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Implant Retained Overdenture: Splint Approach Using Copy Dentures

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 Case Report
Sri Lanka Dental Journal 2019; 49(03) 116-123

Implant Retained Overdenture: Splint Approach Using Copy Dentures

A.A.A.K. Wimalarathna, R.M. Jayasinghe, A.M. Attygalla

Abstract adhering to a variety of techniques during

Implant retained overdenture is one of the conventional denture construction such as
popular dental treatnment modalities among neutral zone impression techniques and using a
completely edentulous people. Positioning of monoplane occlusion scheme.
the implants in highly resorbed alveolar bones is
the most difficult task considering this treatment Implant supported prostheses have been
modality. The usage of a surgical guide or introduced as an effective altermative to overcome
template is one of the recommended approaches many concerns associated with conventional
place the implants in the most desirable position dentures. They have shown multiple advantages
on the alveolar ridges. The common practice of such as alveolar bone preservation, improved
making surgical stents is by using a radiological retention, stability, function, proprioception
guide plate embedded with radiopaque material and comfort?. Dental implant options for
in relation to the planned locations of implants edentulous arches include implant-supported
or by using a 3D printed guide plate. This case fixed prostheses, implant-retained overdentures
report describes a novel technique of using a and implant-supported overdentures (1OD)}
copy denture for fabrication of a surgical stent. Some authors use the terms of implant retained
and supported over dentures synonymously.
Keywords: Implants, Overdenture, Splint, Copy The advantages of implant retained/ supported
denture, Prosthesis. overdentures are described as enhancing function
and phonetics', effectiveness in maintaining oral
Introduction hygiene', increased masticatory efficiency',
Edentulous patients suffer from poor retention increased maximum myoelectric output and less
of their conventional dentures mainly due to age-related alveolar bone loss when compared
severe alveolar bone resorption after long term with conventional complete dentures'.
extractions. Bone resorption is more prominent
in the mandible when compared to maxilla Dental implant treatment has been associated
creating an unfavorable platform for prosthetic with a high success rate over many years. The
rehabilitation'. Therefore, various clinicians 10-year survival rates of implants supported
have attempted to overcome this problem by mandibular overdentures are shown to be

A.A.A.K. Wimalarathna Senior Registrar in Restorative Dentistry, Faculty of Dental Sciences, University of Peradeniya.
E-mail: [email protected]

R.M. Jayasinghe Senior Lecturer, Department of Prosthetic Dentistry, Faculty of Dental Sciences, University of
Peradeniya.
A.M. Attygalla Professor in OMF Surgery, Department of Oral & Maxillofacial Surgery, Faculty of Dental
Sciences,University of Peradeniya.

116
 A.A.A.K. Wimalarathna, R.M. Jayasinghe, A.M. Attygalla

slightly higher than of endosseous implants of Dental Sciences, University of Peradeniya

in the mandible uscd to support fixed full- with the main complaint of edentulousness
arch bridges or single crowns". The studies of both upper and lower jaws with dificulty
conducted by Haraldson et al.", Nacrt et al. " and in mastication. The patient had been an
Bruggenkate et al." have revealed survival rates existing denture wearer with poor retention
of 100% for them. On the other hand some of and difficulty in tolerating the dentures during
the studies have shown the survival rates around speech, especially the lower one. He had been
87% by Engquist2 and 74.8% by Versteegh et edentulous for 12 years and he requested some
al. According to MacGill Consensus Statement form of fixed prostheses in order to overcome
on overdentures in 2002, two implantsare his concerns with removable prosthesis.
suficient for the 1OD in edentulous mandiblel
and four to six implants have been recommended The maxillary arch was identified as U-shaped
for edentulous maxilla5. 1ODs are also a cost and with a high vault hard palate. His mandibular
effective treatment modality compared to implant ridge was U-shaped with an irregular ridge
supported fixed prostheses. They provide facial contour (Figure 1).
support by restoring both dental and alveolar
tissues. Furthermore, they are relatively simple, Radiographic assessment revealed availability
easy to construct and esthetically more pleasing. of sufficient good quality and quantity of bone
(Figure 2). Considering the favorable factors,
it was decided to rehabilitate the patient with
implant retained upper and lower overdentures.
The complete dentures were fabricated using
the conventional technique prior to placement
of implants (Figure 3). At the denture delivery
stage, premature occlusal contacts were removed
and balanced occlusion and articulation were
achieved. The patient was reviewed again
within 48 hours and 1 week later as the common
practice. The patient was asked to wear the
complete dentures for about 1 month prior to
placement of implants.

Figure 1. Pre-operative intra-oral images of

the upper and lower alveolar ridges

Case Presentation
A 70-year-old male patient presented to the
Department of Prosthetic Dentistry, Faculty

117
 Retained Overdenture: Splint Approach Using Copy Dentures
Implant

Figure 2. CBCT images of the desired

implants locations of 13, 23, 33 and
43 regions

G Omm

B Imn

Figure 3. Fabrication of upper and lower

conventional complete dentures
Implant assessment and treatment planninS
were performed with the help of radiographic
investigations. According to the availability
of bone and standard
implant protocols, two
and four conventional
implants were planned
respectively for the mandible and maxilla to
support the overdentures. Implants sites were

118
 A.A.A.K. Wimalarathna, R.M. Jayasinghe, A.M. Attygalla

planned as follows;, bilateral canine regions in

mandible and bilateral canine and first premolar
regions in maxilla. The positions and the
angulations of desired implants were considered
in order to transfer the details
of patient's
alveolar arches by using a surgical stent.

The fundamental ways of making surgical stents

are by using a radiological guide plate which
is with some embedded radiopaque material
into the stent in relation to planned locations of
implants or by using a 3D printed guide plate. In
Figure 4. Different stages of denture copying
this case report, we presented a novel approach
procedure
of surgical stent that fabricated by denture
impression material extruded almost exceeding
copying. After a month of denture wearing,
the periphery of the denture. Once it was set,
patient was satisfied about comfort of newly
borders of the impression were trimmed and
fabricated dentures and they were used to make
location grooves were placed. After applying a
an implant surgical stent by duplicating them
separating medium over the fitting surface and
(Figure 4). after the putty was set, the two halves of the
Slightly larger upper stock trays were used impression were carefully separated and the
where the impression material was loaded to denture was removed out. Sprue holes were
record the external surfaces of the denture using made to pour the cold-cure acrylic into the entire
denture space instead of malted wax in order to
polyvinyl siloxane putty. The tray was filled with
make the surgical stent by directly duplicating
a mixture of silicone putty and
pressed until the from the denture.

Duplicated dentures were inserted into the

patient's mouth and fine adjustments were

99
done. The implant guided holes were made in
the duplicate dentures in relation to the desired
locations for implants (Figure 5). Implants
locations were marked on the oral mucosa
through the guided holes in stent by using
undeletable ink (Figure 6).

Figure 5. Copying dentures were used as

surgical stents

119
 Implant Retained Overdenture: Splint Approach Using Copy Dentures

the denture template,the osteotomies were done

on right and left canine and first premolar
implant sites. Four implants (4.1 mm X 10.0
mm) were placed at the osteotomy sites with a
torque of 50 Ncm and covering screw till 4Ncm.
Similarly, two mandibular implants (3.5 mm X
10 mm) in relation to canine regions were placed
(Figure 7).

After 7 days, sutures were removed. Denture

bases were relined for better adaptability. The
Figure 6. Implant locations were marked patient was recalled after 3 months and retentive
through the guided holes attachments (Ball abutments and metal housings
with O-rings) were placed in the denture using
Full thickness crestal incision was placed from self-cure acrylic resin (Figure 8). The patient
first premolar on one side to opposite in maxilla
showed improvement in lip fullness, reduced
and the mucoperiosteal flap was reflected. The
wrinkles and drooping of mouth. Patient was
surgical template was then placed inside the satisfied with the retention, stability and support
patient's mouth and proposed implant site was of the dentures (Figure 9).
marked with a round surgical bur. While keeping

(a) (b)
Figure 7. Implant locations were marked through the guided holes

Figure 8. Immediately after placement of implants in both upper and lower jaws

120
 A.A.A.K. Wimalarathna, R.M. Jayasinghe, A.M. Attygalla

Figure 9. Pre-and post-operative facial profiles

Discussion locate the implant and the positions of the metal

Two-implant-supported over dentures have housing while inserting the denture due to
been recommended as the treatment of choice poor dexterity compared with bar attachment.
for edentulous mandibles since 2002 when the Geriatric patients are more likely to undergo
implants retained overdentures as the procedure
expert committee has conducted the McGill
Consensus Considering the cost-bencefit is simple; improves their overall functions and
eftect, two inter-foraminal implants supported the quality of life0
overdenture is a reliable treatment option and
IS a good choice for the edentulous lower jaw. Literature describes the importance of using
In addition, recommendations have also been surgical stent as an implant placement guide
made with regard to removable restorations plate. There are different practices in different
on four to six implants in maxilla. Recent areas in the world and done according to the
studies have that 5 year survIval rates
reported - individual preferences of clinicians. Both
between 94% and 100%. marginal loss of <0.6 the base-plate and the teeth of the duplicated
mm during a 5-year period and a higher degree denture was fabricated with cold-cure acrylic
of patient satisfaction when implant supported and using it as a implant surgical template has
overdentures are considered". been described rarely in the literature. It was
really beneficial to avoiding the damages to the
Literature does not suppot any attachment flanges, minimizing the over-trimming of the
fitting surtace and preventing the unnecessary
System as superior to others. The choice of the
attachment system depends on the experience perforations of the teeth/polishing surface of
of the clinician and available facilities. A bar the definitive denture while placing the locaters.
attachment can be used for primary splinting Those are the added advantages of preserving
of the implants in order to minimize axial loads the esthetic outcome and physical strength of
on implants especially when the implants are the denture.
short and with low bone quality. The locator

excellent clinical outcomes, Conclusion

systems yield
Splint construction using copy denture approach
to use them in
although it may be dificult
can be recommended as a technique for the
Very elderly patients due to lack of ability to

121
 Dentures
Implant Retained Overdenture: Splint Approach Using Copy

Batenburg RH, Vissink A. Mandibular

placement of implants during implant retained overdentures supported by two or four
over denture fabrication. It is necessary to do
the CBCT bone assessment prior to locating endosseous implants A 5-year prospective
the implant positions on the splints made using study. Clin Oral Impl Res 2005;16:19-25.
duplicated dentures.
Haraldson T, Jemt T, Stälblad PA,
9.
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