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Continuing Education

Treating a Failing Dentition: Stable Implant-SupportedRemovable Restorations

Authored by Joseph J. Massad, DDS; Swati Ahuja, BDS, MDS; andMahesh Verma, BDS, MDS, MBA, PhD (HC)

Upon successful completion of this CE activity 2 CE credit hours will be awarded

Volume 33 No. 1 34

ABOUT THE AUTHORSDr. Massad is an associate professor inthe department of graduate prosthodonticsat Uni versity of Tennessee Health ScienceCenter, Memphis, Tenn; an associateFaculty at Tufts University School of DentalMedicine, Boston, Mass; an ad junct

associate faculty of the de partment of comprehensivedentistry, the University of Texas Health Science Center Den -tal School, San Antonio, Tex, and adjunct professor indepartment of restorative dentistry at Loma Linda University,Loma Linda, Calif. He has a private practice in Tulsa, Okla. Hecan be reached at [email protected].

Disclosure: Dr. Massad consults/has consulted for andreceives/has received sponsorship from many companies,including the following: DENTSPLY, Nobilium, Sterngold Products,Zimmer Dental, and others not mentioned in this article.

Dr. Ahuja is an adjunct assistantprofessor in the department ofprosthodontics at Uni versity of TennesseeHealth Science Center, Mem phis. She is aprosthodontic consultant for Lu theranMedical Center, NY. She is also a

consultant for 2 private dental clinics in Mumbai, India. Shehas published 16 articles in peer-reviewed journals including2 book chapters. She is an editorial board member for Inter -na tional Journal of Ex perimental Dental Sci en ces andreviewer for many journals. She has been invited to presentlectures internationally. Her topics of in terest are implantoverdentures, hy brid res torations, restorative space inimplant over dentures, and cone beam computed to mo graphyin dental practice. She can be reached at [email protected].

Disclosure: Dr. Ahuja reports no disclosures.

Dr. Verma received his BDS and MDS fromGov ernment Dental College, Trivandrum,Kerala and received his MBA (Healthcare)from Faculty of Management Studies,University of Delhi. He is a Fellow of theInternational College of Den tists, American

College of Dentists, American Acad emy of Implant Dentistry(AAID), National Acad emy of Medical Sciences, InternationalMe dical Sciences Academy, Royal College of Surgeons ofEngland, Royal College of Phy sicians and Sur geons ofGlasgow, Royal College of Surgeons, Faculty of GeneralDentistry Prac tice (England), and the Royal College of Sur -geons of Edinburgh. A visiting clinical professor of the Schoolof Dental Medicine, Tufts Uni versity (Boston) and theTamilnadu MGR Med ical University (Chen nai), Dr. Verma isalso the clinical director of the Maxicourse India for the AAID.He is president of the Indian Academy of Res torative Dentistry,president-elect for the Indian Dental Asso ciation, and vicepresident of the Dental Council of India and the Indian So cietyfor Dental Re search. Dr. Verma is chairperson of the Re searchCommittee for Dental Sci ences at Indian Council of MedicalRe search. He can be reached at [email protected].

Disclosure: Dr. Verma reports no disclosures.

INTRODUCTIONThe treatment options available for a pa tient with nonrestorabledentition are conventional complete dentures, implant-supported overdentures (removable), fixed implant-supportedcomplete dentures, and fixed metal-ceramic implant-supported res torations.1,2 Most restorative dentists be lievethat the treatment of choice for the edentulous patient is afixed-implant prosthesis.2-4 The decision process to restore apa tient with fixed or removable restorations should not bebased on the preference of the dentist or the patient; rather, itshould be determined by evaluating various parameters suchas quality and quantity of hard and soft tissues, oral hygiene,the maxilla-mandibular relationship, lip-line, lip support, andfinances.1,3 In order to get a satisfactory treatment outcome,fixed-implant restorations should be indicated only in patientswith minimal resorption of hard and soft tissues and an optimalmaxillomandibular relationship.4 On the other hand, removableimplant restorations should not only be recommended in pa -


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Treating a Failing Dentition:Stable Implant-SupportedRemovable RestorationsEffective Date: 1/1/2014 Expiration Date: 1/1/2017

tients in whom fixed restorations are con tra in di cated.4-6 Ifdesigned properly, removable im plant restorations are stable,retentive, and resistant to fracture.7-9 They provide excellentphonetics10 and esthetics (es pecially in pa tients with highsmile-lines), and can also help improve the lip support.3

Removable implant restorations are less complicated andeasier to clean than fixed implant restorations.3,11,12 Inaddition, it is easier and less ex pensive to maintain removableimplant res torations13 as opposed to fixed implant res -torations.14-17 Several studies have proven that patients havesimilar to higher satisfaction with implant-supported removablerestorations.9,17,18

For any implant restoration to be successful, it is critical toplan and place implants accurately.3,19 The restorative dentistshould decide the type and the design of the definitiveprosthesis before implant placement, and plan the implantsbased on the design of the final prosthesis. This can be mostpredictably achieved through 3-dimensional (3-D) guidedplanning and 3-D guided im plant surgery.20-22 Combining theCAD/CAM technique, digital implant planning can be ap pliedto clinical practice using 3-D surgical guides.23-25 Thesetechniques help with visualization of bone and the prosthesisat the same time.26 This has helped change the osseous-driven approach to a combination of osseous- and prosthetic-driven approach for implant placement.24,26 Since implantsare placed in a near-to-ideal position, the surgery andprovisionalization can be done predictably in a relatively shorttime.27,28

Another factor that must be evaluated prior to implantplacement is the available restorative and esthetic space.29-31

A reported minimum space requirement for im plant-supportedoverdenture with LOCATOR (ZEST Anchors) attachments is8.5 mm of vertical space and 9.0 mm of horizontal space.32 Aseparate report on maxillary implant overdentures suggestedthat a minimum of 13.0 mm to 14.0 mm of vertical space wasrequired for bar-supported overdentures; and 10 mm to 12 mmfor individual attachment-supported overden tures.32,33

Misch34 and Pasciuta et al35 have reported that a minimum of12.0 mm of vertical restorative space (crest of bone to occlusalplane) is necessary to accomplish a mandibular implant-assisted overdenture. Attempts to fabricate prostheses in thepresence of inadequate restorative space may lead tophysiologically inappropriate contours, structurally weak

prostheses, esthetic compromise, encroachment into freewayspace, and/or suboptimal retention and stability of thetreatment result.36,37 If the restorative space is inadequate,clinical procedures de signed to improve vertical space


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Treating a Failing Dentition: Stable Implant-Supported Removable Restorations

Figure 1.Panoramicradiographic view ofthe patientdemonstrating thefailing dentition.

Figures 2a and 2b.Intraoral frontal viewof the patient (a).Intraoral occlusalview of the patient(b).

a

b

availability can be utilized. These includealveoloplasty,32,38 intentional increase ofvertical dimension of occlusion (VDO),38

occlusal plane re positioning, and managementof overdenture attachment selection. Theseprocedures should be implemented prior toimplant placement, when treatment options arebeing considered.29,30,36,37

This article describes the diagnosis andtreatment of a patient with a failing dentitionwith a collapsed VDO. It will outline how thepatient was optimally restored with transitionalimplant-supported removable restorations onthe day of the surgery.

CASE REPORTDiagnosis and Treatment Planning A 42-year-old white male patient presented tothe authors’ practice with the chief complaint ofnot being able to eat his food and having a poorself-image due to his appearance. The patientwas a recovering drug and alcohol addict with 5years of sobriety. The patient had financialconstraints; how ever, he was concerned aboutbe coming edentulous and refused to go withoutteeth at any point.

The oral examination revealed that he hadseveral missing teeth and a majority of theremaining teeth had a loss of periodontalattachment (Fig ure 1) with generalized andchronic periodontitis. Teeth Nos. 7, 15, 29, and30 were fractured at the cervical level due to extensive decay.Teeth Nos. 7, 11, 12, 15, 18, 29, and 30 had periapical cystsassociated with them (Fig ures 1 to 2b).

Preliminary impressions (Aquasil [DENTSPLY Caulk]) weretaken and poured. Then, these diagnostic study models weremounted on an articulator (2240 Articulator [Whip Mix]) toevaluate the occlusion and the available restorative/estheticspace. The patient had a collapsed VDO with insufficientrestorative and esthetic space in both the arches. In addition,the patient demonstrated poor oral hygiene.

A 3-D cone beam computed to mography (CBCT) scan(CS 9300 [Care stream Dental]) was taken to verify the

clinical findings and to plan the optimal treatment. After athorough diagnostic work-up, all the remaining teeth weredeemed nonrestorable, so the treatment would consist ofextraction of the remaining dentition and rehabilitation withremovable im plant restorations. Pro cedures to in crease therestorative space would have to be employed to fabricate afunctional, esthetic, and structurally resistant prosthesis forthe patient. The restorative space needed for the maxillaryarch would be achieved by increasing the VDO. In addition,alveoloplasty was indicated for the man dibular arch(spanning from first bicuspid to first bicuspid region) to gainthe needed restorative space.


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Figures 3a and 3b. Maxillary final impression (a). Mandibular final impression (b).

a b

Figures 4a to 4d. Intraoral gothic arch tracing assembly: Striking plate was attached to themaxillary record base (a). Maxillary record base with the striking plate placed on themaxillary cast (b).Vertical pin was attached to the mandibular record base (c). Mandibularrecord base with the attached vertical pin placed on the mandibular cast (d).

a b

c d

Striking PlateAttached to Resin Base

Vertical Pin Set in Swivel

A synopsis of the final treatment plan of thepatient was as follows: fabrication of animmediate complete dentures at the optimalVDO; extraction of the remaining teeth; 3-Dguided alveoloplasty in the mandibular arch; 3-D guided implant surgery in the maxilla andthe mandible; placement of 2 small-diameterim plants (ERA Mini Dental Implants[Sterngold]) in the mandible to retain the transi-tional restoration; delivery of the transitionalrestoration at the same appointment; and,finally, the delivery of the definitive prosthesisafter healing of implants.

Phase I: Fabrication of Immediate DenturesMaxillary and mandibular definitive masterimpressions were made with vinylpolysiloxane (VPS) material (Aquasil) instock trays (Figures 3a and 3b). Masterimpressions were poured in type III stone(Microstone [Whip Mix]) to generate mastercasts. Triad Record Bases (DENTSPLYProsthetics) and wax rims were fabricated forthe maxillary and mandibular cast to take thejaw relation records. Since the patient had acollapsed bite, the VDO would have to be re-established for the patient withinphysiological limits. This would help gainrestorative space and improve the estheticsand function for the patient.

Vertical dimension of occlusion wasestablished by the Niswonger method.39 Firstthe vertical dimension at rest (VDR) wasrecorded, by marking a dot on the tip of thepatient’s nose and another dot on his chin.Then, the patient was asked to take a deepbreath and relax, and when the patient was fullyrelaxed, the caliper was used to record thedistance be tween the 2 dots. This measure-ment represents the patient’s physiological restposition (VDR). The proper VDO is 2.0 to 4.0 mm less thanVDR depending on the patient’s physiology.39

Neuromuscular programming and habitual mandibular

posturing in patients with a collapsed VDO may adverselyaffect the optimal recording of vertical and horizontalmaxillomandibular relationship.40 Hence, an intraoral


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Figures 5a to 5d. Maxillary cameo stone cast (a). Silicone facial matrix was constructed onthe cameo cast (b). Silicone facial matrix was positioned on the diagnostic maxillary cast (c).Maxillary prosthetic teeth were set labial to the natural teeth (d).

a b

c d

Figures 6a to 6d. Mandibular cameo stone cast (a). Silicone facial matrix was constructedon the cameo cast (b). Silicone facial matrix seated on the diagnostic mandibular cast (c).Mandibular prosthetic teeth were set labial to the natural teeth (d).

a b

c d

Gothic arch tracer (No bilium) was used forrecording VDO and centric relation (CR). Astriking plate was attached to maxillaryrecord base and a threaded vertical pin wasattached to the mandibular record base perthe manufacturer’s recommendations to takean intraoral CR40,41 (Figures 4a to 4d). Thethreaded vertical pin was rotated clockwiseso that it would contact the striking plate nearthe patient’s VDO. The maxillary andmandibular record bases with the attachedintraoral tracer assembly were placed in thepatient’s mouth. The pa tient was instructed toclose slowly until the tip of the threaded pintouched the striking plate. VDO was verifiedand found to be optimal.

The striking plate was covered with anindelible ink, and then the patient was trainedand directed to make all border movementswhile maintaining contact between thevertical pin and the striking plate. These movementsproduced an arrow-shaped tracing. The apex of the arrowindicates the centric relation position. An interocclusalrecord was taken at the established VDO with the patient inCR position with a VPS bite registration paste (Regisil[DENTSPLY Caulk]).

In dentate patients, teeth may or may not be at an optimallocation buccolingually. This can be verified by taking acameo impression.42-44 A cameo impression was made tocapture the horizontal vestibular space, to determinemuscular pressure allowing a more accurate tooth positionand gum contour, to improve prosthetic stability, esthetics,and to decrease food impaction along the outer prostheticsurfaces. Next, the cameo impression was poured with typeIII dental stone. A facial matrix was fabricated with a lab putty(Lab-Putty [Coltene]) for the maxillary and mandibular cameocasts. This matrix was then positioned on the respectivediagnostic casts to visualize the buccolingual discrepancy inthe position of natural teeth. The excess space between thematrix and the natural teeth indicated that the natural teethwere lingually positioned. To rectify this discrepancy, theprosthetic teeth were set buccal to the natural teeth, withinthe confines of the matrix42-44 (Figures 5a to 6d). This also

helped gain restorative space. Lastly, the records and the casts were sent to the dental

laboratory team for fabrication of immediate dentures thatwould be delivered to the patient on the day of implant surgery.

Phase II: Implant Planning, Extractions, and 3-DGuided Implant SurgeryThe maxilla—The maxilla was treatment planned toreceive 6 implants (Tapered Screw-Vent Implant Sys tem[Zimmer Dental]). A CBCT scan was taken for the patient(as discussed previously) and the implants were plannedon the CBCT scan. A stereo lithography model andsurgical guide (nSequence) were generated from the CTscan. The maxillary surgical guide was planned to betooth- and tissue-supported to im prove its accuracy45 andstability while placing the implants (Figures 7a to 7c).Serial extractions were planned for the maxillary arch toaccomplish the same.

On the day of the surgery, anesthesia was administeredand all the re maining teeth were extracted atraumatically,except the left maxillary cuspid and the right maxillary firstmolar; these 2 teeth were retained to help stabilize thesurgical guide. The surgical guide was placed in the mouth


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Figures 7a to 7c. Stereolithographic model of the maxilla with retained Nos. 3 and 11 (a).Maxillary surgical guide (b). Stereolithographic model of the maxilla (with retained Nos. 3and 11) with the maxillary surgical guide (c).

a

b

c

Patent Pending nSequence

and checked for proper fit. Sixmaxillary implants (TaperedScrew-Vent Implant System)were placed using thesurgical-guided drill kit(Figures 8a and 8b). Drillswere both internally andexternally irrigated to preventany overheating of the bone.Then, the implant mountswere re moved and healingabutments were attached tothe implants. These im plantswould help support themaxillary denture (Figure 9).Next, the 2 retained teethwere extracted.

A bone graft (Puros Allograft[Zim mer Dental]) was used tograft the voids around theimplants; a barrier membrane(CopiOs [Zimmer Dental]) wasthen draped over the bonegraft prior to closure. Finally, apanoramic radiograph wastaken to verify the implantplacement (Figure 10).

The mandible —Themandible was treatmentplanned to receive 4 im plants(Tapered Screw-Vent Im plantSystem) and 2 small-diameter im plants (ERA MiniDental Implant System). ACBCT scan was taken for thepatient as discussedpreviously and the implantswere planned on the CBCTscan. A stereolithographicmo del and a 2-part surgicaltem plate/guide (nSequence)were generated from the CTscan (Figures 11 to 13).


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Figure 9. Animation depicting 5implants placed in the maxillaryarch and retained teeth Nos. 3and 11.

Figure 10. Panoramic radiographof the patient depicting themaxillary implants.

Figure 11. Animated view of the2-part mandibular surgicaltemplate.

Figure 12. Bone-reduction guide(first part of the 2-part surgicaltemplate): occlusal and frontalviews.

Figure 13. Two-part surgicaltemplate placed on themandibular cast.

Figure 16. Animated view ofimplant surgical guide (secondpart of the 2-part guide) beingplaced over the bone-reductionguide.

Figures 17a and 17b. Animatedview of 3-D guided surgery of themaxilla, using the surgical guide,tube inserts, and the surgicaldrills to place the implants (a).The 3-D guided surgery of themandible using the surgical guide,tube inserts, and the surgicaldrills to place the implants (b).

Figure 14. Animated view ofbone-reduction guide placed onthe mandible to guide boneremoval.

Figures 15a and 15b. Bone-reduction guide was placed onthe mandible and the bone wasremoved with rongeurs (a).Animated view of the bone-reduction guide being placed onthe mandible and bone beingremoved with rongeurs (b).

Figures 8a and 8b. The 3-D guided surgery of the maxilla, using thesurgical guide, tube inserts, and the surgical drills to place implants (a).Animated view of 3-D guided surgery of the maxilla, using the surgicalguide, tube inserts, and the surgical drills to place implants (b).

a

a

a

b

b

b

Figure 18. Panoramic radiographof the patient, depicting themaxillary and the mandibularimplants.

Alveoloplasty was indicated for the mandibular arch, hencea tooth-supported guide could not be fabricated for themandible. The man dibular surgical template was a 2-parttemplate; the first part of the template would guide bonereduction, and the second part would guide the placementof implants (Figures 11 to 13). The use of a bone reductionguide during surgery eliminates the arbitrary removal ofosseous structure and helps ensure the man dibular crest isreduced in prescribed dimensions.

On the day of the surgery, anesthesia was administeredand all the remaining teeth were extracted atraumatically. Afull-thickness mu co periosteal flap was raised, the bonereduction guide was placed on the bone (Figures 14 to15b), and the bone was removed with rongeurs and a bone-reduction file. The bone reduction was limited to the anteriorman dibular ridge, spanning from first bicuspid to firstbicuspid region.

After bone reduction completion, the second part of thesurgical guide was placed in the mouth (Figure 16). The 4mandibular implants (Tapered Screw Vent Implants) wereplaced through the guide (nSequence) using the surgical-guided drill kit (Zimmer Dental) (Figures 17a and 17b). Drillswere both internally and externally irrigated to preventoverheating of the bone. Next, the implant mounts wereremoved and healing abutments were attached to theimplants. These implants would help support themandibular denture.

Two small-diameter implants (ERA Mini Dental Implants)were placed (free-handed) to help retain the man dibularrestoration. Finally, a panoramic radiograph was taken to verifythe implant placement (Figure 18).

Phase III: Delivery of the Transitional RestorationsThe maxillary denture was adjusted and relieved toaccommodate the healing abutments, then it was relinedwith a soft reline material (PermaSoft [DENT SPLY Caulk]).The mandibular denture was adjusted and relieved toaccommodate the healing abutments and the ERAattachments. Then, the retentive elements for the mini-im -plants were picked up chairside using autopolymerizingrepair resin (DENT SPLY Repair Material [DENT SPLYCaulk]). Next, the mandibular denture was relined with thesoft reline material. The occlusion was checked and

adjusted as needed. The implant-supported maxillarydenture and the im plant-retained and supported man -dibular denture were delivered to the patient (Figure 19).(The definitive restorations would be fabricated after aperiod of 4 months for healing.) The patient was given homecare instructions and advised to come to the clinic the nextday for a postoperative check.

The patient was pleased with the retention, stability, andesthetics of the restoration (Figure 20).

CLOSING COMMENTSA proper diagnosis and thoughtful treatment planning areprerequisites for achieving a successful rehabilitation.Information gathered during diagnosis can seamlesslyinfluence surgical decision making, optimal implantplacement, and in creating the appropriate design of adefinitive prosthesis. Every step of the treatment should beconsidered crucial to the success of restorations.

In this case report, the patient was transitioned from adebilitated to a rehabilitated state, with stable implant-supported restorations placed in the same appointment. Thedelivery of the transitional prosthesis was accomplished veryefficiently and quickly with minimal adjustments required. The


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Figure 19.Transitionalrestorations placedin the patient’smouth.

Figure 20.Patient’s smile;preoperative aboveand postoperativebelow.

transitional prosthesis had excellent esthetics and the patientwas able to function satisfactorily with it.

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1. Most restorative dentists believe that the treatmentof choice for the edentulous patient is still atraditional removable prosthesis.

a. True b. False

2. The decision process to restore a patient with fixedor removable restorations should be determined byevaluating various parameters such as quality andquantity of hard and soft tissues, oral hygiene, themaxilla-mandibular relationship, lip-line, lip supportand finances.

a. True b. False

3. If designed properly removable implant restorationsare stable, retentive, and resistant to fracture.

a. True b. False

4. Several studies have failed to prove that patients have asimilar-to-higher satisfaction with implant-supportedremovable restorations.

a. True b. False

5. Combining the CAD/CAM technique, digital implantplanning can be applied to clinical practice using 3-Dsurgical guides.

a. True b. False

6. Misch and Pasciuta have reported that a minimum of12.0 mm of vertical restorative space (crest of boneto occlusal plane) is necessary to accomplish amandibular implant-assisted overdenture.

a. True b. False

7. If the restorative space is inadequate, clinicalprocedures designed to improve vertical spaceavailability can be utilized.

a. True b. False

8. The proper vertical dimension of occlusion (VDO) is1.0 to 3.0 mm less than the vertical dimension at rest(VDR), depending on the patient’s physiology.

a. True b. False


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This CE activity was not developed in accordance withAGD PACE or ADA CERP standards.CEUs for this activity will not be accepted by the AGDfor MAGD/FAGD credit.

PROGRAM COMPLETION INFORMATION

If you wish to purchase and complete this activitytraditionally (mail or fax) rather than online, you mustprovide the information requested below. Please be sure toselect your answers carefully and complete the evaluationinformation. To receive credit you must answer 6 of the 8questions correctly.

Complete online at: dentalcetoday.com

TRADITIONAL COMPLETION INFORMATION:Mail or fax this completed form with payment to:

Dentistry TodayDepartment of Continuing Education100 Passaic AvenueFairfield, NJ 07004

Fax: 973-882-3622

PAYMENT & CREDIT INFORMATION:

Examination Fee: $40.00 Credit Hours: 2

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PROGRAM EVAUATION FORMPlease complete the following activity evaluation questions.

Rating Scale: Excellent = 5 and Poor = 0

Course objectives were achieved.

Content was useful and benefited your clinical practice.

Review questions were clear and relevant to the editorial.

Illustrations and photographs were clear and relevant.

Written presentation was informative and concise.

How much time did you spend reading the activity and completing the test?

What aspect of this course was most helpful and why?

What topics interest you for future Dentistry Today CE courses?



ANSWER FORM: VOLUME 33 NO. 1 PAGE 134Please check the correct box for each question below.

1. o a. True o b. False 5. o a. True o b. False




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This CE activity was not developed in accordance withAGD PACE or ADA CERP standards.CEUs for this activity will not be accepted by the AGDfor MAGD/FAGD credit.

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