2009-21-03-139-142-full - Saudi Dental Journal

ISSN (Print) 1013-9052
EISSN 1658-3558

The Saudi Dental Journal,
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Riyadh 11563,
Kingdom of Saudi Arabia

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Email	saudidj@ksu.edu.sa

Rehabilitation of the edentulous mandible with implant-supported overdenture using ball attachments and healing abutments: A case report
Jun-Beom Park

Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 1664 McIntyre Drive, Ann Arbor, MI 48105, USA

Keywords

Implant overdenture; Edentulous mandible; Ball attachment; Healing abutment

Abstract

For many years, osseointegrated implant-supported overdentures have been used in the rehabilitation of the edentulous lower jaw with excellent results. In this report, additional implants with healing abutments were applied posterior to mental foramen on each side was used to achieve additional support to the overdenture.

1. Introduction

Several treatment options with implant have been described for mandibular edentulous patients (Sadowsky, 2007). For many years, osseointegrated implant-supported overdentures have been used in the rehabilitation of the edentulous lower jaw with excellent results (Naert et al., 1991). Two to four interforaminal dental implants is reported to show high success rate (Batenburg et al., 1998; Celik and Uludag, 2007). However, the mucosa-implant-borne treatments may give continuing posterior jaw bone resorption (Jacobs et al., 1992) and implant-borne overdenture may give a long cantile¬ver bar (Sadowsky and Caputo, 2004).

In this report, additional implants were placed posterior to mental foramen with healing abutments to achieve additional support to the overdenture.

2. Case Report

A 53-year-old male patient presented to the Department of Periodontology at the Armed Forces Capital Hospital, Seong-nam-si, Korea, for evaluation of periodontal condition. The patient did not have any medical conditions and was not tak¬ing any medications that were associated with a compromised healing response. Clinical and radiographic examination indi¬cated generalized severe alveolar bone loss and apically in¬volved teeth (Fig. 1A-C). The patient was referred to the Department of Prosthodontics for further evaluation and fab¬rication of treatment plan. Treatment with implant-supported overdenture on the mandible was planned. The patient was given a detailed explanation concerning the present state, pro¬cedures and alternative treatment plans and then informed consent was obtained from the patient.
All the mandibular teeth were removed and the extraction sockets were thoroughly debrided and degranulated to remove all tissue. Following 2 weeks of healing, computed tomo- graphic examination was performed to assess the available bone length and width (Fig. 1D). Four implants were planned to be placed with two in the canine and the others in the first molar region.
Three implants (Implantium, Dentium, Seoul, Korea) were installed first in the lower canines and first molar region with the aid of surgical stent. The defected area next to the extrac¬tion area and the marginal voids between the implant surface and the buccal cortex were grafted with deproteinized bovine bone (Bio-Oss, Geistlich Pharm AG, Wolhausen, Switzerland) (Fig. 2A). An acellular dermal matrix graft (Sure-DermTM; Hans Biomed Corp., Seoul, Korea) was shaped to completely cover the defect and bone graft in a saddle-like manner with the basement membrane side facing the oral cavity and secured under the buccal and lingual flaps. The wound was closed by means of single sutures (Vicryl, Johnson and Johnson Medical Inc., Arlington, TX, USA). The patient was placed on amoxi¬cillin 500 mg 3/day for 5 days, mefenamic acid 500 mg initially then mefenamic acid 250 mg 4/day for 5 days, and chlorhexi-dine digluconate 0.12% 3/day for 4 weeks. The ball attach¬ments (Dentium, Seoul, Korea) were placed and torque to 15 N cm in the both canines and the healing abutment was placed in the first molar region 3 months after implant instal¬lation (Fig. 2B). Vent holes were created in the denture to accommodate the caps for ball attachments (Fig. 2C). With these caps seated on the attachment and the denture in place, self-curing acrylic resin was introduced into the denture vents and allowed to cure with the patient biting in centric relation. The additional surgery to place implant on the left mandibular molar was done. The healing abutment was connected to sup¬port the mandibular overdenture. Meanwhile, the full-mouth tooth extraction was performed on the maxilla and the upper jaw was restored with the complete denture.

The prosthesis was well in function up to 18 months. The clinical assessment showed good result without bleeding on probing and minimal plaque (Fig. 3A). The radiographic eval¬uation showed stable bone level around all implants (Fig. 3B).

3. Discussion

It was reported that no significant differences in the peri-im¬plant health between two implants and four implants (Baten-burg et al., 1998). But the retention and stability of the dentures may be improved with an increasing number of im¬plants (Mericske-Stern, 1990). Continuing posterior jaw bone resorption may be seen for the resilient overdenture design (Ja¬cobs et al., 1992). This could result in a tilting of the overden-ture and unfavorable loading in the anterior region of the edentulous maxilla treated with a removable denture, which in¬volves increased bone resorption in the anterior region (Jacobs et al., 1993). In this view, additional two implants were in¬serted posterior to mental foramen to distribute the load and increase stability (Mericske-Stern, 1998).

In this report, ball attachment was applied because, it is re¬ported that ball attachment are less costly, less technique sen¬sitive (Naert et al., 1991), and easier to clean than bars (Cune et al., 1994) and less wear or fracture of the component than that of gold alloy bars (Schmitt and Zarb, 1998). Moreover, the potential for mucosal hyperplasia reportedly is more easily reduced with ball attachments (Krennmair and Ulm, 2001). It was also reported that the use of the ball attachment may be advantageous for implant-supported overdentures with regard to optimizing stress and minimizing denture movement (Tokuhisa et al., 2003). The approach in this report using ball attachments with healing abutments as supporting structure has an advantage of being incorporated at the chair side. Even though the patient was satisfied with chewing ability with three implants, the patient reported higher satisfaction of increased stability with the fourth implant. The healing abutments can later be changed to other attachment if needed.
Combining ball attachments with additional abutment with healing abutment may be beneficial in increasing the stability. Further follow-up is needed to evaluate long-term result.

References

Batenburg, R.H., Meijer, H.J., Raghoebar, G.M., Vissink, A., 1998. Treatment concept for mandibular overdentures supported by endosseous implants: a literature review. Int. J. Oral Maxillofac. Implants 13, 539-545.

Batenburg, R.H., Raghoebar, G.M., Van Oort, R.P., Heijdenrijk, K., Boering, G., 1998. Mandibular overdentures supported by two or four endosteal implants. A prospective, comparative study. Int. J. Oral Maxillofac. Surg. 27, 435-439.

Celik, G., Uludag, B., 2007. Photoelastic stress analysis of various retention mechanisms on 3-implant-retained mandibular overdentures. J. Prosthet. Dent. 97, 229-235.

Cune, M.S., de Putter, C., Hoogstraten, J., 1994. Treatment outcome with implant-retained overdentures: part II - patient satisfaction and predictability of subjective treatment outcome. J. Prosthet. Dent. 72, 152-158.

Jacobs, R., Schotte, A., van Steenberghe, D., Quirynen, M., Naert, I., 1992. Posterior jaw bone resorption in osseointegrated implant-supported overdentures. Clin. Oral Implants Res. 3, 63-70.

Jacobs, R., van Steenberghe, D., Nys, M., Naert, I., 1993. Maxillary bone resorption in patients with mandibular implant-supported overdentures or fixed prostheses. J. Prosthet. Dent. 70, 135-140.

Krennmair, G., Ulm, C., 2001. The symphyseal single-tooth implant for anchorage of a mandibular complete denture in geriatric patients: a clinical report. Int. J. Oral Maxillofac. Implants 16, 98¬104.

Mericske-Stern, R., 1990. Clinical evaluation of overdenture restora¬tions supported by osseointegrated titanium implants: a retrospec¬tive study. Int. J. Oral Maxillofac. Implants 5, 375-383.

Mericske-Stern, R., 1998. Three-dimensional force measurements with mandibular overdentures connected to implants by ball-shaped retentive anchors. A clinical study. Int. J. Oral Maxillofac. Implants 13, 36-43.

Naert, I., Quirynen, M., Theuniers, G., van Steenberghe, D., 1991. Prosthetic aspects of osseointegrated fixtures supporting overden-tures. A 4-year report. J. Prosthet. Dent. 65, 671-680.

Sadowsky, S.J., 2007. Treatment considerations for maxillary implant overdentures: a systematic review. J. Prosthet. Dent. 97, 340-348.

Sadowsky, S.J., Caputo, A.A., 2004. Stress transfer of four mandibular implant overdenture cantilever designs. J. Prosthet. Dent. 92, 328¬336.

Schmitt, A., Zarb, G.A., 1998. The notion of implant-supported overdentures. J. Prosthet. Dent. 79, 60-65.

Tokuhisa, M., Matsushita, Y., Koyano, K., 2003. In vitro study of a mandibular implant overdenture retained with ball, magnet, or bar attachments: comparison of load transfer and denture stability. Int. J. Prosthodont. 16, 128-134.

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