Achieving Reliable Denture Stability: The Need for Implant-Retained Overdentures to Increase

Poor denture stability and the challenges found in finishing restorative materials (composite, acrylic, porcelain, and metal) are common and widespread problems. It is the author’s belief that these problems will significantly increase along with the aging of the population.
The objective of this case report article is to provide the clinician with some straightforward solutions that can be employed when faced with the challenges associated with the correction of denture instability.

MINIMALLY INVASIVE DENTAL REHABILITATION
Attaching an overdenture to implants or resilient retained roots can improve denture stability. This is no different than earthquake-resistant anchoring of a building to a foundation that allows for a small amount of movement while at the same time retaining the building in place. There are various attachments to provide connection between osseous anchorage and the removable prosthesis. Some attachments can be used on both the natural and man-made roots (ie, ERA Attachment System [Sterngold] and Locator Implant Attachment System [Zest Anchors]). Other attachments are permanently incorporated into implants (ie, Micro ERA [Sterngold]; Atlas Implants [Dentatus]; and MDI Mini Dental Implants [3M ESPE]).
Ideal overdenture attachment characteristics include predictable placement, wear resistance, quick repair, low profile, good retention, patient-friendly use, reasonable cost, and various diameters to fit differing ridge widths.

CASE REPORT
Diagnosis and Treatment Planning

An 80-year-old male patient (retired physician) presented complaining of a mobile mandibular denture and associated pain. In addition, the patient had secondary complaints of speech difficulties, poor mastication, traumatized buccal mucosa, denture sores, poor aesthetics, a prominent mandible, and poor upper lip support. A Class III denture and jaw relationship was noted (Figure 1). This gentleman had been edentulous in the mandible in excess of 30 years, resulting in obvious problems which included the loss of the mandibular ridge and the subsequent loss of adequate denture retention (Figure 2).
In addition to the clinical oral examination, a panoramic radiograph (Figure 3), intraoral radiographs, dental models, photographs, complete dental history, and medical histories were secured to assist in determining a treatment plan.

Figure 1. Preoperative photo showing Class III denture occlusion. Figure 2. Preoperative appearance of the atrophic mandibular ridge.
Figure 3. Preoperative panoramic radiograph.

The patient had a long history of serious cardiac disease and hypertension that, along with possible associated complications, would cause a cautious clinician to limit the extent of any treatment and surgery. (Less was better in this case.)
The diagnosis included denture and skeletal Class III, significant posterior mandibular ridge and keratinized soft-tissue losses, significant medical complications, pain and speech alterations from poor fitting dentures, diminished mastication efficiency from denture instability, poor dental aesthetics, and resultant decreased social interaction.
The treatment goals included stabilizing his health; minimizing any surgery and intraoral treatment; improving denture retention, speech, aesthetics, mastication, and the Class III occlusion. The treatment plan would include: a minimally invasive implant-retained mandibular overdenture, denture relining for stabilization, increased overbite and overjet for improved occlusion, and direct resin composites on the denture teeth for stabilization.
For this case, 2 ERA and 2 Micro ERA implants would be used to retain and stabilize the mandibular denture, both immediately and long-term. This system was chosen because it has: resilience, angle correction of abutments, radicular snap configuration, internal and external retention, vertical movement, hinge movement, 6 different retention grades, fabrication male with integrated spacer, and an optional metal receptor jacket (inside of the denture) placed by the lab or at chairside. In addition, the fabrication and resilient males can be changed without bonding/processing, and there is also a micro version option.
Angle correction of the implants was anticipated due to the residual mandibular morphology. Direct composite resin veneers would be used to reshape the maxillary and mandibular dentition. A combination of soft and hard reline materials would be used to modify the soft-tissue surfaces of the existing dentures and the new denture.

Minimally Invasive Flapless Implant Placement
A minimally invasive flapless implant procedure with local anesthetic was chosen to mitigate any possible untoward complications for this medically compromised patient.
A tissue-punch technique was used to remove soft tissue at the designated 4 implant sites; No. 27 ERA Angled Implant with 3.25 mm diameter, 10 mm length, one mm cuff, acid-etched; No. 23 ERA 0° Micro Head Implant with 2.2 mm diameter, 10 mm, length one mm cuff, acid-etched; No. 25 ERA 0° Micro Head Implant with 2.2 mm diameter, 10 mm, length one mm cuff, acid-etched; and No. 22 ERA Angled Implant with 3.25 mm diameter, 10 mm length, one mm cuff, acid-etched.
A latch-type No. 2 round bur (SS White Burs) was used with sterile saline irrigation to create a small pilot hole (one mm) at each site. Osteotomies for the 3.25-mm diameter ERA Implants (Nos. 22 and 27) and then the 2.2-mm diameter ERA Implants (Nos. 23 and 25) were done.
For the 3.25-mm diameter implant placement sites (Nos. 22 and 27), the 1.6-mm drill (with external sterile saline irrigation) was used to create the osteotomies to 10 mm (full length of the implants). A 0° ERA Correct Angle Gauge (metal post) was placed in the No. 27 first osteotomy hole to act as a guide to prepare the next site No. 22. The 0°, 5°, 11°, and 17° ERA Correct Angle Gauges were placed in the osteotomy sites to determine that the 0° for No. 27, 5° for No. 22, and angled female implant abutment should be used for the Nos. 22 and 27 osteotomy sites.
For the 2.2-mm diameter implant placement sites (Nos. 23 and 25) a 1.6-mm diameter countersink drill (with external sterile saline irrigation) created a pilot hole (as deep as the length of the untapered portion of the implant screw) with a flat area for the complete seating of the ERA female head of the implants. After the first 2.2 mm diameter 0° implant osteotomy, a 0° Correct Angle Gauge was placed in that osteotomy site. The No. 22 (5°) and 27 (0°) ERA Correct Angle Gauges were also in their respective osteotomy sites to allow for alignment of the last 2.2 mm diameter 0° implant. The ERA Correct Angle Gauges are used to determine if a straight 2.2-mm diameter 0° implant will align within the required 7° of the other 2.2-mm diameter implant. The second 2.2-mm diameter 0° implant osteotomy was undertaken with a 1.6 mm diameter countersink drill (with external sterile saline irrigation). A 0° ERA Correct Angle Gauge was placed in this osteotomy site to verify alignment of all 4 implants (Figure 4).
An ERA 3.25 mm combination countersink drill was used (with sterile saline irrigation) to expand the diameter of each 3.25-mm implant osteotomy using the appropriate 10-mm length, and to create proper contours to allow the ERA attachment heads to sit on the bone surface. The bone was not dense enough to require the tapping of the osteotomies with a bone tap and sterile saline irrigation.

Figure 4. Paralleling guide pins in osteotomies Nos. 22 (5°), 23 (0°), 25 (0°), and 27 (0°). Figure 5. Thumb wrench insert ERA implant (Sterngold).
Figure 6. Ratchet insert ERA implant. Figure 7. Air abrasion done to develop 4 relief wells in the denture.
Figure 8. ERA metal retainers Nos. 22 and 23 in denture. Figure 9. ERA Alignment Handles in ERA implants (at Nos. 22, 23, 25, and 27 tooth positions).
Figure 10. Excess cement was removed. Figure 11. Four ERA implants in the mandible occlusal view (at Nos. 22, 23, 25, and 27 tooth positions).

The Nos. 23 and 25 ERA straight implant packages (containing 2.2 mm diameter, 10 mm length, one mm cuff, acid-etched sterile implants) were opened, and the titanium tubes that hold the implants were placed in the package round depressions. The implant insertion tool was inserted into the implant and used to carry the implant to the osteotomy. The self-tapping implant was slowly screwed into the osteotomy site with the Implant Insertion Tool (with external sterile saline irrigation). Sometimes the implant can be fully seated using Insertion Tool with downward pressure (Figure 5). The implant insertion tool is gently tipped to disconnect it from the implant. An ERA Socket with a short handled ratchet wrench was used with downward pressure to slowly complete the seating of the implant into the osteotomy site with external sterile saline irrigation (Figure 6).
Fractures or failures can occur when thermal trauma is created by friction, fast movements with the ratchet wrench that heat the implant, application of excessive torque especially in cortical bone, or if the ratchet is tilted away from a 90° angle to the implant. These actions will damage bone. Failures and fractures can be avoided in dense bone by using a ratchet wrench to slowly seat the implant with a cooling sterile saline irrigation; this is done by taking 7 seconds for each quarter turn, and then waiting for a period of 5 to 10 seconds or more between turns (allows bone displacement/expansion), with the thumb or forefinger of the opposite hand applying downward pressure to the head of the ratchet wrench during use. Implants are fully seated only when all blasted threads are engaged in bone and the apical tip of each implant is stabilized by cortical bone.
The Implant Insertion Tool, ERA Socket, and ratchet were used to place the 3.25 mm ERA implants (with external sterile saline irrigation) in the same manner as for the 2.2 mm implants above.

Prosthetic Procedure
Progressive loading of the implants was chosen due to the patient’s advanced age, dystrophic edentulous ridge, thin soft tissue, and the clinician’s desire to retain all 4 implants indefinitely. At the end of surgery, an immediate improvement in retention was accomplished with progressive loading of the implants.
The existing mandibular denture was relieved and undercut over each of the 4 implants as well as over the edentulous ridge. The tissue surface of the denture was sandblasted and cleaned (Figure 7). Then, reline adhesive was placed on the tissue surface of the denture and thoroughly dried. Next, a soft silicone denture reline material (Sofreliner Tough [Tokuyama Dental America]) was placed on the tissue surface of the denture and it was passively seated in the mouth. Any excess silicone was trimmed and buffed.
About one month post-op to the previous procedures, the metal housing (Nos. 23 and 25) for the polymer males was placed in the mandibular denture. The silicone in the relieved “wells” over Nos. 23 and 25 implants in the denture was removed. The wells were then sandblasted and cleaned. Rubber dam covers were placed over the Nos. 23 and 25 surgical sites for protection and to block out undercuts. The metal housings with black processing males were placed on the Nos. 23 and 25 implants. Hard reliner (Rebase II Quick Set [Tokuyama Dental America]) was then mixed and placed in the denture wells. Next, the mandibular denture was passively seated on the implants and edentulous ridge until the reliner was set (Figure 8).

Figure 12. Denture with Nos. 23 and 25 Standard ERA metal retainers and Nos. 22 and 27 Mini ERA metal retainers. Figure 13. Bullet-shaped polisher (Jazz Supreme [SS White Burs]) was used to impart final polish and luster.
Figure 14. Impression copings (Nos. 22, 23, 25, and 27) in implants. Figure 15. Mandibular impression with copings and implant analogs (Nos. 22, 23, 25, and 27).
Figure 16. Mandibular wax rim in place. Figure 17. The completed dentures.
Figure 18. Note the postoperative lip support. Figure 19. Outcome: a very happy patient!

The metal jackets with black fabrication males have built-in spacers. These were used for immediate loading and retention of the denture. The denture was placed into a solution of Tokuso Resin Hardener II (Tokuyama Dental America) for (a minimum of) 3 minutes. The denture was then rinsed, dried, and polished as necessary with one-step polishers (Jazz Supreme [SS White Burs]). These versatile diamond-impregnated soft polymer polishing instruments trim, smooth, and polish in one action by varying the applied force; heavy force provides trimming, and light force generates fine polishing that provides a high luster quickly. These one-step polishers can be used on composite resins, denture teeth, hard denture reline materials, and most denture acrylics.
The recesses over the 3.25 mm diameter ERA Implants were coated with Sofreliner Tough Primer (Tokuyama Dental America) and air-dried. Tokuyama Sofreliner Tough was placed in the recesses over the 3.25-mm diameter ERA Implants and the denture was seated in the mouth. The patient bit lightly in occlusion. (Note: DentuSil [Bosworth] and Light Liner [Bosworth] are examples of alternative silicone liners that could also be used with these procedures.)
The black processing males were replaced with white retentive Micro ERA males. ERA males are black (processing), white (minimal retention), orange, blue, gray, yellow, and red (maximum retention). The black processing males were removed with a Micro ERA Core Cutter (trephine bur) in a straight handpiece at a slow to medium speed. Short spurts of in and out cutting motion were used to remove the center of the black fabrication male from the metal jacket. An explorer was used to remove the black processing male remnants. New white Micro ERA males were placed in the Micro ERA Metal Housings (Nos. 23 and 25) with a Micro ERA Seating tool. An ERA white male creates a 0.4-mm space for resiliency and hinging.

Osseointegration
The 3.25-mm diameter ERA Implants were left undisturbed for more than the minimum of 3 months to allow osseointegration. The ERA Female abutments were placed in the Nos. 22 and 27 positions. ERA Alignment Handles were snapped into the No. 22 ERA Female 5° Angle Correction abutment and the straight 0° No. 27 ERA abutment. The No. 22 ERA Female 5° Angle Correction assembly, the No. 27 ERA 0° straight assembly, and the 2 straight Micro ERA Alignment Handles were snapped into their respective 3.25-mm and 2.2-mm ERA Implants (Figure 9). The No. 22 ERA Female 5° Angle Correction assembly was rotated until all of the white plastic alignment handles determined the proper path of insertion for the denture. A vertical line was marked across the implant bases and female abutments (Nos. 22 and 27) to verify correction alignment at cementation. The female abutments were removed, and a small amount of self-cure ERA Lock Cement was placed into the bases and female abutments. Next, the female abutments were snapped into the implant bases and realigned by the vertical markings. Then, any excess cement was removed (Figure 10).
Subsequently the 3.25-mm ERA Implant metal jackets with black fabrication males with built-in spacers were placed into the mandibular denture in the same manner as for the 2.2-mm implants (Nos. 23 and 25). These were used for retention of the denture (Figure 11). The 3.25-mm ERA black fabrication males were replaced with 3.25-mm ERA white retention males, using the same technique as was employed for the 2.2-mm implants but with regular ERA instrumentation (Figure 12).

New Mandibular Denture Fabrication
The Class III occlusion was corrected using direct composite resin veneers.
The maxillary denture teeth were sandblasted, washed, and dried. A one-step bonding agent (One Coat 7.0 [Coltène]) was applied to the denture teeth, air-thinned, and light-cured. Then, flowable composite (Synergy Flow [Coltène]) was applied to the occlusal surfaces of the posterior to open the bite, allowing the shift from a Class III to a flat plane Class I occlusion. Next, hybrid composite (Synergy D6 [Coltène]) was applied to the facial surfaces of the denture teeth, shaped into direct veneers, and light-cured.
The use of safe-ended finishing burs (Safe End Composite Finishing Burs [SS White Burs]) allowed for easy trimming and shaping of the composite resin rehabilitation of the maxillary denture dentition. Then, use of the one-step polishers (Jazz Supreme) efficiently imparted high luster to the composite resin as well as to the denture acrylic surfaces adjacent to the teeth (Figure 13).
ERA Impression Copings were placed on each implant female abutment (Figure 14). An open tray was used to take a vinyl polysiloxane impression (SternVantage Putty and SternVantage Monophase [Sterngold]) of the mandible with impression copings. ERA overdenture processing jigs were attached to the ERA Impression Copings (Figure 15).
An experienced dental laboratory team (at Glidewell Laboratories) provided their advice and expertise related to the ERA implants. A wax rim was lab-fabricated and tried-in. Adjustments were done and a bite registration was made (Figure 16). Plastic denture teeth were set in the wax rim. The teeth were tried-in and minimally adjusted. The dental laboratory team packed, processed, and finished the mandibular denture with integrated metal jackets for the remaining female ERA implant abutments.
The denture was delivered and adjusted using an articulating foil (TrollFoil [TrollDental]) that has a thin built-in plastic frame/handle.
The black males can be replaced with white males, and then later with orange males, to increase retention as required (Figures 17 to 19).

BRIEF DISCUSSION OF MATERIALS
This clinical case report demonstrated simple immediate and long-term retention of overdentures with flapless placement of mini- and traditional-sized implants. This was coupled with angle-correcting semi-precision resilient attachments that allowed for an idealized path of insertion without the demand of idealized implant alignment.
Sterngold angle-correcting ERA abutments can be used on almost any brand of existing traditional-sized implants. Resilient ERA males can be utilized in almost any denture and many partial dentures. The wide range of retention strengths of the ERA males allows the clinician alternatives with the initial placement and future altered retention requirements. The range of reline materials offered by manufactures like Bosworth, Sterngold, and Tokuyama have made it possible to provide quick, effective, and economical alterations to removable prosthetics.
A high luster is necessary for implant-retained overdentures and direct restorations, hard relines, composite repair of denture teeth, retrofitting existing dentures to be overdentures, and natural tooth bonding. Since chairside polishing of various restorative materials has often been a confusing and frustrating experience for many clinicians, the simple system (Jazz Supreme [SS White]) was chosen for the purpose of demonstrating how the polishing process can be streamlined. The use of the one-step bonding, hybrid composite, finishing burs, and one-step polishers allowed a very quick rehabilitation of the existing maxillary denture from Class III to Class I with the utilization of a chairside auxiliary for part of the work.

CLOSING COMMENTS
The patient discussed herein is representative of an ever-growing group of medically-compromised patients with chronic dental disabilities who seek oral rehabilitation from general clinicians. The presented technique of angle-correcting resilient implant-retained overdentures, with flap or flapless implant placement, allows an immediate cost-effective treatment plan for denture stabilization.
Economic pressures to control overhead expenses and time have accelerated the growth of the angle correcting semi-precision resilient attachment system with mini- and traditional-sized implants that are coupled with innovative denture liners and polishing systems. Patient demands for increased comfort, aesthetics, and cost effectiveness are propelling the expansion of these new technologies and combination of techniques, as demonstrated in this case presentation.
The average restorative turned surgical-restorative dentist can avoid problems through proper case selection. It is possible for the average restorative dentist to learn to perform minimally invasive implant surgery and overdenture fabrication that patients demand.


Suggested Readings

Ambard AJ, Fanchiang JC, Mueninghoff L, et al. Cleansability of and patients’ satisfaction with implant-retained overdentures: a retrospective comparison of two attachment methods. J Am Dent Assoc. 2002;133:1237-1242.
Doundoulakis JH, Eckert SE, Lindquist CC, et al. The implant-supported overdenture as an alternative to the complete mandibular denture. J Am Dent Assoc. 2003;134:1455-1458.
Carrick JL. Dentistry for an aging population: the ERA Implant Overdenture. Inside Dentistry. 2006;2:82.
Rossein KD. Alternative treatment plans: implant-supported mandibular dentures. Inside Dentistry. 2006;2:42.
Stoker GT, Wismeijer D, van Waas MA. An eight-year follow-up to a randomized clinical trial of aftercare and cost-analysis with three types of mandibular implant-retained overdentures. J Dent Res. 2007;86:276- 280.
Stanford CM. Application of oral implants to the general dental practice. J Am Dent Assoc. 2005;136:1092-1100.
Stanford CM. Dental implants. A role in geriatric dentistry for the general practice? J Am Dent Assoc. 2007;138(suppl):34S-40S.


Dr. Johnson is a chemist, dentist, lecturer, and author. He has taken the opportunity to visit and consult with dental material manufacturer chemists and researchers domestically and internationally. He is former assistant professor of surgery at the Craniofacial Center of University of Illinois at Chicago College of Medicine Department of Surgery, Plastic Surgery Division. Dr. Johnson is a director of the Clinical Research Institute. He can be reached at smile7777@aol.com.

Disclosure: Dr. Johnson reports the following disclosures: Sterngold Dental supplied the dental implant materials and financial support for research to the Clinical Research Institute; SS White Burs supplied rotary and polishing instruments and financial support for research to the Clinical Research Institute; Tokuyama Dental America, Colténe, Harry J. Bosworth, and Troll Dental donated dental materials to the Clinical Research Institute for use in this case study; Glidewell Laboratories donated dental laboratory procedures used in this case study; and The Clinical Research Institute has provided dental materials to the author, as well as travel expenses and honoraria for presentations and publications.