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Kelly Mills
Patients can present with less-than-ideal indications for implant treatment. Often, they will have had some experience of wearing a denture and know that this option is not for them. However, when the patient is certain they want implants, the range of treatments available to the clinician can still be limited by their oral health.
Decisions made about implant system, implant placement timing, number, method and type of prosthesis can all influence the outcome which is both right for the patient in terms of function, comfort and aesthetics, but also optimal for the clinician from a management and maintenance perspective.
In the following case, a plan was conceived to maximise long-term clinical success, with built-in flexibility to manage ongoing conditions and offer further treatment options in the future.
Case presentation
A gentleman in his late sixties came to see me to discuss options for his failing lower teeth. He had a history of high blood pressure although it was being well controlled with medication. He was also taking statins for cholesterol regulation. However, the patient was generally fit and had no allergies or contraindications.
His oral health was less straightforward. He had suffered from advanced, chronic periodontal disease which had affected the upper and lower dentition. The disease had reached a point where he was getting infections on a regular basis and his teeth were also very mobile (Figures 1-3). Patients are often reluctant to lose their remaining teeth, but we had already prepared him psychologically for a more radical treatment plan and he had reached a tipping point.
Treatment planning
The patient had eight failing lower teeth. Following a full examination and radiographic assessment, I concluded I had no option but to extract them. Three treatment options were possible:
- The simplest would be to remove the failing teeth and replace them with a conventional full acrylic denture to match his upper denture. Whilst this would provide a functional outcome, the patient was advised about the challenges adapting to a lower denture, in particular muscle control and destabilising tongue movements.
- The alternative would be to extract the teeth and provide a removable overdenture retained by dental implants. Implants would deliver stability and negate the issues associated with a conventional denture. However, the implant-retained prosthesis would be removable for cleaning and maintenance. Given the patient was at an increased risk of complications arising from his previous periodontal disease, this plan would enable me to easily service the implants. Studies have also shown a high level of patient satisfaction with removal prostheses (Bajunaid, Alshahrani, Aldosari, Almojel, Alanazi, Alsulaim & Habib, 2022) (Heydecke, Boudrias, Awad, De Albuquerque, Lund & Feine, 2003). The option offered the best of both worlds, providing a rigid, stable anchor for the prosthesis, and easy access for maintenance and management.
- The final option was removal of the failing teeth and a fixed prosthesis retained with a minimum of four implants. An immediate temporary bridge could be attached on the day of surgery and would negate the need for a removable denture at any time. However, the requirement for this treatment plan would be meticulous oral hygiene carried out by the patient, to mitigate the risk of recurring peri-implant disease.
In addition to understanding the patient’s desires, motivations and access to finance, acceptance of the plan is critical, as well as what can be tolerated. The transition to full dentures could be troublesome for people who have a full set of natural teeth, for instance.
This gentleman was open to all three plans, but his preference was to avoid a full lower denture. Having worn a conventional upper denture and already made aware of the challenges of full lower dentures from speaking to family and friends, deep down he knew he wanted implants. After discussion of all three options, he indicated his agreement to proceed with an implant-retained overdenture for the mandible and a new conventional denture for the maxilla, to provide improved overall aesthetics and function.
Delayed implant placement rationale
The patient’s history of active, chronic and recurring infection was a concern. I considered whether to place the implants immediately following extraction, or after a healing period. Given the presence of infection, I chose the delayed approach to allow between eight and 12 weeks for the soft and hard tissues to settle and heal. Getting this wrong would either compromise the healing process or jeopardise the implant treatment success.
I proceeded with my normal work-up of the case. Impressions were taken for fabrication of an immediate full lower denture to fit on the day of extraction. The patient then returned to have the failing lower teeth removed. On the same day, he was fitted with his full temporary lower prosthesis, fabricated by Exeter-based Zenith Dental Laboratory.
During the healing period the patient attended the practice for periodic reviews. The denture was checked for comfort and the mouth was examined for sores. Minor adjustments were made. The temporary denture was relined chairside to take account of changes to the patient’s gum anatomy and topography. After each adjustment I confirmed the gentleman was happy.
A CBCT scan was taken of the mandible after 10 weeks to assess the bony anatomy and locate critical anatomical structures including the mental nerve and foramen for the inferior alveolar nerve. There were found to be no contraindications and I concluded that the bone volume and density were sufficient for implant placement.
Implant number for optimum manageability and flexibility
The next key decision focused on the number of implants required to stabilise the lower denture. The more implants placed, the more flexible the plan would be to manage any potential future complications or implement a change of treatment and potentially upgrade to a fixed alternative if required. These decisions are also partly down to a patient’s manual dexterity when removing their denture, and the desired level of stability and retention offered by the final prosthesis.
I decided to place four implants. This number would provide a stable foundation and would futureproof the case should the patient not tolerate the treatment.
Implant placement
Aided by computer-guided planning software, the CBCT scan was assessed and the ideal implant positions planned. The software then allows me to produce a reliable bone-supported guide for a pilot drill with longstops, which I use as a marker for transfer of the implant positioning from the scan to the osteotomy site (Figures 4 and 5). From that point, the rest of the procedure is carried out freehand.
The bone volume, as determined by the CBCT scan, dictates the choice of implant size.
Four copaSKY 3.5 x 13mm implants (bredent medical, Germany) were placed in the patient’s mandible using the newly designed surgical kit (Figure 6). I favour these implants for their short, conical and parallel-walled connection, which leads to a really healthy, cleansable connection area. The implant design also helps to achieve high levels of primary stability when needed. For the best clinical outcome I tend to place them between 1.5 to 2mm subcrestally (Figure 7). I find this is the optimum depth for protection of the implant; it produces a good bony contour with a very favourable soft tissue outcome.
The normal sequence of drilling with copaSKY implants was followed. Healing caps were fitted and the site was closed (Figure 8). The aim was to achieve a good area of keratinised tissue around the implant shoulder, which has shown to improve long-term success (Grischke, Karch, Wenzlaff, Foitzik, Stiesch & Eberhard, 2019) (Lin, Chan & Wang, 2013). I adjusted and relieved the denture around the implant abutments and fitted the prosthesis so that the patient could leave the practice once again with his temporary teeth. Seven days later, he returned for a review and removal of the sutures. A seven-to-eight-week period of healing followed (Figure 9).
Restorative phase
At the eight-week review, impressions were taken for the work-up for the new full upper denture and the final implant-retained lower overdenture (Figure 10). The patient was assessed for colour, phonetics, fit and tooth positioning and the technician was instructed to create a little relief inside the final lower denture, which would be reinforced with a cobalt-chrome frame (Figures 11-14).
The healing abutments were removed from the four implants (Figure 15). Zest Locator® attachments were placed 1 to 1.5mm above the soft tissue margin to facilitate sufficient retention (Figures 16-18). If placed too high, there may not be adequate prosthetic space to sufficiently cover the locator housing cap. Positioned too low, they can lead to soft tissue trauma or poor pick-up of the housing cap. A height of 3mm was optimal for the locators in this case.
Direct or indirect implant pick-up
My preference for loading the locators was with a direct pick-up. I find this method carries a lower risk of error because the clinician is working with a direct reference of what is already in the mouth. Meanwhile, the indirect method relies on the transfer of accurate data to the laboratory. This can lead to inherent problems and result in less flexibility for the clinician on the day of the appointment.
Qu-resin (bredent) was used to pick up the locator housing cap and link this to the denture. This tension-free, self-curing resin is quick setting and easy for intraoral and extraoral application. The aim was to create sufficient relief and avoid interferences. The male attachment components were fitted to provide a secure anchor and the connector was attached. The denture was checked for retention and stability, and was then polished and finished (Figure 19).
Optimal outcome for the patient
The locator processing package comes with a series of retentive elements to allow personalised retention for each specific patient. The overdenture was initially set at a relatively low retention to help the patient get used to removing it at home. Retention will be increased as time passes.
The patient was delighted with the result (Figure 20). It had been a very comfortable process for him, and he had been looking forward to his definitive teeth. At the follow-up review a week after the fitting, he reported how life changing the treatment had been and that he was back to eating everything he wanted, with no hesitation, fear, or discomfort.
Case reflection
The result was textbook in my view. A healthy band of keratinised tissue around all the implants was achieved, and the fit, aesthetics, bite and occlusion were all good, only needing minor adjustments.
Several factors helped to make the treatment a success. The plan for a removable implant-retained overdenture, delayed placement, number of implants, implant system, direct pick-up method and locator height all contributed to the surgical and restorative outcome. The adopted plan will offer maximum flexibility for future treatment options or, should it be necessary, complications management. As with all cases, the key is the thought and time invested in the planning, and the range of products, materials and methods in our workflow that combine to reduce risk and overcome challenges.
About the author: Dr Marcus Gambroudes
Dr Marcus Gambroudes has developed a keen interest in dental implants and cosmetic dentistry. His interests lie in providing full arch reconstructions and immediate restorations.
Marcus works exclusively in private practice in Cape Dental, Warwick. He is a member of the Association of Dental Implantology and the British Academy of Cosmetic Dentistry. Dr Gambroudes qualified from Birmingham University in 2000 and was one of a few dentists awarded with a Clinical Distinction.
For further information:
Email: drgambroudes@outlook.com
Tel.: 01926 491029
Visit: www.capedental.co.uk
Or write to: Cape Road Dental Practice and Implant Centre, 9 Cape Road, Warwick, Warwickshire, CV34 4JP.
References
Bajunaid SO, Alshahrani AS, Aldosari AA, Almojel AN, Alanazi RS, Alsulaim TM, Habib SR (2022). ‘Patients’ Satisfaction and Oral Health-Related Quality of Life of Edentulous Patients Using Conventional Complete Dentures and Implant-Retained Overdentures in Saudi Arabia’, Int J Environ Res Public Health, Jan 4; 19(1): pp557.
Grischke J, Karch A, Wenzlaff A, Foitzik MM, Stiesch M & Eberhard J (2019). ‘Keratinized mucosa width is associated with severity of peri‐implant mucositis. A cross‐sectional study’, Clin Oral Impl Res.; 30: pp 457–465.
Heydecke G, Boudrias P, Awad MA, De Albuquerque RF, Lund JP & Feine JS (2003). ‘Within-subject comparisons of maxillary fixed and removable implant prostheses: Patient satisfaction and choice of prosthesis’, Clin Oral Implants Res., Feb;14(1): pp 125-130.
Lin, GH, Chan HL & Wang HL (2013). ‘The significance of keratinized mucosa on implant health: a systematic review’, J Periodontol., Dec; 84(12): pp 1755-1767.
