accelerated rehabilitation of an edentulous patient with an implant retained dental prosthesis: a...

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: geraldmckenna@nhs.net

� 2007 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2007; 24: 181–184

184 G. McKenna, G. Lillywhite