Overdenture mandible case with anterior alveolar defect and no vestibular sulcus: thoughts?

This patient is a 51 year old heavy smoker with clear medical history and wishes a new lower denture to improve his chewing ability. Maxilla has most of his natural teeth.
I am planning to place two implants (LR3 4.1x10mm, LL3 4.1x8mm) to support an overdenture using Locators. However the CBCT shows there is a quite significant bone defect in LL23 area. Also on the labial there is no vestibular sulcus. Please note that the mandibular teeth have already been extracted. What are your thoughts? What kind of graft (if any) would you use in this case? Thanks.



9 thoughts on: Overdenture mandible case with anterior alveolar defect and no vestibular sulcus: thoughts?

  1. Dr. Moe says:

    Hi,
    The bigger issue for you is going to be the fact that the patient does not have a vestibule. Whenever there is an issue with vestibule you have two options. 1. Vestibulplasty, or 2. Use a hybrid, i.e. a screw retained final prosthesis. The reason is, the issue is going to be when the Pt goes in function with 2 implants in mandible, there will be a slight anterio-posterior rock, which will impinge on Pt’s, “non-vestibule”, vestibule. Patient will come back complaining about the fact that denture is fine until Pt goes into function, and every now and then it really hurts and he can’t wear it or use it, and then it will drive you crazy.
    I have done an overdenture on a patient with minimal vestibule but then he had 5 implants from # 28 to #21 (implants were placed before patient came to me, and had broken his hybrid but did not have the money to pay for another hybrid). Patient loves his overdenture, but I had forewarned him about possible issue with impingement of soft tissue, which he did come back for and I was able to relieve the overdenture and it was perfect.
    You could try relieving the overdenture on facial aspect if you have the same issue.
    Good luck

  2. BJP DDS, DIOCI says:

    First alert is really that the patient is a heavy smoker. research shows and as it was just emphasized at the ICOI Symposium in Vegas earlier this month, three types of patients that will have compromised levels of healing. Cardiovascular, smokers and alcoholics. The nicotine (amongst the 500+ gases that are formed during smoking) prevents angiogenesis so any bone grafting will be limited with the blood supply formation into the grafting material itself. Autogenous bone mixed with mineralized corticocancellous allograft ( re hydrated and mixed in L-PRF) covered with a solid barrier, the same allograft mixed with either PDGF (GEM21S) or BMP2 (Infuse by Medtronics) are all approaches I have taken and gotten good results with . BUT I always encourage the patients to stop smoking and using some kind of smoking cessation approach through their physician three weeks prior the surgery date and for 8-12 weeks post treatment. For the ones that stop smoking, they actually do really well. I agree with Dr. Moe as it is inevitable it will be a major issue. Warn the patient additional bone grafting may be needed. Implants in areas of bone with a greater blood supply will have less issues.Hope this helps.

  3. Dr. Luis Leon says:

    Buenas tardes mi experiencia en 28 a帽os colocando implantes y tratando pacientes con sobredentadura y con antecedentes cl铆nicos como fumador, es tema de primer orden en tratar de que el paciente cosientice que dejar谩 de fumar 3 semanas antes de la cirug铆a y durante el posoperqtotio igual 4 semanas. Si esto no es as铆 no opero. El segundo paso es tomar impresiones para confeccionar una pr贸tesis total inferior. El tercer paso es la cirug铆a extracciones quir煤rgicas, lavado y curetaje 贸seo, aplastia 贸sea, alo inertos + colocaci贸n de 6 Implantes bajo el sistema de broches ( Ball Sistem) . El cuarto paso es la adaptaci贸n e instalaci贸n inmediata de la sobre dentadura. PRONOSTICO : BUENO.

  4. mwjdds,ms says:

    what is the reason for two locators? A better option is a fixed hybrid restoration, especially if the opposing dentition is natural dentition. By using 4 implants and a fixed prosthesis there is no need to bone graft, simply level the spiny anterior alveolus. When extracting 4-3, 4-4 and 4-6 you’ll be levelling the alveolus nearly to the apices of these teeth to create room for the prosthesis so, again no or very minimal bone grafting will be needed and certainly the bone graft won’t be needed to stabilize the implants. Agree with other posters, smoking is of concern but not a deal breaker. Try to get patient to quit if possible. If two implants and locators are to be used because of cost, then place the two implants at the lateral incisor positions to minimize A-P rocking.

  5. Spencer-Chicago says:

    IMHO, any lower full denture that is opposed to natural teeth is a special case. I do NOT like doing them, as the uppers have way more stability and can apply a lot of force against the lower denture, which has no natural retention and questionable stability against lateral displacement.
    IMHO, 2 implants is not enough. In addition, make sure the upper is adjusted for a decent occlusal plane…no supra-erupted teeth creating a roller coaster. Have a short dental arch: definitely no 2nd molars and maybe skip a bicuspid, too…depending on the location of the rise of the posterior ridge.
    Note that force on teeth on the slope of the ridge will push the denture forward and raise it in front, unsnapping it. In the case of no vestibule, you also have lip and chin muscles that act to lift the denture during function. These are reasons that 2 snaps are not enough.

  6. Greg Kammeyer, DDS, MS, DABOI says:

    All above comments are solid: I would add that 1) a male, 2) apposing natural dentition and 3) smoker all add to Your Risk factors for implant failure. All these prosthetic points are true AND the lateral load on a 2 implant locator case should be borne by the residual ridge (traditional denture mechanics). 2 impt OD are for retention not lateral load. With that bone density I wouldn’t expect much bone growth due to low vascularity even with the 3 growth factors mentioned (I use all 3 regularly). You can graft yet I would level the ridge and put in 4 implants vertically with the best AP spread you can get. Be sure to reduce the ridge enough to have adequate thickness for a metal reinforced overdenture and if feasible (without making the muscle pull worse) enough space for a fixed prosthetic. So if the patient still wants to avoid the cost of a fixed complete denture then you have the foundation set for either the failure of an implant or their eventual shifting to a fixed prosthetic, which clearly is indicated here.

    • Angela says:

      TRINIA is a fully biocompatible metal free fiber-reinforced resin CAD-CAM material. Much lighter than Zirconia. Bicon lab uses this material for their over denture fixed or removable flange free cases over the Bicon implants in conjunction with Telescopic abutments. You can go to Bicon.com or contact them to get more information about it.

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