Upper Overdenture and Implants: recommendations for this case?
I have an 82 year old female in good health who presented with a maxillary overdenture retained by very mobile natural teeth. She would like the teeth extracted and replaced with implants. I was thinking of installing 4 implants with with balls attachments. I was also considering an All-on-4 fixed partial denture. What do you recommend?
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25 Comments on Upper Overdenture and Implants: recommendations for this case?
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CRS
3/22/2013
Is there palatal coverage over those large tori? Is it a partial vs an over denture I can 't see the crowns on the teeth. Anyway good bone for anterior implants with left side to premolar area for A-P spread. If you do an all on four you would need to remove a lot of alveolar anterior bone and keep the patient on a liquid diet a year, I would place four implants with as much spread, and use locators after osteointegration, maybe the tori need to go too.
Carter
3/24/2013
Hi thanks for the response.
The actual overdentures had not tori coverage . This is the reason why we cannot propose a total mobile prosthesis, because of big palatal torus. So she wants a new prosthesis but only the most simple treatment.
CRS
3/24/2013
Here is an idea, place 2 implants distally in front of the anterior sinus wall bilaterally, let them osteointegrate 4months, then extract the teeth place the locators. The natural teeth although loose will help retain the denture along with the tori, which are probably helping hold the denture, you could also place two anterior implants at the extraction time,and let then integrate. That's a conservative plan and you'll hava a happy patient who can eat all along the treatment time!
sharon goodwin
3/29/2013
I like this treatment plan! Nice staging!
CRS
4/2/2013
Thanks Sharon I respect your feedback!
Dr M C
3/23/2013
Hi, just go all on 4 , preferrably 5, screw retained. Patient is old and diet will not be heavy and you will do her a favour by getting it fixed rather than she struggle to get the dentures in and out on ball abutments. Sure she won't mind getting to your clinic bi yearly for check up.
Dr. Alex Zavyalov
3/25/2013
Parameters of the CBCT images are too wide. The upper frontal target area should’ve been presented more focused in compare to the skull structures..
nailesh gandhi
3/27/2013
I ageee with you.
Carter
3/27/2013
How can i show you other cbct image? i can manage the image by my software as i wont.
thank
anil managutti
3/28/2013
i recommend u to go for all on four
Richard Hughes, DDS, FAAI
3/30/2013
If the conditions are right, then four implants with a bar retained overdenture would be a nice treatment. I would let the implants integrate for 6 months then proceed with restoration. She will have a better chance with hygiene with a bar versus a fixed detachable pros.
Remember she is older so her bone is not going to respond like someone in their forties and her manual dexterity may be lacking.
K. F. Chow BDS., FDSRCS
3/31/2013
Total clearance of the uppers and issue of an immediate full upper denture. The denture can be prepared beforehand for issue immediately after the extractions. Good suction can be achieved if the tori is relieved, i.e. covered with a spacing material at least 1mm thick before construction of the denture. The patient can be advised on the use of polident or a similar denture adhesive to get used to the denture. Once the gums are healed, denture stabilization can be carried out with the placement of up to six O-ball head mini dental implants with anchorage devices cold cured into the denture. If the denture is well made, stabilization with mini implants can be done immediately after extraction..... about a 1-2hour job. Remember that this is an 82 year old lady. Please leave the tori alone. All on four carries the need for a several months of treatment time and possible failure due to the temporary prosthesis pressing on the implants. At her age, keep it simple and brief as far as possible. I have a case done for both the upper and the lower full dentures on an 80 year old gentleman.
sergio
4/1/2013
As much as I like using minis for various occasions, I've had too much failure with use of minis for maxillary denture stablization purpose.
I would probably use 2 staged surgery with bigger implants unless the patient undertands possible re-do of a few minis over time.
Richard Hughes, DDS, FAAI
4/1/2013
I can see using mini implants on a temporary basis. But not for long term use in an elderly persons maxilla. One has to consider the BIC and bone density etc.
K. F. Chow BDS., FDSRCS
4/1/2013
Okay guys, how about like this. Place in the six minis to stabilize the upper full denture first. Then if none of them fail, leave the dear old lady alone. If at least 2 fail, then proceed to place in two conventionals and let them integrate. The patient can continue to use the denture with the remaining minis. The advantage here is that the denture will not compress on the healing fixtures so much, thus allowing them to integrate successfully. Once integrated, O-ball abutments can be attached and the two conventionals can help stabilize the denture together with the remaining mini O-ball heads. A happy balance is struck.
sergio
4/2/2013
Why put the old lady on possibility of having another surgery if you can just use bigger implants with 2 stage technique with better predictability?
Dr.Chow, I use minis quite a bit for many uses and unlike many who condemn the use of them without the experience ( or with bad past experiences from learning time). But anything tissue supported with minis on maxilar has too high of failure rate in my hands and others according to my colleagues who use minis. If you just put 4 or 6 bigger implants,wait till they fuse, then in about 6 month, the tx will be done with more peace in mind.
K. F. Chow BDS., FDSRCS
4/2/2013
You are absolutely right Sergio, provided the lady can pay for the conventional implants and accept the larger surgery and longer waiting period. The waiting will include not wearing the upper full denture for a few weeks at least to prevent compression failure of the fixtures. I would outline the two options for the patient. Higher cost, larger surgery, longer wait or lower cost, minimal surgery and instant gratification. The second option carries a certain risk of failure and a reasonable rate of success. At worst, the patient will still continue to have a stabilized denture while waiting for 2 large implants to osseointegrate, or...... may be quite happy with just the remaining minis in place. The first option also carries a certain risk of failure especially if the patient insists on wearing the denture over the healing fixtures. We should give the options to the patient and let her decide.
sergio
4/2/2013
Two words stuck out from your statement.
" Instant gratification" ' " MAYBE " quite happy with just minis..'
What you have to add on to that like you said when giving options, is " with a bit higher chance of failure compared to going with bigger implants with waiting period "
I haven't had many patients who still wants minis even after that gets said.
Options have to be presented with both pros and cons for different options.
If you just emphasize healing period, more invasive surgery with bigger implants.. then who wouldn't choose minis? Have to inform patients about everything. That's the key in our profession!!
K. F. Chow BDS., FDSRCS
4/3/2013
Well said my friend! We should inform our patients about everything necessary for them to make an informed decision. Give them the pros and cons for each option and let them choose. Implant dentistry today have far more options than we had yesterday and we should learn them and offer them to patients. "Instant gratification" in many of these cases treated with minis are true and I make no apologies for using the term. I have seen enough grateful patients who instead of enduring 6 months of torture.... all right.... let's call it inconvenience, get their dentures stabilized in a couple of hours. Yeah. I call it instant gratification.
sergio
4/3/2013
Again, you seem to emphasize the fact minis could be done quicker.
Instant gratification in my opinion is only good when the result stays gratifying for long time.
The notion you have about mini implants for upper denture stablization ignores the fact from many studies mini implants have lowest success rate when used for that purpose.( even in Todd Shatkin's studies ; 5yr follow up, and 12 yr follow up ) Quicker healing, shorter surgery,, it doesn't matter. If you do enough endodontic treatments, you would know that when you try to rush a treatment by skipping steps here and there, you inevitably cut down the longevity of the tooth after endo tx.
I believe minis can be used for many pruposes. Just not for upper denture stablization predictably and it is not ethical if one just emphasizes the lower cost, less invasiveness,and less healing time... and leave out the higher possibility that a patient might have to come back to have a few replaced in near future..
K. F. Chow BDS., FDSRCS
4/6/2013
Yes Sergio. I am guilty as charged. Minis can be done quicker than conventionals and provide instant gratification to many patients who would otherwise have to undergo more invasive surgical procedures and wait a much longer time before they can enjoy the benefits of dental implants. Instant gratification in my opinion is good if there is a good chance for it to last a tolerably long time. It is a great blessing for those who do not want to endure long waiting periods and surgeries and pay large sums of money….. and willing to take the slightly higher risk of failure. Yes, it is true that minis used for denture stabilization on the maxilla do have a higher failure rate. But all implants do have a higher rate of failure in the maxilla when compared with the mandible. Having said that, let us look at it in perspective. In Todd Shatkin’s retrospective analysis of 2514 mini implants place over a 5 year period, there is a 98% success rate for fixed prostheses, an overall 90% success rate for both upper and lower removable prostheses. Upper removable prostheses in the study have a success rate of 83%, which in my book is still tolerable provided the patient is informed upfront. Yes, I am guilty as charged because I really think that the risk is worth taking against all the immediate benefits, provided the patient provides an informed consent. Incorrigibly unrepentant.
sergio
4/6/2013
You gonna have to do better than that. 83% ( according to the number from Shatkin 5yr follow up ) isn't something I feel comfortable about. Let's remember something.
In my neck of the woods, people perceive ANY implant procedures are expensive.
It's not about our notion. It's all about what they think and they say to me on daily basis " IMplants are too expensive". Then a few decide to breathe deep and decide to go for it. Whether minis or not, in their minds, they are paying lots and thanks to some of the comercially oriented dentists who successfully imprinted the idea of implants being a forever thing... Implants ARE more durable than other dental treatments but I wouldn't call it once yoou get it, done deal.
There are just too many factors and minis on upper denture stablization have to rely more on factors other than a surgeon's skill..
P/S There were debate among some colleagues who place minis about the numbers in Shatkin's study counting ones with earlier failure or not. My implnt case success rate is close to 100% but my failure rate is naturally lower thn that..
There should be always that bit of reservation when looking at a study written by someone ( or a company ) who either make certain products or perform certain procedure . I think that's our basis of having skeptical mind..
K. F. Chow BDS., FDSRCS
4/8/2013
Even though the success rate in Shatkin’s study for upper removable dentures is 83%, I believe it can be pushed up towards the 90s. Shatkin’s study was done about 8 years ago. Recently, and old lady whom I placed 4 minis, 2 in front and 2 towards the back, to stabilize her full upper denture 10 years ago came back to repair her denture. All 4 were still present. 3 had a sharp ring and 1 had a dull thud when percussed. Yeah, it is just an anecdote and not evidence based...sic. Today, we know a bit more about how minis can work better in the maxilla. If we take into consideration that bone in the anterior ridges are harder than in the posterior, and that success is greater if minis can be torqued in at a torque of 50 to 60Ncm, and that for many cases the bone height is between 12 to 15mm in the upper anterior ridge though it can be very narrow. If we take advantage of these knowledge and practise more astute case selection, I believe that we can have considerably greater success in the maxilla with minis by keeping the minis towards the front and torqueing them in at 50Ncm or more at maximal depths like 12 to 15mm into the bone. I guess in my corner of the jungle over here where the natives are more stoic, we are greater risk –takers and a little more naïve…. No. I am talking too much....... Shadup now!! No no, I must add. He who dares wins !?!
sergio
4/8/2013
Please stick to the science of it instead of justifying it using a words such as " we are greater risk- taker", " he who dares..".
Your statement now sounds so much like agenda based. I can just easily pull out failed cases of upper denture mini and try to convince people minis don't work or do work.
Let's stick to what some of wet fingered dentists are saying about it in general.
I get upset when some idiots who never placed minis speak badly about them on a seminar. On the other side of it, I also don't buy it when someone tries to push some thing that's based on a few of his own cases. I have heard from many clinicians that the reason they do not use minis for upper denture is due to high possiblity of having to replace them in near future. The problem is we do not know on whom the minis will fail. Then best way is to go for more proven way of doing it.
K. F. Chow BDS., FDSRCS
4/10/2013
Sir, I am a scientist and also a dreamer. Implant dentistry was labeled quacky but today has become mainstream because our predecessors scienced and dreamed on. Every scientist should push the envelope to the max and more, after doing the necessary homework first, of course. Respectfully.
