PMC6501258_01
Initial examination: (a) patient's dentures, right side; (b) patient's dentures, left side; (c) DentDu-Brm for the implant planning using barium sulfate resin for the teeth; (d) DentDu fabricated from clear resin.
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The dentures at the time of presentation had been fabricated 3 months previously, and the patient was satisfied with the extraoral appearance of the lips and face and tolerated the vertical dimension (Figures 1(a) and 1(b)). One (DentDu-Brm) for the implant planning using clear resin (Paladur; Heraeus Kulzer, Hanau, Germany) for the base and barium sulfate resin (Acryline DVT, Anaxdent, Stuttgart, Germany) for the teeth (Figure 1(c)). The second one was using the same clear resin for the base and the teeth in order to serve as a transfer guide during restoration (DentDu) (Figure 1(d)).
CBCT bone masking showing generalized advanced atrophy of the maxilla and posterior mandibular atrophy: (a) front view; (b) sinuses in sagittal section; (c) side view; (d) articulated casts show patient's jaw relationship.
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Analysis of the articulated casts showed large vertical distances between the maxillary and mandibular alveolar crests (2.3-2.4 cm in the premolar/molar area, 1.9 cm in the anterior area) and a horizontal distance of 1.3 cm in the anterior area (Figure 2(d)).
Tracking the path of inferior alveolar nerve and location of mental foramen for surgical implant placement: (a) frontal; (b) right side; (c) left side.
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In the same session, based on the CBCT, two implants were placed in positions #22 and #27 (SB line, 3.75 mm x 11 mm, Dentegris) and loaded immediately with a bar-retained overdenture using system-specific, prefabricated, angled, and tapered abutments (Figure 3).
Sinus augmentation and mandibular restoration: (a) OPG after sinus augmentation and implant placement in the mandible; (b) implant-retained bar; (c) clips for retention of the base over the bar; (d) OPG section after loading of the mandibular implants.
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Elastic plastic clips (Preci Matrice; CEKA, Waregem, Belgium) were used to retain the base over the bar (Figure 4).
Implant planning. CBCT of the maxilla with DentDu-Brm in situ before implant placement: (a) sagittal section and (b) axial section.
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CBCT planning software (Sicat Implant, Sicat GmbH, Bonn, Germany) showed that the ideal tooth position was 6.8 mm in front of the alveolar ridge (Figure 5).
(a) DentDu retained on BATTs in occlusion and (b) articulated master cast with the BATTs and DentDu.
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America Inc., Alsip, IL, USA; Figure 6(a)). A master cast was fabricated, and the BATTs were mounted on the implant analogs. The DentDu with retention elements was then positioned on the master cast, and casts were articulated under the guidance of the DentDu and jaw record (Figure 6(b)).
(a) The fabricated maxillary bar; (b) cross section of the bar on a model; (c) ELMES; (d) ELMES conforming to the shape of the bar; (e) cross section on a model demonstrating the use of the ELMES (X) over the bar (Y); (f) casted metal framework (laboratory work shown on a demonstration cast).
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The maxillary bar was designed using a superimposed DentDu and was positioned as far labial as possible to provide support for the denture base (Figures 7(a) and 7(b)). After verification of the bar's fit, an electroformed mesostructure (ELMES; Galvanogold, Wieland) with a thickness of 0.25 mm was fabricated to conform to the shape of the bar (Figures 7(c)-7(e)). Framework was cast with CoCrMo alloy (Ankatit, Anka Guss, Waldaschaff, Germany) and tried in the patient's mouth to check its passive fit (Figure 7(f) and Figures 8(a) and 8(b)).
(a) ELMES try-in; (b) verification of the occlusal relationship with the framework in; (c) ELMES fixed in the framework; (d) external view of the metal framework (S: swivel-type lock attachments).
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Framework was cast with CoCrMo alloy (Ankatit, Anka Guss, Waldaschaff, Germany) and tried in the patient's mouth to check its passive fit (Figure 7(f) and Figures 8(a) and 8(b)). In addition, a framework for an overdenture base was fabricated by casting CoCrMo alloy (Ankatit, Anka Guss; Figure 8 and Figures 9(a) and 9(b)). To provide passive retention and locking, two swivel-type lock attachments (swivel-type lock, Heraeus Kulzer, Hanau, Germany) were cast with a gold alloy (Hera; Heraeus Kulzer) (Figure 8(d) and Figures 9(c) and 9(d)). The fabricated maxillary bar was mounted on the implants, the ELMES was placed on the bar (Figure 8(b)), and the jaw relationship was verified with the framework in place (Figure 8(c)).
(a) Finished maxillary restoration inner side; (b) maxillary restoration in situ (S: swivel-type lock attachments); (c) cross section of the construction on a model: bar (X), ELMES (Y), and metal framework (Z); (d) the veneered construction. (a, d) Laboratory work shown on a demonstration cast.
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In addition, a framework for an overdenture base was fabricated by casting CoCrMo alloy (Ankatit, Anka Guss; Figure 8 and Figures 9(a) and 9(b)). To provide passive retention and locking, two swivel-type lock attachments (swivel-type lock, Heraeus Kulzer, Hanau, Germany) were cast with a gold alloy (Hera; Heraeus Kulzer) (Figure 8(d) and Figures 9(c) and 9(d)). Subsequently, the ELMES was fixed to the framework using a self-cure compomer (AGC Cem, Wieland; Figure 9(c)).
Bars mounted onto the implants: (a) front view and (b) palatal view.
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The denture was finished with the use of an autopolymerizing acrylic resin base material (PalaXpress Ultra; Heraeus Kulzer; Germany) and delivered back to the office on the same day (Figures 10-12).
Final restorations in situ: (a) right; (b) front; (c) left; (d) OPG 3 years after treatment.
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The denture was finished with the use of an autopolymerizing acrylic resin base material (PalaXpress Ultra; Heraeus Kulzer; Germany) and delivered back to the office on the same day (Figures 10-12).
Final restoration delivered: (a) before treatment (lateral); (b) before treatment (frontal); (c) after treatment (lateral); (d) after treatment (frontal).
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The denture was finished with the use of an autopolymerizing acrylic resin base material (PalaXpress Ultra; Heraeus Kulzer; Germany) and delivered back to the office on the same day (Figures 10-12).