The edentulous patient has always pre-sented a unique challenge to therestorative dentist. Depending upon

the quantity/quality of the residual ridge andthe denture bearing area, a patient may ormay not be a successful denture wearer. Withthe addition of osseointregrated implants,even this type of patient can have stabletooth replacements that will function morelike his or her natural dentition by creating afirm attachment of the denture base thatengages the implant or implant-supportedbar yielding a more stable prosthesis.1-3

IMPLANT-SUPPORTED OVERDENTURE:IMPROVING THE PATIENT’S

QUALITY OF LIFEPhase 1—Assessment, Diagnosis,

and Initial TherapyIn this case, the patient (Figures 1 to 3) pre-sented with a maxillary left quadrant fixedbridge that had come out, requesting that itsimply be cemented back into place. Afterclinical and radiographic examinations, itwas determined that the bridge could not berecemented; the patient’s remaining maxil-lary teeth were periodontally compromisedand therefore it was time to think abouttransitioning to some type of completeremovable prosthesis, at least for the maxil-lary arch. It was hoped that the mandibularcuspids could be retained and used in thefinal treatment plan to rebuild the case.

After consultation with a periodontistfor tooth assessment and implant evalua-tion, it was recommended that all remainingmaxillary teeth be extracted. On themandibular arch, the canines still had a goodprognosis both clinically and radiographi-cally. All remaining mandibular teeth had apoor prognosis and it was recommendedthat they be extracted. Phase 1 of treatmentwould involve extraction of the maxillaryteeth and socket grafting by the periodon-tist, along with placement of an immediatetransitional full denture. After about 3months, implant placement would be done.

Due to maxillary sinus limitations and thepatient’s unwillingness to have sinus grafting,4 implants were placed, spacing them in themaxillary central and first bicuspid regions(Figure 4). A treatment denture was deliveredby the surgeon at the time of tooth extractionand relined with soft-tissue conditioner. A soft

reline material (Ufi-Gel SC [VOCO America])in the area of the healing abutments preventstransferring pressure (load) to the implantsand also assists with retention. After aboutanother 4 months (7 months after the extrac-tions), construction of the definitive prosthe-sis was scheduled to begin.

Phase 2—Construction of the Maxillary Prosthesis

The vertical dimension of occlusion was

originally maintained in the immediatedenture by mounting the preoperative castson a semi-adjustable articulator (DenarCombi II Semi Adjustable Articulator[Whip Mix]) using a face-bow transfer andinterocclusal records. The maxillary teethwere then removed from the model and theinterim prosthesis constructed. Using a tra-ditional removable denture technique, thisvertical dimension would be used in the cre-ation of the implant born maxillary pros-thesis. With the maxillary interim denturein place, reference points were placed on thenose and chin of the patient using an indeli-ble pencil. A digital caliper (Dentagauge 1[Erskine Dental]) was used to record the dis-tance between these 2 points as the patientclosed to maximum intercuspation usingthe interim maxillary appliance (Figure 5).

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DENTISTRYTODAY.COM • NOVEMBER 2010

Robert A. Lowe,DDS

CharlesMaragos, CDT

RichardAeziman, CDT

A Team Approach to Implant Reconstruction

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DOCTOR-TECHNICIANPERSPECTIVES

Figure 1. A preoperative retracted view of the patient’soral condition prior to treatment. The periodontal assess-ment and clinical examination revealed a poor prognosisfor a majority of the remaining teeth.

Figure 2. A preoperative maxillary occlusal viewdemonstrated, showing remaining teeth that could notsupport a fixed prosthodontic solution for a good long-term prognosis.

Figure 3. A preoperative view of the mandibular arch.The temporary prosthesis (teeth Nos. 22 to 26) wasremoved. Due to the amount of bone loss and recur-rent decay, Nos. 22 and 27 were the only remainingteeth with a good prognosis.

Figure 4. Due to maxillary sinus positions, 4 implantswere placed between the first premolar regions to sup-port a bar and attachment to secure the maxillary pros-thesis. Sinus lift procedures that would have allowed theimplants to be placed in a more posterior position werenot accepted by the patient.

Figure 5. A measurement was taken with a digital cal-iber of the occlusal vertical dimension (OVD) as itexists with the immediate temporary maxillary denture.The vertical dimension of occlusion (VDO) was estimat-ed in the laboratory from a preoperative mounting ofthe maxillary and mandibular casts prior to removal ofthe teeth on the maxillary cast and the fabrication ofthe immediate maxillary denture.

sendingphoto

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The first clinical challenge in this casewas to create an interocclusal recordwithout the appliance in place at thatsame occlusal vertical dimension(OVD). This would allow the mastermaxillary model for the implant bornprosthesis to be mounted in the samerelative position to the mandibulararch as was the interim maxillary den-ture. A polyvinylsiloxane (PVS) regis-tration putty (Extrude Putty [KerrCorporation]) was mixed in a suffi-cient quantity to cover the maxillaryalveolar process and palate. Thepatient was then instructed to slowlyclose while his mandible was manipu-lated into centric relation position(Figure 6). When the premeasuredposition was reached and verifiedwith the digital caliber, the patientheld his lower jaw in this static posi-tion until the putty was set. Thisrecord allowed the fixture level mas-ter impression to be mounted in thesame position relative to the man -dibular teeth as the intermediate pros-thesis. (The goal is to be in the sameapproximate position as the preopera-tive vertical dimension of occlusion.)This position was then to be verifiedphonetically and corrected as neces-sary at the wax try-in stage.

The fixture level master impres-sion is a combination open- and closed-tray impression. Since the implants inthe central incisor region have 3.5 mmdiameter platforms, open-tray impres-sion copings are the only type avail-able. The stock tray (Tray Away [Bos -worth Dental) was perforated in thearea of the open tray impression cop-ings (Figure 7) to allow easy access toclean off the excess impression materi-al over the retaining screws before theimpression material set. After the mas-ter models were poured-up in the lab,the dental technician constructed aDuralay (Reliance) index to verify inthe mouth that the positions of theimplants on the master model wereindeed accurate and that a passively fit-ting bar could be constructed on themaster model that would precisely fitthe patient’s implants (Figure 8). Thenext step for the dental laboratory teamwas to construct a wax occlusal rim tobe used to take interocclusal records(Figure 9). The position of the midlineand the lip line at the patient’s broadestsmile were marked on the wax rim as areference for the dental technicianwhen placing the maxillary centralincisors in the wax rim. Once interoc-clusal records were completed on thepatient, the wax rim was sent back to

the dental laboratory for placement ofthe maxillary teeth. A wax-up of themandibular anterior teeth on theopposing model will help the dentaltechnician set the maxillary anteriorsegment in harmony with the pro-posed position of the mandibular ante-rior teeth. It will also serve a templatefor the mandibular anterior provision-al restoration (Figure 10).

TREATING THE MANDIBULAR ARCH

At the next clinical appointment, thefocus shifted toward the mandibular

arch where our treatment plan con-sisted of using a combination of poste-rior fixed implant bridges with a con-ventional anterior 6 unit fixed bridge.

The plan was to construct a provi-sional stent from the master diagnos-tic model (Master Diagnostic Wax-up[Valley Dental Arts]) of the mandibu-lar anterior segment.

The mandibular incisors wereextracted and the mandibular cuspidswere prepared as full coverage abut-ments (Figure 11). Figure 12 shows themaxillary wax rim in place after thecompleted provisional restoration wascemented to place. Ovate ponticdesign was used on the provisionalrestoration to guide the healing of thegingival tissues around the extractionsites. In the centric occlusion position,the maxillary anterior teeth and themandibular anterior provisionalrestoration determined the OVD,allowing verification of the spacebetween the arches in the posteriorareas where the remaining toothreplacements would eventually re side.After a few weeks, the tissues hadhealed sufficiently to allow a masterimpression to be taken for fabricationof a mandibular fixed bridge (teethNos. 22 to No. 27) (Figure 13). At thesame appointment, the bar that wasdesigned to help retain the maxillaryoverdenture was tried in to verify apassive fit on the implants (Figure 14).The maxillary overdenture was thenprocessed and the mandibular bridgecompleted by the laboratory. The planwas to deliver the overdenture and tocement the mandibular anteriorbridge prior to beginning the prosthet-ic procedures for the mandibular pos-terior implants. The remaining poste-rior teeth had been extracted, socketsgrafted, and implants had been inte-grating during the try-in process forthe maxillary overdenture (Figures 15and 16). Once delivered, these prosthe-ses would maintain the VDO in theposterior area during the completionof the mandibular reconstruction.

An impression was taken afterdelivery so that an interim mandibu-lar partial denture could be made togive the patient posterior occlusionuntil the mandibular implants wereready for uncovery and restoration(Figure 17). Once fully integrated, amaster impression of the mandibularimplants was made using a closed-traytechnique (Figure 18). The treatmentplan was to construct 2 3-unit fixedimplant bridges to restore the man -dibular posterior teeth. Once the cus-tom abutments were completed, theywere tried in for fit and to verify the

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A Team Approach...

Figure 6. A bite registration putty was usedover the maxillary arch and healing abutments.The patient’s mandible was guided into a posi-tion based on the OVD of the transitional den-ture to approximate that position for fabricationof the wax rim of the implant-born prosthesis.

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Figure 7. After placement of the impressionabutments on the implant platforms, a masterimpression was taken of the maxillary arch.

Figure 8. This photograph illustrates a veryimportant step that is often overlooked…verifica -tion of the accuracy of the master impressionusing a laboratory-fabricated Duralay (Reliance)index.

Figure 9. At the wax-rim stage, the occlusalplane and OVD are evaluated and adjusted asnecessary. Also, the smile line and midline ofthe maxillary central incisors were marked onthe rim with a metal instrument.

Figure 10. The maxillary teeth were placedinto the wax rim to evaluate tooth position andaesthetics. The cuspids were left out of thewax-up so that the wax try-in could be securedto the im plants with screws.

Figure 11. At the mandibular bridge prepara-tion appointment, the mandibular incisors wereremoved after preparation of the cuspid teethas bridge abutments.

Figure 12. The completed mandibular provi-sional bridge. Ovate pontics were made on therestoration that extended into the extractionsites to guide the healing of interproximal tis-sues.

Figure 13. After several weeks of healing, amaster impression was made to fabricate afixed bridge replacing teeth Nos. 22 to 27.

Figure 14. At the bridge delivery appointment,the maxillary bar was tried in to ensure passivefit. Note healing of the ovate pontic sites 23 to26.

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amount of occlusal clearance for therestorations (Figure 19). Since therewas a limited amount of space fromthe top of the implant abutments tothe opposing occlusion in this case, itwas decided to fabricate screw-retained fixed bridgework. The metalunderstructures were tried in as well,and radiographs taken to verify a com-plete seat (Figure 20). Sometimes, thesoft tissues can grow over the implantplatforms and prevent complete seat-ing of the framework and bridge. Insuch cases, a dental laser (soft tissue orall laser tissue) can be safely usedaround the titanium fixtures, unlikeelectrosurgery, to remove the excesstissue. It is also helpful to checkocclusal clearance, with the frame-works in place, to verify the amount ofspace for the placement of porcelain. Ifthere are some areas where the space islimited, it may be necessary to thin themetal substructure (if possible) toallow for the proper thickness ofporcelain.

On the following visit, the mandibu-lar fixed bridges were placed and theimplant screws torqued to 25 Ncm usinga torque wrench. Then, the screw access-es were filled with composite resin(Figure 21). Figure 22 shows a retractedfull-arch view of the completed implantretained reconstruction. The patientwore the maxillary prosthesis success-fully for the next year.

Part 1: Bar Overdenture CaseUsing Bredent Vario Stud

Attachment When Dr. Lowe’s patient came in forhis appointment, he was having trou-ble cleaning and maintaining properoral hygiene with his restorations. Thepatient had existing implants on themaxillary arch—4 fixtures from secondpremolar to second premolar werepositioned evenly for final restoration.A transitional denture was in place.

Concluding that overdentureswere the best way to address the hy -giene issue, Dr. Lowe called RickAeziman at Valley Dental Arts laborato-ry to have a consultation on designoptions. Considering that the patientrequired a flange/peripheral extensionfor adequate lip support, we decided ona fixed removable prosthesis solutionafter discussing a variety of options. Dr.

Lowe had one concern with this solu-tion: in this patient’s case there was acritical lack of vertical height for at -taching the prosthesis. For that reason,after studying the casts and checkingocclusal dimensions, we chose to usethe Bredent Vario Stud AttachmentSystem due to its low profile and excel-lent retentive properties.

Our first step in the laboratorywas to set denture teeth in wax toduplicate the anticipated final resultfor the patient. This would enable Dr.

Lowe to try the presetup in the pa -tient’s mouth to verify overjet, over-bite, phonetics, occlusion, and aes-thetics. A verification jig was also fab-ricated in the laboratory to be used todetermine whether the analogs, aspositioned in the model, correspondcorrectly to the position of the fix-tures clinically.

At the try-in appointment, the doc-tor verified that the model was accuratechairside, using Pattern Resin LS (GCAmerica). Then, the case went back tothe laboratory, where tray adhesiveswere applied to the denture teeth on thelabial and buccal surfaces. The adhesivewas allowed to become tacky. Next, acondensation silicone (Sil-Tech [Ivoclar

Vivadent]) was applied for the matrices. Once the Sil-Tech was set, the

model was placed in a boil-out tank tomelt away the utility wax, leaving theteeth suspended in the matrix. Withthe teeth suspended, we developed acustom-milled bar in ABF-milling wax(Metalor), using the Degussa F1 mil -ling machine. The wax bar was createdwith a 2° taper, to allow adequate reten-tion within the perimeters of the veri-fied denture setup.

Then, allowing for the lack of ver-tical, the Bredent Vario Stud At tach -ments were placed on the lingual sur-face of the bar, using a surveyor (Ney)to position the attachments parallelto each other, and to the bar. Thisprocess helps ensure proper retentionand a precise path of insertion for thefinal prosthesis.

Once the attachments were set inplace, we sectioned the bar in the 5areas between each implant fixture inorder to relieve stress in the wax andresin. With the bar sectioned, thesprues were attached and the bar wasluted with Yeti Bordeaux wax, whichprovided the level of density anddimensional memory (dead wax con-sistency) that was needed. The barwas then placed in the casting ring,using GC Fujivest II as investment.After pouring the investment, thering was put in a BEGO Wiropress SLto cure at 4 bars of atmospheric pres-sure for 10 minutes. Next, the ringwas bench-set the ring for one hour,giving the investment time to fullymature, and for any gases to escape.Next, the ring was burned out in anEWL 5646 (KaVo) furnace, startingwith the furnace cold and heating it to1,652° F (a climb rate of 14.2º F perminute, with a 90-minute hold).

Next, the casting was done using apalladium-based alloy (SUPERIOR Al -loy [Jensen Industries]) that was select-ed because of its high tensile strength.The choice of metals here was especial-ly important to the success of this casebecause of the high occlusal forcesinvolved. The sprues were then sec-tioned off with a separating disk and thecasting was divested using high-pres-sure aluminum oxide sand.

After verifying the fit under a 10-x-20-power microscope, we deter-mined that the bar did not fit passive-ly, a problem we addressed by section-ing the bar in 2 locations. Using a laserwelder (BEGO), we tack welded eachsection, then removed the bar fromthe model and flowed in solder(Special High Fusing White CeramicSolder [Ivoclar Vivadent]), chosen dueto its compatibility with palladium-

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Lab Procedures forthe Implant Retained

Overdenture

Figure 15. The completed mandibular fixedbridge, maxillary denture bar, and implant sup-ported maxillary complete denture with ballattachments in place, as ready for delivery.

Figure 16. The maxillary denture andmandibular fixed bridge in place. A mandibularimpression and centric records were taken atthis time so that a transitional mandibular par-tial denture could be made to provide posteriorocclusion during the next phase of treatment.

Figure 17. The mandibular transitional flexitepartial denture is delivered. The flexite denturewas to be used by the patient during theextraction, socket grafting, and implant integra-tion for the mandibular posterior implants.

Figure 18. After integration of the mandibularposterior implants was completed, a masterimpression was made.

Figure 19. The custom abutments were tried in,and the clearance between the abutments andthe opposing occlusion was assessed for spacerequired for implant born fixed bridges.

Figure 20. An occlusal view of the understruc-tures for the bridges in place on the customabutments.

Figure 21. An occlusal view of the mandibularimplant born fixed bridges in place. Compositeresin was placed in the screw access holes aftertorquing of the screws to the implants.

Figure 22. The completed maxillary implantretained overdenture and mandibular fixedreconstruction. There was a difficulty in match-ing the shade of the denture teeth to theporcelain, even though they were both “A1.”The patient did not have an issue with thisminor discrepancy.

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based alloys. To complete the final milling

process, the Degussa F1 milling ma -chine was employed using eucalyptusoil to disperse the heat and to serve as acutting agent. Polishing steps includedthe use of a Pink High Shine PolishingWheel (Brasseler USA), followed by afelt wheel with tripoli to remove finescratches and blemishes. A final highluster was achieved using rouge on amounted cotton buff.

A 24-carat gold AGC electroform-ing process (Wie land) was next, en -suring a zero-tolerance retentive struc-ture. This 24-carat suprastructure wasprocessed directly over the bar forexceptional fit and retention. In thefinal process, this is attached to the castdenture base by means of tack weldingand a special adhesive.

The laboratory’s cast partial spe-cialists then used the BEGO techniquewith Wironium extra hard alloy tobuild the cast denture base. The mastermodel was placed on the BEGO Sur -veyor to eliminate undesirable under-cuts and to mark the height of contour,allowing the cast base to draw.

To reproduce the refractory mo -del, BEGO Wiroplus S investment wasplaced in the BEGO Wiropress SL at 4bars of atmospheric pressure; thisforces the silicone to exactly duplicatethe blocked out master model. After35 minutes in the chamber, the modelwas separated from the silicone. Thesilicone was given a “rest” for 20 min-utes to allow the material to returnfrom its elongated state to its originaldimensions.

A refractory model was then madeusing BEGO Wiroplus S investmentwhich was mixed under maximum vac-uum for 60 seconds. The investmentwas poured into the silicone mold andplaced in the BEGO Wiropress SL at 4bars of pressure for 20 minutes to com-plete the set. This produced a highlydense and accurate model. The modelwas then separated from the siliconeand placed in a dry-out oven at 250º forabout 20 minutes in order to remove allmoisture (the model turns from gray towhite as it dries).

When the model had cooled, thedesign was transferred from the mas-ter model to the refractory, using a No.2 red pencil. Premanufactured BEGOwax patterns were lightly pressed inplace on the master model.

The wax-up was then ready to besprued, invested, burned out to elimi-nate wax, and cast with Wironiumextra hard chrome cobalt alloy. After

the ring was cool to the touch, the cast-ing was divested and sandblasted with80-grit aluminum oxide. The sprues andbutton were removed and excess flashwas trimmed to fit the duplicated mo -del. Then it was electro-polished in asolution of sulfuric acid, rinsed in water,and dried. Next, it was fit to the mastercast and the bite was checked. Using apolishing wheel (Rubber PolishingWheel [BEGO]), any scratches and blem-ishes were removed. Fi nally, it was buf -fed to a high shine with a BEGO FeltPolishing Wheel and BEGO Rough &Final Polishing Com pound. At thispoint, the case was ready for denturefabrication.

The teeth were reattached to the castmetal denture base using the indexedpolyvinyl matrix with pink utility wax(Henry Schein). When the applied waxreached a solid consistency, the matrixwas removed, and the case was ready forfinal festooning. The prosthesis wasthen sent to Dr. Lowe for a try-in ap -point ment, where he verified form, fit,function, and aesthetics. Approved bydoctor and patient, the case went back tothe laboratory for final processing of theacrylic (SR Ivocap Injection System [Ivo -clar Vi vadent]) to finish the prosthesis.

Part 2: Fixed Implant RetainedMandibular Partial Dentures

Dr. Lowe took a mandibular archimpression fixture level impressionand sent it to the laboratory along withan impression of the maxillary over-denture and a PVS centric occlusionrecord. The impression was poured anda screw-retained bite rim was fabricat-ed, as well as a GC Pattern Resin jig.Implants were placed in the followingpositions: Nos. 20, 21, 28, and 30. Thecase was returned to Dr. Lowe, wherehe took a jaw relation and the modelwas re-verified utilizing the GC PatternResin jig. The case was then returned tothe laboratory for fabrication of theframeworks as follows: Nos. 22 to 27conventional bridgework and Nos. 19to 21 and Nos. 28 to 30 implant bridge-work. The frameworks were verifiedclinically, and lastly the ceramic wasapplied for final insertion and delivery.

After about one year, the patientnoticed that the maxillary denturewas not as retentive as when it wasfirst placed. In fact, he had been usingadhesive to help retain the prosthesis.The ball attachments were replacedwith the most retentive type availableto see if the retention of the prosthesiswould improve. The patient reportedthat the denture would feel “loose”after a few weeks, but he could toler-ate the retentive quality for a fewmonths at a time. We continued to

swap out the attachments, until it wasdecided that there would be a changein attachment type to see if the reten-tive quality could be improved.

Part 3: Changing the Attachmentto Locators

The patient wore the prosthesis forapproximately one year. During thattime, the nylon female componentbegan acquiring plaque, and the Bre -dent balls were showing wear from theinsertion and removal process. Theobvious solution was to change thefemale component for the most reten-tive one available. How ever, the plaquebuildup continued, as did the wear onthe ball attachments. Consulting withValley Dental Arts, Dr. Lowe and hislaboratory team determined that a dif-ferent attachment system was theanswer. So, he asked for an interimdenture to be made for the patient touse while the new attachments werebeing positioned on the primary bar.

To make the interim denture, animpression of the patient’s currentprosthesis was taken, capturing thesoft-tissue landmarks as we wouldwith a reline (Figures 23 and 24). (Inaddition, a new bite registration wastaken.) With this new impression, athick-based model was poured andallowed to set. Then the model’s basewas trimmed and several index pointswere created (Figures 25 and 26).

Before removing the denture, thedoctor fabricated a Sil-Tech puttymatrix over the prosthesis, engagingthe index points beyond the normaltissue borders. Dr. Lowe removed theputty matrix from the model, articu-lated the cast, and set the VDO. Hethen returned the model to the labo-ratory, where a temporary denturewas fabricated for the patient.

Meanwhile, Dr. Lowe decided toreplace the ball attachments with aLocator Attachment (Zest Anchors). (Analternative solution could have been touse one of the new replaceable threadedball attachments from XPdent.) Theadvantage of the locator style for thispatient was that it provides a greateramount of contact between the maleand female components improvingretention. Furthermore, the attach-ments are self-aligning thus minimize.

To make this change, the laborato-ry team sectioned off the ball attach-ments from the bar, repolished theseareas, and tapped and threaded thelocator attachments on the top surfaceof the bar in tripod fashion (Figures 27and 28). The prosthesis was then re -turned to Dr. Lowe, where he luted inthe female component using the direct

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Figure 23. To allow the dental laboratory team tofabricate a temporary maxillary prosthesis for thepatient to wear while the attachments on the barwere changed, an impression of the patient’smaxillary denture bearing area was needed, with-out the bar in place in the existing appliance.

Figure 24. An intaglio view of the maxillarydenture after a master impression was madeinside of it.

Figure 25. The impression was poured up inyellow stone on a base. Once the stone wasset, the denture was removed and the basetrimmed. Notches were made around the basefor indexing purposes.

Figure 26. A PVS putty was used to make an im -pression of the maxillary denture in place on themodel, making sure there was enough material toindex the putty accurately to the stone base. Thisputty impression allowed the laboratory team tomake a duplicate denture for the patient to wearwhile the attachments were changed.

Figure 27. The maxillary denture as altered inorder to place Locator attachments (ZestAnchors) that will fit to the altered titanium bar.

6

technique (Figure 29).

COMPLETION OF THE MAXILLARYPROSTHESIS: SECOND DELIVERY

With the prosthesis successfully tran-

sitioned to Locator attachments, thepatient had enjoyed improved reten-tion to his maxillary appliance (Fig -ure 30). We still do not know why thesuccess with the previous system wasless than adequate. It is assumed that,because of the sinus issues and theinability to place implants in a moreposterior position, this contributed tothe accelerated wear on the attach-ments as well as the plaque retentionwear on the attachments (as notedalso by the laboratory team). TheLocator solution afforded a moreretentive attachment in this case andthe patient was able to have a transi-tional appliance placed that per-formed adequately during the attach-ment replacement process.4-10

AcknowledgementDr. Lowe would like to thank Mr.

Chuck Maragos, CDT, and Mr. RickAeziman, CDT, from Valley DentalArts in Stillwater, Minn, for theirexpert laboratory workmanship andliterary contributions to this article.

References1. van der Bilt A, Burgers M, van Kampen FM, et al.

Mandibular implant-supported overdentures andoral function. Clin Oral Implants Res. 2010 Jun 21[Epub ahead of print].

2. Rismanchian M, Dakhilalian M, Bajoghli F, et al.Implant-retained mandibular bar-supported overlaydentures: a finite element stress analysis of fourdifferent bar heights. J Oral Implantol. 2010 Jun 14[Epub ahead of print].

3. Turkyilmaz I, Tözüm TF, Tumer C. Early versusdelayed loading of mandibular implant-supportedoverdentures: 5-year results. Clin Implant DentRelat Res. 2010;12(suppl 1):e39-e46.

4. Andreiotelli M, Att W, Strub JR. Prosthodontic com-plications with implant overdentures: a systematicliterature review. Int J Prosthodont. 2010;23:195-203.

5. Cehreli MC, Karasoy D, Kökat AM, et al. A system-atic review of marginal bone loss around implantsretaining or supporting overdentures. Int J OralMaxillofac Implants. 2010;25:266-277.

6. Akca K, Cehreli MC, Uysal S. Marginal bone lossand prosthetic maintenance of bar-retainedimplant-supported overdentures: a prospectivestudy. Int J Oral Maxillofac Implants. 2010;25:137-145.

7. Slot W, Raghoebar GM, Vissink A, et al. A systematicreview of implant-supported maxillary overdenturesafter a mean observation period of at least 1 year. JClin Periodontol. 2010;37:98-110.

8. Fromentin O, Lassauzay C, Abi Nader S, et al.Testing the retention of attachments for implantoverdentures—validation of an original force meas-urement system. J Oral Rehabil. 2010;37:54-62.

9. Ellis JS, Burawi G, Walls A, et al. Patient satisfactionwith two designs of implant supported removableoverdentures; ball attachment and magnets. ClinOral Implants Res. 2009;20:1293-1298.

10. Visser A, Raghoebar GM, Meijer HJ, et al. Implant-retained maxillary overdentures on milled barsuprastructures: a 10-year follow-up of surgicaland prosthetic care and aftercare. Int JProsthodont. 2009;22:181-192.

Dr. Lowe graduated magna cum laude fromLoyola University School of Dentistry in 1982 andserved there as an assistant professor in opera-tive dentistry until its closure in 1993. Since Jan -uary 2000, he has been in private practice inCharlotte, NC. Dr. Lowe received Fellowships in theAcademy of General Dentistry, International Col -lege of Dentists, Academy of Dentistry Inter na -tional, and American College of Dentists, and is aDiplomate of the American Board of AestheticDentistry. He lectures internationally and publish-es on aesthetic and restorative dentistry and is aclinical evaluator of materials and products. Healso received the 2004 Gordon Christensen Out -standing Lecturers Award. He can be reached at(704) 364-4711 or at boblowedds@aol.com.

Disclosure: Dr. Lowe [DR. LOWE, Please sub-mit signed copyright and disclosure forms]

Mr. Maragos received his associate degree in den-tal technology from Milwaukee Technical College in1971. He is a member of the Oral Design Grouplead by Willi Geller. He is also one of 3 privilegeddental artisans (technicians) to be accredited bythe American Society for Dental Aesthetics. Mr.Maragos is chief executive officer of Valley DentalArts and Valley Dental Tech nologies and chairmanof the Amara In sti tute. He has re ceived numerousinnovation awards and has published various arti-cles on aesthetics, implant dentistry, and co-auth -ored the book Aesthetic and Restorative Dentistry:Material Selection and Tech nique. He also lecturesinternationally on the profitability of aesthetic den-tal materials. He is an active consultant and prod-uct evaluator to dental manufacturers in the areaof research and development. He can be reachedat chuckm@valleydentalarts.com.

Disclosure: Mr. Maragos reports no conflicts of

interest.

Mr. Aeziman is vice president of Valley DentalArts. He oversees case planning, design, andestimates for the implant restorative cases bothfixed and removable. He earned his associate’sdegree in dental technology from NortheastMetro Tech, and he passed his Certified DentalTechnology exam in 1988. Mr. Aeziman mentorstechnicians and lectures to doctors on implanttechniques, design, and protocol on simple andadvances restorative cases. He can be reachedat rick@valleydentalarts.com.

Disclosure: Dr. Aeziman reports no conflicts ofinterest.

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Figure 29. The Locator attachments in themaxillary denture base.

Figure 30. The completed reconstruction. Theattachments were changed using the originalbar with the patient using a duplicate prosthe-sis made from his original denture. This madethe transition easy for the patient, with nochange in aesthetics or occlusion.

Figure 28. The bar with the Locator attach-ments placed.