DR. RITESH SHIWAKOTI

MScD PROSTHODONTICS

NAZIA MAJEED ZARGARJOURNAL OF OROFACIAL RESEARCH APRIL-JUNE 2013;3(2):152-156

Rehabilitation of an atrophic edentulous jaw is still a real challenge

Maxilla is more frequent to get edentulous

25% the width and 4 mm height of alveolus bone loss occur in the first year after extraction

Over a long term there is extensive bone loss even in the denture wearers

Bone loss occurs in the labial side thus shifting the residual ridge to the lingual side

Thus the atrophic jaw can be restored by endostealimplants and this has become a revolutionary

Age : 54

Sex : Male

Chief complaint : ill fitting mandibular denture and unsatisfied with it

Examination : upper and lower edentulous jaw with resorption more on the mandible

Patient had no other medical disease

So, a maxillary conventional complete denture and a mandibular removable implant overdenture is planned as treatment.

1. A diagnostic impression using alginate is made of the edentulous mandibular ridge and poured

2. Two metal balls was placed on the premolar area of the ridge and fixed with the help of carding wax

3. A template is fabricated over the metal balls using autopolymerising resin

This prepared template was then worn by the patient while taking the panoramic radiograph so that the distance between the mental foramen from the metal balls could be determined

Location of the inferior alveolar nerve needs to be evaluated prior to implant placement

Exact location of the mental foramen and the presence or absence of the anterior loop needs to be determined

Evaluation of the available bone height

The symphyseal height of the mandible was found to be 20 mm

The right metal ball is close to the right mental foramen

There is space between the left metal ball and the left mental foramen

Is was planned that the implant site be selected between the mental foramen as there was optimum symphyseal height and this region presents the optimal density of the bone for implant support

Initially the number of implant was decided as four , two between the mental foramen and two in the posterior region , but due to the financial capability of the patient only two implant was then decided

Right implant was decided to be placed at the place of the right metal ball as its distance from the mental foramen was optimum but the left implant was decided 2 to 3 mm left to the metal ball

This implant area was marked in the template and a 4 mm diameter hole was made

Patient was premedicated with antibiotics (NovamoxCipla 1 gm , 1 hour before surgery)

Surgery was performed using local anesthesia

The template was placed in mouth and surgical mark was made through the implant point hole with a BP blade

Supracrestal incisions were made and the buccal and lingual full thickness mucoperiosteal flaps were raised

Using the surgical template , Nobel Biocare Replace

tappered TiU implant 3.5*16 mm2 were placed at the tooth 34 and 44 locations.

Surgical cover screws were placed and the flaps closed

Patient was instructed to discontinue the use of the lower denture for 2 week following surgery

Sutures were removed after 2 weeks and the denture was soft relined. This allowed the patient to wear the removal prosthesis during the period of osteointegration without transmitting excessive forces to the surgical site

The second stage surgery was done after 4 months according to the Brenmark protocol that states that dental implant are to be submerged beneath the soft tissue at the time of the placement and allowed to heal for least 3 month in the mandible

Here the implant were exposed, the surgical cover screws were removed and the site were irrigated with sterile normal saline. Healing collar were placed, and the gingival tissue were allowed to mature for 1 month for soft tissue healing.

Both the maxillary and the mandibular denture were fabricated beforehand.

A month after the placement of the healing collars a ball abutments ( Nobel Biocare )of the collar height 0.5 mm were placed.

Gold caps were placed on their respective ball abutments and stabilized in the mouth with the help of putty (Reprosil – dentsply)

Two holes were made on the tissue surface of the mandibular denture where gold caps would be attached

Na autopolymerizing resin was placed into the holes in the mandibular denture and the denture was placed in the mouth with the gold caps in place over the ball abutments.

The cold cure was allowed to set and then the denture removed

Gold caps were transferd to the tissue surface of the mandibular denture. Excess of the cold cure was removed

The gold caps were tightened using its activator, to the desired tightness

The maxillary and mandibular complete denture were inserted

On an atrophied edentulous ridge an implant overdenture improves the quality of life of the patient.

An endosteal implant along with ball attachment could be seen from the above case.

Panoramic x-ray plays an important role in guiding the location for the implant placement.

This type of implant supported overdenture improves the retention and stability of the denture.