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IMPLANTS

FOR PERSONAL FILES OR EDUCATIONAL USE ONLY

Efficient Placement of Implant

Overdenture Attachments

George Priest,
DMD

INTRODUCTION
Attachment-retained implant overdentures
are functionally superior to conventional
dentures and are effective and cost-saving
alternatives to fixed implant dental prostheses. In the mandible, the 2-implant overdenture is the least costly implant option,1 it
offers a significant increase in retention and
stability over a complete denture,2 and
demonstrates a considerable improvement
in quality of life.3 For these reasons, the
mandibular 2-implant overdenture has been
described as a standard of care for edentulous mandibles.4-6 Furthermore, solitary
attachments have been shown to be as effective as bars for overdenture retention; there
is no difference in implant prognosis,7 bars
increase the cost of overdentures,8 they
require more space,9 they do not improve
retention or stability,10 and hygiene is more
difficult with bars.11 The cost of 4 implants
and a bar approaches that of a fixed dental
prosthesis with no significant improvement
in bone preservation or patient comfort
compared with a mandibular overdenture
with 2 implants.12
Short-term data also indicate high success rates for the 4-implant maxillary overdenture with solitary attachments. Cavallaro and Tarnow,13 on an admittedly small
sample of 5 patients over a period of 48
months, documented 100% success with
maxillary overdentures on 4 implants. Eccellente et al14 demonstrated high success
rates even after immediate loading protocols. These data indicate that solitary attachments for both mandibular and maxillary overdentures provide an acceptable im plant prognosis and predictable retention
while simplifying implant treatment protocols and reducing costs, making implant
dentistry available to a larger segment of
the population. Use of solitary implant
attachments is therefore likely to become
an established and regularly used restorative protocol.
Dentists now require materials and systems that facilitate the use and placement of
the vast assortment of available implant
attachments. The following patient presentation demonstrates chairside placement of
attachments in an edentulous maxilla with
5 implants. The illustrated technique is also
applicable to mandibular overdentures.

DENTISTRYTODAY.COM DECEMBER 2011

Figure 1. A 63-year-old male

patient presented with a failing
maxillary fixed dental prosthesis
that extended from the maxillary
right canine to left second
molar.

Figure 2. Five endodontically treated teeth supported the failing

prosthesis and 3 implants retained a fixed prosthesis in the
maxillary right quadrant.

Figure 3. The tooth-supported

prosthesis was sectioned distal
to the left canine abutment by
the prosthodontist.

Figure 4. The painful and

failing left second molar was
immediately extracted.

Figure 5. Two additional

implants were placed distal to
the maxillary left canine.

Figure 6. After removal of the

remaining teeth and prostheses,
an interim denture was placed.

Figure 7. Locator abutments

(Zest Anchors) were seated on
the 2 newly integrated and the
3 previously placed implants.

CASE REPORT
Diagnosis and Treatment Planning
A 63-year-old male patient presented to the
office of the prosthodontist with a loose
maxillary tooth-borne fixed dental prosthesis and discomfort in the area of the left second molar (Figure 1). Clinical and panoramic radiographic examination revealed that
the mandibular teeth and prostheses were
intact. Three implants with 3 splinted
crowns replaced the premolars and first
molar in the maxillary right posterior quadrant. Five endodontically treated and periodontally involved teeth retained a fixed
dental prosthesis from the maxillary right
canine to the left second molar (Figure 2).
The second molar abutment was deeply carious and the retainer was loose. To relieve
the patients discomfort, the prosthesis had

been sectioned distal to the canine abutment by the prosthodontist (Figure 3) and
the molar extracted by the treating periodontist (Figure 4).
Definitive treatment options considered and discussed were: (1) retention of
the 4 remaining maxillary teeth and a
removable partial denture adjacent to the
existing implant prosthesis; (2) extraction
of the remaining teeth, additional implant
placement with placement of a ceramo metal fixed dental prosthesis; and (3) extraction of the remaining teeth and a bar
retained removable overdenture or; (4) an
implant overdenture retained by solitary
attachments.
Primarily due to financial restraints,
the patient, prosthodontist, and periodontist agreed upon 2 additional implants in

the maxillary left quadrant and an implant overdenture retained by 5 individual implant attachments.
Due to a severe gag reflex, an open-palate prosthesis
was planned.
Initial Surgical and Prosthodontic Treatment
Two dental implants were placed by the periodontist,
with minimal divergence in relation to the existing
implants, distal to the sectioned fixed dental prosthesis
in the areas of the left first premolar and first molar
(Figure 5). The patient continued to wear the existing
fixed dental prosthesis during the integration period of
3 months. The prostheses were then removed from the
teeth and existing implants, the remaining 4 endodontically treated teeth were extracted, healing abutments
were placed on the 3 previously placed implants and an
interim denture was seated over the 5 implants during
healing of the extraction sites (Figure 6).
Definitive Prosthodontic Therapy
After a 3-month integration period, definitive prosthodontic therapy began with depth measurements from
the implant platforms to the most coronal aspect of the
surrounding gingival levels. Locator Implant Abutment (Zest Anchors) selection was predicated on these

Use of solitary implant attachments is

therefore likely to become an established
and regularly used restorative protocol.
measurements. Selection of the shortest Locator Attachments (Zest Anchors) while maintaining the
retention ring supragingival to the highest point of the
gingival crest is advisable for several reasons: less hollow grinding of denture teeth is required, the denture
base is not unduly weakened, and shorter attachments
facilitate chairside seating of attachment housings.
Locator Abutments were seated on the implants
and tightened to specified torque values (Figure 7).
Locator Processing Spacers (Zest Anchors) were placed
over the Locator Abutments to provide relief in the
denture for chairside attachment of the Locator titanium caps (Zest Anchors) and males (Figure 8), and then
the final impression was made. The cast was poured
and the palatal extent of the open-palate prosthesis
was demarcated (Figure 9). Denture teeth (SR Phonares
[Ivoclar Vivadent]) were selected and arranged for a
wax try-in (Figure 10), and the approved waxing was
then processed with gingival characterization (Figure
11). The palate was reinforced with a metal subframe,
and 5 recesses for chairside seating of the Locator Caps
were provided by the incorporation of the processing
spacers (Figure 12). Prior to attachment placement,
complete basal seating of the prosthesis was ascertained with pressure indicating paste (Figure 13) and
the occlusion was refined (Figure 14). Locator blockout spacer rings (Zest Anchors) were placed on the
abutments followed by titanium caps with processing
males (Figure 15).

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IMPLANTS
Chairside Attachment
A novel gingival-colored composite
resin luting system (Quick Up [VOCO
America), ideal for the chairside placement of implant attachments, was used
to complete the implant overdenture.
The kit (Figure 16) also includes Fit Test
C&B, a silicone for checking interferences and for blocking out undercuts;
Quick Up Adhesive to enhance retention between the denture base and
Quick Up resin; and Quick Up LC, a
light-cured flowable composite resin
for filling voids in the cured material.

Another important application

for Quick Up is inexpensively retrofitting existing dentures and rejuvenation of implant overdentures that
require replacement of attachments.
The method described below can be
used when relining an overdenture
or replacing misaligned or worn
attachments.
First, Quick Up Test C&B silicone
was injected into the overdenture recesses (Figure 17), the overdenture was
seated over the attachment caps and the
Quick Up Test C&B was allowed to set

before the overdenture was removed

(Figure 18). Potential interferences that
were detected between the denture base
and attachments were checked and
eliminated. Next, a No. 8 round bur was
used to place undercuts in the recesses
(Figure 19) to provide mechanical retention between the denture base material
and the Quick Up composite resin. Additionally, the same bur was used to
place vent holes from the attachment
recesses through the palatal surface of
the overdenture to allow escape of excess resin (Figure 20).

Quick Up Adhesive was painted

into the overdenture recesses to enhance retention between the denture
base and the composite resin (Figure
21). Petroleum jelly was applied to
basal surfaces of the denture to prevent unwanted adherence of excess
resin (Figure 22). Using the small
enclosed cartridge tip, Quick Up Test
C&B was injected around potential
undercut areas of the attachments
that could impede removal of the
prosthesis after the resin cured (Figcontinued on page 62

Figure 8. Locator Processing Spacers (Zest

Anchors) were placed over the abutments to
provide relief for chairside attachment of the
Locator caps (Zest Anchors).

Figure 9. After an impression was made,

the cast was poured and the palatal
extent of the open-palate prosthesis was
demarcated.

Figure 10. A denture tooth set-up was

prepared for a wax try-in.

Figure 11. The patient-approved waxing was

then processed with characterized gingival
resin.

Figure 12. Five recesses for chairside

seating of the Locator caps were
incorporated into the open-palate,
metal-reinforced overdenture.

Figure 13. Complete basal seating of the

prosthesis was ascertained with pressure
indicating paste.

Figure 14. Occlusion was refined prior to

seating the attachments.

Figure 15. Locator block-out spacer rings

and titanium caps were placed on the (Zest
Anchors) abutments.

Figure 16. Quick Up (VOCO America) was

used for chairside placement of implant
attachments.

Figure 17. Quick Up Test C&B silicone was

injected into the overdenture recesses to
check for impediments to complete seating.

Figure 18. Following setting of the silicone,

the overdenture was removed and no
interferences were detected.

Figure 19. Mechanical undercuts were

placed into the attachment recesses with a
No. 8 round bur.

Figure 20. The same bur was used to place

palatal vent holes to allow excess resin to
escape.

Figure 21. Quick Up Adhesive was painted

into the overdenture recesses.

Figure 22. Petroleum jelly was applied to

surfaces where adhesion of the resin was
unwanted.

Figure 23. Potential undercuts around the

attachments were blocked out with Quick Up
Test C&B silicone.

DENTISTRYTODAY.COM DECEMBER 2011

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IMPLANTS

Figure 24. Quick Up luting resin was then

injected about two thirds the height of each
recess and the overdenture was seated.

Figure 25. The prosthesis was gently held

in place during curing of the resin.

Figure 26. After 3 minutes, the overdenture

with the incorporated caps was removed.

Figure 27. Slight voids around the caps and

in the access openings were filled with
Quick Up LC flowable composite resin.

Figure 28. Appropriately retentive Locator

males were seated into the overdenture.

Figure 29. The open palate prosthesis

helped the patient overcome his gag reflex.

Figure 30. The implant-retained overdenture

met the patients aesthetic objective of age
appropriate denture teeth (SR Phonares
[Ivoclar Vivadent]).

Figure 31. The patients functional goals of

improved occlusion and mastication were
also realized.

Efficient Placement of Implant...

continued from page 60

ure 23). Quick Up luting resin was

then injected about two thirds of the
height of each recess and the overdenture was seated (Figure 24). One
method of seating the overdenture is
to instruct the patient to gently close,
but the author has found this approach to result in varied amounts of
closing force for each individual patient, and some older patients have
compromised motor control or slight
tremors that might affect the accuracy of the registration. The author,
thus, prefers to gently hold the prosthesis in place by hand (Figure 25) and

Attachment retained implant

overdentures have become a
routine alternative to traditional removable dentures....
has found this technique to result in
more predictable control of the fit and
retention of the attachments. After a
total of 3 minutes, the overdenture
with the incorporated caps was re moved (Figure 26). Slight voids
around the caps or in the access openings were filled with Quick Up LC, a
matching light-cured flowable composite resin (Figure 27). Excess resin
around the attachments was removed
and refined with a No. 8 round bur.
Quick Up resin that extruded through
DENTISTRYTODAY.COM DECEMBER 2011

the palatal openings was smoothed

and polished. This gingival colored
composite resin blends nearly seamlessly with most denture resins. Appropriate Locator males that provided
adequate retention, yet easy removal,
were seated into the overdenture
(Figure 28). In just a few days following seating, the patient was able to
overcome his exaggerated gag reflex
with the aid of the open palate prosthesis (Figure 29). The implant retained overdenture met the patients
aesthetic objective of age appropriate
denture teeth (Figure 30) that blended
with his existing mandibular crowns
and teeth, and his functional and
comfort goals of improved occlusion
and mastication. (Figure 31).
CONCLUSION
Attachment retained implant overdentures have become a routine alternative to traditional removable dentures
and a lower cost alternative to more
complex fixed dental implant prostheses. As demonstrated, new materials
can assist in efficient chairside seating
of a myriad of implant attachments
(such as studs, o-rings, clips, and others). An obvious advantage to placing
attachments, as described in the case
report above, is cost savings by decreasing laboratory fees and reducing chair
time, but more importantly, it may be a
more accurate method of attachment
placement by giving the clinician complete control of attachment placement
and elimination of inaccuracies caused
by laboratory transfers.

Innovative dental materials and

techniques which simplify the technical processes involved in restorative
implant dental treatment present clinicians another incentive to offer
these valuable services to a greater
number of patients who would benefit from implant dentistry.!
Acknowledgement
Dr. Priest would like to thank the
team of dental technicians at Georgia
Dental Lab for their consistent excellence and assistance with the work
presented here.

height space guidelines for implant dentistry

part 1. Implant Dent. 2005;14:312-318.
10. Naert I, Alsaadi G, van Steenberghe D, et al. A
10-year randomized clinical trial on the influence
of splinted and unsplinted oral implants retaining
mandibular overdentures: peri-implant outcome.
Int J Oral Maxillofac Implants. 2004;19:695-702.
11. den Dunnen AC, Slagter AP, de Baat C, et al.
Professional hygiene care, adjustments and complications of mandibular implant-retained overdentures: a three-year retrospective study. J
Prosthet Dent. 1997;78:387-390.
12. Visser A, Raghoebar GM, Meijer HJ, et al.
Mandibular overdentures supported by two or
four endosseous implants. A 5-year prospective
study. Clin Oral Implants Res. 2005;16:19-25.
13. Cavallaro JS Jr, Tarnow DP. Unsplinted implants
retaining maxillary overdentures with partial
palatal coverage: report of 5 consecutive cases.
Int J Oral Maxillofac Implants. 2007;22:808-814.
14. Eccellente T, Piombino M, Piattelli A, et al.
Immediate loading of dental implants in the
edentulous
maxilla.
Quintessence
Int.
2011;42:281-289.

References
1. Takanashi Y, Penrod JR, Lund JP, et al. A cost comparison of mandibular two-implant overdenture
and conventional denture treatment. Int J
Prosthodont. 2004;17:181-186.
2. Heydecke G, Thomason JM, Awad MA, et al. Do
mandibular implant overdentures and conventional complete dentures meet the expectations
of edentulous patients? Quintessence Int.
2008;39:803-809.
3. Allen PF, McMillan AS. A longitudinal study of quality of life outcomes in older adults requesting
implant prostheses and complete removable dentures. Clin Oral Implants Res. 2003;14:173-179.
4. Feine JS, Carlsson GE, Awad MA, et al. The McGill
Consensus Statement on Overdentures.
Montreal, Quebec, Canada. May 24-25, 2002. Int
J Prosthodont. 2002;15:413-414.
5. Thomason JM, Feine J, Exley C, et al. Mandibular
two implant-supported overdentures as the first
choice standard of care for edentulous
patientsthe York Consensus Statement. Br
Dent J. 2009;207:185-186.
6. ADA Council on Scientific Affairs. Dental
endosseous implants: an update. J Am Dent
Assoc. 2004;135:92-97.
7. Naert I, Quirynen M, Hooghe M, et al. A comparative prospective study of splinted and unsplinted Brnemark implants in mandibular overdenture therapy: a preliminary report. J Prosthet
Dent. 1994;71:486-492.
8. Walton JN, MacEntee MI, Hanvelt R. Cost analysis of fabricating implant prostheses. Int J
Prosthodont. 1996;9:271-276.
9. Misch CE, Goodacre CJ, Finley JM, et al.
Consensus conference panel report: crown-

Dr. Priest has maintained a private prosthodontic practice devoted to aesthetic, advanced restorative and implant dentistry for
more than 25 years. In 2008, Dr. Priest relocated his practice from Atlanta, Ga to Hilton
Head Island, SC. He is a Diplomate of the
American Board of Prosthodontics, a Fellow of
the American College of Prosthodontists and a
Fellow of the International College of Dentists.
Dr. Priest is a former professor in graduate
prosthodontics at Emory University and an
innovator and teacher of implant and aesthetic dentistry for more than 20 years. He lectures internationally on topics including implant dentistry, advanced restorative dentistry
and aesthetic excellence. He is a regular contributor to many acclaimed dental journals
including the International Journal of Oral and
Maxillofacial Implants, the Journal of Prosthodontics, and the International Journal of Periodontics and Restorative Dentistry. He has been
named one of Dentistry Todays Leaders in
Continuing Education for the past 7 years. He
can be reached at (843) 342-8890, at
office@georgepriest.com, or at the Web site
priestpros.com.
Disclosure: Dr. Priest is a paid consultant for
VOCO America and is an unpaid consultant for
Ivoclar Vivadent.