Implant Retained Mandibular Overdenture: Treatment Advice?

I’ll preface this by saying I’ve only done a handful of implant cases. I have a patient whom I have treatment planned for an implant retained mandibular overdenture following the extraction of his remaining lower teeth.  Should I use 2 or 4 implants? I understand immediate insertion of the implants is an option but not having done this before do you think this is an ‘easier’ case to start with. The other option is to do it in a delayed approach. So basically, should I extract the teeth and let the bone heal and install the implants later?  Should I place bone grafts and membrane after extractions to preserve bone levels?  I have only done a few implant cases and I would appreciate advice before proceeding.

(click images for larger case photos)

Mandibular Overdenture CCF24

20 thoughts on “Implant Retained Mandibular Overdenture: Treatment Advice?

  1. Hello Doctor,
    Thank you for sharing your case with us. Looking at the CT images, this looks like a case for complete removal of all remaining teeth and mandibular overdenture (possibly maxillary too). I would do it at the same time as the extractions, as doing it in stages is inviting bone remodelling and loss of bone volume at prospective sites. Also, overdenture cases are stated to be the relatively easier cases to start in this field. Place in the lower canine locations rather than the first premolar spots, according to Misch. Uncover implants after at least 3-4 months. You can make a lower soft relined denture after 30 days of implant placement, so patient is not just on a liquid diet. Good Luck!

  2. How about a bridge from 22-27 and a few posterior implants in an effort to rehabilitate this patient rather than debilitate the patient. In addition I suggest you consider a closer look at this patients bone. If you cannot explain the variations in bone density and especially the radiopacities associated with the upper left bicuspids you should get the opinion of a dental radiologist before proceeding. Greg Steiner Steiner Laboratories

    • Greg, are the embellishments necessary. Placing two imaplants at the bottom is all this patient can clean. A fixed bridge, come on ! How many times do we have to say this. This patient is in this particular situation for one reason. Keep it simple. I doubt this patient wants to be in anyone’s office, more than 3-4 times. Bv

      • Opacifications are almost always, just that. He said he has only done a handful of implants. The doctor probably understands when to get an evaluation of a suspicious finding. Bv

  3. Classically, you need to begin with transitional removable partials to establish cosmetic and function parameters to accommodate the patient. Current treatment plan is driven by mostly surgical approach, because you’ve mentioned restoration of lower jaw only.

  4. the cbct looks like you have sufficient bone for over denture and for a fpd. what’s opposing the lower will determine the kind of prosthesis to make. this looks like a straight forward case in the lower arch. my only concern will be your lack of experience. for a fpd i would refer the surgical phase.. good luck

  5. I think this is a great case to begin with. Immediate or delayed approach are both acceptable but depends on your level of comfort. I would recommend a delayed approach for a beginner.

    You may want to introduce the option of a fixed bridge also. It requires more implants and cost but is better restoratively.

    • Thanks for your input Irbad. Ive done a number of edentulous cases but none where i had to extract teeth prior. What time frame would you recommend for a delayed approach?

      • Conservatively, 6 months is the typical delay. Since you’ve already done edentulous cases you may want to try an immediate case. This would be a great case given the data you have provided!

  6. Given this is your first immediate placement case you need to be very aware of the restorative space you will need to fit the implant attachments and the denture. It is most likely to require removal of bone to allow for this. If this is not done you will be frustrated with the denture continually fracturing over the implants. The nice thing about reducing bone height is that the extraction sockets become less of an issue due to the root taper. you can also suture the papilla into each extraction socket thereby gaining primary closure and more attached gingiva. I personally do not do 2 implants any more only 4. I also find that people who already have teeth prefer fixed implant restorations as opposed to removable prosthetics and you will have less patient complaints to deal with. If you are still nervous call someone who has experience doing this and invest some time with them, especially watching it being done. Best Regards

  7. Good info given so far, esp. the part about leaving enough vertical space over the implant for attachments, etc.. This pt appears to have a great deal of bone height and width; he could benefit from one of the Trinia composite frameworks cemented on four Bicon Short Implants. Two in the molar areas and two anteriorly, these rotating abutments “self-align”, making the process reliable,and you can have denture teeth or custom composite teeth on the frame for easy repairs and correction.

    You do need a minimum of 7 mm vertical framework clearance, though.

    There is a video on the Bicon site and a case study of the Trinia technique there also.

  8. Do you want tissue supported denture or implant supported? If you place four implants with 2 anterior and 2 posterior you will have the option. If your patient later desires to upgrade, or is disapointed with an overdenture every one will feel better. Keep in mind if only 2 implants are used and 1 fails the case fails. More is better.

  9. Let’s say you have all the room in the world, 4 is better than 3 and 3 is better than 2 implants. Would you use a locator, ball or bar attachment? If you are dealing with a full upper denture, then you are probably safe with a ball or locator. If you have a full set of periodontally sound teeth on the maxilla, then bar may make more sense.

    I wouldn’t immediately load any overdentured implants. If the patient must have something stable in the mean time, I might suggest provisional “mini implants” during the healing process.

    Did you offer the patient the possibility of a fixed implant bridge and using a screw retained denture as an immediate load? At least 4 implants are needed in this situation and two of the posterior ones would need to be tilted.

    If the patient wants this sort of treatment and can afford it, then you may need a highly trained oral surgeon or periodontist that can place the implants for you and you are better off doing the restorative end of treatment.

  10. I would be cautious about mini transitional implants with less experienced surgeons. If you use them, follow the case up carefully and frequently (weekly). The concept of minis is sound but there is a greater risk of bone loss around the mini which can effect your main implants if they are close enough to them. If you just use them and forget about them you may have an unpleasant surprise waiting for you later when you move to stage 2. Frankly in the mandible, 2 piece submerged implants are very predictable with a silicone relined denture. If you keep the denture out of the patients mouth for 2 weeks they do better. If you use one piece implants do not place the attachments for a period of 4 to 6 months. My recommendations are based on predictability and being generic. I should also mention that my advise to be aware of the required restorative space is critical. You can use mounted models here and I would suggest this if you are new. You can obviously get away with less space in none bar attachment cases

  11. Hi everybody;
    Thanx for the nice case. I would like to remind myself of the differences between implant retained denture and implant supported denture. The first one u only rely on implants for full support without relying on the ridge and soft tissue like in using few implant and seat the C/D over them. The second one u rely on ridge and soft tissue for the support and the implant only going to assist in support like using couple implants with ball and socket.
    I also want to clarify wither u want to do immidiate placing or immidiate loading or both?
    Now here is my humble opinion: if u wanna do it by book, then I would make immidiate transitional C/D, do extraction, let it heal for 5 months, bring patient back, assess, place implants( the more the better but 2 r ok) in single stage( unless u don’t have a good primary stability then do 2 stages) and do a complete relief in the implants areas in the C/D and use tissue conditioner on that area u reliefed( pt. can wear the C/D) or u can postponed this for 4 weeks before pt.can wear back the C/D( better). Wait another 4 months for implants to be osseointegrated and proceed with loading now.
    This way pt. will feel the difference between having the C/D with and without implants.
    Please correct me if I’m wrong.
    All the best

    • Amare, makes good common sense, in my opinion . Not sure if you have to wait that long, but this suggestion carries with it, the greatest possibility of success and cost effectiveness. Bv. Vinci Oral and Facial Surgery. Baton. Rouge, La.

  12. You have plenty of bone, what generates the treatment is what kind of fixture you plan. I would not remove all this beautiful bone for a overdenture. This ia a fixed hybrid case or several implant supported bridges. Dont make the patient a cripple. If you must have a denture then use locators so you are not removing bone for the fixture ala all on four. Consult with a prostodontist you trust.

  13. While there are benefits to placing the denture stabilizing implants at the time the teeth are removed, there are also pitfalls to avoid. Without much experience, it is easy, for example, to place an implant too shallow in a lower cuspid socket which is signifcantlly tipped labially. That superficial Labial Cortical Plate will quickly resorb 2-3 mm and could leave the neck of your implant exposed.

    If you have not done this often, I would advise removing the teeth and then placing implants after initial healing has taken place. There apprears to be plenty of bone and the delay will allow you the needed room for the snap attachments.

    John

    • Thanks for your comment John,

      what time frame would you recommend the surgery after the teeth are extracted?

  14. Dr L, depending upon your implant design, the socket position, and your decision whether or not to follow the socket , the timing will vary. Tapered top implants can more easily follow the labially tilted socket without much danger of exposing a shoulder. Bicon implants are normally placed 2-3 mm below the crestal bone edge and you can, in this high risk resorption area, place one 3-4 mm below the crest at about two months post extraction with confidence.

    The absolutely safest delay is 5-6 months since that cortical plate has little circulation and will resorb slowly. At six months, you can see what will likely happen over the next decade with almost any implant.

    John

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