accelerated rehabilitation of an edentulous patient with an implant retained dental prosthesis: a...
TRANSCRIPT
Case repor t
Accelerated rehabilitation of an edentulous patient with animplant retained dental prosthesis: a case report
Gerald McKenna1 and Graeme Lillywhite2
1Edinburgh Dental Institute, Edinburgh, UK; 2Fixed and Removable Prosthodontics, Restorative Dentistry, Edinburgh Dental Institute,
Edinburgh, UK
Gerodontology 2007; 24; 181–184
Accelerated rehabilitation of an edentulous patient with an implant retained dental prosthesis: a casereport
This case report details the successful rehabilitation of an edentulous patient using a complete upper
prosthesis and a lower implant retained overdenture. The provision of care was split between a specialist
centre and a primary care setting. This approach reduced inconvenience to the patient. Modern surgical
and prosthodontic techniques also reduced the total delivery time.
After initial consultation a new set of complete dentures was prescribed with changes in design to the
originals. The patient was also planned for placement of two mandibular implants to stabilise and retain
the mandibular denture. The first line of treatment involved provision of a new set of dentures con-
structed by the patient’s general dental practitioner. Dental implants were then placed in a specialist
centre and the patient returned to the dental practice for attachment of the lower denture to the dental
implants.
The benefits and success of mandibular implant retained dentures are well documented. With delivery of
the overdenture, the patient reported increased satisfaction with his prostheses which allowed him to eat a
greater range of foods and enabled him to feel confident when speaking and socialising.
Keywords: edentulous, implant, overdenture.
Accepted 9 January 2007
Introduction
The number of patients becoming edentulous in
the United Kingdom is decreasing. At the time of
the first national survey of adult dental health in
1968 over one-third of the population had no
natural teeth, and by 1998 this figure had fallen to
just 13% of all adults1,2. It is estimated that by
2028 only 4% of the same population will be
edentate2.
Functional problems associated with edentu-
lousness, such as poorly retained dentures and
diminished chewing efficiency are widely reported.
The practice of food avoidance is common place.
Other less well documented consequences of
edentulousness include disability (lack of ability to
perform daily tasks such as speaking and eating)
and handicap (reduction of social contact due to
embarrassment associated with wearing complete
dentures)3,4,5.
Although the overall prevalence of total tooth
loss has fallen sharply over recent decades, clinical
management is becoming increasingly more com-
plex. This is a result of patients becoming
edentulous at an older age when they are generally
less able to adapt to the limitations of complete
dentures. Added to this, are higher expectations of
dental treatment by patients and a reluctance to
accept functional compromise that has long been
the acknowledged consequence of total tooth loss.
Oral rehabilitation with an implant-supported
prosthesis, in partially or totally edentulous cases
has become a well-documented therapy over the
past 35 years since Branemark placed the first
endosseous implant in 19656. Numerous studies
have proven the benefits of such treatment in the
edentulous patient7. There have also been rapid
developments in dental implant treatment proto-
cols to reduce the time between implant placement
and restoration.
� 2007 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2007; 24: 181–184 181
As in the case detailed below, early restoration of
dental implants can speed delivery of an implant-
retained overdenture and help convey its benefits
to patient with minimal delay.
Case report
Referral details and history
A medically fit 61-year-old gentleman was referred
by his General Dental Practitioner to a Specialist
Prosthodontist for provision of new dentures. The
patient had worn a complete maxillary denture
successfully for 15 years. However, since losing his
remaining lower natural teeth and receiving a
mandibular complete denture 10 years ago, he had
experienced great difficulty with pain from beneath
the mandibular prosthesis and looseness in func-
tion. He reported functional difficulties, including
problems chewing and speaking, and found social
interaction embarrassing and difficult. Although he
attended wearing his mandibular prosthesis, he
admitted he wore it only very occasionally.
On examination
A comprehensive clinical examination was carried
out which revealed a well-defined maxillary ridge
offering good support. The mandibular ridge was
severely resorbed. The anterior ridge was classified
as Cawood and Howell class VI and the posterior
class V. There was little potential to retain a suc-
cessful mandibular prosthesis. A dental panoramic
tomogram was made of the patient. This showed
there was sufficient bone in the anterior mandible
to place endosseous dental implants between the
mandibular foramen. The bone quality appeared
good.
Treatment plan
The findings were discussed with the patient and a
plan of management agreed. In view of the poor
form of the lower ridge, an implant retained over-
denture was considered most appropriate. However
as the existing dentures were poor it was decided
these should first be remade.
Treatment delivery phase 1 – conventional denture
construction in general practice
The patient’s general dental practitioner produced
new complete dentures to conventional prostho-
dontic principles and according to the prescription
of the specialist prosthodontist. Although improve-
ments were noted, the patient was still unable to
wear and use his mandibular prosthesis. In prepar-
ation for implant placement, a radiographic and
surgical stent was made by duplicating the man-
dibular prosthesis in clear acrylic resin (Fig. 1).
Treatment delivery phase 2 – implant placement
in a specialist centre
After construction of new complete dentures the
patient returned to the specialist centre for implant
placement. Two 13 mm long dental implants of
4 mm diameter were placed in the anterior man-
dible under local anaesthesia using a one-stage
procedure.
A review appointment was made for 1 week at
which time the sutures were removed. The denture
was adjusted, a radiograph taken which confirmed
good positioning of the implants (Fig. 2) and
arrangements made for their restoration with stud
attachments in general practice.
Treatment delivery phase 3 – implant restoration
in general practice
Eight weeks post-implant placement the patient
attended his general dental practitioner. Stud
transfer caps were placed onto the abutments.
A relining impression was made in the denture using
polyvinylsiloxane impression material and a pick up
technique. As well as recording the fitting surface
the transfer caps were captured in the denture.
Upon removal from the mouth, stud analogues
were placed in to the captured transfer caps and the
denture was sent to the laboratory for relining and
Figure 1 Radiographic and surgical stent with slots at
proposed implant sites.
� 2007 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2007; 24: 181–184
182 G. McKenna, G. Lillywhite
insertion of the retentive components for the stud
abutments (Figs 3–5).
Six weeks after delivery of the overdenture the
patient was reviewed and he reported increased
satisfaction with his dentures, being able to wear
them at all times. The overdenture was stable in
function and the patient was able to eat a greater
range of foods, feeling confident when speaking
and socialising (Fig. 6).
Discussion
Studies show that provision of well-constructed
new dentures, either conventional or implant
retained, can have a positive impact on patents’
lives. However, patients fitted with implant
supported overdentures rate general satisfaction,
comfort, stability and ability to chew and speak
significantly higher when compared with patients
fitted with conventional dentures. These improve-
ments have additional positive benefits to the
patients’ social and psychological well being4.
The evidence currently available suggests that a
two-implant overdenture should become the first
choice of treatment for the edentulous mandible8.
Figure 3 Transfer caps on studs ready for pick up in
reline impression.
Figure 5 Stud analogues placed in transfer caps ready
for rebasing and insertion of retentive elements.
Figure 6 Post operative view.
Figure 4 Transfer caps captured in reline impression.
Figure 2 Implants with transmucosal healing caps
1 week post insertion.
� 2007 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2007; 24: 181–184
Accelerated edentulous rehabilitation using dental implants 183
In Scotland it has been recommended to the
Scottish Executive that dental implant treatment
be made available for all adult patients who
cannot wear complete dentures because of severe
atrophy of the alveolar ridges but are capable
of maintaining adequate standards of oral
hygiene9.
The treatment protocols used in this case illus-
trate the shift in opinion regarding loading of
dental implants. Previously, 3 months was thought
to be the minimum length of time required to allow
healing and encourage osseointegration. Now most
centres would facilitate loading at 8 weeks and
some even advocate immediate loading. With early
restoration of the implants in this case, the patient
gained the advantages of an implant-retained
prosthesis at a much earlier stage.
Adopting a team-based approach afforded the
patient a number of advantages in this case but was
made possible by the fact that general dentists can
provide successful mandibular two-implant over-
dentures with minimal training10.
Conclusions
The patient presented had struggled with con-
ventional dentures for 10 years. Due to his
atrophic and poorly defined lower ridge, con-
struction of a satisfactory lower denture had
proved impossible. After provision of a lower im-
plant supported overdenture and a new conven-
tional upper denture the patient reported a huge
improvement in satisfaction. The patient was
managed effectively with close cooperation be-
tween a specialist centre and a general practice
where such a treatment protocol can be carried
out successfully.
References
1. Gray PG, Todd JE, Slack GL, Bulman JS. Adult
Dental Health in England and Wales in 1968. Br Dent
J 1970; 129: 107–116.
2. Steele JG, Treasure E, Pitts NB, Morris J,
Brandnock G. The UK Adult Dental Health Survey
1998. Br Dent J 2000; 189: 598–603.
3. Mojon P, Thomason JM, Walls AW. The impact of
falling rates of edentulism. Int J Prosthodont 2004; 17:
434–440.
4. Thomason JM, Lund J, Chehade A, Feine J.
Patient satisfaction with mandibular implant over-
dentures and conventional dentures 6 months after
delivery. Int J Prosthodont 2003; 16: 467–473.
5. Carlsson GE. Masticatory efficiency: the effect of
age, the loss of teeth and prosthetic rehabilitation. Int
Dent J 1984; 34: 93–97.
6. Zarb GA. The edentulous melieu. J Prosthet Dent
1983; 49: 825–831.
7. Branemark P-I, Zarb GA, Albrektsson T. Tissue-
Integrated Prosthesis: Osseointegration in Clinical Dentistry.
Chicago, IL, USA: Quintesssence, 1985.
8. Feine JS, Carlsson GE, Awad MA et al. The McGill
consesnsus statement on overdentures. Int J Prostho-
dont 2002; 15: 413–414.
9. McCall DR, Bain C, Radford JR et al. Scottish Needs
Assessment Report, Dental Implants. Glasgow: NHS
Health Scotland, 2004 (April) 2004.
10. Esfandiari S, Lund JP, Thomason JM et al. Can
general dentsists produce successful implant over-
dentures with minimal training?. J Dent 2006; 34:
796–801.
Correspondence to:
Dr Gerald McKenna, Edinburgh Dental Institute,
Lauriston Building, Lauriston Place, Edinburgh,
EH3 9HA, UK.
Tel.: 0131 536 4970
E-mail: [email protected]
� 2007 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2007; 24: 181–184
184 G. McKenna, G. Lillywhite