|Year : 2011 | Volume
| Issue : 1 | Page : 34-37
Full mouth implant rehabilitation in a patient with limited inter-arch space using mandibular fixed prosthesis and maxillary overdenture with low-profile attachments: A clinical report
Chakravarthy Ramasamy, George Paul, Abby Abraham
Department of Prosthodontics and Oral Implantology, Meenakshi Ammal Dental College and Hospital, Chennai, India
|Date of Web Publication||2-Feb-2011|
No. 1009A, TVS Colony, Anna Nagar West Extn., Chennai - 600 101
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Restoring the edentulous patient with an esthetic and functional reconstruction may present numerous challenges to the clinician. The patient's occlusal vertical dimension, centric relation, esthetics and phonetics need to be determined and maintained throughout the restorative process. This clinical report describes the fabrication of implant supported fixed prosthesis and implant-tissue supported overdenture with low-profile attachments and its step-by-step approach to provide an esthetic result for a patient with limited inter-arch space.
Keywords: Full mouth rehabilitation, implant-tissue supported, low-profile attachments, overdenture
|How to cite this article:|
Ramasamy C, Paul G, Abraham A. Full mouth implant rehabilitation in a patient with limited inter-arch space using mandibular fixed prosthesis and maxillary overdenture with low-profile attachments: A clinical report. J Dent Implant 2011;1:34-7
|How to cite this URL:|
Ramasamy C, Paul G, Abraham A. Full mouth implant rehabilitation in a patient with limited inter-arch space using mandibular fixed prosthesis and maxillary overdenture with low-profile attachments: A clinical report. J Dent Implant [serial online] 2011 [cited 2020 Sep 18];1:34-7. Available from: http://www.jdionline.org/text.asp?2011/1/1/34/76431
| Introduction|| |
Rehabilitation of the edentulous maxilla continues to be comparatively more challenging than rehabilitating the edentulous mandible. Though single-stage surgery with immediate load concepts are well established in the mandible, they should be considered experimental in the maxilla until long-term, evidence-based data and guidelines are established. 
Overdentures have been shown to improve the quality of life for edentulous patients and to contribute to the well-being of the patient's psychology. Implant-retained overdentures offer better satisfaction than conventional dentures and are indicated when full arch fixed implant prosthesis cannot be made. The removable implant-retained overdenture offers several advantages including enhanced access for hygiene, easy modification of the prosthetic base, and provision of an esthetic labial flange in cases of unfavorable jaw relations. , The retention and stabilization for the overdenture are provided by the denture-bearing area and attachment components like bar and clips, retentive ball and sockets, low-profile attachments and magnets.
The low-profile attachments used here demonstrate promising results when used with implant-retained overdentures in limited inter-arch spaces. 
| Case Report|| |
A 54-year-old Caucasian man reported with a chief complaint of pain and mobility in lower anterior teeth and upper posterior teeth. Radiographic investigation showed generalized bone loss [[Figure 1]a]. A comprehensive treatment plan was made to extract all the teeth and place implant supported overdenture in the upper arch. This was due to the sinus anatomy in the posterior maxilla and the patient's unwillingness for graft placement. An implant supported fixed prosthesis was advised in the lower arch. The treatment plan was discussed with the patient. Atraumatic extractions of the teeth were done [[Figure 1]b] and an immediate denture was fabricated for the patient. Implant surgery was scheduled after 4 months of extraction for a two-stage implant surgical procedure.
|Figure 1 :(a) Preoperative radiograph showing natural teeth with hopeless prognosis|
Figure 1b: Post-extraction radiograph
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Stage I implant surgery
In the maxillary arch, a full thickness muco-periosteal flap was raised under local anesthesia from premolar to premolar region. Three implants (Self thread implants, Hi-tec, Herzlia, Israel) of 3.75 mm diameter and 13 mm length were placed in pre-maxilla region, except for the left distal implant which was 3.3 mm Χ 13 mm. The muco-periosteal flap was closed with horizontal interrupted sutures.
Mandibular implant surgery was carried out on the next day under local anesthesia. A full thickness muco-periosteal flap was raised in the mandibular arch from left second molar region to right second molar region. On the lower right quadrant, implants (Self thread, Hi tech implants, Israel) were placed in the molar (4.2 Χ 11.5 mm), premolar (3.75 Χ 11.5 mm), canine (3.75 Χ 8 mm), lateral incisor (3.3 Χ 16 mm) and central incisor (3.3 Χ 16 mm) regions. On the lower left quadrant, implants were placed in the molar (4.2 Χ 11.5 mm), premolar (3.75 Χ 11.5 mm), canine (3.3 Χ 13 mm) and incisor (3.3 Χ 13 mm) regions. A total of nine implants were placed in the mandibular arch [Figure 2]. The flap was closed using horizontal interrupted sutures. After 1 week, the sutures were removed and the immediate denture was relined with permanent soft denture liner (Permasoft, Dentsply, York, PA, USA) and inserted.
Stage II implant surgery
Healing caps were removed from the mandibular implants and abutment analogs were attached for the impression procedure [[Figure 3]a]. The abutments were then milled to attain parallelism and a shoulder finish line was attained [[Figure 3]b]. After impressions, metal framework was fabricated for the ceramo-metal prosthesis. The prosthesis was fabricated in three parts: right posterior four unit, left posterior and anterior five unit implant supported fixed dental prostheses. The metal framework was tried in [Figure 4] and a new centric record was obtained using an interocclusal registration material (Aluwax, Aluwax Dental Products Co., Grand Rapids, MI, USA). Then, the framework was sent for ceramic buildup [[Figure 5]a]. The prosthesis was cemented (Fuji, Type I, GC, Japan) on the abutments.
|Figure 3a : Abutment analogs in place|
Figure 3b: Occlusal view of abutments after marginal preparation
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|Figure 4 :Locator attachments in maxilla and metal try-in in the mandible|
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|Figure 5 :(a) Occlusal view of the ceramo-metal prosthesis|
Figure 5b: Attachment housing and retention element incorporated into the denture
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Final impressions were made with addition silicone impression material for the maxillary arch to construct maxillary complete denture after a 6-month recall. Healing caps were removed. Low-profile attachments were used due to the limited inter-arch space. A resilient snap type attachment (Locator, Zest Corp., Escondido, CA, USA) was selected, as its total abutment and attachment height is only 3.17 mm, to accommodate the limited inter-arch space. Overdenture abutments were placed intraorally on each implant with a torque wrench (Locator Core Tool; Zest Corp.) applying 20 N cm of force. The attachments, consisting of a metal housing and a plastic resilient retention element, were placed on the abutments and incorporated directly into the denture base with auto-polymerizing resin [[Figure 5]b] in a closed mouth procedure.  The overdenture was tried in the patient's mouth multiple times to check for reduction in retentive values of the Locator attachments.  The patient was comfortable with the stability and retention of the dentures after insertion.
Occlusion was verified with articulating paper with thickness of 63 ╔m (Ardent Horseshoe style, Whipmix Corp., Louisville, Kentucky, USA). The patient was advised on post-insertion care and hygiene maintenance. The patient was recalled for review after 6 months. The patient was pleased with the esthetic result and was comfortable with the stability and retention of the dentures [[Figure 6]a and b].
|Figure 6 :(a) Maxillary and mandibular prostheses in place|
Figure 6b: Patient's smile on treatment completion
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| Discussion|| |
Implants have become an integral part of prosthodontic rehabilitation. Their versatility allows their use in both removable and fixed prostheses. The implant supported overdenture prosthesis can be designed as a combined implant-retained and tissue-supported restoration, which is indicated in compromised situations with four or less implants. When placement of a sufficient number of implants and adequate length is feasible, the superstructure can be totally implant supported.
Careful intraoral examination was crucial to estimate the available inter-arch distance, providing the final prosthesis with the necessary strength, esthetics, and cleansability. In this case, low-profile attachments were preferred to other attachments due to limited inter-arch space. Studies have shown that these attachments demonstrate a greater degree of retention characteristics  and ease in cleansability.  The reduced height of the attachment component also provides easy accommodation for misaligned implants, if any. Long-term prospective trials are required to evaluate the clinical performance of the attachment.
| Summary|| |
This clinical report demonstrates the use of low-profile attachments for a maxillary implant-retained overdenture with limited inter-arch space opposing a full arch implant supported fixed dental prosthesis providing a valuable prosthetic option. The incorporation of the low-profile attachments significantly contributed to denture retention and stability.
| Acknowledgment|| |
The authors like to thank and expresses their gratitude towards (late) Dr. Mohan Kumar for his immense help in preparing the photographs for this case presentation.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]