implant over dentures by dr. ajay vikram singh

Dental Practice // May-June 2013 // Vol 11 No 6 22

Quality life for elderly edentulouspatients with implant overdentures

implantology section

AJAY VIKRAM SINGH, SUNITA SINGH & ALEJANDRO VIVAS ROJO

INTRODUCTIONThe prosthetic management of the complete-ly edentulous patient has long been a majorchallenge for dentistry. The conventionaledentulous ridge supported dentures, wellover centuries, has been the traditional stan-dard of care for these patients but mostpatients could not achieve the satisfactorycomfort with the conventional dentures andsuffer with several problems such as inade-quate retention and stability, inability to chewand eat, soft tissue abrasions, continuousbone loss, phonetics problem, longer adapta-tion period, teeth setting in the neutral zonecausing altered maxillofacial relations.Hence, the implant-retained overdenturescan be one of the ultimate options for thesepatients because it offers several benefits overthe conventional ridge supported denturessuch as improved function, improved reten-tion and stability, reduced size prosthesis,improved chewing efficiency, decreased softtissue abrasion, improved maxillofacial pros-thesis, and prevention of further ridge loss.

While most implant-based treatment hashistorically been focused on fixed implantsupported prosthesis, the implant overden-ture offers several benefits over fixed implantprosthesis to the edentulous patients in termsof improved function, physical health, andesthetics, lower treatment cost, less invasiveprocedures (no bone augmentation proce-dures are usually required), easy maintenanceand repair. The implant overdentures haveonly fewer disadvantages over the fixed pros-thesis such as psychological feeling of bearingremovable prosthesis, regular maintenance,relining, change of components, foodimpaction under the prosthesis, and loss ofridge in the posterior segment where theimplants have not been placed.

A step by step proper evaluation and treat-ment planning for the patients seekingimplant retained prosthesis has been shownto result in an improved quality of life forpatients and predictable results leading toclinical success. The indication for implantprosthesis may be limited due to inadequate

quantity and structure of the bone.Enhancement of esthetic appearance andfacial morphology through replacement oflost hard and soft tissues may be proven easi-er, if not more effective, with removable over-dentures than with conventional fixed pros-thesis, with possibly decreased costs and less

surgical intervention.When the patient seeking a full mouth

prosthesis enters the clinic so many factors“which are very important” should be evalu-ated before reaching a decision for that par-ticular prosthesis. These factors include age ofthe patient, medical problems, physicalhealth, his or her ability to undergo graftingprocedures, ridge form, soft tissue situation,maxilla-mandibular relation, cause of teethloss, bone density and availability to insertimplants, number of implants required toprovide fixed or removable prosthesis,patient’s expectations from the final prosthe-sis, patient’s ability to maintain the prosthe-sis, and cost affordability to the patient.

There is abundance of literatures present-ing a variety of treatment options, casereports, and clinical techniques over the past

FIG 1: Facial Appearance of the patient during his firstappointment

FIG 2: Clinical evaluation showing multiple missingteeth and periodontitis, generalized attrition, andabfractions in the remaining teeth

FIG 3: Preoperative radiograph showing need forextraction and replacement of all teeth

FIG 4: Case planned using CT planning software toplace adequately long implants

FIG 5: Teeth are extracted and implants are immedi-ately placed into the extraction sockets

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30 years, but there is a general consensusabout the treatment protocols and long termdocumented benefits of implant overden-tures. In the author’s clinical practice, thistreatment option has become the mostrewarding care for the edentulous elderlypatients with increased life expectancy andchewing benefits. Although there still remainsa lack of consistency in terms of techniques,prosthetic design, and attachment systems,these aspects have been proven less importantto successful outcomes than once thought.

CASE REPORTExamination and Treatment PlanningA 70 year old male patient reported at ourclinic for the replacement of a few missingteeth and treatment of his periodonticallydiseased teeth (Figure 1). On clinical evalua-tion, it was found that the patient had lost acouple of his teeth because of periodontitisand remaining teeth showed signs of peri-odontal disease such as periodontal pocketsand mobility. It was also found that thepatient has generalized attrition and abfrac-tions due to heavy bite forces on the teeth(Figure 2). On radiographic evaluation(panoramic radiograph), the periodontalbone loss was found with most of the remain-ing teeth. An abundant bone height was seenin the anterior segment of both arches but

there was almost complete loss of verticalbone dimension in the posterior maxilla dueto long time edentulism in the region andsinus pneumatization. In the mandibularposterior segments the teeth were intact butshowed large osseo-defects which mandatethe grafting procedures to place adequatelysized implants in the region (Figure 3). In theanterior maxilla, the teeth number 21, 22,and 23 showed exposed canals with toothnumber 21 showing periapical radiolucencyin the radiograph but teeth were asympto-matic clinically.

After clinical and radiographic evalua-tions, the authors reached the decision for theextraction of all remaining teeth and place-ment of full mouth prosthesis. Now to pres-ent various replacement options, the patientwas evaluated for his physical health, medicalproblems, and financial status to bear thetreatment cost. On general evaluation andmedical history, it was found that the patientwas fit for the dental implant procedure. Toconfirm medical fitness, blood investigationswere done for general blood picture, bloodsugar level (random), thyroxin along withblood pressure and ECG.

Various options were now offered to thepatient for teeth replacement. Keeping inmind various aspects such as his age, poororal hygiene maintenance habit, heavy bite

forces and inadequate bone in posterior seg-ments to insert implants, affordability andpatient’s expectations from the new prosthe-sis, the implant retained over denture wasfinalized as the definitive treatment option.

To evaluate the exact bone dimensionsand bone density, the CT planning was donefor the patient using Implant 3D software sothat adequately long and wide implants canbe inserted with minimal surgical interven-tion and stabilized into the cortex to achieveadequate initial stability (Figure 4). Based onCT planning, placement of three longimplants (3.75 x 18) in the anterior mandibleand four implants (3.75 x 18) in the anteriormaxilla immediately into the extraction sock-ets were planned. After the dental hygieneappointments for scaling and root planing toeradicate the deep pockets and minimizeinfection to the implants, the case was sched-uled for the implant surgery. The patient wasprescribed tab Valium 5mg at night beforethe surgery for sound sleep and tabAugmentin (1 gm) one hour before theimplant surgery.

CLINICAL PROCEDURESThe anterior teeth were extracted with mini-mal trauma to the alveolar bone and soft tis-sue and the granulation tissue was curettedout from the sockets. The extraction socketswere irrigated with parental form of clin-damycin to kill all the residual pathogens inthe sockets before implant osteotomy prepa-rations. The implant osteotomies were pre-pared through the sockets to reach the basalbones (nasal floor and base of the mandible).All the implants were stabilized into the cor-tex to achieve high initial stability (more than40 Ncm), hence the transmucosal abutmentswere immediately screwed on top of implants(transgingival implant placement/ singlestage implant surgery). The periimplant sock-et spaces were grafted using synthetic bone

FIG 6 & 7: Peri- implant socket spaces are grafted, transgingival healing abutments are immediately placed on topof implants and sutures are placed to approximate the soft tissue

FIG 8: Healing after 6 weeks

FIG 9: Denture FIG 10: Posterior teeth are extracted one week beforethe denture placement

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substitute (HA+ β-Tcp). No barrier mem-brane was used. The sutures were placed toapproximate the tissue to fasten healing andto prevent loss of graft (Figure s5-7).Posterior teeth were extracted but a couple ofteeth which were in occlusion were left tomaintain the same chewing efficiency andalso to record the same jaw relations for den-ture fabrication. Patient was put on antibi-otics and analgesics only for 3 days postoper-atively. An interim removable prosthesis wasgiven to the patient for his anterior segmentswhich got stabilized onto the healing abut-ments.

Patient was recalled after 6 weeks for thedenture fabrication, when soft tissue washealed and implant achieved secondary sta-

bility into the bone (Figure 8). Impressionswere made and bite registration was done.Maxillary and mandibular models were artic-ulated using semi adjustable articulators,teeth removed from the models and teeth set-ting was done. The final denture was fabricat-ed in the laboratory (Figure 9). Patient wasrecalled and the remaining teeth were extract-ed. When the extraction sockets got primari-ly healed in a weeks time, patient was recalledfor the final denture delivery (Figure 10).

The transmucosal healing abutments areremoved from the implants and replacedwith the appropriate sized ball abutments;male part (Figures 11 & 12). The ball attach-ments are finally tightened to 35Ncm usingtorque ratchet to avoid future loosening. The

plastic ball caps; female part are seated intothe metal ball caps (Figures 13 & 14). The ballcaps are seated on top of ball attachments inthe mouth (Figure 15). The tissue surface ofthe denture is hollowed at the site of implantsto accommodate the ball caps (Figure 16).The dentures are tried in the mouth for theircomplete seating over the ball caps (Figure17). A piece of rubber dam sheath is placedunder the metal balls to avoid the self cureresin to get flow and locked into the under-cuts (Figure 18). The self cure acrylic resin ismixed and filled into the tissue surface of thedentures and dentures are seated in themouth in the correct occlusion (Figure 19).Authors would like to mention here that theseparating media (petroleum jelly) wasapplied over the denture except the tissuesurface to avoid sticking of the acrylic overthe teeth and flanges. Once the acrylic hard-ens, the dentures were removed from themouth. The ball caps came out embeddedwithin the tissue surface of the dentures(Figure 20). The palatal extension of maxil-lary denture is removed and flanges are short-

ened (Figure 21). The dentures are finishedand polished and seated over the implants inthe mouth (Figure 22 & 23). A post-loadingpanoramic radiograph was done to evaluatethe accurate seating of the denture compo-nents (Figure 24). The patient experienced anoutstanding satisfaction in denture retention,stability, chewing efficacy, improved maxillo-facial relations (improved appearance) fromday one after placing the implant retaineddentures in mouth (Figure 25).

CONCLUSION Conventional ridge supported dentureshave been used as the only standard of carefor decades but implant supported over-denture offers numerous benefits over the

implantology section

FIG 11 & 12: Healing abutments are removed and replaced with ball attachments

FIG 13 & 14: Plastic caps are seated into the metal cap

FIG 16 & 17: Tissue surface of the denture is hollowed to make space of the ball capsFIG 15: Caps are placed onto the ball attachments inpatient’s mouth

conventional dentures in terms ofimproved retention, improved chewing effi-cacy, improved maxillofacial relations,improved speech, reduced size prosthesisand much more. Through meticulous

patient evaluation, treatment planning,ideal communication among surgical, labo-ratory, and restorative colleagues, implantoverdentures provide simple, predictable,and cost-effective treatment to edentulouspatients. Additionally, they provide the

benefits of esthetics, phonetics, bone preser-vation, increased comfort, better psychoso-cial state, and enhanced nutrition, all result-ing in an improved quality of life.

For a complete list of references, emailinfo@dental-practice.biz

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FIG 19: Self cure resin is filled into the denture anddentures are seated in mouth in occlusion over theball caps

FIG 20: Dentures are removed from the mouth afterthe acrylic has set carrying the ball caps embeddedwithin the dentures

FIG 18: Piece of rubber dam is placed to block theundercuts under the ball caps

FIG 22 & 23: Finally finished and polished dentures seated in the patient’s mouthFIG 21: Palatal extension and denture flanges areremoved

FIG 24: Post loading radiograph

FIG 25: A satisfied patient with great satisfaction afterusing implant over dentures

Dr. Ajay Vikram Singh after his graduation in dentistryand receiving PG. certificate training in Implantology fromIndia, received advanced level implant training at variouscenters and continuing education programmes in USA. Healso received continuing education in implantology at theSchool of Dentistry, The University of Queensland inAustralia. Currently, He is an internationally acclaimedmentor, speaker and researcher in the field of implantol-ogy. He has spoken as the key note speaker in the vari-ous national and international implant conferences inIndia and abroad. Besides being the active member ofvarious prestigious implant associations, he is the fellowand Diplomate of international congress of implantology(ICOI). He is the founder president of InternationalAcademy of Implant Dentistry. Dr. Ajay has authored adental implant book Title “Clinical Implantology”Published worldwide with “Elsevier”. Dr. Ajay is thefounder of International Implant Training Centre (IITC),Agra where he trains several dentists from India andabroad in basic and advanced level implantology. Dr. Ajaydoes the private practice at Dr. Ajay Dental Clinic &

Research Centre, Agra. He can be reached at drajayden-talclinic@gmail.com

Dr. Sunita Singh received continuing education in estheticand implant dentistry, and fixed orthodontics at variouscenters in India and USA. She has attended and presentedin many national and international dental conferences.She has received training in Cosmetic Dentistry fromWashington University (USA). She is a member ofAmerican College of Prosthodontists in USA. She is amember of various prestigious implant associations andhas co-authored the text book in implantology title“Clinical Implantology”. She has been practicing with Dr.Ajay Vikram Singh since 2003 at Dr. Ajay Dental Clinic andResearch Center, Agra.

Alejandro Vivas Rojo. DDS Ms. (Venezuela) is an Oral andMaxillofacial Surgeon. Member, American Association ofOral and Maxillofacial Surgery. He is attending Surgeon atHospital dos Lusiadas; Oral and Maxillofacial Service.Lisbon-Portugal.

About the AUTHORS