Q about denture and implants

[DancingKoala]

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Hi guys.
I am a 3rd year dental student working in the clinic and seeking for answers to one of the cases I have.


I have a patient who has been wearing denture for last couple of years.
We just placed 2 implants for him. Our goal is to give him implant supported denture.
Keep in mind that this is my 1st time seeing implant patient and also I don't have any experience with denture.


My questions are
1. What should we do with his old denture? I am sure it doesn't fit anymore since we placed 2 implants with healing caps.
2. When can we give the patient a new denture? Do I just take an impression now while the healing cap is still on and send it to the lab asking them fabricate a denture?
3. The patient will come back in 2 weeks for post-op because we just placed implants with healing caps. What are the following steps? Do we remove the healing caps and wait a couple of month until it completely osteointegrate and put abutments? am I missing anything? precision attachments?
4. What if this was an implant crown case? When am I supposed to take an impression and send to the lab for crown?

Thanks in advance.

 

[DrJeff]

Hi guys.
I am a 3rd year dental student working in the clinic and seeking for answers to one of the cases I have.


I have a patient who has been wearing denture for last couple of years.
We just placed 2 implants for him. Our goal is to give him implant supported denture.
Keep in mind that this is my 1st time seeing implant patient and also I don't have any experience with denture.


My questions are
1. What should we do with his old denture? I am sure it doesn't fit anymore since we placed 2 implants with healing caps.
2. When can we give the patient a new denture? Do I just take an impression now while the healing cap is still on and send it to the lab asking them fabricate a denture?
3. The patient will come back in 2 weeks for post-op because we just placed implants with healing caps. What are the following steps? Do we remove the healing caps and wait a couple of month until it completely osteointegrate and put abutments? am I missing anything? precision attachments?
4. What if this was an implant crown case? When am I supposed to take an impression and send to the lab for crown?

Thanks in advance.

1) Don't be so sure that it won't fit anymore. You might end up being fine with just relieving the denture in the area where the implants/healing caps are and be fine. The bigger factor about if you'll need to make a new denture vs. retrofitting the current one will be if you have enough room vertically and horizontally for the attachments to fit in the existing denture

2) If you have to make a new denture, then you can begin the process with prelimary impressions as you usually would a couple of weeks before you plan on removing the healing caps and placing the attachments. The follow usual denture fabrication steps, and the lab will incorporate the denture born attachments into the new denture when it's time for it to be processed

3) Don't touch the healing caps until the usual integration time has passed. The only time I personally "violate" this rule is in the unlikely event that a healing cap comes off (it does happen from time to time) and I need to put it back inplace

4) If it was an implant crown case. After sufficient integration time, you'd remove the healing caps, and then depending on the clinical situation either take a bone level impression or if you're placing a stock abutment that day, take an impression with an impression cap on the stock abutment, and then send the impression off the the lab for final crown fabrication. If it's a bone level impression, i'm typically then putting the healing caps back on while the lab fabricates the crown. If I placed a stock abutment, then i'm making a temporary for that tooth while the lab fabricates the final crown

Sounds complicated, but after you've done a few cases, it really is very easy and logical the steps that you take to go from placement of the implant to definitive restoration

 

[doc toothache]

Since you are in school, shouldn't your tx plan have been discussed with the faculty supervising the tx?

 

[DancingKoala]

1) Don't be so sure that it won't fit anymore. You might end up being fine with just relieving the denture in the area where the implants/healing caps are and be fine. The bigger factor about if you'll need to make a new denture vs. retrofitting the current one will be if you have enough room vertically and horizontally for the attachments to fit in the existing denture

2) If you have to make a new denture, then you can begin the process with prelimary impressions as you usually would a couple of weeks before you plan on removing the healing caps and placing the attachments. The follow usual denture fabrication steps, and the lab will incorporate the denture born attachments into the new denture when it's time for it to be processed

3) Don't touch the healing caps until the usual integration time has passed. The only time I personally "violate" this rule is in the unlikely event that a healing cap comes off (it does happen from time to time) and I need to put it back inplace

4) If it was an implant crown case. After sufficient integration time, you'd remove the healing caps, and then depending on the clinical situation either take a bone level impression or if you're placing a stock abutment that day, take an impression with an impression cap on the stock abutment, and then send the impression off the the lab for final crown fabrication. If it's a bone level impression, i'm typically then putting the healing caps back on while the lab fabricates the crown. If I placed a stock abutment, then i'm making a temporary for that tooth while the lab fabricates the final crown

Sounds complicated, but after you've done a few cases, it really is very easy and logical the steps that you take to go from placement of the implant to definitive restoration

Thank you for answering my questions. Just couple of thoughts..
1) If I relieve the internal structure of denture to make space for healing caps, how do I make sure that I don't overprep that area so that it doesn't lose retention?
2) what do I do with the preliminary impression? (I know that preliminary impression for crown is used to make temporary crown but I don't know about denture). Do I make a final impression after putting abutment? (I don't know the denture fabrication step🙁)

 

[djeffreyt]

If you over-prep the area for the healing caps, just fill the prepped out area with soft denture reline material and seat it over the ridge and healing caps again. Let it set and once set, complete a very slight additional relief of the soft reline and you are set....but in all honesty, you probably won't be able to make the holes that big that the denture won't fit fine. dental students usually underprep because their cautious...the opposite tends to be very rare.

 

[charlestweed]

Thank you for answering my questions. Just couple of thoughts..
1) If I relieve the internal structure of denture to make space for healing caps, how do I make sure that I don't overprep that area so that it doesn't lose retention?
2) what do I do with the preliminary impression? (I know that preliminary impression for crown is used to make temporary crown but I don't know about denture). Do I make a final impression after putting abutment? (I don't know the denture fabrication step🙁)

As Doctor Toothache pointed out, the supervising faculty (prosth/perio/OS) should discuss the tx plan with both you and your patient.

I believe this is an implant retained overdenture case. The current lower denture now serves as a temporary denture while patient is waiting for the 2 implants to integrate. Once these 2 implants fully integrate, they will not have crowns on them. Instead, they’ll get 2 retententive anchors, which the new overdenture will attach to.

Since there are only 2 implants, you would still need proper denture extension for the stability during mastication. And in order to get proper denture extension, you need to make a custom tray. The preliminary impression, that Dr.Jeff mentioned earlier, is for making the custom tray for the new lower overdenture.

 

[jay47]

As Doctor Toothache pointed out, the supervising faculty (prosth/perio/OS) should discuss the tx plan with both you and your patient.

I believe this is an implant retained overdenture case. The current lower denture now serves as a temporary denture while patient is waiting for the 2 implants to integrate. Once these 2 implants fully integrate, they will not have crowns on them. Instead, they'll get 2 retententive anchors, which the new overdenture will attach to.

Since there are only 2 implants, you would still need proper denture extension for the stability during mastication. And in order to get proper denture extension, you need to make a custom tray. The preliminary impression, that Dr.Jeff mentioned earlier, is for making the custom tray for the new lower overdenture.

Like Charles said, this is likely an implant RETAINED/ASSISTED case, NOT implant SUPPORTED. Implant supported implied that there are 4+ implants and they take the majority of the biting force when the patient bites down. This usually involves multiple bars and retainers for the implant itself. Implant RETAINED simply retains the denture in place and stops it from moving away from the tissues, however, the tissues still bear the vast majority of the force when the patient bites.

See this website for a great review of overdentures: http://www.ffofr.org/education/lectures/implant-dentistry/edentulous-mandible-overlay-dentures/
As others have said, you will most likely keep the existing denture and reline it or retrofit it to the implants. If the patient has been edentulous for a long time and has lost a lot of ridge, then you will likely have plenty of room to reline it for the implant abutments.

 

[DancingKoala]

First of all, Thank you everyone for helping me.
I just got couple of more questions. I am sorry about this 🙁

I want to clarify that I understood all the steps. Please tell me if I am wrong.
1. Place implants + healing caps
2. post op. Also relieve the previous denture where the healing cap is located.
3. precision attachment + locators (I actually don't know the difference between precision attachment and locators)
4. Take preliminary impression to make custom tray. (Do I use system 1 or 2 for the impression? Pt is not edentulous and he still has anterior teeth)
5. Take another impression using custom tray. Send it to the lab and the lab makes the denture.

 

[djeffreyt]

First of all, Thank you everyone for helping me.
I just got couple of more questions. I am sorry about this 🙁

First, I think you should run all this through with your faculty. They are the ones who understand your protocols and implant system and thus can guide you best for your case in school, but here's my two cents.

I want to clarify that I understood all the steps. Please tell me if I am wrong.
1. Place implants + healing caps
2. post op. Also relieve the previous denture where the healing cap is located.
Yes. Place the implants first. Depending on your school's protocol, you may have to place the implant and then put a covering cap on top (a low fitting cap that does not protrude through the gingiva) and then suture the gingiva closed over the top of the implant. You then wait the 4-6 months for osseointegration before you uncover the implant and place a healing cap that pokes through the gingiva. After the gingiva heals around the healing cap, you start the other procedures involving the locators. It depends on your school's implant protocol. But in general, you need integration of the implants before you start making a denture that attaches to them.

3. precision attachment + locators (I actually don't know the difference between precision attachment and locators)
It sounds like your school is going to place locators. They look like small slightly flattened balls that will stick up through the gingiva. Just type locator attachments into Google and a hundred pictures will come up. These small ball attachments come with a cap that fits over them. It's basically like a snap button jacket. The ball is the male end and fits into a female end. The female end will be inside the denture and snap into place over the the locators. A precision attachment is a more general term. I think locator attachments fit under the category of precision attachments, but don't quote me...It's been a long time since I had to use correct terminology...sometimes I forget what instruments are called and ask my assistant for the flat thing or the pokey tool. But there are lots of other precision attachments, like lock and key mechanisms in bridges and partials.

4. Take preliminary impression to make custom tray. (Do I use system 1 or 2 for the impression? Pt is not edentulous and he still has anterior teeth)
5. Take another impression using custom tray. Send it to the lab and the lab makes the denture.
have no idea what system 1 or 2 is. I either never learned it or have forgotten. Anyways, yes, you take a preliminary impression. Alginates will work fine for a preliminary and then you make a custom tray and take the final impression

And now for the bad news...I think most of us have been under the assumption that the patient was edentulous on the arch you were talking about. If he has anterior teeth then this may be a slightly different scenario. Are you guys making an implant supported partial? If so, there are a couple scenarios here. You might be using locators still and doing exactly as we stated above. It is also possible that you are placing two implants, then having crowns made for those implants that have a precision attachment (lock and key) fabricated into the crown and then will fabricate a partial that locks into the crowns in order to avoid clasping from a more standard partial. Again, this is best discussed with your faculty as it's difficult to get all the information without pictures and exact knowledge of what's going on and we really don't want to steer you in the wrong direction.

 

[txaggie03]

Where is the license holder in all this?
😱