Oral Implantology for the Traumatic Brain Injured Patient: A Case Report

Oral implants have improved the quality of life of many patients. Most of these people are not special needs patients. Special needs patients are those who have life situations that may not allow them to function as most of the rest of the population. Traumatic brain injuries, birth defects, genetic disorders, and other conditions may prevent these people from normal oral function. Many of the disabled are not able to perform adequate oral hygiene, and this may predispose them to caries and periodontal infection. Consequently, many of these patients become edentulous or partially edentulous. Dental implants may be appropriate treatment for these patients, but treatment should minimize intraoral surface areas for ease of daily cleansing and to simplify the patient's daily life tasks in the use of dental prostheses.

The object of this article is to demonstrate a cost- and hygiene-effective dental implant treatment for the edentulous traumatic brain injured patient.

The patient, a 24-year-old edentulous female, presented for implant treatment. She had sustained a severe head injury as the result of an auto accident at age 19 and was rendered edentulous. She took daily oral medications—modafinil (Provigil) 2000 mg, buspirone (Buspar) 10 mg, oxybutynin (Ditropan) 15 mg, risperidone (Risperdal) 2 mg, and duloxetine (Cymbalta) 60 mg. An oral examination and a panoramic radiographic examination were done. Since the accident, severe osseous resorption had been noted, and clinical ridges were severely atrophic. The patient was not manually dexterous and was unable to appropriately perform effective oral hygiene and to retain conventional removable complete dentures. A computerized tomographic scan of the maxilla and mandible assessed the osseous bone. Appropriately sized implants were selected to fit into the proposed sites.

Discussion among the patient, her physician, and her mother led to the decision to provide implant-supported and retained bimaxillary removable denture treatment. Maxillary and mandibular complete dentures were constructed using a lingualized occlusal scheme. The patient accommodated well to the dentures after 6 months. For the implant placement appointment, she was orally sedated with 10 mg of diazepam an hour before, and her pulse and blood pressure were monitored. A total of 3.6 mL articaine 4% (Septocaine) was infiltrated into the maxilla. An apically positioned full/split-thickness flap was raised, and six 3.7 × 10 mm (Implant Direct, Ventura, Calif) maxillary implants were surgically installed at sites #4, 6, 8, 9, 11, and 13. Each site was closed with 4-0 polyglycolic acid suture (Vicryl). Then, 1.8 mL articaine 4% was infiltrated into the anterior mandible, an apically positioned flap was raised, and two 3.7 × 10 mm implants (Implant Direct) were placed in the mandible at sites #22 and #27. The site was closed with polyglycolic acid suture. The removable dentures acted as stents. Sutures were removed after 1 week.

Four of the maxillary implants—#4, 8, 9, and 13—were used to provide support and indirect retention; 2—#6 and 11—acted as retainers (Locators) (Figures 1–7). In the mandible, 2 implants at sites #22 and #27 were used to retain a complete overdenture. The patient was instructed to wear the dentures as little as conveniently possible during the healing phase to prevent occlusal force transmission through the mucosa to the osseointegrating implants. After 4 months of healing and osseointegration, the sites were locally anesthetized and the implants surgically exposed; 4 support/indirect retention abutments were placed, prepared for parallelism, and impressed. Cast coping crowns for the maxillary overdenture were constructed for the support abutments and were subsequently installed in the maxillary denture by a pick-up technique. The 2 retainer implants were fitted with locator retainers, and housing was installed in the maxillary overdenture, also by a pick-up technique. The palate was removed from the existing maxillary denture for the patient's comfort and to expose the palate for gustatory function. She had adequate oral control, which reduced the potential for swallowing the now smaller prosthesis. The 2 mandibular implants were fitted with locator retainers and were installed through a pick-up technique. The lingualized occlusal scheme was maintained. The patient was seen for routine follow-up and adjustment appointments and has been functioning well without complications for 2 years. The patient's mother and caregivers are able to adequately cleanse the intraoral abutments and retainers daily.

The Glasgow Coma Scale predicts 6 month postinjury mortality at the first postinjury month on the basis of 3 categories: eye opening response, verbal response, and motor response. Points are assigned to obtain a score that quantifies the status of the patient for purposes of prognosis and treatment. Other classifications are based on computerized tomography and magnetic resonance examinations that predict outcome and mortality but do not correlate with each other.1 This patient obviously survived a severe head injury but with serious debilitation. She can barely speak, has limited body movement, and requires a wheelchair.

An important goal for treatment of debilitated patients is to simplify their daily oral functions and facilitate hygiene routines for patients and caregivers. Minimizing oral hardware for support and retention of prostheses can make life easier for debilitated patients and their caregivers. Many of these patients are not able to personally effectively perform oral hygiene, and a caregiver is routinely providing it. Minimizing implant retainers and support abutments can ensure more effective cleansing and can reduce exposed surface areas that can accumulate plaque.

Implant-supported or -retained removable dentures may be made smaller, and it is possible for the patient to swallow or aspirate the denture. Each patient's oral and pharyngeal anatomy and oral proprioception should be assessed for accidental ingestion or aspiration of the truncated denture. The constructed palate-less denture is smaller than conventional dentures, and it is possible for some debilitated patients to actually swallow the appliance and have it lodge in the pharynx, esophagus, or bronchi.2 

Acrylic-based fixed implant-supported complete dentures have been described by Schnitman.3 Cavalarro and Tarnow reported 5 successful cases of unsplinted implants retaining removable overdentures.4 Flanagan reported a case where unsplinted implants supported and retained complete acrylic-based removable dentures constructed for a patient with congenital oral-nasal communication.5 This type of prosthesis consists of denture teeth processed in an acrylic base that in turn is fitted to components for support or retention. These dentures can be removable or fixed. Standard or custom cast abutments can be fitted with custom cast coping crowns embedded in the prosthesis by a pick-up technique. The coping-denture complex can then be definitively cemented for fixed treatment. Alternatively, integrated implants can be fitted with removable denture retainers for very satisfactory retention and stability, or a combination of these can be used for support and retention.

For these types of unsplinted implant-supported/retained maxillary acrylic-based prostheses, some parameters have been suggested. In the maxilla, implants should be placed far apart for maximum distribution of occlusal forces. Implants should have a minimum 3.7 mm diameter and 10 mm length, and a minimum of 6 implants should be placed. A 0 degree or lingualized occlusal scheme may be best for function and stability.4 

Special needs patients can benefit from new technologies in implant dentistry. The clinician can treat many of these patients with acrylic-based implant-supported and -retained prosthetics to minimize costs, improve oral function, and simplify daily oral hygiene. Maxillary complete dentures can be made without a palate to enhance patient comfort and gustatory function. Each patient's abilities should be evaluated for the potential to swallow any constructed prosthesis. Generally, a 0 degree or lingualized occlusal scheme should be used.