Simple Flapless Surgical Overdenture Techniques

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1 Volume 33 No. 3 Page 104 Simple Flapless Surgical Overdenture Techniques Authored by Timothy Kosinski, DDS Upon successful completion of this CE activity 1 CE credit hour will be awarded Opinions expressed by CE authors are their own and may not reflect those of Dentistry Today. Mention of specific product names does not infer endorsement by Dentistry Today. Information contained in CE articles and courses is not a substitute for sound clinical judgment and accepted standards of care. Participants are urged to contact their state dental boards for continuing education requirements.

Simple Flapless Surgical Overdenture Techniques Effective Date: 3/1/2014 Expiration Date: 3/1/2017 ABOUT THE AUTHOR Dr.

He received his Mastership in Bio chemistry from Wayne State University School of Medicine.

American Academy of Implant Dentistry, the American and International Colleges of Dentists, and the Academy of Dentistry International; and he received his Mastership in the AGD.

He serves on the editorial review board of REALITY and is both president of and editor for the Michigan Academy of General Dentistry. Dr.

2 Simple Flapless Surgical Overdenture Techniques Effective Date: 3/1/2014 Expiration Date: 3/1/2017 ABOUT THE AUTHOR Dr. Kosinski received his DDS from and currently is an adjunct clinical professor at the University of Detroit (UDM) Mercy School of Dentistry. He received his Mastership in Bio chemistry from Wayne State University School of Medicine. He is a Diplomate of the American Board of Oral Implantology/Implant Dentistry, the International Congress of Oral Implantologists, and the American Society of Osseointegration; a Fellow of the American Academy of Implant Dentistry, the American and International Colleges of Dentists, and the Academy of Dentistry International; and he received his Mastership in the AGD. He is a member of Omicron Kappa Upsilon and the Pierre Fauchard Academy. He serves on the editorial review board of REALITY and is both president of and editor for the Michigan Academy of General Dentistry. Dr. Kosinski was the UDM School of Dentistry Alumni Association s Alumnus of the Year, and in 2009 received the Academy of General Dentistry s Lifelong Learning and Service Recognition. He has published more than 85 articles on the surgical and prosthetic phases of implant dentistry and is a contributor to the textbooks, Principles and Practices of Implant Dentistry, and 2010 s Dental Implantation and Technology. He was featured on Nobelbiocare s Nobelvision and lectures extensively. He can be reached via at drkosin@aol.com. to conventional dentures. Creating palateless reconstructions as replacements for full palatal coverage is accepted well by our patients. Case planning and diagnosis is the critical beginning for consideration for fabrication of implant-retained overdentures. First, we must consider the desires of our patients for their final restorations. Fixed prostheses versus removable prostheses must be discussed in detail to meet patients expectations. Cost factors often play into the final result; however, it is my experience that creating an appliance that is aesthetic and functional is a good option for many patients. Also to be considered is the manual dexterity of each patient and his or her ability to clean and maintain the site, not only initially but also in the years to come. Removable implant-retained overdentures are easy to maintain with little effort and are extremely cost effective, considering the tremendous advantage they provide in allowing our patients to chew and Figure 1. Our patient presented with no maxillary teeth. He had a desire to improve his quality of life with an implant-retained overdenture. Figure 2. Preoperative panoramic radiograph illustrating the position of the vital anatomy, including the maxillary right and left maxillary sinuses. The premaxilla had adequate bone for dental implant placement, but the posterior maxilla presented with extremely large sinuses. Disclosure: Dr. Kosinski reports no disclosures. INTRODUCTION Predictable dental implant surgical placement today leads to positive long-term prognoses. Precision prosthetic components that are reasonable in cost provide stable retention and support implant overdentures well. These implant-retained overdentures act as outstanding alternatives Figure 3. An icat/ct scan was done to determine the amount of width of available bone in the premaxilla area to accept dental implants. This technique would allow a flapless surgical placement. 1

function much more normally. Having the palate removed from the design allows the taste buds in the palate to function properly. It is a definite improvement in the quality of life of our patients.

This includes manual palpation of the ridges, evaluation of the 2-D panoramic radiograph, use of bone calipers to approximate width of the ridges, digital periapical radiographs with bone markers,

With the advent of computed tomography (CT) diagnostics, 3-D images are created, which allow the practitioner to precisely determine not only vital anatomy, such as the sinuses, but also the height

When considering implants for maxillary implant-retained overdentures, we will need a minimum of 4 implants in the maxilla.

Thus, placement of the implants is a critical factor in achieving ideal final prosthetic reconstruction of the overdenture.

3 function much more normally. Having the palate removed from the design allows the taste buds in the palate to function properly. It is a definite improvement in the quality of life of our patients. 1 Surgical placement of dental implants in the past was done through radiographic evaluation and intraoral examination. This includes manual palpation of the ridges, evaluation of the 2-D panoramic radiograph, use of bone calipers to approximate width of the ridges, digital periapical radiographs with bone markers, and measuring study casts. Bone quality, especially in the maxillary region, could only be determined at the time of surgical osteotomy creation. With the advent of computed tomography (CT) diagnostics, 3-D images are created, which allow the practitioner to precisely determine not only vital anatomy, such as the sinuses, but also the height and width of available bone. 2 Risks are evaluated prior to any surgical intervention. When considering implants for maxillary implant-retained overdentures, we will need a minimum of 4 implants in the maxilla. These implants, too, need to be in positions that allow for proper draw of the chosen attachments. Thus, placement of the implants is a critical factor in achieving ideal final prosthetic reconstruction of the overdenture. Often, improperly placed or angled implants create a hardship for the patient and laboratory technician, as proper draw is not established. This may lead to poorly seating overdentures or excessive adjustments being made to eliminate sore areas. The advent of the use of CT diagnostics and CT guides helps the practitioner to establish proper positioning. 3 In addition, the quality of bone can be determined in many instances, thus establishing a platform for success. CASE REPORT Diagnosis and Treatment Planning A 46-year-old male presented to our office with an ill-fitting 4 5 Figures 4 and 5. Maxillary edentulous ridges seemed to indicate adequate height and width of bone to surgically place 4 maxillary implants to support an implant-retained overdenture. 6 7 Figures 6 and 7. A 2.3-mm pilot drill was used to determine proper angulation and availability of bone. Final length was also determined using this drill. 8 9 Figures 8 and 9. A 3.4-mm diameter drill was used after the 2.8-mm diameter drill to create the final osteotomy to accept 3.7 mm x 10 mm dental implants (Glidewell Laboratories). The digital radiograph shows proper depth and angulation. The facial plate of bone was left completely intact for this flapless surgical procedure. conventional maxillary complete denture that made him gag, de creasing his quality of life physically and emotionally (Figure 1). Furthermore, he felt embarrassed by his appearance. There were no medical contraindications to dental im plant therapy. Options were discussed, including the fabrication of another conventional maxillary denture, or placement of implants to retain a fixed hybrid appliance and an implantretained overdenture. 2

Fabrication of a fixed appliance would require sinus augmentation to allow for more implants to be placed in the posterior region to support such a device.

This process was determined to be cost effective to the patient as a means of restoring form and function, and to im prove aesthetics dramatically.

(Figure 2). A CT scan advanced our visual field to a third dimension (Figure 3).

of the large maxillary si nuses. 3 Certainly, other techniques (such as sinus elevations) should always be considered.

Teeth would need to be cantilevered to the facial, and they would be extremely long into the gingiva. Lip support is often compromised by such a prosthesis design.

Clinical Protocol The surgical process began with making an initial opening Continuing Education 10 11 12 14 Figure 15.

4 Fabrication of a fixed appliance would require sinus augmentation to allow for more implants to be placed in the posterior region to support such a device. Four maxillary implants were considered to secure an implant-retained overdenture using the LOCATOR attachment system (ZEST Anchors). This process was determined to be cost effective to the patient as a means of restoring form and function, and to im prove aesthetics dramatically. Conventional radiographs, in cluding panoramic and periapical digital radiographs, allowed us to visualize vertical height but not bone angulations or horizontal bone availability (Figure 2). A CT scan advanced our visual field to a third dimension (Figure 3). It was clear by the radiographs that placing implants in the very posterior portion of the maxilla would not have been possible without a more invasive surgical intervention because of the large maxillary si nuses. 3 Certainly, other techniques (such as sinus elevations) should always be considered. Because of the significant amount of horizontal bone loss (Fig ure 4), the patient also lost a good amount of lip support, so fabrication of an overdenture with some facial and lip support was appropriate. When there is bone loss vertically, following longterm resorption after tooth extraction, fabrication of fixed bridgework or hybrids can become challenging (Figure 5). Teeth would need to be cantilevered to the facial, and they would be extremely long into the gingiva. Lip support is often compromised by such a prosthesis design. Overdentures eliminate the aesthetic concerns, are easy to maintain with proper home care, are stable, and are an excellent alternative to conventional techniques. Clinical Protocol The surgical process began with making an initial opening Continuing Education Figure 15. The first implant was properly positioned and checked using a radiograph. 13 Figures 10 to 14. The Glidewell Laboratories implants were torqued to 35 Ncm (even in the porous maxillary bone). Initial stability was created by the design of the implant body itself. Figure 16. Subsequent osteotomies were made for the remaining 3 dental implants. Parallelism of the dental implants is key to maintain stability of an overdenture. with a 2.3-mm diameter pilot drill (Figure 6). This drill easily penetrated the cortical plate and allowed proper angulation of the implant in front of the maxillary sinus area. Simple digital radiographs al lowed us to evaluate not only angulation but also the depth (Figure 7). Clear markings on 3

Continuing Education 18 19 Figure 17. Four Glidewell implants were placed using a flapless procedure. Figures 18 and 19.

Following approximately 4 months of healing, the implants were exposed. Figure 21.

LOCATOR attachments (ZEST Anchors) were then torqued into the dental implants so that approximately 1.

The underside of the palateless (horseshoe-shaped) implant-retained ovedenture holds the female portions of the LOCATOR

The palateless, metal-reinforced, implant-retained overdenture was very stable, providing outstanding functional stability

The aesthetic, natural-looking maxillary implant-retained overdenture dramatically improved the quality of life of our

This was the only end-cutting bur used in the surgical process; subsequent burs were used to simply widen the osteotomy site.

The Glidewell Laboratories implant system was chosen here because of its high quality, incredible initial stability, and

5 Continuing Education Figure 17. Four Glidewell implants were placed using a flapless procedure. Figures 18 and 19. Digital radiographs and a panoramic radiograph, showing parallel position of the implants. Figure 20. Following approximately 4 months of healing, the implants were exposed. Figure 21. Healed tissue cuffs demonstrated attached gingiva around the integrated dental implants. Figure 22. LOCATOR attachments (ZEST Anchors) were then torqued into the dental implants so that approximately 1.5 mm of the attachment was supragingival, allowing for plenty of room for denture tooth positioning. Figure 23. The underside of the palateless (horseshoe-shaped) implant-retained ovedenture holds the female portions of the LOCATOR attachments. Figure 24. The palateless, metal-reinforced, implant-retained overdenture was very stable, providing outstanding functional stability and removing any gag reflex. Figure 25. The aesthetic, natural-looking maxillary implant-retained overdenture dramatically improved the quality of life of our patient. the surgical drill helped in visualizing proper depth. This was the only end-cutting bur used in the surgical process; subsequent burs were used to simply widen the osteotomy site. Therefore, it was imperative that proper positioning was determined while using the 2.3-mm pilot drill. The Glidewell Laboratories implant system was chosen here because of its high quality, incredible initial stability, and simple prosthetic applications. The Glidewell dental implant design is a minimally invasive, bone-condensing implant system designed for dual stabilization of the implant in place, providing a true initial mechanical lock.3 The surgical techniques in the placement of this implant is both user friendly and simple. Chairside efforts are dramatically reduced due to the simple stage surgical drilling. As the cost of implant materials decreases, my ability to provide high quality dentistry at a reasonable fee increases. Our patients are very 4

6 responsive to this and appreciative. Once the angulation of the first osteotomy was determined, we moved forward to the next diameter burs (a 2.8-mm diameter drill [Figures 8 and 9]). The final 3.4-mm diameter osteotomy drill was used to create a site for the 3.7-mm diameter implant, which was then threaded into position using a torque wrench (Figures 10 to 13). The 35 Ncm of torque was achieved with the implant system (even in the relatively soft anterior maxillary bone) (Figure 14). 4 Once the first implant was deemed to be positioned correctly, the other implants were simply paralleled to the first. Four maxillary implants were then ideally placed using a flapless technique (Figures 15 and 16). Since a flapless technique was used, healing occurred more promptly (Figures 17 to 19). Conventional denture fabrication techniques were then used to create the final aesthetic contours. We created an outstanding functional and aesthetic result, exceeding the patient s expectations in function. The gagging reflex that a full palate conventional denture had previously created was totally eliminated (Figures 20 and 21). Because the implants were properly positioned, LOCATOR attachments were torqued into each im plant, and a palateless maxillary overdenture was fabricated. The LOCATOR attachments provided excellent stability, and be cause the implants were spaced ideally, excellent retention (Figure 22). Be cause of their design, the patient was able to easily align and seat the overdenture. However, it was important that the implants were placed in a parallel position to each other, thus simplifying the prosthetic construction. According to the manufacturer, the attachments resist wear and maintain satisfactory retention for up to 56,000 cycles of function. The male portions can be easily changed chairside with minimal inconvenience to the patient (Figures 23 and 24). The LOCATORs come in a variety of retentions from extra light (blue) to heavy (clear). In this case, the light retention attachments were used. The patient s chewing function and efficiency, as well as his quality of life, were all dramatically improved using simple, easy to follow, cost-effective dental surgical and prosthetic techniques (Figure 25). Postop erative oral hygiene instructions were given to the patient. The attachments were easily maintained intraorally with brushing and a simple wipe with a washcloth. The underside of the overdenture can be cleaned with a simple brush. CLOSING COMMENTS We are fortunate to practice in a time when we can provide our patients with comprehensive, safe, and precise surgical techniques. Visualizing the case as finished before starting is helpful in achieving outstanding functional and aesthetic final results. CT diagnosis and scanning software make the surgical process simpler for even the less experienced dental implant surgeon. 5 Considerations for any and all vital anatomy is easier to assess. How ever, not every situation warrants CT diagnosis or surgical planning. Since the general practitioner is the professional whom patients consult concerning their dental condition, the practitioner must educate oneself with the treatment modalities that may be appropriate. REFERENCES 1. Geckili O, Bilhan H, Mumcu E, et al. Comparison of patient satisfaction, quality of life, and bite force between elderly edentulous patients wearing mandibular two implant-supported overdentures and conventional complete dentures after 4 years. Spec Care Dentist. 2012;32: Benavides E, Rios HF, Ganz SD, et al. Use of cone beam computed tomography in implant dentistry: the International Congress of Oral Implantologists consensus report. Implant Dent. 2012;21: Ganz SD. Restoratively driven implant dentistry utilizing advanced software and CBCT: realistic abutments and virtual teeth. Dent Today. 2008;27: Abal S. Implant considerations in the esthetic zone. Inclusive. 2013;4: Amet EM, Ganz SD. Implant treatment planning using a patient acceptance prosthesis, radiographic record base, and surgical template. Part 1: Presurgical phase. Implant Dent. 1997;6:

7 POST EXAMINATION INFORMATION To receive continuing education credit for participation in this educational activity you must complete the program post examination and answer 4 out of 5 questions correctly. Traditional Completion Option: You may fax or mail your answers with payment to Dentistry Today (see Traditional Completion Information on following page). All information requested must be provided in order to process the program for credit. Be sure to complete your Payment, Personal Certification Information, Answers, and Evaluation forms. Your exam will be graded within 72 hours of receipt. Upon successful completion of the postexam (answer 4 out of 5 questions correctly), a letter of completion will be mailed to the address provided. Online Completion Option: Use this page to review the questions and mark your answers. Return to dentalcetoday.com and sign in. If you have not previously purchased the program, select it from the Online Courses listing and complete the online purchase process. Once purchased the program will be added to your User History page where a Take Exam link will be provided directly across from the program title. Select the Take Exam link, complete all the program questions and Submit your answers. An immediate grade report will be provided. Upon receiving a passing grade, complete the online evaluation form. Upon submitting the form, your Letter Of Completion will be provided immediately for printing. POST EXAMINATION QUESTIONS 1. Case planning and diagnosis is the critical beginning for consideration for fabrication of implant-retained overdentures. 2. Having the palate removed from the design allows the taste buds in the palate to function properly, improving the quality of life for our patients. 3. Bone quality, especially in the maxillary region, can only be determined at the time of surgical osteotomy creation. 4. When considering implants for maxillary implantretained overdentures, a minimum of 6 implants will be needed in the maxilla. 5. CT diagnosis and scanning software makes the surgical process simpler for even the less experienced dental implant surgeon. General Program Information: Online users may log in to dentalcetoday.com any time in the future to access previously purchased programs and view or print letters of completion and results. This CE activity was not developed in accordance with AGD PACE or ADA CERP standards. CEUs for this activity will not be accepted by the AGD for MAGD/FAGD credit. 6

8 PROGRAM COMPLETION INFORMATION If you wish to purchase and complete this activity traditionally (mail or fax) rather than online, you must provide the information requested below. Please be sure to select your answers carefully and complete the evaluation information. To receive credit you must answer 4 of the 5 questions correctly. Complete online at: dentalcetoday.com TRADITIONAL COMPLETION INFORMATION: Mail or fax this completed form with payment to: Dentistry Today Department of Continuing Education 100 Passaic Avenue Fairfield, NJ Fax: PAYMENT & CREDIT INFORMATION: Examination Fee: $20.00 Credit Hours: 1 Note: There is a $10 surcharge to process a check drawn on any bank other than a US bank. Should you have additional questions, please contact us at (973) o o I have enclosed a check or money order. I am using a credit card. My Credit Card information is provided below. o American Express o Visa o MC o Discover Please provide the following (please print clearly): Exact Name on Credit Card Credit Card # Signature Expiration Date This CE activity was not developed in accordance with AGD PACE or ADA CERP standards. CEUs for this activity will not be accepted by the AGD for MAGD/FAGD credit. / PERSONAL CERTIFICATION INFORMATION: Last Name First Name Profession / Credentials Street Address Suite or Apartment Number ANSWER FORM: VOLUME 33 NO. 3 PAGE 104 Please check the correct box for each question below. 1. o a. True o b. False 2. o a. True o b. False 3. o a. True o b. False 4. o a. True o b. False 5. o a. True o b. False (PLEASE PRINT CLEARLY OR TYPE) PROGRAM EVAUATION FORM Please complete the following activity evaluation questions. Rating Scale: Excellent = 5 and Poor = 0 Course objectives were achieved. Content was useful and benefited your clinical practice. Review questions were clear and relevant to the editorial. Illustrations and photographs were clear and relevant. Written presentation was informative and concise. How much time did you spend reading the activity and completing the test? What aspect of this course was most helpful and why? License Number City State Zip Code Daytime Telephone Number With Area Code Fax Number With Area Code Address What topics interest you for future Dentistry Today CE courses? 7

A Sequential Approach to Implant-Supported Overdentures

Volume 35 No. 3 Page 68 A Sequential Approach to Implant-Supported Overdentures Authored by Timothy Kosinski, DDS Upon successful completion of this CE activity, 2 CE credit hours may be awarded Opinions