3. CASE PRESENTATION
Pt. : 80-year-old Caucasian male
University : Dept. of Prosthodontics at university hospital of Tubingen,
Germany.
C/C : discomfort and dissatisfaction concerning his existing maxillary denture.
O/E : poorly adapted & aesthetically compromised maxillary denture
supported by 2 posterior teeth with telescopic crowns and lower jaw with
telescopic rpd on 5 anterior abutment teeth.
4. INTRAORAL PHOTOGRAPH OF THE PATIENT (A) POORLY ADAPTED
MAXILLARY DENTURE AND (B) UPPER JAW WITH TELESCOPIC CROWNS
ON THE
REMAINING NATURAL TEETH
5. TREATMENT PLAN
Based on patient’s complaints, clinical and radiographical examinations
included : implant-supported bar-retained maxillary overdenture with two
telescopic hybrid double crowns as posterior abutments with a technical
adaptation of the existing telescopic denture in the lower jaw.
6. SURGICAL INTERVENTION
DIAMETER AND LENGTH OF THE IMPLANT : 3.75 * 10 mm.
COMPANY : BEGO Implant Systems GmbH, Germany)
LOCATION : region of 14, 24, 12 and 22. The posterior implants were placed
with an angulation in accordance with the anterior wall of the sinus.
BONE GRAFTING : bone substitutes were placed at the buccal site of left first
premolar region.
The denture was adapted and relined with soft silicone relining material and
pt. was asked to wear denture after 5 days.
7. A) IMPLANTS PLACED IN SITU AND (B) POSTOPERATIVE INTRAORAL
PANORAMIC RADIOGRAPH CONFIRMING THE POSITION OF THE
IMPLANTS.
8. PROSTHETIC INTERVENTION
The second stage of surgery was performed after 6 months of
osseointegration.
After 3 weeks, the old posterior metal crowns were removed, the preparation
of the teeth were refined to allow the marginal fit of hybrid double crowns.
A pick-up coping impression was made with polyether impression material
using customized resin tray.
The maxillomandibular records were obtained with the old relined dentures
and recorded with the putty polyvinyl siloxane elastomer which help in making
a custom maxillary registration tray with wax bite blocks made from light
curing resin.
9. PROSTHETIC INTERVENTION
In the next visit, the two primary copings of the molars were tried on and checked for marginal
fit.
The implant abutments were delivered in separated sets of two. These were connected
intraorally with a resin and pick up impression was made with customised acrylic tray with
polyether material.
The casts were mounted on the articulator using a provisional jaw relationship. A bar retainer
was divided into two portions due to the angulation of the posterior implants.
Each block of segments was screwed on top of the implant abutments. The abutments and
the individual segments were affixed with pattern resin in the patient’s mouth followed by
Definitive pick-up impression
The final maxilla–mandibular relation in vertical and horizontal dimension was recorded with
the telescopic denture in the lower and the wax blocks of the custom tray in the upper
followed by facebow transfer.
11. PROSTHETIC INTERVENTION
The occlusal plane was not parallel to the Camper’s line in the sagittal axis.
The occlusion plane was corrected in wax-up try-in, and the shade of the tooth
was selected.
The wax-up try-in was done for the proper alignment of the anterior teeth
before the milled bar retainer was designed. Bilateral balanced occlusion
scheme was achieved.
The prosthesis framework try-in with two swivel ledges, two separated milled
bar retainers and crowns with friction pins were fabricated
12. PROSTHETIC INTERVENTION
(A) Final intraoral situation with implant and attachments
and (B) internal surface of the overdenture with the
counter bar and the
attachments.
13. PROSTHETIC INTERVENTION
Delivery appointment :
Upper original abutments were screwed on the implants with a torque and two
separated milled bars were screwed on implant abutments. The hybrid double
crowns were cemented using zinc phosphate cement .
The posteriors of the lower denture were modified with a light-curing resin to
ensure static and dynamic occlusion.
14. PRETREATMENT (A–D) &
POST-TREATMENT (E–H)
(A, E) PRESENTS THE LATERAL VIEW WITH
THE APPLIANCE IN PLACE,
(B, F) PRESENTS THE AESTHETIC SMILE
(C, G) PRESENTS THE INTRAORAL
PHOTOGRAPH, (D, H) PRESENTS THE
INTRAORAL FRONTAL VIEW OF THE
MAXILLARY AND
MANDIBULAR APPLIANCE IN OCCLUSION.
15. LEARNING POINT
The tooth and implant-supported overdenture retained by a milled bar allows
the clinician to overcome particular problems associated with the treatment of
maxillary arch using implants.
Also, the use of telescopic crowns compared with conventional removable
partial dentures has several advantages such as good stability and retention,
stable occlusion and enhanced masticatory efficiency due to the controlled
sensory feeling.
This promises a long-term solution for the elderly especially regarding oral
hygiene and stable oral health and quality of life.
16. DISCUSSION
In the current case, considering the remaining natural teeth and the condition
of maxillary bone it was planned to treat the case with tooth and implant-
supported hybrid double crown combined with a milled bar partial
overdenture.
In palatal coverage by a complete denture, the oral environment is altered
because of the less space available for the tongue which could affect the
masticatory function, speech and disturb sensorimotor function.
Other treatment options : fixed implant-retained prosthesis. Furthermore, a
fixed restoration would not allow sufficient support of the upper lip and
sophisticate the hygiene measures as pt. is 80 year old
17. DISCUSSION
The implant-supported milled bar overdenture compared with Implant-
Supported Overdenture with Mucosal Support, presents several advantages
including limiting bone resorption, extending the life of the attachments, less
prosthetic complications and maintenance needs.
The limitations of these type of treatment and prosthesis includes critical
treatment planning for positioning and placement of implants, and technique
sensitive fabrication techniques.
The patient was informed to maintain good oral hygiene and to have a regular
follow-up.
18. REFERENCES
Straioto FG, de Azevedo AM, do Prado CJ, et al. Rehabilitation of maxillary
edentulism with implant-supported milled-bar prostheses. Implant Dent
2006;15:366–71.
Martínez-Lage- Azorín JF, Segura-Andrés G, Faus-López J, et al. Rehabilitation
with implant-supported overdentures in total edentulous patients: a review. J Clin
Exp Dent 2013;5:e267–72.
Cricchio G, Lundgren S. Donor site morbidity in two different approaches to
anterior iliac crest bone harvesting. Clin Implant Dent Relat Res 2003;5:161–9.
Nkenke E, Schultze-Mosgau S, Radespiel-Tröger M, et al. Morbidity of harvesting
of chin grafts: a prospective study. Clin Oral Implants Res 2001;12:495–502.
19. REFERENCES
Clavero J, Lundgren S. Ramus or chin grafts for maxillary sinus inlay and local
onlay augmentation: comparison of donor site morbidity and complications. Clin
Implant Dent Relat Res 2003;5:154–60.
Tipton PA. The milled bar-retaine removable bridge implant-supported prosthesis:
a treatment alternative for the edentulous maxilla. J Esthet Restor Dent
2002;14:208–16.
Kiener P, Oetterli M, Mericske E, et al. Effectiveness of maxillary overdentures
supported by implants: maintenance and prosthetic complications. Int J
Prosthodont 2001;14:133–40.
