TEAMWORK IN IMPLANT DENTISTRY: THE PROVISION OF A MAXILLARY IMPLANT RETAINED OVERDENTURE

CRAIG PARKER (BCHD, MFGDP(UK), DPDS,CERT [DENTAL IMPLANTOLOGY]), DENTAL SURGEON, FGDP(UK) BOARD MEMBER AND PRINCIPAL OF PRIMLEY PARK DENTAL IMPLANTS, LEEDS
JONATHAN HUGHES (DIP. CDT [RCS ENG]), CLINICAL DENTAL TECHNICIAN AND HEAD OF HUGHES DENTAL LABORATORY, HARROGATE

Introduction
In 2007, the GDC recognised clinical dental technicians (CDTs) as a profession complementary to dentistry. Clinical dental technicians are registered dental professionals who provide complete dentures direct to patients and other dental devices on prescription from a dentist. They are also qualified dental technicians. Patients with natural teeth or implants must see a dentist before the CDT can begin treatment. We hope to be able to demonstrate the advantage of combining the skills of the dentist and CDT for the benefit of the patient, from treatment planning to fitting and aftercare. Jonathan Hughes (CDT) was treating the patient in this case, undertaking the clinical stages of the denture construction and implant bar verification as well as providing technical support for the dental implant surgeon, Craig Parker. Complex and highly technical treatment plans are challenging for dentists and dental technicians operating alone, so to be able to come together and work as a team helps to overcome difficulties faced when treating these patients. It also enables the clinicians to concentrate on providing aspects of treatment according to their own areas of strength. This should lead to a more predictable and successful outcome for the patient.

Figure 1 reflex. He was unhappy with his appearance (figure 1) and inability to masticate effectively. The patient and his GDP were happy with the mandibular dentition and requested that we limit our intervention to the maxilla. The dental surgeon and CDT worked alongside one another from the initial consultation to the final review. A history of the patients presenting complaint revealed that he had elected to have many of his failing incisor and premolar teeth extracted within the last few years, with a view to wearing with a partial denture. This had been unsuccessful because of a gagging reflex and he been attempting to manage without a prosthesis. He had had his molar teeth extracted over 20 years ago without the provision of any restoration. The GDP was now hopeful that we might be able to provide an implant retained restoration as a solution. A social history informed us the patient was a 55 year old self employed electrician, with a grown up family. His medical history was clear. His diet and the potential existence of para-functional habits were discussed in detail and discounted.

Figure 2 associated with mandibular overclosure. Extraoral examination revealed nothing of note, except that his masseter muscles seemed large and there were no signs associated with the temporo-mandibular joint or muscles of mastication. Intraorally, the soft tissues were healthy and the periodontal health was good, with all sextants scoring zero on Basic Periodontal Examination (BPE). Only three maxillary teeth remained at UR3, UL2 and UL3, with UR3 and UL2 significantly broken down. A retained root was present in the UL6 region. The mandibular arch was largely complete but demonstrated tooth surface loss in the incisor and canine region. The lower incisors had some superficial staining and the molars were restored with old, but sound amalgam restorations (LL5, LR6, LR7 and LR8) and porcelain fused to a metal full crown (LL6) (figure 2).

Special Investigation
Periapical radiographs provided by the GDP indicated that the remaining teeth had no periodontal bone loss and were free of caries and periapical pathology. A cone beam computed tomograph (CBCT) was prescribed (see discussion) using the existing upper partial denture as a radiographic template. Foil markers were attached to the midline of the denture teeth. This is an economical, simple and effective way of providing a radiographic template. The CBCT

Case History
Implant overdenture treatment for the edentulous maxilla is challenging due to inherent anatomic and biomechanical problems. This case demonstrates the close collaboration between a dentist and a CDT in an attempt to deliver a successful treatment outcome for the patient in a difficult clinical scenario. The patient was referred by his GDP complaining of an inability to tolerate his upper partial denture due to a gagging

Examination
An explanation of the different roles of a CDT and dentist was given to the patient and consent obtained for examination. Visual examination of the patients face suggested general symmetry with a decreased lower face height, possibly

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Figure 3

conforming to the existing occlusal vertical dimension. An increase in space would require an increase in occlusal vertical dimension. The CBCT was referred to a consultant radiologist for examination, who confirmed the absence of pathology associated with structures visible on the scan outside the dento-alveolar region.

Figure 4

Diagnosis
The history, examination and special investigations suggested that the patient had a healthy periodontal condition and was suffering overclosure, compromised aesthetics and poor mastication due to the loss of the majority of his maxillary teeth. The inability to tolerate a maxillary denture was considered to be due to poor stability, although the existing denture had ideal tooth position, occlusion and fit. The poor tolerance of his existing denture was considered to be further compromised by gagging, attributed to a conventionally positioned post dam.

or without precision attachments; provision of a fixed, or removable, implant-supported prosthesis on six implants including possible bilateral maxillary sinus augmentation; or a removable implant retained full-arch prosthesis on four implants. A decision was made to provide the latter with implants on UR4, UR2, UL2, UL4 supporting a milled, titanium Dolder bar, retaining a full denture in the maxilla. A final treatment plan was formulated and written consent gained from the patient: 1 Extract UR3, UL2, UL3 and UL6 root and fit an immediate full upper temporary denture 2 Place dental implants UR4, UR2, UL2, UL4 3 Provide a full upper denture without palatal coverage, retained by an implant-supported milled bar

(figure 3) was studied and confirmed the presence of the retained root UL6. It indicated sufficient vertical and orofacial ridge dimensions to accommodate dental implants in the UR4, UR2, UL2 and UL4 regions should this be required (figure 4). Reduced vertical alveolar bone in the posterior maxilla necessitated that implant placement further back would require maxillary sinus augmentation. Measurements from the CBCT indicated that 7mm vertical space above the implant fixture head was available to accommodate restorative implant components (figure 4), if

Treatment
Visit 1 CDT present Alginate impressions were taken and a silicone putty (Express, 3M ESPE, MN USA) registration was taken in a centric tray (Ivoclar Vivadent, Liechstenstein). The centric tray registration enables models to be articulated at an over closed vertical dimension, with an indication of antero-posterior intermaxillary

Treatment Plan
Treatment options were considered with the patient (see discussion) including: extracting the remaining maxillary teeth and providing a conventional full denture; retaining the maxillary canine roots and providing a full overdenture, with

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relationship. This was required for the construction of a gnathometer for the next visit. Visit 2 CDT present Occlusion was recorded using a gnathometer (Ivoclar Vivadent, Liechtenstein). The gnathometer consists of an upper plate (figure 6) and a lower plate with a screw (figure 7). Ink dots were marked on the patients nose and chin. The patient was asked to speak and count, and the vertical face height at rest (phonetic rest position) was recorded. The screw in the mandibular rim of the gnathometer was then adjusted to a height that allowed comfortable closure (2-4mm freeway space) (figure 8). The maxillary plate was then covered using a chinagraph pencil (figure 9). The patient was asked to make lateral and protrusive movements, and the mandibular pin described an envelope of movement onto the plate (figure 10). The most posterior point on the tracing represents the retruded position of the mandible. A perspex guide was locked to the maxillary plate with sticky wax (Kemdent, UK) restricting the patient to occlude only in the retruded position (figure 11). Occlusal face height was checked again in the retruded position; it was verified that the patient was

comfortable and that there was an allowance of 2-4mm freeway space (figure 12). Bite registration material (Futar-D, Kettenbach, Germany) was used to locate the rims to one another (figure 13). An upper special tray impression was taken with a polyether (Impregum, 3M ESPE, MN USA) in a spaced, cold cure acrylic tray with the periphery modified with green stick compound. Visit 3 CDT present A wax try-in was carried out to check comfort, occlusion, stability, aesthetics and tolerance to the proposed post-dam position (figure 14). Visit 4 Dentist and CDT present The remaining maxillary teeth were extracted and an immediate full upper acrylic denture was fitted. Visit 5 Dentist present Five weeks later dental implants were placed on UR4, UR2, UL2 and UL4 (4.1mm diameter, 10mm, soft tissue level, regular neck, standard-plus, Straumann, Switzerland). For the sake of brevity, details of surgery have not been included here.

Visit 6 Dentist present Implants were reviewed after one week to check comfort and healing. Visit 7 Dentist and CDT present Twelve weeks later, full osseointegration of the dental implants was checked and verified by comfort, clinical appearance (figure 15), gentle periodontal probing (and baseline probing depths recorded), percussion tests and periapical radiographs. A closed-tray impression was taken using snap-on copings (Straumann, Switzerland) and polyether impression material in a modified, cold-cured, acrylic special tray (figures 16, 17). Visit 8 Dentist and CDT present The occlusion was recorded with a gnathometer again, as in Visit 2, but this time with a screw-retained upper acrylic plate for accuracy (figure 18). A cold-cure resin (Pi-Ku-Plast, Bredent, Germany) verification jig was used to check the accurate registration of implants (figures 19, 20). A special tray had been constructed to facilitate a pickup impression should the jig need to be sectioned and reconnected. This was not required.

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The models were mounted on an articulator (Gnathomat, Ivoclar Vivadent, Liechtenstein). Visit 9 CDT present A screw retained wax try-in on a cold cure acrylic baseplate was carried out and checked as per Visit 3 (figure 21). The try-in is carried out before manufacture of the bar so that the bar can be designed digitally by the laboratory within the contours of the proposed prosthesis (figure 22). Visit 10 Dentist and CDT present A computer aided design and computer aided manufacture (CAD-CAM) produced milled, titanium, Dolder bar (manufactured by ISUS, Dentsply-ES, Belgium ) was checked for passive fit (figure 23). A bar retained wax try-in on cold-cure acrylic baseplate was carried out and checked for final verification, as per Visit 9 (figures 24-27). Visit 11 Dentist and CDT present The full acrylic, bar retained denture was fitted with checks as per Visit 9 and Visit 10 (figures 28-31). The patient was instructed in denture insertion, denture removal and appropriate hygiene procedures.

Visit 12 Dentist and CDT present At the review appointment one week later, the patients oral hygiene and comfort were checked, as were the stability, aesthetics and phonetics of the denture. No adjustments were necessary. Baseline periodontal probing depths were repeated. Visit 13 Dentist present Three month review checks were repeated. Visit 14 Dentist and CDT present Six month review checks were repeated with special attention to any loss of soft tissue support that would make a reline necessary. No abnormalities were detected and the patient was happy.

anatomical boundaries and adequate bone height and space, no additional imaging is required for implant placement.1 There are many limitations to conventional clinical and radiographic examinations, particularly when treatment planning for full arch restoration in the maxilla. The thick fibrous soft tissues of the maxilla very often give the clinical appearance of a bulky alveolar ridge when in reality surgery exposes a knife-edged ridge, often with a variety of deficiencies that can be quite extensive. The complex and varied topography of the ridge can make it enormously difficult to predict the bony outline form of the maxilla with conventional ridge-mapping techniques. Also, one of the major benefits of the use of digital treatment planning is the ability to visualise the bone available for implants relative to the proposed restorative position of the restored teeth. This requires CBCT to be taken with the patient wearing an accurate radiographic template, based on the idealised arch design. In this case, we used the patients existing denture with foil markers attached to the labial surfaces of the denture teeth. This enables the clinician to accurately assess

Discussion
As explained, CBCT was prescribed as a special investigation to aid treatment planning. There is little consensus in the UK and Europe regarding the use of cross-sectional imaging. Recent European guidelines state that if the clinical assessment of implant sites indicates that there is sufficient bone width and the conventional radiographic examination reveals the relevant

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ridge dimensions and horizontal and vertical ridge discrepancies, relative to the ideal arch design. This is virtually impossible to evaluate with conventional clinical and radiographic examination and can have a fundamental influence on treatment planning. It is the authors opinion that it is impossible for the patient to consent to a surgical intervention when the potential restorative options have not been fully evaluated and communicated to the patient using three-dimensional treatment planning. The patients existing denture was considered to be well designed and constructed, yet on evaluation had inadequate retention and stability, largely because of the inability to incorporate sufficient palatal extension due to the patients gagging reflex. It was decided that the provision of a new upper denture with or without precision attachments on the remaining canines would provide insufficient improvement in retention and stability. The decision was made to provide an implant retained overdenture. The literature indicates that an implant retained, overdenture prosthesis provides predictable results, with enhanced stability, function and a high degree of patient satisfaction compared to conventional removable dentures.2

It is important here to differentiate between an implant retained overdenture and an implant supported overdenture. The former is essentially soft tissue borne with retention and stability enhanced by a bar, or individual retentive anchors attached to dental implants. The retainer normally allows some movement of the prosthesis so that stresses are transferred to the oral mucosa rather than to the dental implants. The latter is rigidly held and normally involves six implants connected with a two degree milled bar retaining a removable prosthesis with a spark eroded, closely fitting, secondary framework with parallel friction pins and swivel latch attachments. Cost and complexity of this treatment option in this instance were deemed to be too high. For the same reasons, it was decided that a fixed, implant supported restoration was not appropriate in this case. Much controversy exists regarding case selection and the criteria for designing a maxillary implant overdenture. A review of the literature reveals that when bone quantity and quality are satisfactory, overdenture and fixed prostheses both achieved a 92% implant survival over five years.3 However, it has also been suggested in the literature that maxillary implant overdentures (MIOs) have been documented with a high implant loss

relative to other endosseous implant treatment modalities.4-6 In comparison to the edentulous mandible, implant overdenture therapy for the maxilla is often compromised by reduced bone quantity/quality7, 8 and also subjected to higher biomechanical forces.9 There are no specific guidelines for the number of implants necessary to support a maxillary overdenture.10, 11 However, for a design without palatal coverage, there appears to be a consensus in the reviewed literature that a minimum of four implants is favourable.12-15 A decision had to be made regarding whether to use a bar design, which splints the implants together, or a system of individual, retentive anchor elements. We made the decision to provide a splinted solution because of concerns regarding high occlusal stresses on the implants. However, on studying the literature a lack of standardisation of prosthetic procedures,12 number of implants,16,17 marginal bone measurements,18 bone quantity,8 and loading conditions,4,16 as well as insufficient sample size,17,18 have plagued an objective assessment of the preferred retention system for MIOs.

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In fact, Trakas et al19 concluded that it appears there is no significant difference in mean bone loss between subjects with ball or bar retained overdentures. The use of a bar in this situation involved similar cost to individual retentive anchors but future maintenance of a bar could prove to be more complex and costly (see below). With regard to patient satisfaction, patients appear to be equally satisfied with bars or solitary anchors retaining a maxillary, implant overdenture4,16. Unsplinted anchorage systems may require less space within the prosthesis, be easier to clean and be more economical, as well as being less technique sensitive and easier when managing splinted designs20. In the vertical axis, a minimum distance of 13-14 mm from the implant platform to

the incisal edges is necessary with a bar design, allowing 4.0 mm for the bar and 1.0 mm below the bar for hygiene, as well as space for the clip and acrylic/tooth housing21. Using digital treatment planning, vertical space assessment can be made from the CBCT prior to commencing treatment. Available vertical and orofacial space for retentive elements can also then be verified from the digital impression of the preliminary wax try-in, before definitive bar design is finalised.

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Although costs and complexity are reduced in the initial provision of an MIO, it should be recognised that maintenance issues can be significant, time consuming and costly in the longer term. Clarifying this issue with the patient from the outset is important to gain informed consent to this form of treatment. MIOs are reported to have a high number of complications11, 22, 23, 24 and may require more post-insertion maintenance than implant-supported fixed prostheses23, 25, 26. Higher incidence of mechanical problems with MIOs, especially without palatal coverage27, 24 relative to mandibular prostheses may be due to higher loading found in the maxilla from opposing natural teeth or fixed restorations11. Furthermore, limitations in vertical space for prosthetic components are more common in the maxilla because of contour and phonetic

REFERENCES
4 1 Harris D Horner, Grondahl K, Jacobs R, Helmrot E, Benic G et al. E.A.O Guidelines for the use of diagnostic imaging in implant dentistry 2011. A consensus workshop organized by the European Association of Osseointegration at the Medical University of Warsaw. Clin Oral Implant Res. 2012; 23:1243-53. Laurito D, Lamazza L, Spink MJ, De Biase A. Tissue supported implant prosthesis (overdenture): the search for the ideal protocol. A literature review. Ann Stomatol (Roma) 2012 Jan;3(1):2-10 Jemt T, Lekholm U. Implant treatment in edentulous maxillae: a 5-year follow-up report on patients with different degrees of jaw resorption. Int J Oral Maxillofac Implants

1995;10:303-11. Bergendal T, Engquist B. Implantsupported overdentures: a longitudinal prospective study. Int J Oral Maxillofac Implants 1998;13:253-62. Jemt T, Chai J, Harnett J, Heath MR, Hut- ton JE, Johns RB, et al. A 5-year prospective multicenter follow-up report on over-dentures supported by osseointegrated implants. Int J Oral Maxillofac Implants 1996;11:291-8. Johns RB, Jemt T, Heath MR, Hutton JE, McKenna S, McNamara DC, et al. Int J Oral Maxillofac Implants 1992;7:513522. Chan MF, Narhi TO, de Baat C, Kalk W. Treatment of the atrophic edentulous max- illa with implantsupported overdentures: a review of the literature. Int J Prosthodont 1998;11:7-15.

Hutton JE, Heath MR, Chai JY, Harnett J, Jemt T, Johns RB, et al. Factors related to success and failure rates at 3-year follow-up in a multicenter study of overdentures supported by Branemark implants. Int J Oral Maxillofac Implants 1995;10:3342. 9 Rodriguez AM, Orenstein IH, Morris HF, Ochi S. Survival of various implant-supported prosthesis designs following 36 months of clinical function. Ann Periodont 2000;5:101-8. 10 Kronstrom M, Widbom C, Soderfeldt B. Patient evaluation after treatment with maxillary implant-supported overdentures. Clin Implant Dent Relat Res 2006;8:39-43. 11 Chan MF, Narhi TO, de Baat C, Kalk W. Treatment of the atrophic edentulous maxilla with implant-

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supported overdentures: a review of the literature. Int J Prosthodont 1998;11:7-15. Kiener P, Oetterli M, Mericske E, Mericske-Stern R. Effectiveness of maxillary overdentures supported by implants: maintenance and prosthetic complications. Int J Prosthodont 2001;14:133-40. Lewis S, Sharma A, Nishimura R. Treatment of edentulous maxillae with osseointegrated implants. J Prosthet Dent 1992;68:503-8. Mericske-Stern R. Treatment outcomes with implant-supported overdentures: clinical considerations. J Prosthet Dent 1998;79:66-73. Naert I, Gizani S, van Steenberghe D. Rigidly splinted implants in the resorbed maxilla to retain a hinging overdenture: a series of clinical reports for up to 4 years. J Prosthet Dent

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considerations,28 which may result in compromises in design and material failure29. After a five year follow up, Watson et al29 reported a threefold increase in fractures in the body of the prosthesis with overdentures for the maxilla compared to the mandible. However, Smedberg et al30 in a six year study found that a cast, chrome cobalt framework reinforcement eliminated this complication. We made the decision not to incorporate such a framework because of space limitations, but in the event of prosthesis fracture we will attempt to redesign the prosthesis to incorporate a strengthener. Regardless of the anchorage system, the predominant complication in maxillary overdenture therapy involves failure of the retention system resulting from loosening or fracture. Jemt et al23

while a repair is carried out. We considered it most appropriate to prepare for the failure of the prosthesis and be ready to manage the situation with the least inconvenience to the patient.

Summary
This case demonstrates a pragmatic, yet systematic, team approach to resolving a challenging clinical situation. It is essential to understand and accept the challenges presented and limitations of the treatment options available in the provision of an MIO. The dental surgeon and clinical dental technician collaborated using their combined skills set. Working as a team gives each clinician a greater appreciation of the difficulties faced clinically and technically. We believe that an enhanced standard of care is delivered to patients by using this team approach.

Figure 31 reported as high as 17% clip retention problems and 22% clip fractures in the first year. The provision of an acrylic denture incorporating a clip is relatively inexpensive approach and this enabled us to produce a spare denture for the patient to use in the event of fracture

1998;79:156-64. 16 Narhi TO, Hevinga M, Voorsmit RA, Kalk W. Maxillary overdentures retained by splinted and unsplinted implants: a retrospective study. Int J Oral Maxillofac Implants 2001;16:259-66. 17 Quirynen M, Naert I, van Steenberghe D. Fixture design and overload influence marginal bone loss and fixture success in the Branemark system. Clin Oral Implants Res 1992;3:104-11. 18 Schwartz-Arad D, Kidron N, Dolev E. A long-term study of implants supporting overdentures as a model for implant suc- cess. J Periodontol 2005;76:1431-5. 19 Trakas T, Michalakis K, Kang K, Hirayama H. Attachment systems for implant retained overdentures: a literature review. Implant Dent 2006;15:24-34.

20 Watson CJ, Tinsley D, Sharma S. Implant complications and failures: the complete overdenture. Dent Update 2001;28:234-8, 240. 21 Phillips K, Wong KM. Space requirements for implant bar-andclip overdentures. Compend Contin Educ Dent 2001;22:5168, 520, 522. 22 Ekfeldt A, Johansson LA, Isaksson S. Implant-supported overdenture therapy: a retrospective study. Int J Prosthodont 1997;10:366-74. 23 Jemt T, Book K, Linden B, Urde G. Failures and complications in 92 consecutively inserted overdentures supported by Branemark implants in severely resorbed edentulous maxillae: a study from prosthetic treatment to first annual check-up. Int J Oral Maxillofac Implants 1992;7:162-7.

24. Widbom C, Soderfeldt B, Kronstrom M. A retrospective evaluation of treatments with implant-supported maxillary overdentures. Clin Implant Dent Relat Res 2005;7:166- 72. 25 Jemt T, Book K, Lie A, Borjesson T. Mucosal topography around implants in edentulous upper jaws. Photogrammetric threedimensional measurements of the effect of replacement of a removable prosthesis with a fixed prosthesis. Clin Oral Implants Res 1994;5:220-8. 26 Zarb GA, Schmitt A. The edentulous predicament II: The longitudinal effectiveness of implant supported overdentures. J Am Dent Assoc 1996;127:6672. 27 Sadowsky SJ. The implantsupported prosthesis for the edentulous arch: design

considerations. J Prosthet Dent 1997;78:28-33. 28 Smedberg JI, Nilner K, Frykholm A. A six-year follow-up study of maxillary overdentures on osseointegrated implants. Eur J Prosthodont Restor Dent 1999;7:51-6. 29 Watson RM, Jemt T, Chai J, Harnett J, Heath MR, Hutton JE, et al. Prosthodontic treatment, patient response, and the need for maintenance of complete implant-sup- ported overdentures: an appraisal of 5 years of prospective study. Int J Prosthodont 1997;10:345-54. 30 Smedberg JI, Nilner K, Frykholm A. A six- year follow-up study of maxillary overden- tures on osseointegrated implants. Eur J Prosthodont Restor Dent 1999;7:51-6.

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