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May 9, 2008

By Joel Hauptman, DDS, and Mauricio Hervas, DDS, MS

Abstract

The described technique uses the immediate denture for vertical dimension, centric relation, esthetics, and function in order to design the bar and overdenture. This reduces the number of patient appointments to three:

1. Fixture level impression with immediate denture and bite registration in a closed-mouth technique
2. Bar try-in and wax denture set-up
3. Denture delivery

Introduction

Since endosseous implants were introduced in the late 1970s, different alternatives became available for edentulous patients in treatment planning for the maxillary arch. The use of implants became especially beneficial where a large palatal torus was present in the edentulous maxilla. (1-4)

The conventional and traditional way of accomplishing this result requires several appointments after the initial implant fixture level impression. An occlusion rim is required to determine vertical dimension, centric relation, and tooth position. A denture wax set-up is essential to evaluate esthetics and function. (5) Only after these steps are accomplished can the bar be designed since the space from teeth and implants is critical. After the bar is fabricated and checked in the mouth for passive fit, the superstructure is cast and the denture teeth set up for the second time. This is assessed with the clinical try-in and then the final prosthesis can be processed. (6)

Utilizing an immediate denture allows the restorative dentist to facilitate the fabrication of an implant-retained overdenture without compromising the esthetics, phonetics, or function. The case presented describes the technique.

A 58-year-old female presented to the faculty practice of Nova Southeastern University, College of Dental Medicine, with an immediate denture that was not tolerated well due to the large maxillary tori. The patient's chief complaint was "I want a denture that allows me to taste food, that looks good, and that doesn't crowd my tongue." The medical history included a past history of diabetes, diabetic neuoropathy, bariatric bypass surgery, and drug addiction 20 years ago, which has since been resolved through drug rehabilitation. She has been drug-free for 20 years, but she has a 66-pack/year smoking history. Her medications include Glucophage 2000 mg for diabetes; Topomax, 100 mg for food addiction; Neurontin, 1,200 mg for neuropathy; Elavil, 100 mg for depression; and HRT for menopausal symptoms. The dental history included a full-arch maxillary reconstruction, endodontic therapy, periodontal therapy, and extractions. The clinical exam revealed a healthy, completely edentulous maxillary arch with a large maxillary torus and significant xerostomia due to her numerous medications. The diagnosis was edentulous maxillary arch with a poorly tolerated maxillary denture. The treatment plan for the maxillary arch included four ITI implants with a maxillary implant-retained bar overdenture using Bredent attachments.

Technique

Step 1. Final denture impression: The immediate denture was used to serve as the custom tray for the making of the final impression. The intaglio of the denture was relieved in order to create space for the final impression and at the same time determine the position of the implants which had healing abutments. This final impression was made in a closed-mouth position in centric relation such that the occlusion was maintained at the appropriate vertical dimension.

Step 2. Implant transfer coping pick-up: Once the final impression material was set, the healing abutment replicas in the denture were perforated in order to create openings for the impression posts. The denture was placed back into the mouth and held in place to relate implant transfer coping to the denture. The transfer copings were connected to the denture by adding impression material around the posts (Figures 1 and 2).

Figure 1 — Patient's intraoral photograph after healing process with healing abutments in place

Figure 2 — Final impression with implant analogs set in place and ready to pour master cast

Step 3. Master cast: A master cast was fabricated using type III stone (Microstone, Whip Mix Corporation, Louisville, Ky.) along with implant laboratory analogs and mounted on a semi-adjustable articulator (Whip Mix Model 3430, Whip Mix Corporation, Louisville, Ky.) (Figure 3).

Figure 3 — Lab analogs in place with soft tissue moulage

Step 4. Bar fabrication: A polyvinylsiloxane, heavy lab putty (Aquasil Putty, DENTSPLY International, Inc., York, Pa.) (Figure 4) was used in order to relate the position of the teeth in the immediate denture and the master cast with the exact position of the implants.

This index provides the dental laboratory technician with the relation of the teeth to the implants and the space for the bar and attachments. The bar was cast in high noble alloy.

Figure 4 — Lab putty index for bar fabrication. Picture shows bar relation to denture tooth position.

At this point, the bar and attachments can be fabricated and tried in the mouth along with the tooth set-up in wax of the maxillary prosthesis (Figure 5).

Figure 5 — Bar try-in

After reevaluation of the vertical dimension, centric relation, and fit of the bar, the case can be processed and completed by the next visit (Figures 6, 7, and 8).

Figure 6 — Undersurface of prosthesis with superstructure and attachments in place

Figure 7 — Denture delivery

Figure 8 — Maxillary complete denture in mouth with full smile

Summary

The proposed technique eliminated the need for a custom tray, occlusal wax rim, and denture teeth wax try-in by using a previously fabricated immediate denture at the appropriate occlusal vertical dimension that satisfied the patient's functional and esthetic demands. The technique considerably reduced the number of office visits and chair time.

Acknowledgement

Thanks go to Sharon C. Siegel, DDS, MS, chair of the Department of Prosthodontics at Nova Southeastern University, College of Dental Medicine, in Fort Lauderdale, Fla., for her assistance in reviewing the manuscript.

Joel Hauptman, DDS, is an assistant professor in the Department of Prosthodontics and director of the Predoctoral Prosthodontics Clinic at Nova Southeastern University, College of Dental Medicine. He has maintained a private practice for 40 years limited to restorative dentistry and prosthodontics and is currently practicing in the faculty practice at Nova Southeastern University, College of Dental Medicine.

J. Mauricio Hervas, DDS, MS, is an assistant professor in the Department of Prosthodontics at Nova Southeastern University College of Dental Medicine. He has a certificate in prosthodontics from The Ohio State University, College of Dentistry, a Fellowship in Implant Dentistry and a Masters of Science Degree from The Ohio State University, College of Dentistry. He is the director of the Predoctoral Implant Program and has a private practice limited implant prosthodontics.

References

1. Zitzmann NU, Marinello CP. Fixed or removable implant-supported restorations in the edentulous maxilla: literature review. Pract Periodontics Aesthet Dent 2000; 12(6):599-608.

2. Simons AM, Campbell Z. The implant-supported overdenture prosthesis for the edentulous maxilla. J Oral Implantol 1993; 19(1):39-42.

3. Desjardins RP. Prosthesis design for osseointegrated implants in the edentulous maxilla. Int J Oral Maxillofac Implants 1992; 7(3):311-20.

4. Eckert SE, Carr AB. Implant-retained maxillary overdentures. Dent Clin North Am 2004; 48(3):585-601.

5. Boucher CO. Complete denture prosthodontics — the state of the art. J Prosthet Dent 1975; 34(4):372-83.

6. Boerrigter EM et al. Patient satisfaction with implant-retained mandibular overdentures. A comparison with new complete dentures not retained by implants — a multicentre randomized clinical trial. Br J Oral Maxillofac Surg 1995; 33(5):282-8.

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