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Rehabilitating Atrophied Ridges with Implant-Supported Overdentures
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© 2020 |Published
by Scholars Middle East Publishers, Dubai, United Arab Emirates 0 Saudi Journal of Oral and Dental Research Abbreviated Key Title: Saudi J Oral Dent Res ISSN 2518-1300 (Print) |ISSN 2518-1297 (Online) Scholars Middle East Publishers, Dubai, United Arab Emirates Journal homepage: http://scholarsmepub.com/sjodr/ Case Report Rehabilitation of Maxillary and Mandibular Atrophied Edentulous Ridge with Implant Supported Overdenture Prosthesis: A Case Report Dr. Priyesh Kesharwani MDS1* , Dr. Bhavan Chand Yemineni2 , Dr. Rahul Vinay Chandra Tiwari, FOGS, MDS3 , Dr. Amit Shivakant Vathare, MDS4 , Dr. Dheeraj Voulligonda5 , Dr. Amartya Prakash Srivastava6 , Dr. Heena Tiwari, BDS, PGDHHM7 1 Oral and Maxillofacial Surgeon, Consultant and Private Practitioner DENT-O-FACIAL Multispeciality Clinic, Mira road, Thane-Mumbai 2 Associate Professor, Dept of Dental and Oral Surgery, ASRAM Medical College, Eluru, Andhra Pradesh 3 Assistant Professor, Department of Oral and Maxillofacial Surgery, Sri Sai College of Dental Surgery, Vikarabad, India 4 Prosthodontist & Implantologist, Jaysingpur, Shirol, Kolhapur, Maharashtra 5 Senior Lecturer, Department of Oral Medicine and Radiology, Sri Sai College of Dental Surgery, Vikarabad, Telangana, India 6 Senior lecturer, Dept of OMFS, Saraswati Dental college and Hospital, Lucknow, UP 7 Government Dental Surgeon, Chhattisgarh, India DOI: 10.36348/sjodr.2020.v05i01.00X | Received: 09.12.2019 | Accepted: 22.12.2019 | Published: X *Corresponding author: Dr. Priyesh Kesharwani MDS Abstract The most frequently encountered clinical situation in a dental practice is the completely edentulous dental arch for which implant supported overdentures has been the predictable procedure over time. Implant supported overdentures have proved to be one of the best alternative options in prosthetic rehabilitation of various cases of edentulism. Implant provides enhancement of retention, support, stability of the overdenture makes it an ideal treatment modality. Overdenture satisfies the patient’s expections, improve quality of life with their long term serviceability and predictable outcomes. This case report focuses on rehabilitation with an implant supported overdenture of edentulous atrophic maxilla and mandible. Keywords: Edentulous, Overdenture, Rehabilitation. Copyright @ 2020: This is an open-access article distributed under the terms of the Creative Commons Attribution license which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use (NonCommercial, or CC-BY-NC) provided the original author and source are credited. INTRODUCTION Complete tooth loss or edentulism is a debilitating and irreversible condition that represents the ultimate consequence of oral disease [1]. Edentulism is associated with greater disability and earlier mortality in the elderly, even after adjusting for confounders such as socioeconomic status and health behavior [2]. The major purpose of dental prostheses is to reduce masticatory impairment and poorer quality of life by replacing the lost teeth. The most common prostheses for edentulism are complete dentures, which cannot completely restore lost function, e.g. chewing performance is only 30% of that for dentate individuals [3]. Implant supported overdentures has become a benefit for the patients facing complete edentulism as it lessens the challenges posed by removable complete denture prosthesis such as poor stability and compromised mastication. The transition from dentulous to edentulous state poses different challenges to the patient as well as the clinician. Bone resorption especially in mandible is an important factor to be considered during rehabilitation. Traditional removable prostheses need continuous adjustments. Implant supported overdentures are customizable and excellent esthetics makes it a captivating treatment modality for many potential patients. An implant supported overdenture is a type of overdenture that is supported by and attached to implants differing from the regular denture that rests solely on the gingiva. Implant supported overdentures has individual attachments that snap onto attachments present on the implants. McGill has recommended the usage of two implants to support a mandibular denture as a basic standard of care thereby improving the quality of life related to oral health [4]. With the use of implant- supported prosthesis, progress in masticatory function, retention and stability, and preservation of the alveolar bone have been reported [5-8]. Van Steenberghe et van Steenberghe et al. first reported on the possibility of using mandibular overdentures supported by two
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Priyesh Kesharwani et
al; Saudi J Oral Dent Res, Jan 2020; 5(1): X © 2020 |Published by Scholars Middle East Publishers, Dubai, United Arab Emirates 1 implants to treat problems where usually conventional mandibular dentures would be used [9]. The vast majority of patients, an overdenture on two implants in the mandible is the first choice of treatment when complaining about the lack of stability in their mandibular denture [10-12]. Thomason et al. [13] concluded that there is now overwhelming evidence to support the proposal that a two-implant overdenture should become the first choice of treatment for the edentulous mandible. The numbers of implants in the edentulous mandible for support of an overdenture are well studied [14, 15]. Slot et al. [16] showed in a metaanalysis that the survival of implants used to support a maxillary overdenture is high if concepts were used with at least 4 implants supplied with either a bar or ball anchorage. Finally, from the systematic review of Roccuzzo et al. [17], it can be concluded that the question of how many implants should support a maxillary overdenture is still open. CASE REPORT A 63 year old female patient came to department with the chief complaint of loose fitting lower denture with difficulty in mastication and speech. On examination, patient had resorbed alveolar ridge which lead to inadequate retention of the lower and upper denture prosthesis and patient is known to be a previous denture wearer for past 2 years. The Orthopantomograph findings showed the presence of insufficient bone height and width, with dense cortical bone surrounded by dense trabecular bone. Thus implant supported overdenture was planned with two implants in mandibular canine region and four implants in maxillary arch along with independent ball type attachments. Blood investigations and informed consent was taken after discussing the treatment procedure with the patient. Irreversible hydrocolloid impression was made and pre-surgical diagnostic casts were prepared. Inter-occlusal distance was measured in the diagnostic casts. The implant location was marked at B and D positions independent of each other. Surgical Phase Under antibiotic prophylaxis and standard aseptic protocol, preparation of the patient was done by anaesthetizing the mandibular anterior segment with inferior alveolar nerve block using local anaesthesia of 2% lignocaine with 1:80,000 adrenalines. After the region was anaesthetized, full thickness crestal incision was made with surgical blade number 15 extending from first premolar on right side to first premolar on left side. The mucoperiosteal flap was elevated and bone was exposed. A pilot drill was introduced into the bone and two osteotomy sites were created in mandibular ridge and four osteotomy sites preparation was done in maxillary ridge. Two surgical implants (3.3 x 13 mm) were inserted in mandible (Fig. 1) and four surgical implants were placed in maxilla (4.5 x 12, 4.5 x 12, 4.5 x 14 and 4.5 x 14) using motor driver at 35 rpm and the landmark of reach was checked with profile gauge (fig 2). After the implant seating tip has reached the adequate depth, cover screws are placed. Later flaps are approximated, suturing done using 3-0 vicryl suture material. Antibiotics and anti –inflammatory coverage was given to patient. Patient was recalled on the 10th day of surgery, suture removal was done. Post operatively after 3 months the implants were well prepared to receive the prosthesis. The second stage surgery was performed in which cover screws were removed and healing abutments were inserted into the implants. After a time period of two weeks, peri-implant soft tissue healing was examined, and existing denture was relined after relieving at the abutment site. Later, the healing abutment is removed using a 1.25 mm hex driver. A periodontal probe was used to measure the gingival cuff height at the right and left canine site of implant location. Selected ball abutments were placed onto each implant using 1.25 mm hex driver and 30 Ncm torque wrench. A transferable mark with an indelible pencil is placed on top of each ball abutment and old denture is seated to ideally determine the location for attachment housings. It is followed by preparation of recesses in the intaglio surface of the denture to accommodate the housings (Fig. 3). Lingual vent holes are made for escape of excess acrylic. Placement of nylon processing insert into each of the housings is done with insert seating tool. Seating of the attachment housing onto each ball type abutment is done. Undercuts are blocked out under the housing and soft tissue to prevent acrylic resin from locking the denture onto the abutment. Application of self-curing acrylic is done into recessed area and around titanium housings for bonding of the housings to denture. Insertion of denture was done and guiding the patient into proper occlusion with the opposing arch. After the curing of acrylic, denture is removed. Excess acrylic is removed around the housings and lingual vent hole later it is polished (Fig. 4). Replace nylon retention insert instead of processing insert into the housings. The insert must seat securely in place and be in level with the housings rim. Overdenture is seated over the ball abutments (Fig. 5 - 8). Proper instructions have been given to the patient on insertion and removal of prosthesis (Fig. 9). The patient was recalled at 1 week, 3 weeks, 2 months, 6 months follow up appointments.
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Priyesh Kesharwani et
al; Saudi J Oral Dent Res, Jan 2020; 5(1): X © 2020 |Published by Scholars Middle East Publishers, Dubai, United Arab Emirates 2 Fig-1: Mandibular implant placement Fig-2: maxillary implant placement Fig-3: Intaglio surface of the denture to accommodate the housings Fig-4-8: Overdenture is seated over the ball abutments Fig-9: Removal of prosthesis DISCUSSION When restoring the edentulous maxilla with dental implants, the most important decision to make is whether the patient should be restored with a fixed or removable prosthesis [18]. Problems arising from lack of retention and stability among mandibular prosthetics can be overcome by placing osseointegrated dental implants, used to retain an overdenture [19]. The transformation of an implant-supported overdenture to a tissue implant- supported overdenture with a full palatal coverage was recommended in a similar case like ours [20]. It was also reported that higher bending moments may develop on the implants supporting overdentures than a fixed prosthesis. Therefore, it was recommended to increase the number of implants supporting the prosthesis in order to prevent the bending moments that may cause bone loss [21, 22]. While it is accepted that the 2-implant overdenture is not the gold standard of implant therapy it is the minimum standard that should be sufficient for most people, taking into account performance, patient satisfaction, cost, and clinical time
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Priyesh Kesharwani et
al; Saudi J Oral Dent Res, Jan 2020; 5(1): X © 2020 |Published by Scholars Middle East Publishers, Dubai, United Arab Emirates 3 [23]. One study of 101 patients [24] with a follow-up of over 10 years concluded that implant-retained overdentures are a favorable solution for edentulous patients. A literature review18 recommends the placement of at least 4 implants between the mental foramina and between 4 and 6 implants in the maxilla for the placement of overdentures supported by micromilled bars. CONCLUSION There are numerous approaches to treat edentulous patients, however those techniques are invasive, expensive and time consuming but implant supported overdenture prosthesis proves to be relatively easy due to its innumerable advantages. Dental implants in patients wearing overdentures had a high survival rate in the long term. Age, sex, and splinting did not have a significant influence on implant survival. The provided treatment gave the patient self-confidence and comfortable function due to palatal freedom, and the esthetic was improved dramatically with the use of an indirect micro-ceramic composite having above- mentioned superior properties instead of acrylic base and artificial teeth in the fabrication of the prosthesis. REFERENCES 1. Cunha-Cruz, J., Hujoel, P.P., Nadanovsky, P. (2007). Secular trends in socio-economic disparities in edentulism: USA, 1972-2001. J Dent Res, 86:131–6. 2. Holm‐Pedersen, P., Schultz‐Larsen, K., Christiansen, N., & Avlund, K. (2008). Tooth loss and subsequent disability and mortality in old age. Journal of the American Geriatrics Society, 56(3), 429-435. 3. Cunha, T.R., Della Vecchia, M.P., Regis, R.R., Ribeiro, A.B., Muglia, V.A., Mestriner, W, Jr. (2013). A randomised trial on simplified and conventional methods for complete denture fabrication: masticatory performance and ability. J Dent, 41:133–42. 4. 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