143rd publication sjodr- 3rd name

1. © 2020 |Published by Scholars Middle East Publishers, Dubai, United Arab Emirates 0
Saudi Journal of Oral and Dental Research
Abbreviated Key Title: Saudi J Oral Dent Res
ISSN 2518-1300 (Print) |ISSN 2518-1297 (Online)
Scholars Middle East Publishers, Dubai, United Arab Emirates
Journal homepage: http://scholarsmepub.com/sjodr/
Case Report
Rehabilitation of Maxillary and Mandibular Atrophied Edentulous
Ridge with Implant Supported Overdenture Prosthesis: A Case Report
Dr. Priyesh Kesharwani MDS1*
, Dr. Bhavan Chand Yemineni2
, Dr. Rahul Vinay Chandra Tiwari, FOGS, MDS3
, Dr.
Amit Shivakant Vathare, MDS4
, Dr. Dheeraj Voulligonda5
, Dr. Amartya Prakash Srivastava6
, Dr. Heena Tiwari, BDS,
PGDHHM7
1
Oral and Maxillofacial Surgeon, Consultant and Private Practitioner DENT-O-FACIAL Multispeciality Clinic, Mira road, Thane-Mumbai
2
Associate Professor, Dept of Dental and Oral Surgery, ASRAM Medical College, Eluru, Andhra Pradesh
3
Assistant Professor, Department of Oral and Maxillofacial Surgery, Sri Sai College of Dental Surgery, Vikarabad, India
4
Prosthodontist & Implantologist, Jaysingpur, Shirol, Kolhapur, Maharashtra
5
Senior Lecturer, Department of Oral Medicine and Radiology, Sri Sai College of Dental Surgery, Vikarabad, Telangana, India
6
Senior lecturer, Dept of OMFS, Saraswati Dental college and Hospital, Lucknow, UP
7
Government Dental Surgeon, Chhattisgarh, India
DOI: 10.36348/sjodr.2020.v05i01.00X | Received: 09.12.2019 | Accepted: 22.12.2019 | Published: X
*Corresponding author: Dr. Priyesh Kesharwani MDS
Abstract
The most frequently encountered clinical situation in a dental practice is the completely edentulous dental arch for which
implant supported overdentures has been the predictable procedure over time. Implant supported overdentures have
proved to be one of the best alternative options in prosthetic rehabilitation of various cases of edentulism. Implant
provides enhancement of retention, support, stability of the overdenture makes it an ideal treatment modality.
Overdenture satisfies the patient’s expections, improve quality of life with their long term serviceability and predictable
outcomes. This case report focuses on rehabilitation with an implant supported overdenture of edentulous atrophic
maxilla and mandible.
Keywords: Edentulous, Overdenture, Rehabilitation.
Copyright @ 2020: This is an open-access article distributed under the terms of the Creative Commons Attribution license which permits unrestricted
use, distribution, and reproduction in any medium for non-commercial use (NonCommercial, or CC-BY-NC) provided the original author and source
are credited.
INTRODUCTION
Complete tooth loss or edentulism is a
debilitating and irreversible condition that represents
the ultimate consequence of oral disease [1].
Edentulism is associated with greater disability and
earlier mortality in the elderly, even after adjusting for
confounders such as socioeconomic status and health
behavior [2]. The major purpose of dental prostheses is
to reduce masticatory impairment and poorer quality of
life by replacing the lost teeth. The most common
prostheses for edentulism are complete dentures, which
cannot completely restore lost function, e.g. chewing
performance is only 30% of that for dentate individuals
[3].
Implant supported overdentures has become a
benefit for the patients facing complete edentulism as it
lessens the challenges posed by removable complete
denture prosthesis such as poor stability and
compromised mastication. The transition from
dentulous to edentulous state poses different challenges
to the patient as well as the clinician. Bone resorption
especially in mandible is an important factor to be
considered during rehabilitation. Traditional removable
prostheses need continuous adjustments. Implant
supported overdentures are customizable and excellent
esthetics makes it a captivating treatment modality for
many potential patients.
An implant supported overdenture is a type of
overdenture that is supported by and attached to
implants differing from the regular denture that rests
solely on the gingiva. Implant supported overdentures
has individual attachments that snap onto attachments
present on the implants.
McGill has recommended the usage of two
implants to support a mandibular denture as a basic
standard of care thereby improving the quality of life
related to oral health [4]. With the use of implant-
supported prosthesis, progress in masticatory function,
retention and stability, and preservation of the alveolar
bone have been reported [5-8]. Van Steenberghe et van
Steenberghe et al. first reported on the possibility of
using mandibular overdentures supported by two

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© 2020 |Published by Scholars Middle East Publishers, Dubai, United Arab Emirates 1
implants to treat problems where usually conventional
mandibular dentures would be used [9]. The vast
majority of patients, an overdenture on two implants in
the mandible is the first choice of treatment when
complaining about the lack of stability in their
mandibular denture [10-12]. Thomason et al. [13]
concluded that there is now overwhelming evidence to
support the proposal that a two-implant overdenture
should become the first choice of treatment for the
edentulous mandible. The numbers of implants in the
edentulous mandible for support of an overdenture are
well studied [14, 15]. Slot et al. [16] showed in a
metaanalysis that the survival of implants used to
support a maxillary overdenture is high if concepts were
used with at least 4 implants supplied with either a bar
or ball anchorage. Finally, from the systematic review
of Roccuzzo et al. [17], it can be concluded that the
question of how many implants should support a
maxillary overdenture is still open.
CASE REPORT
A 63 year old female patient came to
department with the chief complaint of loose fitting
lower denture with difficulty in mastication and speech.
On examination, patient had resorbed alveolar ridge
which lead to inadequate retention of the lower and
upper denture prosthesis and patient is known to be a
previous denture wearer for past 2 years. The
Orthopantomograph findings showed the presence of
insufficient bone height and width, with dense cortical
bone surrounded by dense trabecular bone. Thus
implant supported overdenture was planned with two
implants in mandibular canine region and four implants
in maxillary arch along with independent ball type
attachments.
Blood investigations and informed consent
was taken after discussing the treatment procedure with
the patient. Irreversible hydrocolloid impression was
made and pre-surgical diagnostic casts were prepared.
Inter-occlusal distance was measured in the diagnostic
casts. The implant location was marked at B and D
positions independent of each other.
Surgical Phase
Under antibiotic prophylaxis and standard
aseptic protocol, preparation of the patient was done by
anaesthetizing the mandibular anterior segment with
inferior alveolar nerve block using local anaesthesia of
2% lignocaine with 1:80,000 adrenalines. After the
region was anaesthetized, full thickness crestal incision
was made with surgical blade number 15 extending
from first premolar on right side to first premolar on left
side. The mucoperiosteal flap was elevated and bone
was exposed. A pilot drill was introduced into the bone
and two osteotomy sites were created in mandibular
ridge and four osteotomy sites preparation was done in
maxillary ridge.
Two surgical implants (3.3 x 13 mm) were
inserted in mandible (Fig. 1) and four surgical implants
were placed in maxilla (4.5 x 12, 4.5 x 12, 4.5 x 14 and
4.5 x 14) using motor driver at 35 rpm and the landmark
of reach was checked with profile gauge (fig 2). After
the implant seating tip has reached the adequate depth,
cover screws are placed. Later flaps are approximated,
suturing done using 3-0 vicryl suture material.
Antibiotics and anti –inflammatory coverage was given
to patient. Patient was recalled on the 10th day of
surgery, suture removal was done. Post operatively after
3 months the implants were well prepared to receive the
prosthesis.
The second stage surgery was performed in
which cover screws were removed and healing
abutments were inserted into the implants. After a time
period of two weeks, peri-implant soft tissue healing
was examined, and existing denture was relined after
relieving at the abutment site. Later, the healing
abutment is removed using a 1.25 mm hex driver. A
periodontal probe was used to measure the gingival cuff
height at the right and left canine site of implant
location. Selected ball abutments were placed onto each
implant using 1.25 mm hex driver and 30 Ncm torque
wrench. A transferable mark with an indelible pencil is
placed on top of each ball abutment and old denture is
seated to ideally determine the location for attachment
housings. It is followed by preparation of recesses in the
intaglio surface of the denture to accommodate the
housings (Fig. 3). Lingual vent holes are made for
escape of excess acrylic. Placement of nylon processing
insert into each of the housings is done with insert
seating tool. Seating of the attachment housing onto
each ball type abutment is done. Undercuts are blocked
out under the housing and soft tissue to prevent acrylic
resin from locking the denture onto the abutment.
Application of self-curing acrylic is done into recessed
area and around titanium housings for bonding of the
housings to denture. Insertion of denture was done and
guiding the patient into proper occlusion with the
opposing arch. After the curing of acrylic, denture is
removed. Excess acrylic is removed around the
housings and lingual vent hole later it is polished (Fig.
4). Replace nylon retention insert instead of processing
insert into the housings. The insert must seat securely in
place and be in level with the housings rim.
Overdenture is seated over the ball abutments (Fig. 5 -
8). Proper instructions have been given to the patient on
insertion and removal of prosthesis (Fig. 9). The patient
was recalled at 1 week, 3 weeks, 2 months, 6 months
follow up appointments.

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© 2020 |Published by Scholars Middle East Publishers, Dubai, United Arab Emirates 2
Fig-1: Mandibular implant placement
Fig-2: maxillary implant placement
Fig-3: Intaglio surface of the denture to accommodate the
housings
Fig-4-8: Overdenture is seated over the ball abutments
Fig-9: Removal of prosthesis
DISCUSSION
When restoring the edentulous maxilla with
dental implants, the most important decision to make is
whether the patient should be restored with a fixed or
removable prosthesis [18]. Problems arising from lack
of retention and stability among mandibular prosthetics
can be overcome by placing osseointegrated dental
implants, used to retain an overdenture [19]. The
transformation of an implant-supported overdenture to a
tissue implant- supported overdenture with a full palatal
coverage was recommended in a similar case like ours
[20]. It was also reported that higher bending moments
may develop on the implants supporting overdentures
than a fixed prosthesis. Therefore, it was recommended
to increase the number of implants supporting the
prosthesis in order to prevent the bending moments that
may cause bone loss [21, 22]. While it is accepted that
the 2-implant overdenture is not the gold standard of
implant therapy it is the minimum standard that should
be sufficient for most people, taking into account
performance, patient satisfaction, cost, and clinical time

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[23]. One study of 101 patients [24] with a follow-up of
over 10 years concluded that implant-retained
overdentures are a favorable solution for edentulous
patients. A literature review18 recommends the
placement of at least 4 implants between the mental
foramina and between 4 and 6 implants in the maxilla
for the placement of overdentures supported by
micromilled bars.
CONCLUSION
There are numerous approaches to treat
edentulous patients, however those techniques are
invasive, expensive and time consuming but implant
supported overdenture prosthesis proves to be relatively
easy due to its innumerable advantages. Dental implants
in patients wearing overdentures had a high survival
rate in the long term. Age, sex, and splinting did not
have a significant influence on implant survival. The
provided treatment gave the patient self-confidence and
comfortable function due to palatal freedom, and the
esthetic was improved dramatically with the use of an
indirect micro-ceramic composite having above-
mentioned superior properties instead of acrylic base
and artificial teeth in the fabrication of the prosthesis.
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