Attachment-Retained Gingival Prosthesis for Implant-Supported Fixed Dental Prosthesis in the Maxilla: A Clinical Report Ivete Aparecida de Mattias Sartori, DDS, MSc, PhD,1 Yuri Uhlendorf, DDS, MSc,2 Luiz Eduardo Marques Padovan, DDS, MSc, PhD,1 Paulo Domingos Ribeiro Junior, MSD, PhD,3 ´ Ana Claudia Moreira Melo, DDS, MSc, PhD,4 & Rodrigo Tiossi, DDS, MSc, PhD4 1
Professor, Master’s Program Director, Latin American Institute of Dental Research and Education (ILAPEO), Curitiba, Brazil Private Practitioner, Latin American Institute of Dental Research and Education (ILAPEO), Curitiba, Brazil 3 Professor, Sacred Heart University (USC), Bauru, Brazil 4 ´ Brazil Professor, Fluminense Federal University (UFF), Niteroi, 2
Keywords Implant-supported dental prosthesis; dental implants; mouth rehabilitation; maxillary complete denture; edentulous mouth. Correspondence Ivete Aparecida de Mattias Sartori, Latin American Institute of Dental Research and Education (ILAPEO), Rua Jacarezinho, 656, ˆ 80710-150. Curitiba, PR, Brazil. Merces E-mail: [email protected] The authors deny any conflicts of interest. Accepted October 22, 2013
Abstract The rehabilitation of edentulous maxillae is a complex procedure due to the involvement of esthetic and functional requirements. A trial maxillary denture can be used to identify the need for adequate upper lip support when replacing removable complete dentures by implant-fixed dental prostheses. This clinical report describes the outcome of the rehabilitation of an edentulous atrophic maxilla with unfavorable maxillomandibular relationship and deficient upper lip support. A trial denture was fabricated and used to diagnose the need for a prosthesis capable of restoring the upper lip support. The reduced upper lip support was also confirmed by a lateral cephalogram. The patient was rehabilitated by an implant-fixed dental prosthesis associated with an attachment-retained gingival prosthesis. The case presented shows that when loss of upper lip support is detected and the patient does not wish to undergo further surgical reconstruction procedure, the retention of a gingival prosthesis using a ball attachment is a satisfactory treatment option.
doi: 10.1111/jopr.12159
Similar to gingival tissue, the masticatory mucosa covering the alveolar process near the cervical portion of teeth has a defined shape and texture, associated with tooth eruption and with optimal gingival esthetics. Edentulous patients present further tissue loss associated with compromised upper lip support.1,2 Several reconstructive procedures have been described to optimize the esthetics in such cases, including orthognathic surgery and bone grafting.3 A removable gingival prosthesis is an alternative to surgical procedures. It provides upper lip support when surgical limitations are present. When a reduced occlusal vertical dimension is diagnosed, prosthetic compensations are needed in fixed partial4,5 and full-arch restorations.6 However, the prostheses must be designed to enable adequate hygiene, and horizontal (anteroposterior) compensation should not be used to compensate for reduced upper lip support. Gingival prostheses have been recommended to provide extra lower lip support.7 Such a prosthesis is simple and safe to use and is easy to fabricate, install, and maintain hygiene,8,9 and is also recommended to restore advanced tissue loss.10,11 The removable gingival prosthesis can be fabricated using ei654
ther heat-cured acrylic resin (which is inexpensive, durable, and provides a smooth finish) or resilient silicone. Silicone is less durable. The association of a precision attachment with a removable gingival prosthesis has been described using both materials.7,9 However, to our knowledge, the option to associate precision attachments and a gingival prosthesis to provide extra upper lip support has not been reported. Recent studies on the possible types of prostheses for maxillary rehabilitation do not include this recommendation,12-16 even when a compromised upper lip support has been previously diagnosed.17 This study aims to present a clinical case in which a removable gingival prosthesis was associated with a ball attachment to provide extra upper lip support for a full-arch, implant-fixed dental prosthesis.
Clinical report A 54-year-old female patient with good general health (ASA I) attended the Latin American Institute of Dental Research and Education (ILAPEO), Curitiba, Brazil. She had a maxillary removable complete denture associated with five implants in the
C 2014 by the American College of Prosthodontists Journal of Prosthodontics 23 (2014) 654–658
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mandible. The denture supported a screw-retained fixed dental prosthesis (FDP). Her chief complaint was discomfort with the nonfunctional maxillary complete denture. Both prostheses presented adequate esthetic appearance and were fitted to the supporting tissues (Figs 1 and 2); however, a large horizontal and vertical compensation by the upper denture base was present. The radiographic exam showed an atrophic maxillary alveolar ridge with severe bone resorption. An impression of the superior and inferior arches was performed, and a maxillary record base and occlusal rim were fabricated. The acrylic resin in the buccal flange was removed to aid diagnosing the upper lip support. After the form of the occlusal upper rim was determined and the artificial teeth were selected, the maxillary cast was assembled in a semi-adjustable articulator (Bio Art, S˜ao Carlos, Brazil) using a facebow (Bio Art). An interocclusal record was used to transfer the maxillomandibular relationship and assemble the mandibular cast in the articulator. The artificial teeth were then arranged in wax, and the trial maxillary denture was tested for functional and esthetic aspects. The upper lip support was found to be unsatisfactory in the trial denture try-in (Figs 3 and 4) when compared to the upper lip support provided by the patient’s complete denture (Figs 1 and 2). Two lateral cephalometric x-rays were taken, one with the complete denture of the patient in place and another one with the patient wearing the trial denture. The two radiographs were then overlapped (Fig 5), and the deficient upper lip support was confirmed. Two treatment options to correct the upper lip support were then suggested: premaxilla bone grafting or prosthetic horizontal compensation. The prosthetic options included removable complete denture, overdenture retained by bar or ball attachments and dental implants, and implant-supported FDP associated with a removable gingival prosthesis (epithesis) retained by a ball attachment. The computed tomography scan of the patient showed limited bone availability for implant placement. Bilateral maxillary sinus lifting or zygomatic implants were the available surgical options. The patient opted for zygomatic implants in the posterior region and conventional implants in the premaxilla. She did not wish for a removable restoration, such as a complete denture or a removable overdenture retained by dental implants. To compensate for the deficient upper lip support, she therefore opted for an implant-supported FDP associated with a removable gingival prosthesis retained by a ball attachment. To fabricate a surgical guide for implant placement, the trial maxillary denture was duplicated using clear acrylic resin after the clinician and the patient approved the functional and esthetic aspects. The regions of the surgical guide (otherwise known as the multifunctional guide) where the implants were to be placed were removed to allow their correct placement. Two zygomatic implants were placed in the posterior region of the maxilla (45 mm in length, Zigom´atico CM; Neodent, Curitiba, Brazil) in a hospital and under general anesthesia. Four conventional implants (3.5 mm diameter × 10 mm length, Alvim CM; Neodent) were placed in the anterior region of the maxilla. Prosthetic abutments (mini conical abutments; Neodent) were screwed to the implants, and on the next day an impression was made for prosthesis fabrication.
Attachment-Retained Gingival Prosthesis
The multifunctional guide was used for the implant impression. The multifunctional guide was placed in the patient’s mouth and connected to impression transfers using acrylic resin (Pattern Resin LS; GC America, Chicago, IL). Light consistency silicone impression material (Vigodent, Rio de Janeiro, Brazil) was injected under the multifunctional guide between the impression transfers. A small amount of putty silicone (Vigodent) was placed in the center of the palate to provide an adequate impression of the region filled with the light consistency material. Acrylic resin (Pattern Resin LS) was placed on three regions (two posterior, one anterior) of the occlusal surface of the multifunctional guide to register the centric relation. The impression transfers were then unscrewed, and the impression was removed. An implant-FDP was fabricated with a rigid cast bar splinting the implants and acrylic resin.18 Before the inclusion of the acrylic denture base and artificial teeth, a spherical pivot line precision attachment component (Rhein 83 S.R.L., Bologna, Italy) was laser welded to the cast bar. After the FDP was finished and polished, it was screwed to the working cast, and a removable gingival prosthesis was waxed. The stainless steel housing component was then inserted in the acrylic gingival prosthesis (Figs 6 and 7). The prosthesis was installed 2 days after the surgery (Figs 8–11). The sutures were removed 10 days after the surgery, and the removable gingival prosthesis was installed. A new lateral cephalometric x-ray was taken with the patient wearing the gingival prosthesis (Fig 12).
Discussion Some compensation (vertical, horizontal, or both) is common in the rehabilitation of the atrophic maxilla. A convex emergence profile from the ridge crest is recommended to allow adequate oral hygiene in a manner similar to natural tooth FDP pontics.2 However, the convex contour limits the upper lip support provided by the implant-fixed prosthesis, and if concave shapes are used, they prevent adequate hygiene and are not recommended. The lip line and lip support influence esthetics and the selection of the design for the implant-supported prosthesis of maxillary edentulous patients.14 To diagnose and visualize the upper lip support after the implant rehabilitation, a duplicate denture with a removed buccal flange has previously been recommended.14 Trimming the buccal flange of the trial denture is another method to diagnose upper lip support.15 The trial denture with the diagnostic tooth arrangement also helps identify the occlusal plane and the appropriate occlusal vertical dimension (OVD).15 For the present report, the trial denture without the buccal flange was used, enabling the diagnosis of insufficient upper lip support. Tracing the lateral cephalograms confirmed the clinical finding of deficient upper lip support. Overlapping the two initial radiographs (with the complete denture and with the trial denture) showed that the OVD established by the diagnostic tooth arrangement was able to restore height to the lower third of the face; however, the upper lip support was more favorable when the patient was wearing the complete denture, and the patient was more satisfied with the lip support provided by the denture. Since she did not want to go
C 2014 by the American College of Prosthodontists Journal of Prosthodontics 23 (2014) 654–658
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Figure 1 Initial clinical examination with both upper and lower prostheses in position.
Figure 4 Patient smile with the trial denture. Note the insufficient upper lip support.
Figure 2 Patient smile with the initial oral rehabilitation.
Figure 5 Overlapping of the cephalometric tracings with the trial denture (full line) and with the complete denture (dotted line).
Figure 3 Lateral view of the trial denture. Note the large horizontal (anteroposterior) distance from the diagnostic tooth arrangement to the alveolar ridge.
through any further surgical procedure, two restorative options were then suggested: implant-supported removable overdenture or implant-supported FDP associated with a removable gingival prosthesis. She opted for the latter. The removable gingival prosthesis therefore needed to be fabricated to provide adequate upper lip support. The removable gingival prosthesis was necessary to allow adequate hygiene, since a fixed buccal flange in 656
Figure 6 Implant-supported FDP and the removable gingival prosthesis. Note the design that was required in the dental prosthesis for adaptation of the gingival prosthesis.
C 2014 by the American College of Prosthodontists Journal of Prosthodontics 23 (2014) 654–658
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Attachment-Retained Gingival Prosthesis
Figure 10 Upper lip support at rest after the prosthetic rehabilitation. Figure 7 Gingival prosthesis attached to the implant-fixed dental prosthesis.
Figure 11 Upper lip support when smiling.
Figure 8 Implant-fixed dental prosthesis after installation.
Figure 9 Gingival prosthesis installed.
an implant-fixed complete denture would impair hygiene by the patient. Also, the patient did not want a removable restoration other than the gingival prosthesis. The use of an implant-supported FDP associated with a removable gingival prosthesis can replace a larger volume of tissue without impairing proper cleaning.10 It may also be effective in solving phonetic issues and provide adequate muscle
Figure 12 Lateral cephalometric x-ray after rehabilitation with the gingival prosthesis.
C 2014 by the American College of Prosthodontists Journal of Prosthodontics 23 (2014) 654–658
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tone.11,19 The main objective of the gingival prosthesis used for the present clinical report was to provide adequate lip support for the patient without performing reconstructive surgery. The dimensions and aspect of the gingival prosthesis were similar to that of a gingival prosthesis used to close unsightly spaces between teeth. Despite the advantages, this type of rehabilitation has not been previously associated with implant-supported full-arch maxillary rehabilitation.12,14,16 Several materials, including pink auto-cure and heat-cured acrylic, thermoplastic acrylic, composite resin, silicone, or porcelain-based materials, have been used for the fabrication of gingival prostheses.10 The advantage of heat-cured acrylic resins is that they are inexpensive and durable, provide a smooth surface, and present adequate color stability.10 Their disadvantages include their hardness and rigidity, which could lead to difficult fit with the underlying tissues and possible fracture.8 Silicone-based materials are more subject to staining and have lower durability.8 A ball attachment was used to improve retention of the gingival prosthesis. Ball-type precision attachments are largely used to improve retention in removable overdentures and have shown satisfactory results in a previous in vitro study.20 Such association also enabled the use of a heat-cured acrylic resin without the need for extensions between the teeth to improve retention, lowering the risk of fracture and providing more comfortable placement and removal.7,10 The need to associate a retention component to the gingival prosthesis is further reinforced when the disadvantages of such restoration are considered, that is the possibility of inhaling or swallowing due to the difficult retention.8 Also, the option for a two-piece restoration was selected to provide a convex emergence profile from the ridge crest allowing adequate oral hygiene by the patient to the implants and prosthesis after removing the gingival prosthesis. Had the prosthesis been fabricated in one piece, a resulting concave shape to the buccal region of the prosthesis would impair adequate hygiene. It is also important that the patient accepts the idea of a removable gingival prosthesis. In the present report, the patient was not worried by this, since the upper lip support provided by the gingival prosthesis was satisfactory, thus compensating for the inconvenience of a removable prosthesis. The corrected upper lip support was confirmed in the final lateral cephalogram taken with the patient wearing the gingival prosthesis.
Conclusions An implant-supported FDP associated with a removable gingival prosthesis with a retention system has been shown to be a reliable treatment option in a patient where an unfavorable upper lip support was diagnosed, and the patient did not want to undergo further surgical procedure. Further in vivo randomized clinical research studies are recommended to evaluate the longevity and patient satisfaction with the restoration option proposed by this clinical report.
References 1. Pietrokovski J, Harfin J, Levy F: The influence of age and denture wear on the size of edentulous structures. Gerodontology 2003;20:100-105 658
2. Bedrossian E, Sullivan RM, Fortin Y, et al: Fixed-prosthetic implant restoration of the edentulous maxilla: a systematic pretreatment evaluation method. J Oral Maxillofac Surg 2008;66:112-122 3. Khojasteh A, Mohajerani H, Momen-Heravi F, et al: Sandwich bone graft covered with buccal fat pad in severely atrophied edentulous maxilla: a clinical report. J Oral Implantol 2011;37:361-366 4. Coachman C, Salama M, Garber D, et al: Prosthetic gingival reconstruction in a fixed partial restoration. Part 1: introduction to artificial gingiva as an alternative therapy. Int J Periodontics Restorative Dent 2009;29:471-477 5. Salama M, Coachman C, Garber D, et al: Prosthetic gingival reconstruction in the fixed partial restoration. Part 2: diagnosis and treatment planning. Int J Periodontics Restorative Dent 2009;29:573-581 6. Lin WS, Ercoli C, Lowenguth R, et al: Oral rehabilitation of a patient with bruxism and cluster implant failures in the edentulous maxilla: a clinical report. J Prosthet Dent 2012;108:1-8 7. Brygider RM: Precision attachment-retained gingival veneers for fixed implant prostheses. J Prosthet Dent 1991;65:118122 8. Lai YL, Lui HF, Lee SY: In vitro color stability, stain resistance, and water sorption of four removable gingival flange materials. J Prosthet Dent 2003;90:293-300 9. Ajita CO, Anchieta RB, Martin M, Jr., et al: Association of fixed partial denture and gingival prosthesis as alternative approach to recover esthetics and function in anterior maxillary region. J Prosthodont Res 2012;56:222-226 10. Barzilay I, Irene T: Gingival prostheses—a review. J Can Dent Assoc 2003;69:74-78 11. Carvalho W, Barboza EP, Gouvea CV: The use of porcelain laminate veneers and a removable gingival prosthesis for a periodontally compromised patient: a clinical report. J Prosthet Dent 2005;93:315-317 12. Desjardins RP: Prosthesis design for osseointegrated implants in the edentulous maxilla. Int J Oral Maxillofac Implants 1992;7:311-320 13. Henry PJ: A review of guidelines for implant rehabilitation of the edentulous maxilla. J Prosthet Dent 2002;87:281-288 14. Neves FD, Mendonca 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 15. Cooper L, De Kok IJ, Reside GJ, et al: Immediate fixed restoration of the edentulous maxilla after implant placement. J Oral Maxillofac Surg 2005;63:97-110 16. Papaspyridakos P, Chen CJ, Chuang SK, et al: A systematic review of biologic and technical complications with fixed implant rehabilitations for edentulous patients. Int J Oral Maxillofac Implants 2012;27:102-110 17. Zitzmann NU, Margolin MD, Filippi A, et al: Patient assessment and diagnosis in implant treatment. Aust Dent J 2008;53 Suppl 1:S3-10 18. Lee HJ, Aparecida de Mattias Sartori I, Alcantara PR, et al: Implant stability measurements of two immediate loading protocols for the edentulous mandible: rigid and semi-rigid splinting of the implants. Implant Dent 2012;21:486-490 19. Worthington P, Bolender CL, Taylor TD: The Swedish system of osseointegrated implants: problems and complications encountered during a 4-year trial period. Int J Oral Maxillofac Implants 1987;2:77-84 20. Rodrigues RC, Faria AC, Macedo AP, et al: An in vitro study of non-axial forces upon the retention of an O-ring attachment. Clin Oral Implants Res 2009;20:1314-1319
C 2014 by the American College of Prosthodontists Journal of Prosthodontics 23 (2014) 654–658
Professor, Master’s Program Director, Latin American Institute of Dental Research and Education (ILAPEO), Curitiba, Brazil Private Practitioner, Latin American Institute of Dental Research and Education (ILAPEO), Curitiba, Brazil 3 Professor, Sacred Heart University (USC), Bauru, Brazil 4 ´ Brazil Professor, Fluminense Federal University (UFF), Niteroi, 2
Keywords Implant-supported dental prosthesis; dental implants; mouth rehabilitation; maxillary complete denture; edentulous mouth. Correspondence Ivete Aparecida de Mattias Sartori, Latin American Institute of Dental Research and Education (ILAPEO), Rua Jacarezinho, 656, ˆ 80710-150. Curitiba, PR, Brazil. Merces E-mail: [email protected] The authors deny any conflicts of interest. Accepted October 22, 2013
Abstract The rehabilitation of edentulous maxillae is a complex procedure due to the involvement of esthetic and functional requirements. A trial maxillary denture can be used to identify the need for adequate upper lip support when replacing removable complete dentures by implant-fixed dental prostheses. This clinical report describes the outcome of the rehabilitation of an edentulous atrophic maxilla with unfavorable maxillomandibular relationship and deficient upper lip support. A trial denture was fabricated and used to diagnose the need for a prosthesis capable of restoring the upper lip support. The reduced upper lip support was also confirmed by a lateral cephalogram. The patient was rehabilitated by an implant-fixed dental prosthesis associated with an attachment-retained gingival prosthesis. The case presented shows that when loss of upper lip support is detected and the patient does not wish to undergo further surgical reconstruction procedure, the retention of a gingival prosthesis using a ball attachment is a satisfactory treatment option.
doi: 10.1111/jopr.12159
Similar to gingival tissue, the masticatory mucosa covering the alveolar process near the cervical portion of teeth has a defined shape and texture, associated with tooth eruption and with optimal gingival esthetics. Edentulous patients present further tissue loss associated with compromised upper lip support.1,2 Several reconstructive procedures have been described to optimize the esthetics in such cases, including orthognathic surgery and bone grafting.3 A removable gingival prosthesis is an alternative to surgical procedures. It provides upper lip support when surgical limitations are present. When a reduced occlusal vertical dimension is diagnosed, prosthetic compensations are needed in fixed partial4,5 and full-arch restorations.6 However, the prostheses must be designed to enable adequate hygiene, and horizontal (anteroposterior) compensation should not be used to compensate for reduced upper lip support. Gingival prostheses have been recommended to provide extra lower lip support.7 Such a prosthesis is simple and safe to use and is easy to fabricate, install, and maintain hygiene,8,9 and is also recommended to restore advanced tissue loss.10,11 The removable gingival prosthesis can be fabricated using ei654
ther heat-cured acrylic resin (which is inexpensive, durable, and provides a smooth finish) or resilient silicone. Silicone is less durable. The association of a precision attachment with a removable gingival prosthesis has been described using both materials.7,9 However, to our knowledge, the option to associate precision attachments and a gingival prosthesis to provide extra upper lip support has not been reported. Recent studies on the possible types of prostheses for maxillary rehabilitation do not include this recommendation,12-16 even when a compromised upper lip support has been previously diagnosed.17 This study aims to present a clinical case in which a removable gingival prosthesis was associated with a ball attachment to provide extra upper lip support for a full-arch, implant-fixed dental prosthesis.
Clinical report A 54-year-old female patient with good general health (ASA I) attended the Latin American Institute of Dental Research and Education (ILAPEO), Curitiba, Brazil. She had a maxillary removable complete denture associated with five implants in the
C 2014 by the American College of Prosthodontists Journal of Prosthodontics 23 (2014) 654–658
Sartori et al
mandible. The denture supported a screw-retained fixed dental prosthesis (FDP). Her chief complaint was discomfort with the nonfunctional maxillary complete denture. Both prostheses presented adequate esthetic appearance and were fitted to the supporting tissues (Figs 1 and 2); however, a large horizontal and vertical compensation by the upper denture base was present. The radiographic exam showed an atrophic maxillary alveolar ridge with severe bone resorption. An impression of the superior and inferior arches was performed, and a maxillary record base and occlusal rim were fabricated. The acrylic resin in the buccal flange was removed to aid diagnosing the upper lip support. After the form of the occlusal upper rim was determined and the artificial teeth were selected, the maxillary cast was assembled in a semi-adjustable articulator (Bio Art, S˜ao Carlos, Brazil) using a facebow (Bio Art). An interocclusal record was used to transfer the maxillomandibular relationship and assemble the mandibular cast in the articulator. The artificial teeth were then arranged in wax, and the trial maxillary denture was tested for functional and esthetic aspects. The upper lip support was found to be unsatisfactory in the trial denture try-in (Figs 3 and 4) when compared to the upper lip support provided by the patient’s complete denture (Figs 1 and 2). Two lateral cephalometric x-rays were taken, one with the complete denture of the patient in place and another one with the patient wearing the trial denture. The two radiographs were then overlapped (Fig 5), and the deficient upper lip support was confirmed. Two treatment options to correct the upper lip support were then suggested: premaxilla bone grafting or prosthetic horizontal compensation. The prosthetic options included removable complete denture, overdenture retained by bar or ball attachments and dental implants, and implant-supported FDP associated with a removable gingival prosthesis (epithesis) retained by a ball attachment. The computed tomography scan of the patient showed limited bone availability for implant placement. Bilateral maxillary sinus lifting or zygomatic implants were the available surgical options. The patient opted for zygomatic implants in the posterior region and conventional implants in the premaxilla. She did not wish for a removable restoration, such as a complete denture or a removable overdenture retained by dental implants. To compensate for the deficient upper lip support, she therefore opted for an implant-supported FDP associated with a removable gingival prosthesis retained by a ball attachment. To fabricate a surgical guide for implant placement, the trial maxillary denture was duplicated using clear acrylic resin after the clinician and the patient approved the functional and esthetic aspects. The regions of the surgical guide (otherwise known as the multifunctional guide) where the implants were to be placed were removed to allow their correct placement. Two zygomatic implants were placed in the posterior region of the maxilla (45 mm in length, Zigom´atico CM; Neodent, Curitiba, Brazil) in a hospital and under general anesthesia. Four conventional implants (3.5 mm diameter × 10 mm length, Alvim CM; Neodent) were placed in the anterior region of the maxilla. Prosthetic abutments (mini conical abutments; Neodent) were screwed to the implants, and on the next day an impression was made for prosthesis fabrication.
Attachment-Retained Gingival Prosthesis
The multifunctional guide was used for the implant impression. The multifunctional guide was placed in the patient’s mouth and connected to impression transfers using acrylic resin (Pattern Resin LS; GC America, Chicago, IL). Light consistency silicone impression material (Vigodent, Rio de Janeiro, Brazil) was injected under the multifunctional guide between the impression transfers. A small amount of putty silicone (Vigodent) was placed in the center of the palate to provide an adequate impression of the region filled with the light consistency material. Acrylic resin (Pattern Resin LS) was placed on three regions (two posterior, one anterior) of the occlusal surface of the multifunctional guide to register the centric relation. The impression transfers were then unscrewed, and the impression was removed. An implant-FDP was fabricated with a rigid cast bar splinting the implants and acrylic resin.18 Before the inclusion of the acrylic denture base and artificial teeth, a spherical pivot line precision attachment component (Rhein 83 S.R.L., Bologna, Italy) was laser welded to the cast bar. After the FDP was finished and polished, it was screwed to the working cast, and a removable gingival prosthesis was waxed. The stainless steel housing component was then inserted in the acrylic gingival prosthesis (Figs 6 and 7). The prosthesis was installed 2 days after the surgery (Figs 8–11). The sutures were removed 10 days after the surgery, and the removable gingival prosthesis was installed. A new lateral cephalometric x-ray was taken with the patient wearing the gingival prosthesis (Fig 12).
Discussion Some compensation (vertical, horizontal, or both) is common in the rehabilitation of the atrophic maxilla. A convex emergence profile from the ridge crest is recommended to allow adequate oral hygiene in a manner similar to natural tooth FDP pontics.2 However, the convex contour limits the upper lip support provided by the implant-fixed prosthesis, and if concave shapes are used, they prevent adequate hygiene and are not recommended. The lip line and lip support influence esthetics and the selection of the design for the implant-supported prosthesis of maxillary edentulous patients.14 To diagnose and visualize the upper lip support after the implant rehabilitation, a duplicate denture with a removed buccal flange has previously been recommended.14 Trimming the buccal flange of the trial denture is another method to diagnose upper lip support.15 The trial denture with the diagnostic tooth arrangement also helps identify the occlusal plane and the appropriate occlusal vertical dimension (OVD).15 For the present report, the trial denture without the buccal flange was used, enabling the diagnosis of insufficient upper lip support. Tracing the lateral cephalograms confirmed the clinical finding of deficient upper lip support. Overlapping the two initial radiographs (with the complete denture and with the trial denture) showed that the OVD established by the diagnostic tooth arrangement was able to restore height to the lower third of the face; however, the upper lip support was more favorable when the patient was wearing the complete denture, and the patient was more satisfied with the lip support provided by the denture. Since she did not want to go
C 2014 by the American College of Prosthodontists Journal of Prosthodontics 23 (2014) 654–658
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Figure 1 Initial clinical examination with both upper and lower prostheses in position.
Figure 4 Patient smile with the trial denture. Note the insufficient upper lip support.
Figure 2 Patient smile with the initial oral rehabilitation.
Figure 5 Overlapping of the cephalometric tracings with the trial denture (full line) and with the complete denture (dotted line).
Figure 3 Lateral view of the trial denture. Note the large horizontal (anteroposterior) distance from the diagnostic tooth arrangement to the alveolar ridge.
through any further surgical procedure, two restorative options were then suggested: implant-supported removable overdenture or implant-supported FDP associated with a removable gingival prosthesis. She opted for the latter. The removable gingival prosthesis therefore needed to be fabricated to provide adequate upper lip support. The removable gingival prosthesis was necessary to allow adequate hygiene, since a fixed buccal flange in 656
Figure 6 Implant-supported FDP and the removable gingival prosthesis. Note the design that was required in the dental prosthesis for adaptation of the gingival prosthesis.
C 2014 by the American College of Prosthodontists Journal of Prosthodontics 23 (2014) 654–658
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Attachment-Retained Gingival Prosthesis
Figure 10 Upper lip support at rest after the prosthetic rehabilitation. Figure 7 Gingival prosthesis attached to the implant-fixed dental prosthesis.
Figure 11 Upper lip support when smiling.
Figure 8 Implant-fixed dental prosthesis after installation.
Figure 9 Gingival prosthesis installed.
an implant-fixed complete denture would impair hygiene by the patient. Also, the patient did not want a removable restoration other than the gingival prosthesis. The use of an implant-supported FDP associated with a removable gingival prosthesis can replace a larger volume of tissue without impairing proper cleaning.10 It may also be effective in solving phonetic issues and provide adequate muscle
Figure 12 Lateral cephalometric x-ray after rehabilitation with the gingival prosthesis.
C 2014 by the American College of Prosthodontists Journal of Prosthodontics 23 (2014) 654–658
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tone.11,19 The main objective of the gingival prosthesis used for the present clinical report was to provide adequate lip support for the patient without performing reconstructive surgery. The dimensions and aspect of the gingival prosthesis were similar to that of a gingival prosthesis used to close unsightly spaces between teeth. Despite the advantages, this type of rehabilitation has not been previously associated with implant-supported full-arch maxillary rehabilitation.12,14,16 Several materials, including pink auto-cure and heat-cured acrylic, thermoplastic acrylic, composite resin, silicone, or porcelain-based materials, have been used for the fabrication of gingival prostheses.10 The advantage of heat-cured acrylic resins is that they are inexpensive and durable, provide a smooth surface, and present adequate color stability.10 Their disadvantages include their hardness and rigidity, which could lead to difficult fit with the underlying tissues and possible fracture.8 Silicone-based materials are more subject to staining and have lower durability.8 A ball attachment was used to improve retention of the gingival prosthesis. Ball-type precision attachments are largely used to improve retention in removable overdentures and have shown satisfactory results in a previous in vitro study.20 Such association also enabled the use of a heat-cured acrylic resin without the need for extensions between the teeth to improve retention, lowering the risk of fracture and providing more comfortable placement and removal.7,10 The need to associate a retention component to the gingival prosthesis is further reinforced when the disadvantages of such restoration are considered, that is the possibility of inhaling or swallowing due to the difficult retention.8 Also, the option for a two-piece restoration was selected to provide a convex emergence profile from the ridge crest allowing adequate oral hygiene by the patient to the implants and prosthesis after removing the gingival prosthesis. Had the prosthesis been fabricated in one piece, a resulting concave shape to the buccal region of the prosthesis would impair adequate hygiene. It is also important that the patient accepts the idea of a removable gingival prosthesis. In the present report, the patient was not worried by this, since the upper lip support provided by the gingival prosthesis was satisfactory, thus compensating for the inconvenience of a removable prosthesis. The corrected upper lip support was confirmed in the final lateral cephalogram taken with the patient wearing the gingival prosthesis.
Conclusions An implant-supported FDP associated with a removable gingival prosthesis with a retention system has been shown to be a reliable treatment option in a patient where an unfavorable upper lip support was diagnosed, and the patient did not want to undergo further surgical procedure. Further in vivo randomized clinical research studies are recommended to evaluate the longevity and patient satisfaction with the restoration option proposed by this clinical report.
References 1. Pietrokovski J, Harfin J, Levy F: The influence of age and denture wear on the size of edentulous structures. Gerodontology 2003;20:100-105 658
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C 2014 by the American College of Prosthodontists Journal of Prosthodontics 23 (2014) 654–658
