the buccal and lingual cortices creating an
During placement of endosseous implants, gentle surgical “egg crate” configuration.30 The purpose of this clinical re-
technique and adequate irrigation and blood supply are prereq- port is to describe the fracture of a patient’s atrophic edentu-
uisite to the process of osseointegration.17-19 The traditional lous mandible after placement of two wide-diameter implants

Journal of Prosthodontics 19 (2010) 625–629 

c 2010 by The American College of Prosthodontists 625
Mandibular Fracture in Conjunction with Endosseous Dental Implants Oh et al

that penetrated the inferior border of the mandible and that op-
posed a natural maxillary dentition under normal function. This
report also reviewed preoperative strategies for prosthodontic
rehabilitation.

Clinical report
The patient, a 63-year-old white man, presented to the Max-
illofacial Prosthetics Clinic at the University of California, Los
Angeles in July 2004, complaining of difficulty wearing his
conventional mandibular complete denture (CD) and desiring
dental implant-assisted overdenture (IOD). Past medical his- Figure 2 Preoperative panoramic radiographic image exhibiting ad-
tory included mild chronic obstructive pulmonary disease, heart vanced atrophy of the mandible (7 mm height of anterior mandible).
murmur, and hypertension. The patient had suffered a gunshot
wound in the mandible with the entry wound on the left and
exit wound on the right, approximately 30 years earlier, for tations the patient chose the mandibular 2-IOD, retained with
which he underwent multiple reconstructive surgeries, includ- a tissue bar for the edentulous mandible. He desired to main-
ing a bone graft with a titanium mesh in the right posterior tain his natural dentition in the maxilla. The patient’s existing
mandible. The last mandibular surgery was in 1990 to resolve mandibular CD was relined using a tissue conditioner (Visco-
the infection caused by oral exposure of the retained Ti mesh gel, Dentsply DeTrey GmbH, Konstanz, Germany) to provide
used for grafting. stability and restore occlusal vertical dimension. The prosthesis
Intraoral examination revealed natural dentition in the max- was tested in the mouth for esthetics and function and dupli-
illa and a severely atrophic edentulous mandible (Prosthodon- cated in a clear acrylic resin (Teets, Co-Oral-Ite Dental Mfg Co,
tic Diagnostic Index, Edentulous Class IV). The preexisting Diamond Springs, CA) using a denture duplicator flask kit
conventional mandibular CD was neither stable nor retentive. (Lang Dental Mfg, Wheeling, IL). The duplicate denture was
Cephalometric and panoramic radiographic examination re- modified to a surgical template and used during the surgical
vealed advanced resorption of the mandible with deficient bone procedure to direct implant position.
(7 mm in height) in the symphyseal area (Figs 1 and 2). The pa- Wide-diameter implants (5.0-mm diameter) were selected
tient was informed of the possible consequences of prosthodon- to increase the contact surface area of the implant with the
tic rehabilitation of the edentulous mandible without addressing bone. Under local anesthesia, a crestal incision was made and
the maxillary dentition. These included difficulty in establish- a mucoperiosteal flap was reflected between the mental fora-
ing proper occlusion, compromised stability of the mandibu- men. Gentle surgical technique was used to create implant os-
lar denture, and increased bone resorption of the mandible. teotomy sites under copious irrigation during drilling. Two short
The proposed treatment options were as follows: conventional (8.5-mm length) two-stage endosseous screw-type implants
maxillary/mandibular CDs; maxillary CD opposing mandibu- (Osseotite, 3i, Palm Beach Gardens, FL) were placed in the
lar 2 IOD (2-IOD), 4 IOD (4-IOD), or fixed bone anchored right and left mandibular canine sites where the implants en-
bridge; maxillary/mandibular 2-IOD or 4-IOD; or do nothing. gaged and penetrated the inferior border of the mandible (Fig 3).
Onlay grafting procedures to augment the mandible were ruled The implants were submerged and allowed to heal undisturbed.
out because of anticipated accelerated bone graft resorption The patient did not wear his denture for 1 week postopera-
and the patient’s past surgical history. Due to financial limi- tively. Following this period, the intaglio surface of the existing
denture was aggressively relieved and relined with a resilient
tissue conditioning material (Visco-gel), which was replaced
every other week. The patient was instructed to maintain a soft

Figure 1 Preoperative cephalometric radiographic image exhibiting nat- Figure 3 Postoperative, panoramic radiographic image exhibiting two
ural dentition in maxilla, atrophic edentulous mandible, and opaque par- screw-type endosseous wide-diameter implants in each canine area,
ticles from gunshot wound in posterior mandible. penetrating inferior border of mandible.

626 Journal of Prosthodontics 19 (2010) 625–629 

c 2010 by The American College of Prosthodontists
Oh et al Mandibular Fracture in Conjunction with Endosseous Dental Implants

Figure 4 Panoramic radiographic image exhibiting displacement of right Figure 6 Panoramic radiographic image exhibiting reunion of fractured
implant, along with fracture of mandible at implant site and radiolucency mandible and removal of hardware.
around left implant.

long lag screw (Arthrex Inc) was also placed (Fig 5). Following
diet and remove the denture from his mouth at night. Over the reduction, the fracture was noted to have good stability, the
next months, in the right symphyseal area, the patient expe- region was irrigated copiously, and the intraoral incision was
rienced several episodes of inflammation and associated pain, closed in a watertight manner. The patient was instructed not
which appeared to subside with antibiotics. to use the denture for 6 weeks and placed on Clindamycin,
Three months following surgery, the patient presented with 300 mg four times daily for 7 days.
pain and swelling in the right submandibular area. Intraoral The patient’s postoperative course was uneventful, and he
examination revealed hyperplastic granulation tissue and puru- was discharged from the hospital two days later. He was re-
lent exudate from the periimplant area in the right mandible. A called biweekly, until an improvement in symptoms was noted
panoramic radiograph showed evidence of a right mandibular with no evidence of extraoral swelling or lymphadenopathy.
fracture, displacement of the right implant into the submandibu- At the 6-week follow-up appointment, a follow-up panoramic
lar soft tissue space, and signs of infection around the left im- radiograph was made, showing evidence of good bony align-
plant (Fig 4). Review of the medical history did not reveal any ment, bony callus formation, and healing around the fracture
contributory findings, and the patient did not report a history of site. The patient did not report discomfort or other adverse
external trauma to the region. The patient was placed on Clin- symptoms. The existing denture was relined with a tissue con-
damycin (Cleocin, Pfizer Inc, New York, NY), 300 mg orally, ditioner (Visco-gel), and the patient continued on a soft diet
four times daily for 7 days and advised to remain on a pureed, regimen. Approximately 4 months later, the hardware was re-
soft diet. moved, and following complete healing of the soft tissues, a
An open reduction was planned to remove both implants new mandibular conventional CD was fabricated (Fig 6).
and reduce the mandibular fracture. Under local anesthesia and
IV sedation, the left implant was identified and removed with-
out complications. The right implant site was noted to have
Discussion
a mandibular fracture with the implant displaced in the sub- Implant site preparation and placement should be gentle and
mandibular area. The implant was removed, and the fracture atraumatic with copious irrigation for successful osseointegra-
site was debrided of all reactive granulation tissue. The bony tion, particularly in the anterior portion of the atrophic edentu-
fragments were approximated and stabilized with a 1.7-mm lous mandible with dense cortical bone.2,3 Inadequate irrigation
4-hole Ti bone fixation plate (Arthrex Inc, Naples, FL) and and cooling while drilling in dense cortical bone may result in
6-mm bone screws (Arthrex Inc). A 2.0-mm-wide and 12-mm- elevated bone temperatures without apparent visual evidence,
leading to bone necrosis with compromised and delayed healing
at the implant-bone interface.17,19 The risk of thermal injury and
resulting lack of osseointegration can be greater in site prepara-
tions for wide-diameter implants with their increased drill size
and peripheral speeds, especially in dense cortical bone with
reduced vascularity.2,3,17,19 Thus, operator experience and judg-
ment are critical in determining bone density. Using sharp drills
of incremental size, gentle surgical technique, and light and in-
termittent drilling pressure with copious irrigation are critical
to avoid the harmful effects of temperature increase.17,19,31
Wide-diameter implant site preparation and placement in the
atrophic mandible may alter the critical amount of remain-
ing bone needed to maintain mandibular integrity and pre-
Figure 5 Panoramic radiographic image exhibiting fixation of mandible vent fracture with loading, yet it could predispose the jaw
with titanium plate and displaced right implant in submandibular soft to breakage, especially if the bone were subject to over-
tissue. heating and uneven stress distribution.10-13,21-23 The stress

Journal of Prosthodontics 19 (2010) 625–629 

c 2010 by The American College of Prosthodontists 627
Mandibular Fracture in Conjunction with Endosseous Dental Implants Oh et al

distribution pattern may be unfavorable around the implant awareness of potential complications are necessary prerequi-
during the healing period, until hard and dense lamellar bone sites when contemplating this procedure.
replaces soft woven bone.21-23 The combination of wide-
diameter osteotomies resulting in inadequate remaining bone
volume of the atrophic mandible, coupled with bone overheat- References
ing could have contributed to the lack of implant integration and 1. Winkler S, Monasky GE: The edentulous mandible opposing
mandibular fracture. The implants, although not immediately maxillary natural teeth: treatment considerations utilizing implant
loaded, were subjected to functional loading from the den- overdentures. Implant Dent 1993;2:44-47
ture soft liner through the soft tissue, by the opposing natural 2. Keller EE: Reconstruction of the severely atrophic edentulous
dentition. mandible with endosseous implants: a 10-year longitudinal study.
Wide-diameter implants are often chosen to provide pros- J Oral Maxillofac Surg 1995;53:305-320
thesis support when vertical height of bone is not available, 3. Stellingsma C, Meijer HJ, Raghoebar GM: Use of short
but bone volume is present.25,29,30 Short wide-diameter im- endosseous implants and an overdenture in the extremely
plants appear to withstand functional loading and maintain resorbed mandible: a five-year retrospective study. J Oral
Maxillofac Surg 2000;58:382-387
stable marginal bone level, but may require a longer healing
4. Stellingsma K, Raghoebar GM, Meijer HJ, et al: The extremely
period before supporting the prosthesis.3,4,8 The load bear- resorbed mandible: a comparative prospective study of 2-year
ing requirements of implants assisting an IOD are reduced as results with 3 treatment strategies. Int J Oral Maxillofac Implants
forces of occlusion are shared between the implants and the 2004;19:563-577
mucoperiosteum. Implant survival for short implants was sig- 5. Stoker GT, Wismeijer D, van Waas MA: An eight-year follow-up
nificantly greater than for longer implants placed in augmented to a randomized clinical trial of aftercare and cost-analysis with
mandible with an autologous bone graft.3,8 The lack of can- three types of mandibular implant-retained overdentures. J Dent
cellous bone and blood supply in the anterior mandible led to Res 2007;86:276-280
necrosis of the poorly adapted graft and loss of the implants dur- 6. Goodacre CJ, Kan JY, Rungcharassaeng K: Clinical
ing the healing phase.3 Distraction osteogenesis is an alternative complications of osseointegrated implants. J Prosthet Dent
1999;81:537-552
mode of treatment in increasing vertical height of an atrophic
7. Timmerman R, Stoker GT, Wismeijer D, et al: An eight-year
edentulous mandible; however, care must be taken to mini- follow-up to a randomized clinical trial of participant satisfaction
mize potential complications such as fracture of the mandible, with three types of mandibular implant-retained overdentures.
neurological disturbances, and resorption of the transport J Dent Res 2004;83:630-633
segment.9 8. Tawil G, Aboujaoude N, Younan R: Influence of prosthetic
Increasing the number of implants does not appear critical in parameters on the survival and complication rates of short
reducing the stress in an atrophic mandible, nor were significant implants. Int J Oral Maxillofac Implants 2006;21:275-282
differences noted in stress distribution in the bone containing 9. Raghoebar GM, Stellingsma K, Meijer HJ, et al: Vertical
two or four implants.20 When two implants are placed bilater- distraction of the severely resorbed edentulous mandible: an
ally, the canine sites are usually chosen for implant placement assessment of treatment outcome. Int J Oral Maxillofac Implants
2008;23:299-307
depending on the arch size, shape, and jaw relationship, and for
10. Mason ME, Triplett RG, Van Sickels JE, et al: Mandibular
additional implants if placed at a later date.4,7,20 Reported pros- fractures through endosseous cylinder implants: report of cases
thetic complications were minor for tissue-bar retained IODs and review. J Oral Maxillofac Surg 1990;48:311-317
in the atrophic edentulous mandible,4 and the retention and sta- 11. Tolman DE, Keller EE: Management of mandibular fractures in
bility of the IOD did not diminish significantly over time.7 In patients with endosseous implants. Int J Oral Maxillofac Implants
general, restoration of an atrophic edentulous mandible with 1991;6:427-436
2-IOD appears to increase patient’s expectations and reduce 12. Shonberg DC, Stith HD, Jameson LM, et al: Mandibular fracture
direct and aftercare costs, although the long-term effect of pos- through an endosseous implant. Int J Oral Maxillofac Implants
terior mandibular resorption by means of the IOD is yet to be 1992;7:401-404
determined.1,5 13. Thaller SR: Fractures of the edentulous mandible: a retrospective
review. J Craniofac Surg 1993;4:91-94
14. Iwashita Y: Basic study of the measurement of bone mineral con-
Conclusion tent of cortical and cancellous bone of the mandible by computed
tomography. Dentomaxillofac Radiol 2000;29:209-215
Placement of wide-diameter implants in conjunction with bi- 15. Solar P, Ulm CW, Thornton B, et al: Sex-related differences in
cortical penetration may jeopardize the structural integrity of the bone mineral density of atrophic mandibles. J Prosthet Dent
the severely atrophic mandible; therefore, computed tomogra- 1994;71:345-349
phy (CT) planning is important for proper implant placement 16. Blahout RM, Hienz S, Solar P, et al: Quantification of bone
planning. Inadequate remaining bone volume after placement resorption in the interforaminal region of the atrophic mandible.
of wide-diameter implants increases stress concentration from Int J Oral Maxillofac Implants 2007;22:609-615
17. Cordioli G, Majzoub Z: Heat generation during implant site
functional loading, or thermal bone injury from implant surgery
preparation: an in vitro study. Int J Oral Maxillofac Implants
may contribute to mandible fracture at the implant site. Implants 1997;12:186-193
may engage the inferior portion of the mandible for stability, 18. Albrektsson T, Wennerberg A: Oral implant surfaces: Part
but the bone volume and density when penetrating the inferior 1–review focusing on topographic and chemical properties of
border of a severely atrophic mandible should be considered. different surfaces and in vivo responses to them. Int J
Careful case selection, the use of CT planning, and patient Prosthodont 2004;17:536-543

628 Journal of Prosthodontics 19 (2010) 625–629 

c 2010 by The American College of Prosthodontists
Oh et al Mandibular Fracture in Conjunction with Endosseous Dental Implants

19. Scarano A, Carinci F, Quaranta A, et al: Effects of bur wear study in the rabbit tibia. Int J Oral Maxillofac Surg 1996;25:
during implant site preparation: an in vitro study. Int J 229-235
Immunopathol Pharmacol 2007;20:23-26 26. Jeong CM, Caputo AA, Wylie RS, et al: Bicortically stabilized
20. Meijer HJ, Starmans FJ, Steen WH, et al: A three-dimensional implant load transfer. Int J Oral Maxillofac Implants
finite element study on two versus four implants in an edentulous 2003;18:59-65
mandible. Int J Prosthodont 1994;7:271-279 27. Pierrisnard L, Renouard F, Renault P, et al: Influence of implant
21. Papavasiliou G, Kamposiora P, Bayne SC, et al: length and bicortical anchorage on implant stress distribution.
Three-dimensional finite element analysis of stress-distribution Clin Implant Dent Relat Res 2003;5:254-262
around single tooth implants as a function of bony support, 28. Kitagawa T, Tanimoto Y, Nemoto K, et al: Influence of cortical
prosthesis type, and loading during function. J Prosthet Dent bone quality on stress distribution in bone around dental implant.
1996;76:633-640 Dent Mater J 2005;24:219-224
22. Hedia HS: Stress and strain distribution behavior in the bone due 29. Miyamoto I, Tsuboi Y, Wada E, et al: Influence of cortical bone
to the effect of cancellous bone, dental implant material and the thickness and implant length on implant stability at the time of
bone height. Biomed Mater Eng 2002;12:111-119 surgery–clinical, prospective, biomechanical, and imaging study.
23. Chang MC, Ko CC, Liu CC, et al: Elasticity of alveolar bone near Bone 2005;37:776-780
dental implant-bone interfaces after one month’s healing. 30. Himmlova L, Dostalova T, Kacovsky A, et al: Influence of
J Biomech 2003;36:1209-1214 implant length and diameter on stress distribution: a finite
24. Korioth TW, Hannam AG: Deformation of the human mandible element analysis. J Prosthet Dent 2004;91:20-25
during simulated tooth clenching. J Dent Res 1994;73:56-66 31. Van Der Zel JM: Implant planning and placement using optical
25. Ivanoff CJ, Sennerby L, Lekholm U: Influence of mono- and scanning and cone beam CT technology. J Prosthodont
bicortical anchorage on the integration of titanium implants. A 2008;17:476-481

Journal of Prosthodontics 19 (2010) 625–629 

c 2010 by The American College of Prosthodontists 629