Continuing Education

Volume 33 No. 1 Page 134

Treating a Failing Dentition:

Stable Implant-Supported
Removable Restorations
Authored by Joseph J. Massad, DDS; Swati Ahuja, BDS, MDS; and
Mahesh Verma, BDS, MDS, MBA, PhD (HC)
Upon successful completion of this CE activity 2 CE credit hours will be awarded

Opinions expressed by CE authors are their own and may not reflect those of Dentistry Today. Mention of
specific product names does not infer endorsement by Dentistry Today. Information contained in CE articles and
courses is not a substitute for sound clinical judgment and accepted standards of care. Participants are urged to
contact their state dental boards for continuing education requirements.

Continuing Education

Treating a Failing Dentition:

Dr. Verma received his BDS and MDS from

Government Dental College, Trivandrum,
Kerala and received his MBA (Healthcare)
from Faculty of Management Studies,
University of Delhi. He is a Fellow of the
International College of Dentists, American
College of Dentists, American Academy of Implant Dentistry
(AAID), National Academy of Medical Sciences, International
Medical Sciences Academy, Royal College of Surgeons of
England, Royal College of Physicians and Surgeons of
Glasgow, Royal College of Surgeons, Faculty of General
Dentistry Practice (England), and the Royal College of Surgeons of Edinburgh. A visiting clinical professor of the School
of Dental Medicine, Tufts University (Boston) and the
Tamilnadu MGR Medical University (Chennai), Dr. Verma is
also the clinical director of the Maxicourse India for the AAID.
He is president of the Indian Academy of Restorative Dentistry,
president-elect for the Indian Dental Association, and vice
president of the Dental Council of India and the Indian Society
for Dental Research. Dr. Verma is chairperson of the Research
Committee for Dental Sciences at Indian Council of Medical
Research. He can be reached at dpmaids@gmail.com.

Stable Implant-Supported
Removable Restorations
Effective Date: 1/1/2014

Expiration Date: 1/1/2017

ABOUT THE AUTHORS

Dr. Massad is an associate professor in
the department of graduate prosthodontics
at University of Tennessee Health Science
Center, Memphis, Tenn; an associate
Faculty at Tufts University School of Dental
Medicine, Boston, Mass; an adjunct
associate faculty of the department of comprehensive
dentistry, the University of Texas Health Science Center Dental School, San Antonio, Tex, and adjunct professor in
department of restorative dentistry at Loma Linda University,
Loma Linda, Calif. He has a private practice in Tulsa, Okla. He
can be reached at joe@joemassad.com.
Disclosure: Dr. Massad consults/has consulted for and
receives/has received sponsorship from many companies,
including the following: DENTSPLY, Nobilium, Sterngold Products,
Zimmer Dental, and others not mentioned in this article.

Disclosure: Dr. Verma reports no disclosures.

INTRODUCTION
Dr. Ahuja is an adjunct assistant
professor in the department of
prosthodontics at University of Tennessee
Health Science Center, Memphis. She is a
prosthodontic consultant for Lutheran
Medical Center, NY. She is also a
consultant for 2 private dental clinics in Mumbai, India. She
has published 16 articles in peer-reviewed journals including
2 book chapters. She is an editorial board member for International Journal of Experimental Dental Sciences and
reviewer for many journals. She has been invited to present
lectures internationally. Her topics of interest are implant
overdentures, hybrid restorations, restorative space in
implant overdentures, and cone beam computed tomography
in dental practice. She can be reached at sahuja@uthsc.edu.

The treatment options available for a patient with nonrestorable

dentition are conventional complete dentures, implantsupported overdentures (removable), fixed implant-supported
complete dentures, and fixed metal-ceramic implantsupported restorations.1,2 Most restorative dentists believe
that the treatment of choice for the edentulous patient is a
fixed-implant prosthesis.2-4 The decision process to restore a
patient with fixed or removable restorations should not be
based on the preference of the dentist or the patient; rather, it
should be determined by evaluating various parameters such
as quality and quantity of hard and soft tissues, oral hygiene,
the maxilla-mandibular relationship, lip-line, lip support, and
finances.1,3 In order to get a satisfactory treatment outcome,
fixed-implant restorations should be indicated only in patients
with minimal resorption of hard and soft tissues and an optimal
maxillomandibular relationship.4 On the other hand, removable
implant restorations should not only be recommended in pa-

Disclosure: Dr. Ahuja reports no disclosures.

1

Continuing Education

Treating a Failing Dentition: Stable Implant-Supported Removable Restorations

tients in whom fixed restorations are contraindicated.4-6 If
designed properly, removable implant restorations are stable,
retentive, and resistant to fracture.7-9 They provide excellent
phonetics10 and esthetics (especially in patients with high
smile-lines), and can also help improve the lip support.3
Removable implant restorations are less complicated and
easier to clean than fixed implant restorations.3,11,12 In
addition, it is easier and less expensive to maintain removable
implant restorations13 as opposed to fixed implant restorations.14-17 Several studies have proven that patients have
similar to higher satisfaction with implant-supported removable
restorations.9,17,18
For any implant restoration to be successful, it is critical to
plan and place implants accurately.3,19 The restorative dentist
should decide the type and the design of the definitive
prosthesis before implant placement, and plan the implants
based on the design of the final prosthesis. This can be most
predictably achieved through 3-dimensional (3-D) guided
planning and 3-D guided implant surgery.20-22 Combining the
CAD/CAM technique, digital implant planning can be applied
to clinical practice using 3-D surgical guides.23-25 These
techniques help with visualization of bone and the prosthesis
at the same time.26 This has helped change the osseousdriven approach to a combination of osseous- and prostheticdriven approach for implant placement.24,26 Since implants
are placed in a near-to-ideal position, the surgery and
provisionalization can be done predictably in a relatively short
time.27,28
Another factor that must be evaluated prior to implant
placement is the available restorative and esthetic space.29-31
A reported minimum space requirement for implant-supported
overdenture with LOCATOR (ZEST Anchors) attachments is
8.5 mm of vertical space and 9.0 mm of horizontal space.32 A
separate report on maxillary implant overdentures suggested
that a minimum of 13.0 mm to 14.0 mm of vertical space was
required for bar-supported overdentures; and 10 mm to 12 mm
for individual attachment-supported overdentures.32,33
Misch34 and Pasciuta et al35 have reported that a minimum of
12.0 mm of vertical restorative space (crest of bone to occlusal
plane) is necessary to accomplish a mandibular implantassisted overdenture. Attempts to fabricate prostheses in the
presence of inadequate restorative space may lead to
physiologically inappropriate contours, structurally weak

Figure 1.
Panoramic
radiographic view of
the patient
demonstrating the
failing dentition.

Figures 2a and 2b.

Intraoral frontal view
of the patient (a).
Intraoral occlusal
view of the patient
(b).

prostheses, esthetic compromise, encroachment into freeway

space, and/or suboptimal retention and stability of the
treatment result.36,37 If the restorative space is inadequate,
clinical procedures designed to improve vertical space
2

Continuing Education

Treating a Failing Dentition: Stable Implant-Supported Removable Restorations

availability can be utilized. These include
alveoloplasty,32,38 intentional increase of
vertical dimension of occlusion (VDO),38
occlusal plane repositioning, and management
of overdenture attachment selection. These
procedures should be implemented prior to
implant placement, when treatment options are
being considered.29,30,36,37
This article describes the diagnosis and
treatment of a patient with a failing dentition
with a collapsed VDO. It will outline how the
patient was optimally restored with transitional
implant-supported removable restorations on
the day of the surgery.

Figures 3a and 3b. Maxillary final impression (a). Mandibular final impression (b).

Striking Plate
Attached to Resin Base
a

CASE REPORT
Diagnosis and Treatment Planning
A 42-year-old white male patient presented to
the authors practice with the chief complaint of
not being able to eat his food and having a poor
c
d
self-image due to his appearance. The patient
was a recovering drug and alcohol addict with 5
years of sobriety. The patient had financial
constraints; however, he was concerned about
becoming edentulous and refused to go without
teeth at any point.
The oral examination revealed that he had
Vertical Pin Set in Swivel
several missing teeth and a majority of the
remaining teeth had a loss of periodontal Figures 4a to 4d. Intraoral gothic arch tracing assembly: Striking plate was attached to the
maxillary record base (a). Maxillary record base with the striking plate placed on the
attachment (Figure 1) with generalized and maxillary cast (b).Vertical pin was attached to the mandibular record base (c). Mandibular
chronic periodontitis. Teeth Nos. 7, 15, 29, and record base with the attached vertical pin placed on the mandibular cast (d).
30 were fractured at the cervical level due to extensive decay.
clinical findings and to plan the optimal treatment. After a
Teeth Nos. 7, 11, 12, 15, 18, 29, and 30 had periapical cysts
thorough diagnostic work-up, all the remaining teeth were
associated with them (Figures 1 to 2b).
deemed nonrestorable, so the treatment would consist of
Preliminary impressions (Aquasil [DENTSPLY Caulk]) were
extraction of the remaining dentition and rehabilitation with
taken and poured. Then, these diagnostic study models were
removable implant restorations. Procedures to increase the
mounted on an articulator (2240 Articulator [Whip Mix]) to
restorative space would have to be employed to fabricate a
evaluate the occlusion and the available restorative/esthetic
functional, esthetic, and structurally resistant prosthesis for
space. The patient had a collapsed VDO with insufficient
the patient. The restorative space needed for the maxillary
restorative and esthetic space in both the arches. In addition,
arch would be achieved by increasing the VDO. In addition,
the patient demonstrated poor oral hygiene.
alveoloplasty was indicated for the mandibular arch
A 3-D cone beam computed tomography (CBCT) scan
(spanning from first bicuspid to first bicuspid region) to gain
(CS 9300 [Carestream Dental]) was taken to verify the
the needed restorative space.
3

Continuing Education

Treating a Failing Dentition: Stable Implant-Supported Removable Restorations

A synopsis of the final treatment plan of the
patient was as follows: fabrication of an
immediate complete dentures at the optimal
VDO; extraction of the remaining teeth; 3-D
guided alveoloplasty in the mandibular arch;
3-D guided implant surgery in the maxilla and
the mandible; placement of 2 small-diameter
implants (ERA Mini Dental Implants
[Sterngold]) in the mandible to retain the transitional restoration; delivery of the transitional
restoration at the same appointment; and,
finally, the delivery of the definitive prosthesis
after healing of implants.

Phase I: Fabrication of Immediate Dentures

Maxillary and mandibular definitive master
impressions were made with vinyl
polysiloxane (VPS) material (Aquasil) in
Figures 5a to 5d. Maxillary cameo stone cast (a). Silicone facial matrix was constructed on
stock trays (Figures 3a and 3b). Master the cameo cast (b). Silicone facial matrix was positioned on the diagnostic maxillary cast (c).
impressions were poured in type III stone Maxillary prosthetic teeth were set labial to the natural teeth (d).
(Microstone [Whip Mix]) to generate master
a
b
casts. Triad Record Bases (DENTSPLY
Prosthetics) and wax rims were fabricated for
the maxillary and mandibular cast to take the
jaw relation records. Since the patient had a
collapsed bite, the VDO would have to be
re-established for the patient within
physiological limits. This would help gain
restorative space and improve the esthetics
and function for the patient.
c
d
Vertical dimension of occlusion was
established by the Niswonger method.39 First
the vertical dimension at rest (VDR) was
recorded, by marking a dot on the tip of the
patients nose and another dot on his chin.
Then, the patient was asked to take a deep
breath and relax, and when the patient was fully
relaxed, the caliper was used to record the
Figures 6a to 6d. Mandibular cameo stone cast (a). Silicone facial matrix was constructed
distance between the 2 dots. This measure- on the cameo cast (b). Silicone facial matrix seated on the diagnostic mandibular cast (c).
ment represents the patients physiological rest Mandibular prosthetic teeth were set labial to the natural teeth (d).
position (VDR). The proper VDO is 2.0 to 4.0 mm less than
posturing in patients with a collapsed VDO may adversely
39
VDR depending on the patients physiology.
affect the optimal recording of vertical and horizontal
Neuromuscular programming and habitual mandibular
maxillomandibular relationship.40 Hence, an intraoral
4

Continuing Education

Treating a Failing Dentition: Stable Implant-Supported Removable Restorations

Gothic arch tracer (Nobilium) was used for
a
recording VDO and centric relation (CR). A
striking plate was attached to maxillary
record base and a threaded vertical pin was
attached to the mandibular record base per
the manufacturers recommendations to take
an intraoral CR40,41 (Figures 4a to 4d). The
threaded vertical pin was rotated clockwise
so that it would contact the striking plate near
c
the patients VDO. The maxillary and
mandibular record bases with the attached
b
intraoral tracer assembly were placed in the
patients mouth. The patient was instructed to
close slowly until the tip of the threaded pin
touched the striking plate. VDO was verified
and found to be optimal.
Patent Pending
The striking plate was covered with an
nSequence
indelible ink, and then the patient was trained
Figures 7a to 7c. Stereolithographic model of the maxilla with retained Nos. 3 and 11 (a).
and directed to make all border movements Maxillary surgical guide (b). Stereolithographic model of the maxilla (with retained Nos. 3
while maintaining contact between the and 11) with the maxillary surgical guide (c).
vertical pin and the striking plate. These movements
helped gain restorative space.
produced an arrow-shaped tracing. The apex of the arrow
Lastly, the records and the casts were sent to the dental
indicates the centric relation position. An interocclusal
laboratory team for fabrication of immediate dentures that
record was taken at the established VDO with the patient in
would be delivered to the patient on the day of implant surgery.
CR position with a VPS bite registration paste (Regisil
[DENTSPLY Caulk]).
Phase II: Implant Planning, Extractions, and 3-D
In dentate patients, teeth may or may not be at an optimal
Guided Implant Surgery
location buccolingually. This can be verified by taking a
The maxillaThe maxilla was treatment planned to
cameo impression.42-44 A cameo impression was made to
receive 6 implants (Tapered Screw-Vent Implant System
[Zimmer Dental]). A CBCT scan was taken for the patient
capture the horizontal vestibular space, to determine
(as discussed previously) and the implants were planned
muscular pressure allowing a more accurate tooth position
on the CBCT scan. A stereolithography model and
and gum contour, to improve prosthetic stability, esthetics,
surgical guide (nSequence) were generated from the CT
and to decrease food impaction along the outer prosthetic
scan. The maxillary surgical guide was planned to be
surfaces. Next, the cameo impression was poured with type
tooth- and tissue-supported to improve its accuracy45 and
III dental stone. A facial matrix was fabricated with a lab putty
(Lab-Putty [Coltene]) for the maxillary and mandibular cameo
stability while placing the implants (Figures 7a to 7c).
casts. This matrix was then positioned on the respective
Serial extractions were planned for the maxillary arch to
diagnostic casts to visualize the buccolingual discrepancy in
accomplish the same.
the position of natural teeth. The excess space between the
On the day of the surgery, anesthesia was administered
matrix and the natural teeth indicated that the natural teeth
and all the remaining teeth were extracted atraumatically,
were lingually positioned. To rectify this discrepancy, the
except the left maxillary cuspid and the right maxillary first
prosthetic teeth were set buccal to the natural teeth, within
molar; these 2 teeth were retained to help stabilize the
the confines of the matrix42-44 (Figures 5a to 6d). This also
surgical guide. The surgical guide was placed in the mouth
5

Continuing Education

Treating a Failing Dentition: Stable Implant-Supported Removable Restorations

and checked for proper fit. Six
maxillary implants (Tapered
Screw-Vent Implant System)
were placed using the
surgical-guided
drill
kit
(Figures 8a and 8b). Drills
were both internally and
externally irrigated to prevent
any overheating of the bone.
Then, the implant mounts
were removed and healing
abutments were attached to
the implants. These implants
would help support the
maxillary denture (Figure 9).
Next, the 2 retained teeth
were extracted.
A bone graft (Puros Allograft
[Zimmer Dental]) was used to
graft the voids around the
implants; a barrier membrane
(CopiOs [Zimmer Dental]) was
then draped over the bone
graft prior to closure. Finally, a
panoramic radiograph was
taken to verify the implant
placement (Figure 10).
The
mandible The
mandible was treatment
planned to receive 4 implants
(Tapered Screw-Vent Implant
System) and 2 smalldiameter implants (ERA Mini
Dental Implant System). A
CBCT scan was taken for the
patient
as
discussed
previously and the implants
were planned on the CBCT
scan. A stereolithographic
model and a 2-part surgical
template/guide (nSequence)
were generated from the CT
scan (Figures 11 to 13).

Figures 8a and 8b. The 3-D guided surgery of the maxilla, using the
surgical guide, tube inserts, and the surgical drills to place implants (a).
Animated view of 3-D guided surgery of the maxilla, using the surgical
guide, tube inserts, and the surgical drills to place implants (b).

Figure 9. Animation depicting 5

implants placed in the maxillary
arch and retained teeth Nos. 3
and 11.

Figure 10. Panoramic radiograph

of the patient depicting the
maxillary implants.

Figure 12. Bone-reduction guide

(first part of the 2-part surgical
template): occlusal and frontal
views.

Figure 11. Animated view of the

2-part mandibular surgical
template.

Figure 13. Two-part surgical

template placed on the
mandibular cast.

Figure 14. Animated view of

bone-reduction guide placed on
the mandible to guide bone
removal.

Figure 16. Animated view of

implant surgical guide (second
part of the 2-part guide) being
placed over the bone-reduction
guide.

Figures 17a and 17b. Animated

view of 3-D guided surgery of the
maxilla, using the surgical guide,
tube inserts, and the surgical
drills to place the implants (a).
The 3-D guided surgery of the
mandible using the surgical guide,
tube inserts, and the surgical
drills to place the implants (b).

Figures 15a and 15b. Bonereduction guide was placed on

the mandible and the bone was
removed with rongeurs (a).
Animated view of the bonereduction guide being placed on
the mandible and bone being
removed with rongeurs (b).

Figure 18. Panoramic radiograph

of the patient, depicting the
maxillary and the mandibular
implants.

Continuing Education

Treating a Failing Dentition: Stable Implant-Supported Removable Restorations

Alveoloplasty was indicated for the mandibular arch, hence
a tooth-supported guide could not be fabricated for the
mandible. The mandibular surgical template was a 2-part
template; the first part of the template would guide bone
reduction, and the second part would guide the placement
of implants (Figures 11 to 13). The use of a bone reduction
guide during surgery eliminates the arbitrary removal of
osseous structure and helps ensure the mandibular crest is
reduced in prescribed dimensions.
On the day of the surgery, anesthesia was administered
and all the remaining teeth were extracted atraumatically. A
full-thickness mucoperiosteal flap was raised, the bone
reduction guide was placed on the bone (Figures 14 to
15b), and the bone was removed with rongeurs and a bonereduction file. The bone reduction was limited to the anterior
mandibular ridge, spanning from first bicuspid to first
bicuspid region.
After bone reduction completion, the second part of the
surgical guide was placed in the mouth (Figure 16). The 4
mandibular implants (Tapered Screw Vent Implants) were
placed through the guide (nSequence) using the surgicalguided drill kit (Zimmer Dental) (Figures 17a and 17b). Drills
were both internally and externally irrigated to prevent
overheating of the bone. Next, the implant mounts were
removed and healing abutments were attached to the
implants. These implants would help support the
mandibular denture.
Two small-diameter implants (ERA Mini Dental Implants)
were placed (free-handed) to help retain the mandibular
restoration. Finally, a panoramic radiograph was taken to verify
the implant placement (Figure 18).

Figure 19.
Transitional
restorations placed
in the patients
mouth.

Figure 20.
Patients smile;
preoperative above
and postoperative
below.

adjusted as needed. The implant-supported maxillary

denture and the implant-retained and supported mandibular denture were delivered to the patient (Figure 19).
(The definitive restorations would be fabricated after a
period of 4 months for healing.) The patient was given home
care instructions and advised to come to the clinic the next
day for a postoperative check.
The patient was pleased with the retention, stability, and
esthetics of the restoration (Figure 20).

CLOSING COMMENTS
A proper diagnosis and thoughtful treatment planning are
prerequisites for achieving a successful rehabilitation.
Information gathered during diagnosis can seamlessly
influence surgical decision making, optimal implant
placement, and in creating the appropriate design of a
definitive prosthesis. Every step of the treatment should be
considered crucial to the success of restorations.
In this case report, the patient was transitioned from a
debilitated to a rehabilitated state, with stable implantsupported restorations placed in the same appointment. The
delivery of the transitional prosthesis was accomplished very
efficiently and quickly with minimal adjustments required. The

Phase III: Delivery of the Transitional Restorations

The maxillary denture was adjusted and relieved to
accommodate the healing abutments, then it was relined
with a soft reline material (PermaSoft [DENTSPLY Caulk]).
The mandibular denture was adjusted and relieved to
accommodate the healing abutments and the ERA
attachments. Then, the retentive elements for the mini-implants were picked up chairside using autopolymerizing
repair resin (DENTSPLY Repair Material [DENTSPLY
Caulk]). Next, the mandibular denture was relined with the
soft reline material. The occlusion was checked and
7

Continuing Education

Treating a Failing Dentition: Stable Implant-Supported Removable Restorations

transitional prosthesis had excellent esthetics and the patient
was able to function satisfactorily with it.
16.

REFERENCES
1.

2.

3.
4.

5.

6.

7.

8.
9.

10.

11.

12.

13.

14.

15.

Neves FD, Mendona G, Fernandes Neto AJ. Analysis of

influence of lip line and lip support in esthetics and selection
of maxillary implant-supported prosthesis design. J Prosthet
Dent. 2004;91:286-288.
Sadowsky SJ. The implant-supported prosthesis for the
edentulous arch: design considerations. J Prosthet Dent.
1997;78:28-33.
DeBoer J. Edentulous implants: overdenture versus fixed.
J Prosthet Dent. 1993;69:386-390.
Zitzmann NU, Marinello CP. Treatment plan for restoring the
edentulous maxilla with implant-supported restorations:
removable overdenture versus fixed partial denture design.
J Prosthet Dent. 1999;82:188-196.
Zitzmann NU, Marinello CP. Implant-supported removable
overdentures in the edentulous maxilla: clinical and
technical aspects. Int J Prosthodont. 1999;12:385-390.
Zitzmann NU, Marinello CP. Treatment outcomes of fixed or
removable implant-supported prostheses in the edentulous
maxilla. Part I: patients assessments. J Prosthet Dent.
2000;83:424-433.
De Albuquerque RF Jr, Lund JP, Tang L, et al. Within-subject
comparison of maxillary long-bar implant-retained
prostheses with and without palatal coverage: patient-based
outcomes. Clin Oral Implants Res. 2000;11:555-565.
Henry PJ. Future therapeutic directions for management of the
edentulous predicament. J Prosthet Dent. 1998;79:100-106.
Heydecke G, Boudrias P, Awad MA, et al. Within-subject
comparisons of maxillary fixed and removable implant
prostheses: patient satisfaction and choice of prosthesis.
Clin Oral Implants Res. 2003;14:125-130.
Lundqvist S, Haraldson T, Lindblad P. Speech in connection
with maxillary fixed prostheses on osseointegrated implants:
a three-year follow-up study. Clin Oral Implants Res.
1992;3:176-180.
Feine JS, de Grandmont P, Boudrias P, et al. Within-subject
comparisons of implant-supported mandibular prostheses:
choice of prosthesis. J Dent Res. 1994;73:1105-1111.
Kaptein ML, Hoogstraten J, de Putter C, et al. Dental
implants in the atrophic maxilla: measurements of patients
satisfaction and treatment experience. Clin Oral Implants
Res. 1998;9:321-326.
Naert I, Quirynen M, Theuniers G, et al. Prosthetic aspects
of osseointegrated fixtures supporting overdentures. A 4year report. J Prosthet Dent. 1991;65:671-680.
Jemt T. Fixed implant-supported prostheses in the
edentulous maxilla. A five-year follow-up report. Clin Oral
Implants Res. 1994;5:142-147.
Jemt T. Failures and complications in 391 consecutively
inserted fixed prostheses supported by Brnemark implants

17.

18.

19.
20.

21.

22.

23.

24.
25.

26.

27.

28.

29.

30.
31.

in edentulous jaws: a study of treatment from the time of

prosthesis placement to the first annual checkup. Int J Oral
Maxillofac Implants. 1991;6:270-276.
Smedberg JI, Lothigius E, Bodin I, et al. A clinical and
radiological two-year follow-up study of maxillary
overdentures on osseointegrated implants. Clin Oral
Implants Res. 1993;4:39-46.
Zitzmann NU, Marinello CP. Treatment outcomes of fixed or
removable implant-supported prostheses in the edentulous
maxilla. Part II: clinical findings. J Prosthet Dent.
2000;83:434-442.
de Grandmont P, Feine JS, Tach R, et al. Within-subject
comparisons of implant-supported mandibular prostheses:
psychometric evaluation. J Dent Res. 1994;73:1096-1104.
Engelman MJ, Sorensen JA, Moy P. Optimum placement of
osseointegrated implants. J Prosthet Dent. 2003;59:467-473.
Danforth RA, Dus I, Mah J. 3-D volume imaging for
dentistry: a new dimension. J Calif Dent Assoc.
2003;31:817-823.
Verstreken K, Van Cleynenbreugel J, Marchal G, et al.
Computer-assisted planning of oral implant surgery: a threedimensional approach. Int J Oral Maxillofac Implants.
1996;11:806-810.
Park C, Raigrodski AJ, Rosen J, et al. Accuracy of implant
placement using precision surgical guides with varying
occlusogingival heights: an in vitro study. J Prosthet Dent.
2009;101:372-381.
Balshi SF, Wolfinger GJ, Balshi TJ. Guided implant
placement and immediate prosthesis delivery using
traditional Brnemark System abutments: a pilot study of 23
patients. Implant Dent. 2008;17:128-135.
Ganz SD. Presurgical planning with CT-derived fabrication of
surgical guides. J Oral Maxillofac Surg. 2005;63(9 suppl 2):59-71.
Marchack CB. CAD/CAM-guided implant surgery and
fabrication of an immediately loaded prosthesis for a partially
edentulous patient. J Prosthet Dent. 2007;97:389-394.
Hultin M, Svensson KG, Trulsson M. Clinical advantages of
computer-guided implant placement: a systematic review.
Clin Oral Implants Res. 2012;23(suppl 6):124-135.
Hmmerle CH, Stone P, Jung RE, et al. Consensus
statements and recommended clinical procedures regarding
computer-assisted implant dentistry. Int J Oral Maxillofac
Implants. 2009;24(suppl):126-131.
Sanz M, Naert I; Working Group 2. Biomechanics/risk
management (Working Group 2). Clin Oral Implants Res.
2009;20(suppl 4):107-111.
AbuJamra NF, Stavridakis MM, Miller RB. Evaluation of
interarch space for implant restorations in edentulous patients:
a laboratory technique. J Prosthodont. 2000;9:102-105.
Ahuja S, Cagna DR. Defining available restorative space for
implant overdentures. J Prosthet Dent. 2010;104:133-136.
Massad JJ, Ahuja S, Cagna D. Implant overdentures:
selections for attachment systems. Dent Today.
2013;32:128-132.

Continuing Education

Treating a Failing Dentition: Stable Implant-Supported Removable Restorations

39. Niswonger ME. The rest position of the mandible and the
centric relation. J Am Dent Assoc. 1934;21:1572-1582.
40. Massad JJ, Connelly ME, Rudd KD, et al. Occlusal device
for diagnostic evaluation of maxillomandibular relationships
in edentulous patients: a clinical technique. J Prosthet Dent.
2004;91:586-590.
41. Wojdyla SM, Wiederhold DM. Using intraoral Gothic arch
tracing to balance full dentures and determine centric
relation and occlusal vertical dimension. Dent Today.
2005;24:74-77.
42. Cagna DR, Massad JJ, Schiesser FJ. The neutral zone
revisited: from historical concepts to modern application.
J Prosthet Dent. 2009;101:405-412.
43. Beresin VE, Schiesser FJ. The Neutral Zone in Complete
and Partial Dentures. 2nd ed. St. Louis, MO: Mosby;
1978:15, 73-108, 158-183.
44. Beresin VE, Schiesser FJ. The neutral zone in complete
dentures. J Prosthet Dent. 1976;36:356-367.
45. Ozan O, Turkyilmaz I, Ersoy AE, et al. Clinical accuracy of
3 different types of computed tomography-derived
stereolithographic surgical guides in implant placement.
J Oral Maxillofac Surg. 2009;67:394-401.

32. Lee CK, Agar JR. Surgical and prosthetic planning for a
two-implant-retained mandibular overdenture: a clinical
report. J Prosthet Dent. 2006;95:102-105.
33. Sadowsky SJ. Treatment considerations for maxillary implant
overdentures: a systematic review. J Prosthet Dent.
2007;97:340-348.
34. Misch CE. The edentulous mandible: an organized approach
to implant-supported overdentures. In: Misch CE, ed.
Contemporary Implant Dentistry. 3rd ed. St. Louis, MO:
Mosby Elsevier; 2008:297-298.
35. Pasciuta M, Grossmann Y, Finger IM. A prosthetic solution
to restoring the edentulous mandible with limited interarch
space using an implant-tissue-supported overdenture: a
clinical report. J Prosthet Dent. 2005;93:116-120.
36. Ahuja S, Cagna DR. Classification and management of
restorative space in edentulous implant overdenture
patients. J Prosthet Dent. 2011;105:332-337.
37. Chaimattayompol N, Arbree NS. Assessing the space
limitation inside a complete denture for implant attachments.
J Prosthet Dent. 2003;89:82-85.
38. Drummond J, Maillou P, Smith KT, et al. A useful solution
to a space problema striking plate. Dent Update.
2003;30:269-270.

Continuing Education

Treating a Failing Dentition: Stable Implant-Supported Removable Restorations

POST EXAMINATION INFORMATION

POST EXAMINATION QUESTIONS

To receive continuing education credit for participation in

this educational activity you must complete the program
post examination and answer 6 out of 8 questions correctly.

1. Most restorative dentists believe that the treatment

of choice for the edentulous patient is still a
traditional removable prosthesis.
a. True

Traditional Completion Option:

You may fax or mail your answers with payment to Dentistry
Today (see Traditional Completion Information on following
page). All information requested must be provided in order
to process the program for credit. Be sure to complete your
Payment, Personal Certification Information, Answers,
and Evaluation forms. Your exam will be graded within 72
hours of receipt. Upon successful completion of the postexam (answer 6 out of 8 questions correctly), a letter of
completion will be mailed to the address provided.

b. False

2. The decision process to restore a patient with fixed

or removable restorations should be determined by
evaluating various parameters such as quality and
quantity of hard and soft tissues, oral hygiene, the
maxilla-mandibular relationship, lip-line, lip support
and finances.
a. True

b. False

3. If designed properly removable implant restorations

are stable, retentive, and resistant to fracture.

Online Completion Option:

Use this page to review the questions and mark your
answers. Return to dentalcetoday.com and sign in. If you
have not previously purchased the program, select it from
the Online Courses listing and complete the online
purchase process. Once purchased the program will be
added to your User History page where a Take Exam link
will be provided directly across from the program title.
Select the Take Exam link, complete all the program
questions and Submit your answers. An immediate grade
report will be provided. Upon receiving a passing grade,
complete the online evaluation form. Upon submitting
the form, your Letter of Completion will be provided
immediately for printing.

a. True

b. False

4. Several studies have failed to prove that patients have a

similar-to-higher satisfaction with implant-supported
removable restorations.
a. True

b. False

5. Combining the CAD/CAM technique, digital implant

planning can be applied to clinical practice using 3-D
surgical guides.
a. True

b. False

6. Misch and Pasciuta have reported that a minimum of

12.0 mm of vertical restorative space (crest of bone
to occlusal plane) is necessary to accomplish a
mandibular implant-assisted overdenture.

General Program Information:

Online users may log in to dentalcetoday.com any time in
the future to access previously purchased programs and
view or print letters of completion and results.

a. True

b. False

7. If the restorative space is inadequate, clinical

procedures designed to improve vertical space
availability can be utilized.

This CE activity was not developed in accordance with

AGD PACE or ADA CERP standards.
CEUs for this activity will not be accepted by the AGD
for MAGD/FAGD credit.

a. True

b. False

8. The proper vertical dimension of occlusion (VDO) is

1.0 to 3.0 mm less than the vertical dimension at rest
(VDR), depending on the patients physiology.
a. True

10

b. False

Continuing Education

Treating a Failing Dentition: Stable Implant-Supported Removable Restorations

PROGRAM COMPLETION INFORMATION

PERSONAL CERTIFICATION INFORMATION:

If you wish to purchase and complete this activity

traditionally (mail or fax) rather than online, you must
provide the information requested below. Please be sure to
select your answers carefully and complete the evaluation
information. To receive credit you must answer 6 of the 8
questions correctly.

Last Name
First Name

Profession / Credentials

Suite or Apartment Number

TRADITIONAL COMPLETION INFORMATION:

Mail or fax this completed form with payment to:

City

Dentistry Today

State

Zip Code

Daytime Telephone Number With Area Code

Department of Continuing Education

100 Passaic Avenue
Fairfield, NJ 07004

Fax Number With Area Code

Fax: 973-882-3622

E-mail Address

PAYMENT & CREDIT INFORMATION:

ANSWER FORM: VOLUME 33 NO. 1 PAGE 134

Examination Fee: $40.00 Credit Hours: 2

Please check the correct box for each question below.

1. o a. True

o b. False

5. o a. True

o b. False

2. o a. True

o b. False

6. o a. True

o b. False

I have enclosed a check or money order.

3. o a. True

o b. False

7. o a. True

o b. False

I am using a credit card.

4. o a. True

o b. False

8. o a. True

o b. False

Note: There is a $10 surcharge to process a check drawn on

any bank other than a US bank. Should you have additional
questions, please contact us at (973) 882-4700.

License Number

Street Address

Complete online at: dentalcetoday.com

(PLEASE PRINT CLEARLY OR TYPE)

My Credit Card information is provided below.

o American Express o Visa o MC o Discover

Please provide the following

PROGRAM EVAUATION FORM

Please complete the following activity evaluation questions.

(please print clearly):

Rating Scale: Excellent = 5 and Poor = 0

Course objectives were achieved.

Exact Name on Credit Card

Content was useful and benefited your clinical practice.

Review questions were clear and relevant to the editorial.

/
Credit Card #

Illustrations and photographs were clear and relevant.

Expiration Date

Written presentation was informative and concise.

How much time did you spend reading the activity and
completing the test?

Signature

What aspect of this course was most helpful and why?

This CE activity was not developed in accordance with

AGD PACE or ADA CERP standards.
CEUs for this activity will not be accepted by the AGD
for MAGD/FAGD credit.

What topics interest you for future Dentistry Today CE courses?

11