clinical reports implant overdenture using the locator
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Received: November 21, 2016
Revised: December 2, 2016
Accepted: December 2, 2016
Copyright © 2016. The Korean Academy of Oral & Maxillofacial Implantology
This is an Open Access article distributed under the terms of the Creative Commons Attrib-
ution Non-Commercial License (http://creative-commons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
pISSN : 1229-5418
Implantology 2016; 20(4): 208-219
https://doi.org/10.32542/implantology.20160019
eISSN : 0000-0000
OPEN ACCESS
The Korean Academy of Oral & Maxillofacial Implantology Vol. 20, No. 4, 2016208
Clinical Reports
Implant Overdenture using the Locator System
and the Gothic Arch Tracer in a Mandibular
Edentulous Patient: A Clinical Report
Seoung-Jin Hong1, Seung-Ryong Ha1*, Dong-Jae Seong1, Hyeon-Min Kim2, Jae-Hyuk Ban3,
Hyun-Woo Kim4
1Department of Dentistry, Ajou University School of Medicine, Suwon, Korea2Department of Oral and Maxillofacial Surgery, Gil Medical Center, Gachon University, Incheon, Korea3Department of Oral and Maxillofacial Surgery, BK Dental Hospital, Cheongju, Korea4Director of Yongin Seoul Dental Clinic, Yongin, Korea
*Corresponding author: Seung-Ryong Ha, dragon_001@hanmail.net
Abstract
Patients restored with the mandibular complete denture were often faced with complications of
poor stability and retention of the prosthesis. Two implants overdenture is recognized as a
standard treatment method for the edentulous mandible. In a 64-year-old man who represented
severe mobility in all remaining teeth, the maxillary complete denture and the mandibular
implant-retained overdenture were planned after extracting all the remaining teeth. Two
implants were placed in mandibular both canine regions. To fabricate the denture, final
impression was taken using a duplicate of the existing temporary denture. It is difficult to guide
the mandible into the centric relation position in some denture patients. The Gothic arch tracer
was used for accurate centric relation record. For conjunction with dental implants, locator
attachments were used.
Keywords: Denture precision attachment, Gothic arch tracer, Implant overdenture
I. Introduction
Patients wearing complete dentures are frequently suffered from problems of poor
retention and instability of the denture, low chewing efficiency, and pain during
mastication. Several clinical reports have described that these complications may be
successfully improved by implant-retained or implant-supported dental prostheses1-3.
According to McGill consensus statement4, two implants overdenture is recognized as
the standard treatment of edentulous mandible and the evidence exists. Many studies
have demonstrated that implant-retained overdenture in mandible provides improvement
in retention, stability, chewing efficiency, biting force, quality of life, and patient
satisfaction5-7. Because of the smaller prosthesis space requirement, ease of cleansing,
The Korean Academy of Oral & Maxillofacial Implantology Vol. 20, No. 4, 2016 209
IMPLANTOLOGY
lower technical sensitivity, and more economical advantages, solitary type have been preferred to
bar type attachments8,9. Compared to other solitary type attachments, locators are required smaller
space10, dual retention structure (the outer and inner contact surfaces between female and male
parts)11 and higher retention force12. Additionally, locators are self-aligning12, compensation for up
to 40° implants axial discrepancy is possible11 and could be easily repaired and replaced13.
It is not easy to induce the mandible into the centric relation position for some denture patients
resulted from the wrong habitual closure due to inadequate dentures14, trismus15, or temporomandibular
joint abnormalities16-19. Several methods of manipulating centric relation have been demonstrated in
the literature20. The Gothic arch tracing is the one of those methods. It is reported that it could
produce a precise and reproducible centric relation record21-23. This study demonstrates the
application of a Gothic arch tracer and locator attachments for fabrication of the maxillary complete
denture and the mandibular implant-retained overdenture.
II. Case report
A 64-year-old healthy man visited the Ajou University Dental Hospital for treatment of his
maxillary complete denture and mandibular removable partial denture. All the remaining teeth had
severe mobility (Fig. 1). After extracting of all the remaining teeth, maxillary complete denture and
mandibular implant-retained overdenture were planned. There was no problem of medical history
for implant placement.
Fig. 1. Intraoral photo taken at first visit.
Seoung-Jin Hong et al. : Implant Overdenture using the Locator System and the Gothic Arch Tracer in a Mandibular Edentulous Patient: A
Clinical Report. Implantology 2016
The Korean Academy of Oral & Maxillofacial Implantology Vol. 20, No. 4, 2016210
Clinical Reports
An impression was taken using alginate impression materials (Aroma Fine Plus Normal set, GC,
Japan) for the fabrication of an immediate temporary denture. The record base and occlusion rim was
produced, contoured for phonetics, esthetics, and determined vertical dimension of occlusion. The
Gothic arch tracer (Gnathometer M type 2, Ivoclar Vivadent, Germany) was attached to the record
base and occlusion rim so that the central bearing pin was located in the center of the tracing plate.
The pin was adjusted for lightly touched on the plate. Wax of occlusal rim was removed until the
central bearing point was the only contact between the mandibular and maxillary record bases.
Record bases were placed intraorally and instruction of mandibular movements to the patient was
necessary to record a Gothic arch tracing. After the patient has described a well-defined Gothic arch,
a dimple was made in the recorded plate at the apex of the arrow for maintenance in centric relation
during a record was being made. In this way, the interocclusal record of centric relation was obtained
using the Gothic arch tracer. A temporary denture was prepared and the remained teeth were
extracted and followed by the immediate placement of the internal submerged type implants on #33
(4.0 mm × 11.5 mm; AR System, Biotem, Seongnam, Korea) and #43 (4.0 mm × 10.0 mm; AR System,
Biotem, Seongnam, Korea). Two mandibular implants in both canine regions were surgically placed
following the manufacturer’s protocol, and final implant insertion torques, greater than 30 Ncm were
achieved (Fig. 2, 3). A healing abutment, measuring 4.5 mm in diameter with 5 mm in height
(HAA455S, Biotem, Seongnam, Korea) on #33 and 4.5 mm in diameter with 7 mm in height
(HAA457S, Biotem, Seongnam, Korea) on #43, was tightened onto the implant. The temporary
denture was relined by a tissue conditioner (Visco-gel, Dentsply, Germany) and placed.
Fig. 2. Placement of implant fixtures (AR system, Biotem, Seongnam, Korea).
Seoung-Jin Hong et al. : Implant Overdenture using the Locator System and the Gothic Arch Tracer in a Mandibular Edentulous Patient: A
Clinical Report. Implantology 2016
The Korean Academy of Oral & Maxillofacial Implantology Vol. 20, No. 4, 2016 211
IMPLANTOLOGY
Fig. 3. Panoramic view after placement of implant fixtures.
Seoung-Jin Hong et al. : Implant Overdenture using the Locator System and the Gothic Arch Tracer in a Mandibular Edentulous Patient: A
Clinical Report. Implantology 2016
Fig. 4. Upper and lower temporary dentures were duplicated with acrylic resin to use as a custom tray.
Seoung-Jin Hong et al. : Implant Overdenture using the Locator System and the Gothic Arch Tracer in a Mandibular Edentulous Patient: A
Clinical Report. Implantology 2016
Fig. 5. The interocclusal record of centric relation was checked using the Gothic arch tracer with the vinyl polysiloxane bite registration material and the horizontal incisal line was marked using bonding brush.
Seoung-Jin Hong et al. : Implant Overdenture using the Locator System and the Gothic Arch Tracer in a Mandibular Edentulous Patient: A
Clinical Report. Implantology 2016
The Korean Academy of Oral & Maxillofacial Implantology Vol. 20, No. 4, 2016212
Clinical Reports
3 months after implant placement, a new set of temporary dentures for custom tray was duplicated
to precisely represent definitive prosthesis occlusion. The maxillary and mandibular temporary
denture was duplicated in acrylic resin (Orthodontic Resin, Dentsply, USA) (Fig. 4). Final
impressions were taken with the polyether impression material (Monophase, 3M ESPE, Germany)
after border molding with modeling plastic impression compound (Peri Compound, GC, Japan)
using a custom tray duplicated of the temporary denture. Wash impressions were taken by closed
mouth functional impression technique. In this case, temporary denture was duplicated as a custom
tray, for appropriate horizontal relation and vertical dimensions, jaw relations were recorded. The
patient was asked various functional movements of closed mouth such as Gothic arch tracing in the
pre-recorded vertical dimension. Functional movements were depicted by the patients. The interocclusal
record of centric relation was checked using the Gothic arch tracer with the vinyl polysiloxane bite
registration material (Futar D, Roydent, USA) and the horizontal incisal line was marked using
bonding brush (Dental Lab Disposable Micro applicators Brushes, Dental supply in, China) (Fig. 5).
The stone cast was mounted in a semi-adjustable articulator (Stratos® 300, Ivoclar Vivadent,
Germany) (Fig. 6). Acrylic artificial teeth (SR Vivodent, Ivoclar Vivadent, Germany) were set on the
semi-adjustable articulator. For ideal tooth set-up with a dorsal increase of the occlusal plane in
models according to the Spee and Wilson curves into account, a setting-up template was used (Fig. 7).
Wax dentures try-in were done in the mouth. Fit, esthetics, retention, stability and support were
evaluated finally. For the improvement of retention, the relining impression of the maxillary complete
denture was made with the polyether impression material (Monophase, 3M ESPE, Germany) and the
Fig. 6. Master model fabricated.
Seoung-Jin Hong et al. : Implant Overdenture using the Locator System and the Gothic Arch Tracer in a Mandibular Edentulous Patient: A
Clinical Report. Implantology 2016
The Korean Academy of Oral & Maxillofacial Implantology Vol. 20, No. 4, 2016 213
IMPLANTOLOGY
closed-mouth technique with an occlusal inter-digitation using the maxillary wax-denture (Fig. 8).
The midline was corrected. The setting of acrylic artificial teeth was also corrected. Final
prostheses were fabricated by the heat curing system. Curing definitive denture and laboratory
remounting was performed, but was not grinded because of balanced occlusion (Fig. 9-11).
Fig. 7. Ideal tooth set-up with a dorsal increase of the occlusal plane in models according to the Spee and Wilson curves.
Seoung-Jin Hong et al. : Implant Overdenture using the Locator System and the Gothic Arch Tracer in a Mandibular Edentulous Patient: A
Clinical Report. Implantology 2016
Fig. 8. Relining impression of the maxillary complete wax denture with the polyether impression material (closed-mouth technique with an occlusal interdigitation).
Seoung-Jin Hong et al. : Implant Overdenture using the Locator System and the Gothic Arch Tracer in a Mandibular Edentulous Patient: A
Clinical Report. Implantology 2016
The Korean Academy of Oral & Maxillofacial Implantology Vol. 20, No. 4, 2016214
Clinical Reports
Fig. 9. Definitive dentures.
Seoung-Jin Hong et al. : Implant Overdenture using the Locator System and the Gothic Arch Tracer in a Mandibular Edentulous Patient: A
Clinical Report. Implantology 2016
Fig. 10. Intaglio surface of upper denture.
Seoung-Jin Hong et al. : Implant Overdenture using the Locator System and the Gothic Arch Tracer in a Mandibular Edentulous Patient: A
Clinical Report. Implantology 2016
Fig. 11. Intaglio surface of lower denture.
Seoung-Jin Hong et al. : Implant Overdenture using the Locator System and the Gothic Arch Tracer in a Mandibular Edentulous Patient: A
Clinical Report. Implantology 2016
The Korean Academy of Oral & Maxillofacial Implantology Vol. 20, No. 4, 2016 215
IMPLANTOLOGY
The definitive denture was delivered in patient oral cavity. The retention, stability, and esthetic was
evaluated and denture was shown to be properly fabricated (Fig. 12, 13). The healing abutments were
taken off and hand-tightened in a clockwise direction. Mobility, clinical signs of infection, pain and
radiographic bone loss were not shown, and the implants were convinced to be osseointegrated.
Abutments of 4 mm cuff height on #33 (HG Locator® Abutment; Standard, Zest Anchors, USA) and 5 mm
on #43 were tightened to 30 Ncm on both implants. The blue male part (Liner, Zest Anchors, USA) of the
locator was then incorporated into the overdenture with a direct technique using an auto-polymerizing
pattern resin (Pattern Resin LS, GC, America). The overdenture was polished and then inserted in the
mouth, and minimal adjustments were taken to the occlusion and fit. The patient was instructed prosthetic
maintenance and oral hygiene. At a 1-year follow-up after treatment, the patient remained satisfied with
his treatment choice and its effect on his masticatory efficiency and quality of life.
Fig. 12. The definitive denture was placed in the oral cavity.
Seoung-Jin Hong et al. : Implant Overdenture using the Locator System and the Gothic Arch Tracer in a Mandibular Edentulous Patient: A
Clinical Report. Implantology 2016
Fig. 13. Extra-oral view of lip support. Before (left) and after (right) treatment.
Seoung-Jin Hong et al. : Implant Overdenture using the Locator System and the Gothic Arch Tracer in a Mandibular Edentulous Patient: A
Clinical Report. Implantology 2016
The Korean Academy of Oral & Maxillofacial Implantology Vol. 20, No. 4, 2016216
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III. Discussion
Implant overdenture treatment can provide the appropriate support, retention and stability of the
denture, and restored functions and esthetic such as lip support and phonation via a denture flange24.
When planning a bar attachment, the inter-arch distance has to be evaluated. Pasciuta et al.25
described that minimum 14 mm inter-arch distance was required when considering artificial teeth,
denture base, bar thickness, and the hygienic space from the bar to the mucosa. When the inter-arch
distance is insufficient, the bar attachment may resulted in over-contour of the denture, fracture of
the denture, or poor oral hygiene10. When bar splinting attachments is considered for retention, the
resilient type ERA attachments, and different direction multiple clips, the rigid type friction pin, and
swivel latchet have been used previously8. Retention loss is the problem in such attachment caused
by wearing during the repeated removal and insertion of the denture26. In that case, plastic male
parts may be changed. However, metal female parts are required to re-manufacture. To avoid this
situation, the locator attachment system can be selected. It allows 0.2 mm vertical movement and
durable. The locator is easy to use and post-treatment complications are less. Special technical
training is not required. The reported satisfaction of the patient is quite high27. In the majority of the
attachment systems, reduction28 or total loss in retentive force was found9. The wear patterns and
related deformations of attachment during the mastication are different from during insertion-removal
procedure. Denture rotation around the attachments resulted from displacing mucosa under the base
of the denture when occlusal loads are applied29. The resiliency of attachments is determined by the
amount of transmitted loads to the attachments from occlusal loads30,31. For reducing the denture
movement and, thereby, also reducing the forces on the implants, an optimal stress distribution is
important32. The locator retentive force is decreased down to 40% of its full retentive values when
simulated mastication with a non-linear descending curve. The nylon parts were severely worn33.
This represents maintenance correlated with mastication is needed for locator system33.
For the successful restoration in edentulous patients, the appropriate centric relation record is
required. The wear and the deformation of attachment can be reduced by accurate centric relation.
The retentive force is also maintained for a long time, relatively. A precise centric relation record can
be obtained using the Gothic arch tracer. In addition, for the accuracy of the Gothic arch tracer
record, stable record bases are prerequisite. Especially in the Gothic arch tracing technique,
inaccuracy could be resulted from any movement of the record bases during recording of centric
relation. The closed mouth functional impression technique was used and interocclusal record of
The Korean Academy of Oral & Maxillofacial Implantology Vol. 20, No. 4, 2016 217
IMPLANTOLOGY
centric relation was checked using Gothic arch tracer simultaneously, contribute to stabilize bases,
and thereby minimize movement of bases during the tracing and mounting procedures.
IV. Conclusion
This clinical report describes complete denture in the maxilla and the implant overdenture using
the locator system in the mandible for edentulous patient. For accurate centric relation record, the
interocclusal record was obtained using the Gothic arch tracer.
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