See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/346775939

Implant Retained Overdenture: Splint Approach Using Copy Dentures

Article · December 2020

CITATIONS READS

0 371

3 authors:

Aruna Wimalarathna Manori Jayasinghe

University of Peradeniya University of Peradeniya
27 PUBLICATIONS   2 CITATIONS    39 PUBLICATIONS   47 CITATIONS   

SEE PROFILE SEE PROFILE

Ajith Manjula Attygalla

University of Peradeniya
70 PUBLICATIONS   93 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Radialfoream as beginner flap in microsurgery View project

Dental implant View project

All content following this page was uploaded by Aruna Wimalarathna on 09 December 2020.

The user has requested enhancement of the downloaded file.

 Case Report
Sri Lanka Dental Journal 2019; 49(03) 116-123

Implant Retained Overdenture: Splint Approach Using Copy Dentures

A.A.A.K. Wimalarathna, R.M. Jayasinghe, A.M. Attygalla

Abstract adhering to a variety of techniques during

Implant retained overdenture is one of the
popular dental treatnment modalities among
completely edentulous people. Positioning of
the implants in highly resorbed alveolar bones is
the most difficult task considering this treatment
modality. The usage of a surgical guide or
template is one of the recommended approaches
place the implants in the most desirable position
on the alveolar ridges. The common practice of
making surgical stents is by using a radiological
guide plate embedded with radiopaque material
in relation to the planned locations of implants
or by using a 3D printed guide plate. This case
report describes a novel technique of using a
copy denture for fabrication of a surgical stent.
Keywords: Implants, Overdenture, Splint, Copy
denture, Prosthesis.
Introduction
Edentulous patients suffer from poor retention
of their conventional dentures mainly due to
severe alveolar bone resorption after long term
extractions. Bone resorption is more prominent
in the mandible when compared to maxilla
creating an unfavorable platform for prosthetic
rehabilitation'. Therefore, various clinicians
have attempted to overcome this problem by
conventional denture construction such as
neutral zone impression techniques and using a
monoplane occlusion scheme.
Implant supported prostheses have been
introduced as an effective altermative to overcome
many concerns associated with conventional
dentures. They have shown multiple advantages
such as alveolar bone preservation, improved
retention, stability, function, proprioception
and comfort?. Dental implant options for
edentulous arches include implant-supported
fixed prostheses, implant-retained overdentures
and implant-supported overdentures (1OD)}
Some authors use the terms of implant retained
and supported over dentures synonymously.
The advantages of implant retained/ supported
overdentures are described as enhancing function
and phonetics', effectiveness in maintaining oral
hygiene', increased masticatory efficiency',
increased maximum myoelectric output and less
age-related alveolar bone loss when compared
with conventional complete dentures'.
Dental implant treatment has been associated
with a high success rate over many years. The
10-year survival rates of implants supported
mandibular overdentures are shown to be

A.A.A.K. Wimalarathna Senior Registrar in Restorative Dentistry, Faculty of Dental Sciences, University of Peradeniya.
E-mail: aaakwimalarathna@gmail.com

R.M. Jayasinghe Senior Lecturer, Department of Prosthetic Dentistry, Faculty of Dental Sciences, University of
Peradeniya.
A.M. Attygalla Professor in OMF Surgery, Department of Oral & Maxillofacial Surgery, Faculty of Dental
Sciences,University of Peradeniya.

116
 A.A.A.K. Wimalarathna, R.M. Jayasinghe, A.M. Attygalla
slightly higher than of endosseous implants
in the mandible uscd to support fixed full-
arch bridges or single crowns". The studies
conducted by Haraldson et al.", Nacrt et al. " and
Bruggenkate et al." have revealed survival rates
of 100% for them. On the other hand some of
the studies have shown the survival rates around
87% by Engquist2 and 74.8% by Versteegh et
al. According to MacGill Consensus Statement
on overdentures in 2002, two implantsare
suficient for the 1OD in edentulous mandiblel
and four to six implants have been recommended
for edentulous maxilla5. 1ODs are also a cost
effective treatment modality compared to implant
supported fixed prostheses. They provide facial
support by restoring both dental and alveolar
tissues. Furthermore, they are relatively simple,
easy to construct and esthetically more pleasing.
Figure 1. Pre-operative intra-oral images of
the upper and lower alveolar ridges
Case Presentation
A 70-year-old male patient presented to the
Department of Prosthetic Dentistry, Faculty
117
of Dental Sciences, University of Peradeniya
with the main complaint of edentulousness
of both upper and lower jaws with dificulty
in mastication. The patient had been an
existing denture wearer with poor retention
and difficulty in tolerating the dentures during
speech, especially the lower one. He had been
edentulous for 12 years and he requested some
form of fixed prostheses in order to overcome
his concerns with removable prosthesis.
The maxillary arch was identified as U-shaped
and with a high vault hard palate. His mandibular
ridge was U-shaped with an irregular ridge
contour (Figure 1).
Radiographic assessment revealed availability
of sufficient good quality and quantity of bone
(Figure 2). Considering the favorable factors,
it was decided to rehabilitate the patient with
implant retained upper and lower overdentures.
The complete dentures were fabricated using
the conventional technique prior to placement
of implants (Figure 3). At the denture delivery
stage, premature occlusal contacts were removed
and balanced occlusion and articulation were
achieved. The patient was reviewed again
within 48 hours and 1 week later as the common
practice. The patient was asked to wear the
complete dentures for about 1 month prior to
placement of implants.
 Retained Overdenture: Splint Approach Using Copy Dentures
Implant

Figure 2. CBCT images of the desired

implants locations of 13, 23, 33 and
43 regions

G Omm

B Imn

Figure 3. Fabrication of upper and lower

conventional complete dentures
Implant assessment and treatment planninS
were performed with the help of radiographic
investigations. According to the availability
of bone and standard
implant protocols, two
and four conventional
implants were planned
respectively for the mandible and maxilla to
support the overdentures. Implants sites were

118
 A.A.A.K. Wimalarathna, R.M. Jayasinghe, A.M. Attygalla

planned as follows;, bilateral canine regions in

mandible and bilateral canine and first premolar
regions in maxilla. The positions and the
angulations of desired implants were considered
in order to transfer the details
of patient's
alveolar arches by using a surgical stent.

The fundamental ways of making surgical stents

are by using a radiological guide plate which
is with some embedded radiopaque material
into the stent in relation to planned locations of
implants or by using a 3D printed guide plate. In
Figure 4. Different stages of denture copying
this case report, we presented a novel approach
procedure
of surgical stent that fabricated by denture
impression material extruded almost exceeding
copying. After a month of denture wearing,
the periphery of the denture. Once it was set,
patient was satisfied about comfort of newly
borders of the impression were trimmed and
fabricated dentures and they were used to make
location grooves were placed. After applying a
an implant surgical stent by duplicating them
separating medium over the fitting surface and
(Figure 4). after the putty was set, the two halves of the
Slightly larger upper stock trays were used impression were carefully separated and the
where the impression material was loaded to denture was removed out. Sprue holes were
record the external surfaces of the denture using made to pour the cold-cure acrylic into the entire
denture space instead of malted wax in order to
polyvinyl siloxane putty. The tray was filled with
make the surgical stent by directly duplicating
a mixture of silicone putty and
pressed until the from the denture.

Duplicated dentures were inserted into the

patient's mouth and fine adjustments were

99
done. The implant guided holes were made in
the duplicate dentures in relation to the desired
locations for implants (Figure 5). Implants
locations were marked on the oral mucosa
through the guided holes in stent by using
undeletable ink (Figure 6).

Figure 5. Copying dentures were used as

surgical stents

119
 Implant Retained Overdenture: Splint Approach Using Copy Dentures

the denture template,the osteotomies were done

on right and left canine and first premolar
implant sites. Four implants (4.1 mm X 10.0
mm) were placed at the osteotomy sites with a
torque of 50 Ncm and covering screw till 4Ncm.
Similarly, two mandibular implants (3.5 mm X
10 mm) in relation to canine regions were placed
(Figure 7).

After 7 days, sutures were removed. Denture

Figure 6. Implant locations were marked
through the guided holes
Full thickness crestal incision was placed from
first premolar on one side to opposite in maxilla
and the mucoperiosteal flap was reflected. The
surgical template was then placed inside the
patient's mouth and proposed implant site was
marked with a round surgical bur. While keeping
bases were relined for better adaptability. The
patient was recalled after 3 months and retentive
attachments (Ball abutments and metal housings
with O-rings) were placed in the denture using
self-cure acrylic resin (Figure 8). The patient
showed improvement in lip fullness, reduced
wrinkles and drooping of mouth. Patient was
satisfied with the retention, stability and support
of the dentures (Figure 9).

(a) (b)
Figure 7. Implant locations were marked through the guided holes

Figure 8. Immediately after placement of implants in both upper and lower jaws

120
 A.A.A.K. Wimalarathna, R.M. Jayasinghe, A.M. Attygalla

Figure 9. Pre-and post-operative facial profiles

Discussion locate the implant and the positions of the metal

Two-implant-supported over dentures have
been recommended as the treatment of choice
for edentulous mandibles since 2002 when the
expert committee has conducted the McGill
Consensus Considering the
eftect, two inter-foraminal implants supported
overdenture is a reliable treatment option and
IS a good choice for the edentulous lower jaw.
In addition, recommendations have also been
made with regard to removable restorations
on four to six implants in maxilla. Recent
studies have that 5 year survIval rates
reported - individual preferences of clinicians. Both
between 94% and 100%. marginal loss of <0.6
mm during a 5-year period and a higher degree
of patient satisfaction when implant supported
overdentures are considered".
Literature does not suppot any
System as superior to others. The choice of the
attachment system depends on the experience
of the clinician and available facilities. A bar
attachment can be used for primary splinting
of the implants in order to minimize axial loads
on implants especially when the implants are
short and with low bone quality. The locator
housing while inserting the denture due to
poor dexterity compared with bar attachment.
Geriatric patients are more likely to undergo
implants retained overdentures as the procedure
cost-bencefit is simple; improves their overall functions and
the quality of life0
Literature describes the importance of using
surgical stent as an implant placement guide
plate. There are different practices in different
areas in the world and done according to the
the base-plate and the teeth of the duplicated
denture was fabricated with cold-cure acrylic
and using it as a implant surgical template has
been described rarely in the literature. It was
really beneficial to avoiding the damages to the
attachment flanges, minimizing the over-trimming of the
fitting surtace and preventing the unnecessary
perforations of the teeth/polishing surface of
the definitive denture while placing the locaters.
Those are the added advantages of preserving
the esthetic outcome and physical strength of
the denture.

excellent clinical outcomes, Conclusion

systems yield
Splint construction using copy denture approach
to use them in
although it may be dificult
can be recommended as a technique for the
Very elderly patients due to lack of ability to

121
 Dentures
Implant Retained Overdenture: Splint Approach Using Copy

Batenburg RH, Vissink A. Mandibular

placement of implants during implant retained overdentures supported by two or four
over denture fabrication. It is necessary to do
the CBCT bone assessment prior to locating endosseous implants A 5-year prospective
the implant positions on the splints made using study. Clin Oral Impl Res 2005;16:19-25.
duplicated dentures.
Haraldson T, Jemt T, Stälblad PA,
9.
References Lekholm U. Oral function in subjects with
overdentures supported by osseointegrated
1. Samyukta, Abirami G. Residual Ridge implants. Scand J Dent Res 1988;96(3):235-
Resorption in Complete Denture Wearers J. 42
Pharm. Sci. & Res 2016;8(6):565-569.
10. Naert I, Quirynen M, Hooghe M, van
2. Luthra R, Sharma A, Kaur P. Implant Steenberghe D. A comparative prospective
Supported Overdenture: A Case Report. study of splinted and unsplintedBrånemark
PeriodonProsthodon. 2016, 2:2. implants in mandibular overdenture
therapy: A preliminary report. J Prosthet
3. Galind DE The implant-supported Dent 1994;71(5):486-92. 17.
milled-bar mandibular overdenture. J
Prosthodont2001;10:46-51. 11. Bruggenkate CM, Muller K, Oosterbeek
HS. Clinical evaluation of the ITI (F-type)
4 Worthington P, Bolender CL, Taylor TD. hollow cylinder implant. Oral Surg Oral
The Swedish system of osseointegrated Med Oral Pathol 1990,70(6):693-7.
implants: Problems and complications
encountered during a 4-year trial period. Int
12. Engquist B. Six years' experience ofsplinted
J Oral Maxillofac Implants 1987;2(2):77-
and nonsplinted implants supporting
84. overdentures in upper and lower jaws. In:
Schepers E, Naert I, Theuniers G, (Editors).
5. Zarb GA, Schmitt A. The edentulous
Overdentures on Oral Implants, Leuven:
predicament. II: The longitudinal
Leuven University Press; 1991. p. 27-41.
effectiveness of implant-supported
overdentures. J Am Dent Assoc
13. Versteegh PA, van Beek GJ, Slagter AP,
1996;127(1):66-72. Ottervanger JP. Clinical evaluation of
Carr AB, Laney WR. Maximum occlusal mandibular overdentures supported by
6.
force levels in patients with osseointegrated multiple-bar fabrication: A follow-up
oral implant prostheses and patients with study of two implant systems. Int J Oral
Maxillofac Maxillofac Implants 1995;10(5):595-603.
complete dentures. Int J Oral
Implants 1987;2(2):101-8.
14. Boerrigter EM, Geertman ME, Van Oort RP,
Bouma J, Raghoebar GM, van Waas MA,
7. Bakke M, Holm B, Gotfredsen K. et
Masticatory function and patient satisfaction al. Patient satisfaction with implant-retained
with implant-supported mandibular mandibular overdentures. A comparison
overdentures: A prospective 5-year study. with new complete dentures not retained
Int J Prosthodont 2002;15(6):575-81. by implants A multicentre randomized
clinical trial. Br J Oral Maxillofac Surg8
8. Visse A, Raghoebar GM, Meijer HJ, 1995,33(5):282-8.
122
 A.A.A.K. Wimalarathna, R.M. Jayasinghe, A.M. Attygalla
15. Jivraj S, Chee W, Corrado P. Treatment
planning of the edentulous maxilla. British
Dental Journal 2006; 201: 261-279.
16. Feine JS, Carlsson GE, Awad MA (2002)
The McGill consensus statement on
overdentures. Mandibular two-implant over
dentures as first choice standard of care for
edentulous patients. Gerodontology 19:3-4
17. Gotfredsen K, Holm B. Implant-supported
mandibular overdentures retained with
ball or bar attachments: A randomized
prospective 5-year study. Int J Prosthodont
2000;13(2):125-30.
18. Krennmair G, Krainhofner M, Piehslinger
E (2007) Implant-supported mandibular
overdentures retained with a milled bar: A
Retrospective Study. Int J Oral Maxillefac
123
View publication stats
Implants 22: 987-994.
19. Arat BS, Baykasoglu C, Kutay 0, Mugan
A. Effect of attachment types and number
of implants supporting mandibular over
dentures on stress distribution: A computed
tomography-based 3D finite element
analysis. J Biomech 2015; 48: 130-137.
20. Müller F, Duvernay E, Loup A, Vázquez,
L, Herrmann FR, et al. Implant-supported
mandibular over dentures in very old adults,
a randomized controlled trial. J Dent Res
2013; 92: 154-160.
21. Kola MZ, Shah AH, Khalil HS, et al.
Surgical templates for dental implant
positioning; current knowledge and clinical
perspectives. Niger J Surg. 2015;21(1):1-5.