Management of a failed mandibular

staple implant: A clinical report

Ronald L. Ettinger, BDS, MDS, DDSc,a and Ali Fakhry, DDS, MSb
University of Iowa, Iowa City, Iowa; McGill University, Faculty of
Dentistry, Montreal, Quebec
A 48-year-old woman sought treatment because her staple implant-retained overdenture was no longer retentive, and
the denture was worn over the abutments. After unsuccessfully attempting to move the retentive nuts along the transosseous posts of the staple implant, the posts were cut off at the level of the bone. Two endosseous implants were
placed around the staple implant, and a new implant-retained overdenture was fabricated and inserted using ball attachments for retention. This article describes the treatment for this patient, who has been wearing the new dentures
successfully for the past 4 years. (J Prosthet Dent 2010;104:359-363)
The mandibular staple bone
plate transosteal implant was first
described by Small and Kobernick.1
Small2 stated that after observing
failures of subperiosteal implants, he
believed survival of implants could be
improved if the bulk of the metal was
placed away from the mucosa. Thus,
Small and Kobernick1 used transmandibular stainless steel threaded
pins in the mandibles of dogs. After
histologic examination, they found
that the bone around the staples was
free of inflammation and infection
and that epithelial migration was not
a problem. The next step was to try
this procedure in patients.2 The first
5 staple implants that they placed
had 2 or 3 threaded pins attached
to a curved plate that was seated on
the inferior border of the mandible.
The next 5 implants had 4 pins; the
following 25 had 7 pins. The failures
they experienced were primarily with
the 2- and 3-pin staples, but after 5
years they reported a success rate of
95%. Metz3 also described the use of
a staple implant for a patient with an
atrophic mandibular arch.
The mandibular staple implant
is an alloplastic implant designed to
retain a complete mandibular den-

ture. Placement of the staple implant

is typically performed under general
anesthesia and involves a submental
skin incision with exposure of the inferior border of the mandible. Using a
surgical drill guide assembly, the bone
is drilled in an apicocoronal direction.
The staple implant is composed of a
metal plate, which is held in place on
the inferior border of the mandible,
and supports 2 transosseous threaded posts that penetrate the full thickness of the mandible and project into
the mouth in the interforaminal area.
Locking nuts engage the threaded
posts and are in contact with bone
to help fix the staple implant at the
superior aspect of the mandible. Corresponding fastener nuts help to support the superstructure of the denture.
The staple bone implant has 2 to 5
additional parallel retention pins that
help stabilize the bone plate. The plate
is typically made of titanium alloy, a
corrosion resistant alloy containing
90% titanium, 5% aluminum, and 4%
vanadium. Authors of several retrospective studies4-7 reported survival
rates for this implant of 86% to 100%.
The complications that have been
most often reported are gingival hyperplasia, crestal bone loss, and in-

fections around the transmucosal

threaded posts.5-7 The use of endosseous implants to supplement or replace existing mandibular staple bone
plate implants has been described as
a treatment for failing or failed transmucosal posts.8-9 Although rare, fractures of the posts and the mandible
have been reported, as well as injury
to the mental nerve and its accompanying anterior loop.10 Since endosseous implants have become a more
popular treatment option, few staple
implants are placed. However, there
are still patients who have these implants and are in need of ongoing
care. This article describes the management of a patient with a failing
staple implant, which was resolved by
surgically removing the transmucosal
posts and placing 2 endosseous implants.

CLINICAL REPORT
A 48-year-old woman sought treatment because her mandibular complete
overdenture was no longer retentive
and had perforations. The perforations were over the abutments of a
staple implant that had been placed
19 years previously. The patient had

Professor, Department of Prosthodontics and Dows Institute for Dental Research, University of Iowa.
Associate Professor and Director of the General Practice Residency Program, McGill University, Faculty of Dentistry; Former
Associate Professor, Department of Periodontics, University of Iowa.

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Volume 104 Issue 6

1 Panoramic pretreatment radiograph showing staple bone plate configuration with 2

transosseous pins and 3 stabilizing posts.

2 Clinical presentation of staple implants locking and

fastener nuts, as well as exposed threaded post on left side.
been edentulous since the age of 16,
had never removed her dentures at
night, and had not seen a dentist in
4 years.
In the maxilla, there was hyperplastic tissue around both tuberosities. The maxillary denture was
unstable, and the teeth were worn.
There was also mild denture stomatitis. The mandible had a standard
staple implant with 3 retentive pins
and 2 transosseous posts supporting
a bar overdenture (Fig. 1). The metal
superstructure, including the cast bar
and attachment, was loose, and there
were perforations in the mandibular
denture over both abutments. The
denture was not in contact with the
soft tissues in the anterior mandible.
Several threads along the left transosseous post were clinically exposed.
Slight to moderate plaque accumula-

tion was noted around the abutments

and the threaded exposed post (Fig.
2). Radiographically, horizontal bone
loss was visible around the transosseous pins; this bone loss was more pronounced on the left side. There were
no apparent signs of pathology. The
patient reported multiple episodes
of denture fracture, with unsuccessful attempts to repair the thin acrylic
resin housing. Intraoral examination
of the existing dentures revealed that
the occlusal vertical dimension could
not be increased further.
The initial treatment focused on
treating the denture stomatitis. The
patient was prescribed topical ketoconazole cream 2% (Teva Pharmaceuticals USA, Inc, North Wales, Pa)
to be used after meals and was instructed to remove the dentures when
sleeping. To temporarily stabilize the

The Journal of Prosthetic Dentistry

existing dentures, tissue conditioner

(Lynal; Dentsply Caulk, Milford, Del)
was placed in both dentures after
cleaning them.
In an effort to provide vertical
clearance for the fabrication of a new
mandibular denture, the treatment
plan included provisions for freeing
the fastener nuts, screwing the locking nuts down the threads, and cutting off the excess transosseous pins
before making new dentures. The fastening nuts were so firmly in place that
all attempts to unscrew them failed.
Further pressure to free the fastening
nuts caused discomfort to the patient.
At the risk of fracturing the transosseous pins, the authors recommended
cutting off the supra-alveolar portion
of the transosseous pins at the bone
level and placing 2 standard endosseous implants to support a new man-

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December 2010

3 Panoramic radiographs showing reduction of supra-alveolar portions of

transosseous pins and placement of 2 endosseous implants.

4 Ball attachments used to retain mandibular overdenture.

dibular overdenture. The patient was
informed that the location and size of
the implants would depend on the location of the mental foramina and the
volume of bone available around the
existing staple implant.
Upon acceptance of the proposed
treatment plan by the patient, mucoperiosteal flaps were raised, exposing the base of the transosseous
pins. The supra-alveolar portions of
the pins were sectioned at the level
of the crestal bone using burs (fissure bur; Brasseler USA, Savannah,
Ga) under copious irrigation. Care
was taken to minimize the spread of
metal particles by using close suctioning. The surgical site was irrigated and
flaps were sutured (Chromic Gut 5-0;
Ethicon, Inc, Somerville, NJ). Tissue
conditioner (Lynal; Dentsply Caulk)
was replaced in the patients existing

Et tinger and Fakhry

5 Intraoral view of maxillary complete denture and mandibular overdenture.

mandibular denture. The patient was

prescribed a 1-time dose of 800 mg
of ibuprofen following surgery and
0.12% chlorhexidine gluconate rinse
to be used twice per day.
Preliminary impressions were then
made for the fabrication of new dentures. Following the trial insertion
stage, the mandibular denture waxing
was duplicated in acrylic resin (Great
Lakes Orthodontics, Ltd, Tonawanda, NY) and used as a surgical guide
for the placement of the endosseous
implants.
The implant surgery involved reflecting buccal and lingual full-thickness envelope flaps. Because of the
lateral proximity of the mental foramen to the right transosseous pin,
there was insufficient bone clearance
to place a standard implant in the
area of the right canine. Instead, a 4.1

x 8-mm implant (Standard Implant;

Straumann USA, Andover, Mass) was
placed medial to the transosseous
pin, in the position of the mandibular
right lateral incisor. On the left side,
sufficient bone width was available
between the exposed mental foramen
and the transosseous pin, allowing
the placement of a standard 4.1 x 10mm implant (Straumann USA) in the
position of the left canine (Fig. 3).
The patient was prescribed 0.12%
chlorhexidine gluconate rinse twice
per day and amoxicillin 500 mg (21
tablets) 3 times daily. The patient
also took 800 mg of ibuprofen before
leaving the office and was instructed
to take the same dosage every 6 hours
for the first 48 hours as needed for
pain. The patient was instructed to
not wear the mandibular denture for
2 weeks.

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Volume 104 Issue 6

Healing was uneventful and at 2
weeks, the previous mandibular denture was again relined with tissue conditioner (Lynal; Dentsply Caulk). In
the area of the implant healing caps,
the tissue conditioner was relieved.
Three months later, ball attachments
(Straumann USA) were placed (Fig.
4), and the dentures were considered
definitive.
The patient has been wearing the
dentures comfortably for the past 4
years and returns for recalls every 6
months; no significant complications
have been reported. At the third-year
recall, the patient had a denture irritation in the left mylohyoid region,
which healed after adjusting the denture (Fig. 5). Clinical and radiographic
follow-up at 4 years revealed minimal
to no crestal bone loss around the endosseous implants.

DISCUSSION
In a retrospective study8 of bone staple implants, which followed implants
placed over a 7- to 11-year period, patients needed frequent maintenance
of their prostheses. The attachments
on the implants were changed in 18
patients because they fractured. The
failure rate was 9%, with limited bone
loss associated with the transosseous pins. For the patient described
in this report, moderate bone loss
was observed around and between
the threaded pins. If that had not occurred, the dentures could have been
remade. Secondly, if the fastening and
locking nuts had been moveable, it
would have been possible to screw the
nut down the threaded post, section
off the excess, and remake the dentures. Since neither of these options
was available, endosseous implants
were used to supplement the loss of
the transosseous posts of the staple
implant.
The use of endosseous implants to
supplement previously existing mandibular staple bone plate implants is
not a unique treatment and has been
described by others.8,9 Balshi8 placed
3 endosseous implants and restored

the mandibular arch with a fixed prosthesis for a patient for whom one of
the transossteal threaded pins had
fractured. Wolfinger et al9 reported
on a patient who was unhappy with
the retention and stability of the ball
attachments on her staple implant.
The authors added 3 endosseous implants and restored the arch with a
fixed prosthesis.
The mental foramen is located on
the anterolateral aspect of the mandible and displays a posterosuperior
emergence path. Injury to the mental
nerve during the preparation of the
implant osteotomy can result in various degrees of sensory dysfunction.
Radiographic studies have described
the presence of a corresponding anterior loop, its mesial extent ranging
from 0 to 7.5 mm.10 Radiographs,
however, may result in underestimation or overestimation of the length
of the anterior loop. Therefore, when
there is doubt concerning the proximity of the foramen to the proposed
implant site, a computerized tomography scan should be obtained prior
to implant placement. Alternatively,
the positioning of the implant in relation to the mental foramen and its
corresponding anterior loop can be
confirmed surgically to avoid injury
to the mental nerve. In the patient described in this report, the implant on
the left side was placed at a distance
of 5 mm from the mental foramen.
On the right side of the mandible,
the proximity of the mental foramen
to the transosseous pin precluded the
safe placement of an implant between
the most distal aspect of the endosseous implant and the mental foramen.
This, in turn, required the placement
of a shorter endosseous implant mesial to the right transosseous pin.
The surgical retrieval of a staple
implant requires hospitalization and
can be associated with a high level of
morbidity. After discussing the risks
and benefits associated with the surgical retrieval of the staple implant,
including the associated cost, the
patient elected not to undergo such
a procedure. Instead, a more con-

The Journal of Prosthetic Dentistry

servative approach was chosen that

consisted of placing 2 endosseous
implants around the remaining staple
implant framework. This treatment
modality allowed the provision of sufficient interocclusal clearance for the
fabrication of a new implant-retained
overdenture in the mandible. Regular
maintenance visits, including routine
clinical and radiographic examinations, were implemented to monitor
changes to the bone levels around
the endosseous implants and residual
transosseous pins.

SUMMARY
The management of a patient who
presented with a failing mandibular
staple implant that had been placed
19 years previously is described. Resorption occurred around the transosseous posts of the staple implant. The
treatment option of screwing the nuts
of the posts down and making new
dentures was not possible because
the nuts could not be moved. The patient desired an implant-retained denture, so the transosseous posts were
sectioned at the bone level, and 2 endosseous implants were placed in the
bone near the posts. A new implantretained overdenture was made. The
patient has been wearing this denture
successfully for 4 years. There are few
existing reports in the literature that
discuss this treatment modality.

REFERENCES
1. Small IA, Kobernick SD. Implantation of
threaded stainless steel pins in the dog
mandible. J Oral Surg 1969;27:99-109.
2. Small IA. Chalmers J. Lyons memorial lecture:
metal implants and the mandibular staple
bone plate. J Oral Surg 1975;33:571-85.
2. Metz HH. Mandibular staple implant for
an atrophic mandibular ridge: solving
retention difficulties of a denture. J Prosthet
Dent 1974;32:572-8.
4. Small IA, Misiek D. A sixteen-year evaluation of the mandibular staple bone plate. J
Oral Maxillofac Surg 1986;44:60-6.
5. Schaberg SJ, Pfeifer DL, Scharpf HO,
Sazima HJ. The mandibular staple bone
plate: long term evaluation of 40 cases. Mil
Med 1986;151:596-602.
6. Small IA. The fixed mandibular implant:
a 6-year review. J Oral Maxillofax Surg
1993;51:1206-10.

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December 2010
7. Meijer HJ, van Oort RP, Raghoebar GM,
Schoen PJ. The mandibular staple bone
plate: a long-term retrospective evaluation.
J Oral Maxillofax Surg 1998;56:141-6.
8. Balshi TJ. Osseointegrated Brnemark
implants used to retreat a fractured
mandibular bone plate staple implant: a
case report. Int J Oral Maxillofac Implants
1992;7:256-8.

9. Wolfinger GJ, Rogoff GS, Harrison JA, Callum JO. Prosthodontic management of a
combination transosteal/endosteal implant
reconstruction: a clinical report. J Prosthodont 1996;5:76-83.
10.Greenstein F, Tarnow T. The mental foramen and nerve: clinical and anatomical
factors related to dental implant placement: a literature review. J Periodontol
2006;77:1933-43.

Corresponding author:
Dr Ronald L. Ettinger
Department of Prosthodontics and Dows
Institute for Dental Research
University of Iowa
Iowa City, IA 52242
Fax: 319-335-8895
E-mail: ronald-ettinger@uiowa.edu
Copyright 2010 by the Editorial Council for
The Journal of Prosthetic Dentistry.

Noteworthy Abstracts of the Current Literature

Difference in opalescence of restorative materials by the illuminant
Yu B, Lee YK.
Dent Mater 2009;25:1014-21. Epub 2009 Apr 15.
Objectives. To determine the differences in the opalescence parameter (OP) of indirect and direct resin composites,
veneer ceramics and bovine enamel relative to the CIE standard illuminants D65, A and F2.
Methods. BelleGlass NG (indirect resin; 10 shades) and Estelite Sigma (direct resin; 12 shades), and 4 shades of
veneer ceramics were investigated. Bovine enamel was used as a reference. Reflected and transmitted colors of specimens were measured relative to the illuminants D65, A and F2 with a reflection spectrophotometer. OP values relative
to the three illuminants [OP(D65), OP(A) and OP(F2)], difference in OP (OP) and OP difference ratio relative to
OP(D65) [OP/OP(D65)] by the change of illuminants were calculated. Within each restorative material, OP and
OP/OP(D65) values were analyzed with two-way analysis of variance (ANOVA), with the fixed factors of the shade
designation and the combination of illuminants ( = 0.05).
Results. OP and OP/OP(D65) values were influenced by the two factors within each restorative material based on
two-way ANOVA. High opalescent materials showed higher OP values. OP(D65) was lower than OP(F2) and OP(A)
values. Restorative materials showed lower OP/OP(D65) values than bovine enamel. Correlation coefficients between OP values relative to different illuminants were higher than 0.961 (P < 0.01).
Significance. Direct resin composites instead of ceramics or indirect resin composites should be recommended in
clinical dentistry since they showed similar opalescence properties as compared with natural tooth enamel.
Reprinted with permission of the Academy of Dental Materials.

Et tinger and Fakhry