CC
A 66-year-old female is referred to a prosthodontist for implant restoration with complaints that her “dentures are old and loose.”
HPI
The patient has been wearing prosthesis for 30 years and has been wearing existing prosthesis for the past 10 years. It has progressively become loose, and it is functionally inadequate.
PMHX/PSHX/Medications/Allergies/SH/FH
Noncontributory.
Examination
General. Very petite.
Maxillofacial. Opening, temporomandibular joint and muscles are with in normal limits. Collapsed vertical with existing prosthesis; inadequate facial support for tissues and reduced height. At correct vertical, the patient demonstrated a class 1 skeletal relationship.
Intraoral examination
Overclosure and reduced vertical dimension of occlusion. Extremely atrophic ridges. Soft tissues are within normal limits. The patient has significant resorption of the mandibular ridge and virtually no sulcus. Existing prosthesis was unstable and extremely worn.
Labs
No laboratory studies were indicated.
Assessment
Edentulous atrophic maxilla and mandible with poorly fitting dentures requiring prosthetic rehabilitation.
Treatment
Several options are available for patients with adequate bone height and width. Patients with inadequate bone require grafting (see chapters on bone grafting elsewhere in this text) before surgical placement of implants or consideration for zygoma implants (see the discussion of zygoma implants in this chapter). There was adequate bone in the maxilla to place four conventional implants. However, the mandible required significant grafting for placement of implants to stabilize the prosthesis and prevent the mandible from the risk of fracture. Cone-beam computed tomography (CBCT) imaging and additional prosthetic planning are helpful. A team approach involving an oral and maxillofacial surgeon and a prosthodontist or restorative dentist is helpful, and proper communication is a must. The following treatment options were presented to the patient by referring to a prosthodontist.
- 1.
Conventional upper and lower full dentures at correct occlusal vertical dimension. Shortfalls of instability, discomfort, and further mandibular and maxillary ridge resorption were discussed.
- 2.
Conventional maxillary denture with mandibular overdenture after mandibular ridge augmentation with two implants or four implants was presented.
- 3.
Maxillary overdenture with four implants along with mandibular ridge augmentation with four implants to stabilize dentures and prevent further fracture of the mandible.
- 4.
Zygomatic implants with combination of conventional implants for fixed upper prosthesis against mandibular fixed prosthesis with five implants after mandibular ridge augmentation.
- 5.
Maxillary and mandibular augmentation along with eight implants in the maxilla and six in mandible to restore dentition with an implant-supported crown and bridge ( Figs. 36.1 and 36.2 ).
• Fig. 36.1 Edentulous patient with collapsed occlusal vertical dimension.
• Fig. 36.2 Panoramic radiograph. Note the extreme resorption of the mandible and maxilla.
Treatment
The patient chose option 3, four implants in the maxilla with mandibular ridge augmentation and four implants to stabilize the denture. This option in the author’s opinion was best because a removable prosthesis provides the option of adding a flange and bulk necessary to support facial tissue and adequately restore vertical dimension of occlusion. This option presents an excellent balance of cost, practicality, bore regeneration, and ease of posttreatment prosthetic maintenance.
Phase 1: Preprosthetic phase
The new interim prosthesis was fabricated at the correct vertical dimension, and the patient was allowed to function for 4 weeks so centric relation could be determined accurately. A preoperative CBCT scan was obtained with the prosthesis and markers for better understanding of the existing bone. Treatment was planned for four implants in the mandible with bone graft harvested from the hip and four implants in the maxilla. A mandibular prosthesis was planned to be retained and supported with a bar. The maxillary prothesis was planned to be retained with four locator attachments.
Phase 2: Surgical phase
Under general anesthesia, the maxillofacial surgeon harvested bone from the hip. With chin incision, the mandibular ridge was augmented, and four endosteal implants were placed. The mandible was plated with plates to prevent future fracture. Four implants were placed in the maxillary arch. The patient did not wear the mandibular denture for 6 weeks. A new mandibular denture was fabricated after 6 weeks. The patient was followed up at 1-, 2-, and 4-week intervals. Bone and implants were allowed to integrate for 4 months. Upon completion of healing, the mandibular and maxillary implants were uncovered, and the prosthesis was relined so the patient could function while the definitive prosthesis was being fabricated.
Phase 3: Prosthetic phase
Four weeks after the implants were uncovered, multiunit abutments were placed on the mandibular implants, and locator abutments were placed in the maxillary arch. Final impressions were made. Jaw registration was recorded, and teeth setup was done. The mandibular bar with four locator abutments was fabricated using a computer-aided design and computer-aided manufacturing approach, and a maxillary cast Co–Cr framework was fabricated. Processed bases were made, and attachments were picked up in the bases so that more accurate occlusal records could be made. The teeth were set to satisfy esthetic and phonetic requirements. The final prosthesis was processed and delivered to the patient. Maintenance instructions were given, and the patient was followed up with every 6 months for hygiene follow-up. Once a year, the bar was removed, and maintenance was performed. The patient has been followed up with for 6 years with no complications. Locator matrices (nylon inserts) were changed every other year to maintain appropriate retention. Teeth wear has been minimal.
Complications
Complications can be divided into those related to surgery or to the prosthetic. Surgical complications of implant-related surgery and bone grafting are discussed elsewhere in the text. Most common prosthetic complications involve soreness at the surgical site. The patient did not wear any prosthesis for 6 weeks because changes in oral tissue after surgery were substantial, and a new prosthesis was needed. The new mandibular prothesis was fabricated 6 weeks after surgery. Soreness was addressed with a soft tissue conditioner, which was changed every 4 weeks ( Figs. 36.3 to 36.8 ).
