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Implantology

Authors: Dr. Happy Bajaj, Dr. Anmol Mahajan

Abstract:

Preservation of alveolar bone and maintenance of proprioception is the main aim of tooth supported overdenture. The other advantages are increased stability and retention of the prosthesis and patient comfort. Due to different reasons like cost, incomplete knowledge of indications and applications, the precision attachments are usually neglected or ignored to use for prosthesis. Precision attachments owing to its advantage of additional retention increases the efficiency of tooth supported over-denture and gives the patient a sense of excellent satisfaction by increasing retention.In this case report we have described a tooth supported over-denture using semi precision attachments for the mandibular arch.
Key words: overdenture, precision attachment, custom made attachment, pattern resin, biological denture, hybrid denture
 
Fig 1 Pre operative Fig 2 Tooth preparation wrt 33, 43, 44, and post space prepared in 33, 44
Fig 3 Custom post pattern fabricated with pattern resin using direct technique Fig 4 pick up impression of custom post using addition silicone
Fig 5 fabrication resin pattern of post core and ball attachment using indirect technique Fig 6 cemectation of post with ball attachment using resin cement


Introduction

The elderly population is rapidly increasing, as is their need for dental treatment. Considering the number of partially or completely edentulous patients, various types of treatment may be indicated, including conventional complete dentures and both tooth-supported and implant-supported overdentures 1,2.Conventional complete dentures rely upon the condition of residual alveolar ridge and mucosa for the purpose of retention, stability and support. Due to continued bone resorption, the adaptation problems i.e. loosening of dentures are observed with a higher incidence for mandibular rather than the maxillary dentures3. Though implants can provide a fixed replacement for natural dentition, due to the cost factor it is not affordable to all.

Overdenture is the prosthesis, which is fabricated over the existing natural teeth or roots or implants. Retention of a few remaining teeth to support denture will preserve the alveolar bone and the periodontal receptors. The healthy periodontal ligament around the teeth maintains the morphology of the alveolar ridge 4. This article describes fabrication of tooth supported overdenture using direct and indirect technique for fabrication of coping and attachment.

 
Fig 7 Try in Fig 8 Processed denture, intaligo surface of lower denture with permanent soft liner


Case Report

A 41 year old female patient reported to the Prosthodontics Department, Guru Nanak Dev Dental College, sunam complaining of missing teeth causing inability to masticate food and difficulty in speech. She wanted replacement of missing teeth so that the function can be restored. On examination the following findings were seen—completely edentulous maxilla and three teeth were present in mandible with relation to 33, 43,44 [ fig 1]. Radiographs were made, diagnostic casts were articulated at the anticipated occlusal vertical dimension, and the treatment was carefully planned. Several treatment options were offered to the patient, and a new complete maxillary denture with a tooth-supported mandibular overdenture was selected.

Mandibular left canine and right premolar show adequate bone and periodontal support and the mandibular right canine presented reasonable bone height. The ability to accommodate abutment copings was assessed, and ball attachment were selected for mandibular left canine and right premolar and short coping with metal coverage for the mandibular right canine. Endodontic treatment was performed and abutment teeth were prepared to create adequate space for the overlying denture. The teeth were reduced to 0.5 to 1.0 mm above the alveolar ridge and the tooth were rounded to a dome-shaped contour [ fig 2].
 
Fig 9 post operative


A combination of direct and indirect impression techniques was used, and the root canals were prepared to receive posts. The posts were made of pattern resin with retention at their cervical ends. With the posts in position, vinyl polysiloxane impression was made. The impressions were poured in Type IV gypsum. The post was inserted into the cast and used for intraradicular attachment waxing to avoid any loss of the length and diameter of the attachment. And using indirect technique coping was fabricated using pattern resin [ fig 3,4, 5].

For preparing the ball attachment, an implant ball attachment was indexed using putty {addition silicone). Index was used to fabricated ball attachment by using pattern resin and attachment was attached to post pattern. The configuration of all ball attachment was same. Casting was carried out by using base metal alloy and the retrieved attachments were air abraded with Al2O3 (50 μm particle size) to remove the residual investment material. Minor voids were removed using round carbide bur and the ball attachment was finished and polished while keeping the post unaltered.

The short copings with metal coverage for the canine and the ball attachments for the canines and premolar were fitted, adjusted, and cemented with U-200 resin cement [ fig 6]. Once the coping was cemented to abutment teeth fabrication of overdenture was made in conventional manner, jaw relation recorded , trial was made [ fig 7] and denture was fabricated. The attachments that are placed have to be parallel to each other to avoid unwanted leverage forces. So, they were placed parallel to each other using a surveyor. In order to incorporate ball attachment to the denture permanent soft denture liner was used [fig 8].

Discussion:

Complete edentulous state affects the oral and general health as well as the quality of life of patients 5,6,7. The satisfactory treatment outcome of patients rehabilitated with complete denture relies on the successful influences of prosthesis retention and stability [8]. Redford et al demonstrated that more than 50% of conventional mandibular denture have problem with retention and stability and that mandibular denture have more problems than maxillary dentures, primarily because of poor prosthetic retention[9]. Retention of teeth or tooth roots in the alveolar bone can improve bone maintenance around and between these structures.

Bone maintenance is the most significant advantage of tooth borne overdenture because the maintenance of bone volume and vertical height can produce increased prosthetic retention and stability. It also gives patient better functions, comfort and control because of proprioception 10. The choice of ball attachment in this clinical report was considered because this attachment exhibits a simple design, easy maintenance and allows multi- directional movement of the retentive housing. This system provides vertical movement during mastication allowing minimum stress transferred to supporting roots, directing the occlusal force to supporting soft tissues. However, it is necessary to inform the patient that the shelf life of soft liner of this system are affected by wear, resulting in a gradually loss of retention. Consequently, there is need for follow-up appointments to check the hygiene situation and the eventual replacement of the soft liner when retention levels begin to decrease 11,12.

References
 
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