Clinical Reports Implant Overdenture using the Locator ...

Received: November 21, 2016

Revised: December 2, 2016

Accepted: December 2, 2016

Copyright © 2016. The Korean Academy of Oral & Maxillofacial Implantology

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pISSN : 1229-5418

Implantology 2016; 20(4): 208-219

https://doi.org/10.32542/implantology.20160019

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The Korean Academy of Oral & Maxillofacial Implantology Vol. 20, No. 4, 2016208

Clinical Reports

Implant Overdenture using the Locator System

and the Gothic Arch Tracer in a Mandibular

Edentulous Patient: A Clinical Report

Seoung-Jin Hong1, Seung-Ryong Ha1*, Dong-Jae Seong1, Hyeon-Min Kim2, Jae-Hyuk Ban3,

Hyun-Woo Kim4

1Department of Dentistry, Ajou University School of Medicine, Suwon, Korea2Department of Oral and Maxillofacial Surgery, Gil Medical Center, Gachon University, Incheon, Korea3Department of Oral and Maxillofacial Surgery, BK Dental Hospital, Cheongju, Korea4Director of Yongin Seoul Dental Clinic, Yongin, Korea

*Corresponding author: Seung-Ryong Ha, [email protected]

Abstract

Patients restored with the mandibular complete denture were often faced with complications of

poor stability and retention of the prosthesis. Two implants overdenture is recognized as a

standard treatment method for the edentulous mandible. In a 64-year-old man who represented

severe mobility in all remaining teeth, the maxillary complete denture and the mandibular

implant-retained overdenture were planned after extracting all the remaining teeth. Two

implants were placed in mandibular both canine regions. To fabricate the denture, final

impression was taken using a duplicate of the existing temporary denture. It is difficult to guide

the mandible into the centric relation position in some denture patients. The Gothic arch tracer

was used for accurate centric relation record. For conjunction with dental implants, locator

attachments were used.

Keywords: Denture precision attachment, Gothic arch tracer, Implant overdenture

I. Introduction

Patients wearing complete dentures are frequently suffered from problems of poor

retention and instability of the denture, low chewing efficiency, and pain during

mastication. Several clinical reports have described that these complications may be

successfully improved by implant-retained or implant-supported dental prostheses1-3.

According to McGill consensus statement4, two implants overdenture is recognized as

the standard treatment of edentulous mandible and the evidence exists. Many studies

have demonstrated that implant-retained overdenture in mandible provides improvement

in retention, stability, chewing efficiency, biting force, quality of life, and patient

satisfaction5-7. Because of the smaller prosthesis space requirement, ease of cleansing,

The Korean Academy of Oral & Maxillofacial Implantology Vol. 20, No. 4, 2016 209

IMPLANTOLOGY

lower technical sensitivity, and more economical advantages, solitary type have been preferred to

bar type attachments8,9. Compared to other solitary type attachments, locators are required smaller

space10, dual retention structure (the outer and inner contact surfaces between female and male

parts)11 and higher retention force12. Additionally, locators are self-aligning12, compensation for up

to 40° implants axial discrepancy is possible11 and could be easily repaired and replaced13.

It is not easy to induce the mandible into the centric relation position for some denture patients

resulted from the wrong habitual closure due to inadequate dentures14, trismus15, or temporomandibular

joint abnormalities16-19. Several methods of manipulating centric relation have been demonstrated in

the literature20. The Gothic arch tracing is the one of those methods. It is reported that it could

produce a precise and reproducible centric relation record21-23. This study demonstrates the

application of a Gothic arch tracer and locator attachments for fabrication of the maxillary complete

denture and the mandibular implant-retained overdenture.

II. Case report

A 64-year-old healthy man visited the Ajou University Dental Hospital for treatment of his

maxillary complete denture and mandibular removable partial denture. All the remaining teeth had

severe mobility (Fig. 1). After extracting of all the remaining teeth, maxillary complete denture and

mandibular implant-retained overdenture were planned. There was no problem of medical history

for implant placement.

Fig. 1. Intraoral photo taken at first visit.

Seoung-Jin Hong et al. : Implant Overdenture using the Locator System and the Gothic Arch Tracer in a Mandibular Edentulous Patient: A

Clinical Report. Implantology 2016


Clinical Reports

An impression was taken using alginate impression materials (Aroma Fine Plus Normal set, GC,

Japan) for the fabrication of an immediate temporary denture. The record base and occlusion rim was

produced, contoured for phonetics, esthetics, and determined vertical dimension of occlusion. The

Gothic arch tracer (Gnathometer M type 2, Ivoclar Vivadent, Germany) was attached to the record

base and occlusion rim so that the central bearing pin was located in the center of the tracing plate.

The pin was adjusted for lightly touched on the plate. Wax of occlusal rim was removed until the

central bearing point was the only contact between the mandibular and maxillary record bases.

Record bases were placed intraorally and instruction of mandibular movements to the patient was

necessary to record a Gothic arch tracing. After the patient has described a well-defined Gothic arch,

a dimple was made in the recorded plate at the apex of the arrow for maintenance in centric relation

during a record was being made. In this way, the interocclusal record of centric relation was obtained

using the Gothic arch tracer. A temporary denture was prepared and the remained teeth were

extracted and followed by the immediate placement of the internal submerged type implants on #33

(4.0 mm × 11.5 mm; AR System, Biotem, Seongnam, Korea) and #43 (4.0 mm × 10.0 mm; AR System,

Biotem, Seongnam, Korea). Two mandibular implants in both canine regions were surgically placed

following the manufacturer’s protocol, and final implant insertion torques, greater than 30 Ncm were

achieved (Fig. 2, 3). A healing abutment, measuring 4.5 mm in diameter with 5 mm in height

(HAA455S, Biotem, Seongnam, Korea) on #33 and 4.5 mm in diameter with 7 mm in height

(HAA457S, Biotem, Seongnam, Korea) on #43, was tightened onto the implant. The temporary

denture was relined by a tissue conditioner (Visco-gel, Dentsply, Germany) and placed.

Fig. 2. Placement of implant fixtures (AR system, Biotem, Seongnam, Korea).




IMPLANTOLOGY

Fig. 3. Panoramic view after placement of implant fixtures.



Fig. 4. Upper and lower temporary dentures were duplicated with acrylic resin to use as a custom tray.



Fig. 5. The interocclusal record of centric relation was checked using the Gothic arch tracer with the vinyl polysiloxane bite registration material and the horizontal incisal line was marked using bonding brush.




Clinical Reports

3 months after implant placement, a new set of temporary dentures for custom tray was duplicated

to precisely represent definitive prosthesis occlusion. The maxillary and mandibular temporary

denture was duplicated in acrylic resin (Orthodontic Resin, Dentsply, USA) (Fig. 4). Final

impressions were taken with the polyether impression material (Monophase, 3M ESPE, Germany)

after border molding with modeling plastic impression compound (Peri Compound, GC, Japan)

using a custom tray duplicated of the temporary denture. Wash impressions were taken by closed

mouth functional impression technique. In this case, temporary denture was duplicated as a custom

tray, for appropriate horizontal relation and vertical dimensions, jaw relations were recorded. The

patient was asked various functional movements of closed mouth such as Gothic arch tracing in the

pre-recorded vertical dimension. Functional movements were depicted by the patients. The interocclusal

record of centric relation was checked using the Gothic arch tracer with the vinyl polysiloxane bite

registration material (Futar D, Roydent, USA) and the horizontal incisal line was marked using

bonding brush (Dental Lab Disposable Micro applicators Brushes, Dental supply in, China) (Fig. 5).

The stone cast was mounted in a semi-adjustable articulator (Stratos® 300, Ivoclar Vivadent,

Germany) (Fig. 6). Acrylic artificial teeth (SR Vivodent, Ivoclar Vivadent, Germany) were set on the

semi-adjustable articulator. For ideal tooth set-up with a dorsal increase of the occlusal plane in

models according to the Spee and Wilson curves into account, a setting-up template was used (Fig. 7).

Wax dentures try-in were done in the mouth. Fit, esthetics, retention, stability and support were

evaluated finally. For the improvement of retention, the relining impression of the maxillary complete

denture was made with the polyether impression material (Monophase, 3M ESPE, Germany) and the

Fig. 6. Master model fabricated.




IMPLANTOLOGY

closed-mouth technique with an occlusal inter-digitation using the maxillary wax-denture (Fig. 8).

The midline was corrected. The setting of acrylic artificial teeth was also corrected. Final

prostheses were fabricated by the heat curing system. Curing definitive denture and laboratory

remounting was performed, but was not grinded because of balanced occlusion (Fig. 9-11).

Fig. 7. Ideal tooth set-up with a dorsal increase of the occlusal plane in models according to the Spee and Wilson curves.



Fig. 8. Relining impression of the maxillary complete wax denture with the polyether impression material (closed-mouth technique with an occlusal interdigitation).




Clinical Reports

Fig. 9. Definitive dentures.



Fig. 10. Intaglio surface of upper denture.



Fig. 11. Intaglio surface of lower denture.




IMPLANTOLOGY

The definitive denture was delivered in patient oral cavity. The retention, stability, and esthetic was

evaluated and denture was shown to be properly fabricated (Fig. 12, 13). The healing abutments were

taken off and hand-tightened in a clockwise direction. Mobility, clinical signs of infection, pain and

radiographic bone loss were not shown, and the implants were convinced to be osseointegrated.

Abutments of 4 mm cuff height on #33 (HG Locator® Abutment; Standard, Zest Anchors, USA) and 5 mm

on #43 were tightened to 30 Ncm on both implants. The blue male part (Liner, Zest Anchors, USA) of the

locator was then incorporated into the overdenture with a direct technique using an auto-polymerizing

pattern resin (Pattern Resin LS, GC, America). The overdenture was polished and then inserted in the

mouth, and minimal adjustments were taken to the occlusion and fit. The patient was instructed prosthetic

maintenance and oral hygiene. At a 1-year follow-up after treatment, the patient remained satisfied with

his treatment choice and its effect on his masticatory efficiency and quality of life.

Fig. 12. The definitive denture was placed in the oral cavity.



Fig. 13. Extra-oral view of lip support. Before (left) and after (right) treatment.




Clinical Reports

III. Discussion

Implant overdenture treatment can provide the appropriate support, retention and stability of the

denture, and restored functions and esthetic such as lip support and phonation via a denture flange24.

When planning a bar attachment, the inter-arch distance has to be evaluated. Pasciuta et al.25

described that minimum 14 mm inter-arch distance was required when considering artificial teeth,

denture base, bar thickness, and the hygienic space from the bar to the mucosa. When the inter-arch

distance is insufficient, the bar attachment may resulted in over-contour of the denture, fracture of

the denture, or poor oral hygiene10. When bar splinting attachments is considered for retention, the

resilient type ERA attachments, and different direction multiple clips, the rigid type friction pin, and

swivel latchet have been used previously8. Retention loss is the problem in such attachment caused

by wearing during the repeated removal and insertion of the denture26. In that case, plastic male

parts may be changed. However, metal female parts are required to re-manufacture. To avoid this

situation, the locator attachment system can be selected. It allows 0.2 mm vertical movement and

durable. The locator is easy to use and post-treatment complications are less. Special technical

training is not required. The reported satisfaction of the patient is quite high27. In the majority of the

attachment systems, reduction28 or total loss in retentive force was found9. The wear patterns and

related deformations of attachment during the mastication are different from during insertion-removal

procedure. Denture rotation around the attachments resulted from displacing mucosa under the base

of the denture when occlusal loads are applied29. The resiliency of attachments is determined by the

amount of transmitted loads to the attachments from occlusal loads30,31. For reducing the denture

movement and, thereby, also reducing the forces on the implants, an optimal stress distribution is

important32. The locator retentive force is decreased down to 40% of its full retentive values when

simulated mastication with a non-linear descending curve. The nylon parts were severely worn33.

This represents maintenance correlated with mastication is needed for locator system33.

For the successful restoration in edentulous patients, the appropriate centric relation record is

required. The wear and the deformation of attachment can be reduced by accurate centric relation.

The retentive force is also maintained for a long time, relatively. A precise centric relation record can

be obtained using the Gothic arch tracer. In addition, for the accuracy of the Gothic arch tracer

record, stable record bases are prerequisite. Especially in the Gothic arch tracing technique,

inaccuracy could be resulted from any movement of the record bases during recording of centric

relation. The closed mouth functional impression technique was used and interocclusal record of


IMPLANTOLOGY

centric relation was checked using Gothic arch tracer simultaneously, contribute to stabilize bases,

and thereby minimize movement of bases during the tracing and mounting procedures.

IV. Conclusion

This clinical report describes complete denture in the maxilla and the implant overdenture using

the locator system in the mandible for edentulous patient. For accurate centric relation record, the

interocclusal record was obtained using the Gothic arch tracer.

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Clinical Reports

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