Interdisciplinary Management of Implant Overdenture Therapy

INTRODUCTION
The management of complicated dental problems often requires an interdisciplinary approach to diagnosis, treatment planning, and therapy. Staging interactions among multiple providers and processes is critical to an optimal therapeutic outcome. The dental patient presented here required thorough diagnosis and treatment planning, as well as carefully orchestrated interdisciplinary management to arrive at a successful treatment result.

PATIENT PRESENTATION AND EVALUATION
A 61-year-old female presented for dental evaluation and treatment of her failing natural dentition (Figure 1). The patient indicated having seen 5 dentists in the last several years, suggesting that none were able to satisfy her treatment requests or stay within her economic means. She also expressed displeasure with her smile aesthetics, indicating that her teeth had drifted over the past few years. The patient desired to improve her oral function and appearance.

Figure 1. Pretreatment facial appearance: profile repose, frontal repose, and frontal full smile views.	Figure 2. Pretreatment panoramic radiograph.
Figure 3. Pretreatment intraoral frontal view in maximal intercuspal position.	Figure 4. Pretreatment intraoral maxillary occlusal view.
Figure 5. Pretreatment intraoral mandibular occlusal view.	Figure 6. Maxillary immediate denture impression (a) and working cast (b). Mandibular immediate denture impression (c) and working cast (d).

Following review of medical and dental histories, thorough intra- and extraoral examinations were accomplished. A radiographic survey was completed, including a full- mouth series of periapical and bitewing radiographs and a panoramic radiograph (Figure 2). In general, the patient possessed a rapidly failing maxillary and mandibular dentition, generalized periodontal bone loss, and recurrent cervical caries, with functional and aesthetic compromise. The maxillary occlusal plane was canted. Excessive maxillary gingival display, consistent with vertical maxillary excess, and overabundant mandibular anterior tooth display, consistent with dentoalveolar extrusion, adversely affected smile aesthetics. Radiographs indicated bilateral pneumatized maxillary sinuses.
Pretreatment photographs were made depicting repose, average animation, full animation, intraoral maximum intercuspal (Figure 3) and eccentric positions, and occlusal views of the maxilla (Figure 4) and mandible (Figure 5). Thermoplastic stock impression trays (Strong-Massad Denplant Tray [Global Dental Impression Trays]) were gently heated and carefully adapted to the maxillary and mandibular dental arches and vestibular areas. Vinyl polysiloxane (VPS) (Aquasil Ultra [DENTSPLY Caulk]) impressions were made using a layering technique to accurately capture both tooth positions and functional vestibular borders. Completed impressions were cast in dental stone (Figure 6). Resultant dental casts were mounted in a semi-adjustable articulator using a face-bow transfer registration and an interocclusal record made in the centric relation position.
   In order to address aesthetic concerns expressed by the patient, a smile analysis was undertaken. Specific attention was given to:

• facial and tooth arrangement symmetry
• dentogingival display
• buccal corridor visibility
• anterior-posterior occlusal plane orientation
• medial-lateral occlusal plane orientation
• maxillary and mandibular lip dimensions.

This analysis revealed the following:

• asymmetrical smile display
• vertical maxillary excess
• excessive, right-side, maxillary gingival display
• moderate, left-side, maxillary gingival display
• asymmetrical, reverse occlusal plane orientation
• mandibular dentoalveolar extrusion
• excessive mandibular tooth display in repose and smile
• excessively narrow buccal corridors
• flat to reverse anterior-posterior occlusal plane
• thin, diminished maxillary vermillion lip dimensions
• adequate mandibular vermillion lip dimensions for patient’s age. 

Figure 8. Based on calculated mandibular anterior dentoalveolar extrusion, 10 mm of alveolar vertical reduction is necessary to accommodate the planned overdenture and implant attachment system.	Figure 9. Maxillary paraocclusal record base with central bearing plate. Mandibular paraocclusal record base with central bearing pin.

Using a periodontal probe, linear distances between the maxillary vermillion border and the maxillary free gingival margins during full smile were recorded. These measurements were transferred to the maxillary cast using digital calipers. Individual measurements between mandibular incisal edges and the margin of the mandibular vermillion border in repose were recorded (Figures 7a and 7b). These dimensions were then transferred to the mandibular cast.

THE TREATMENT PLAN
The patient’s residual dentition was determined to be affected by substantial periodontal, aesthetic, and restorative compromised. Any attempt to adequately restore existing teeth would result in guarded short-term and very poor long-term prognoses. In order to satisfy the patient’s desire for improved oral function and appearance, and to provide durable dental restorations, it was decided to extract the remaining teeth, accomplish carefully planned osteoplasty/ ostecomy of the residual edentulous ridges, surgically place dental implants, and provide maxillary and mandibular immediate dentures (Figure 8). Upon adequate postoperative healing and osseointegration, fabrication of maxillary and mandibular implant-supported overdentures was planned.

PREOPERATIVE THERAPY
Paraocclusal record bases were fabricated on the patient’s dental casts. A central bearing device (Jaw Recorder [Global Dental Impression Trays]) was then attached to the record bases in preparation for interocclusal registration procedures (Figure 9). Next, clinical evaluations of the planned vertical and horizontal maxillomandibular relationships were accomplished.
An indelible marking stick was used to place a dot on the tip of the patient’s nose and anterior prominence of the chin. Sitting upright in the dental chair, the patient was instructed to deeply inhale and exhale several times, open the mouth wide, and then slowly close the mouth until lip contact is first perceived. This mandibular posture approximated the rest vertical dimension (RVD). This sequence of breathing and mandibular posture was practiced several times. A measuring divider was used to record the distance between reference marks on the nose and chin. When a consistent and repeatable distance was established and recorded (RVD), approximately 3 mm was subtracted to arrive at the proposed occlusal vertical dimension (OVD) to be use during subsequent prosthodontic procedures.¹ The 3-mm difference between RVD and OVD represents a clinically acceptable interocclusal distance or freeway space. Interocclusal distance varies and may be affected by many factors, including age, physical/emotional conditions, fatigue, medications, and typical interpersonal variability.²

Figure 10. With the central bearing device posturing the mandible at the planned occlusal vertical dimension, note anterior tooth interferences restricting eccentric movements.	Figure 11. Tooth reduction matrix off and on the mandibular cast. Note tooth structure extending beyond the matrix, which was to be eliminated from the cast.

Figure 12. Gothic arch tracing produced on the central bearing plate by the patient.

Having recorded the proposed OVD of the planned prosthesis, the record bases with attached central bearing device were placed in the patient’s mouth. The central bearing pin was adjusted to contact the central bearing plate at the desired OVD. The patient was instructed to make repeated mandibular movements between protrusion and centric relation while keeping the central bearing pin in contact with the plate. Additionally, the patient was instructed to make mandibular movements from centric relation to right and left lateral excursions. As the patient accomplished the protrusive and lateral mandibular movement while maintaining contact between the central bearing pin and plate, it was noted clinically that occlusal interferences obstructing full range mandibular movements occurred involving anterior teeth and second molars (Figure 10). With the patient’s permission, the elimination of these occlusal interferences was planned.
On the mandibular cast, a pressure formed tooth reduction matrix was fabricated (Essix A+ [DENTSPLY Essix Raintree Glenroe]). Transferring the tooth reduction matrix to the patient’s mouth, occlusal adjustment of the offending teeth through the reduction matrix was accomplished (Figure 11). This process assured that the full range of mandibular motion was possible. The tooth reduction matrix was then transferred back to the mandibular cast in order to guide similar modification of the teeth on the cast.
Next, registration of the patient’s centric relation mandibular position was performed. The central bearing plate attached to the maxillary record base was painted with ink and replaced in the patient’s mouth. The patient was again instructed to perform protrusive, left lateral and right lateral mandibular movement, always returning to the centric relation position at the completion of each prescribed movement. After repeating each movement several times, the maxillary record base and bearing plate were removed and the resultant Gothic arch was evaluated (Figure 12). The apex of the tracing—ie, the junction between left lateral, right lateral, and protrusive paths—represents a mandibular posture that corresponds to centric relation. For patients with healthy temporomandibular joints (TMJs) and unencumbered mandibular motion, the Gothic arch created by a central bearing device is a crisp, clean tracing. However, for patients possessing TMJ inflammation, TMJ derangement, or a limited range of mandibular movement, the tracing produced on the bearing plate may be erroneous and/or difficult to read. Appropriate therapeutic intervention may be required in order to assure resolution of TMJ problems prior to the confident registration of a treatment position and predictable prosthodontic restoration.^3,4
Upon identification of an acceptable Gothic arch tracing with a discernable centric relation point, a clear centering disk was adhered to the bearing plate using sticky wax (Figure 13). The small perforation in the centering disk was positioned directly over the apex of the Gothic arch. This perforation, or indentation, assisted the patient in returning to the centric relation position during interarch registration procedures.

The maxillary record base and bearing plate were returned to the patient’s mouth, and the patient’s mandible was carefully manipulated to the centric relation position. Upon closure, the patient felt the central bearing pin enter the perforation in the clear centering disk on the bearing plate. While maintaining this centric relation position, a VPS interocclusal registration material (Regisil Rigid [DENTSPLY Caulk]) was injected between the maxillary and mandibular teeth (Figure 13). Upon polymerization of the registration material, the record was removed, inspected for completeness/accuracy, and trimmed in preparation for cast mounting. A face-bow transfer record was also made.
The maxillary cast was mounted in a semiadjustable articulator using the face-bow transfer registration. Next, the carefully trimmed interocclusal record was used to mount the mandibular cast against the maxillary cast in the articulator.
In order to account for the dentoalveolar extrusion and gummy smile associated with the patient’s chief complaint and affecting her dental appearance, diagnostic calculation of optimal tooth position within the patient’s smile was made. This consideration, in turn, impacted planned surgical intervention and space management in the mandibular arch. Locating the proposed mandibular incisal edges at the superior margin of the resting mandibular vermillion border, and using the average vertical height of mandibular incisors, the vertical position of the planned anterior prosthetic free gingival margins were identified on the cast.
Previous professional literature describes the oral space necessary to accommodate implant overdentures.⁵ Most popular attachment systems may be used if vertical space between the crest of the soft-tissue edentulous ridge and the occlusal plane is 10 to 15 mm. Less restorative space requires more strategic management of attachment system selection and incorporation, excessive denture tooth adjustment during the set-up process, incorporation of metal frameworks for prosthesis structural reinforcement, and possible displacement denture teeth away from aesthetically and functionally optimal positions. In order to establish favorable spatial conditions for the present patient, approximately 10 mm of anterior vertical mandibular alveolar ridge reduction was required following tooth extraction and prior to implant placement.
The relative approximation of the maxillary teeth to the maxillary lip during full smile was recorded. Measurements from the apex of the free gingival margins to the inferior margin of the maxillary vermillion border during full animation were transferred to the mounted maxillary cast. The resultant line represented the proposed location for the cervical aspects of the anterior denture teeth for the planned prosthesis (Figures 7a and 7b).

Figure 14. Functional maxillary vestibular impression on the maxillary working cast (a). Contours of the vestibular impression captured with facial matrix (b) to aid in denture tooth set-up (c).	Figure 15. Postoperative panoramic radiograph illustrating implant placement.

Additionally, it was observed that the existing buccal corridors presented excessive negative space. In order to negate this aesthetic detractor, setting the maxillary denture premolar and molar denture teeth to a more facial position than existing natural teeth was considered. To accomplish this reorientation of posterior denture teeth, encroachment on the normal physiologic function of the checks and tongue muscles needed to be avoided.6 A functional vestibular impression was made by injecting a rigid VPS (Aquasil Ultra Heavy [DENTSPLY Caulk]) into the maxillary buccal and labial vestibules. The patient was instructed purse her lips outward and forcibly smile, open wide and close. This sequence of oral movements was repeated several times until the VPS registration polymerized. The functional vestibular impression was removed and inspected (Figure 14). Using the same process, a second functional impression was made of the mandibular buccal and labial vestibules.
The physiologic influence of tongue movements on mandibular denture tooth position was recorded using a functional lingual vestibular impression. Rigid VPS was injected bilaterally into the lingual vestibules. The patient was instructed to place the tip of the tongue forward out of the mouth and then move the tongue side to side. Next, the patient retracted the tip of the tongue to touch the posterior palate. These tongue movements were repeated several times. Upon polymerization, the functional lingual vestibular impression was removed and inspected.
Evaluation of the vestibular registrations revealed that posterior denture teeth could be set facial to the natural posterior tooth predecessors. In doing so, an improvement in buccal corridor aesthetics would result from improved denture tooth positions, reduced negative space display, and reduced denture base display. The registered absence of lingual vestibular space provided additional supported to the value of facial movement of posterior denture teeth. In order to guide denture fabrication, vestibular registrations were adapted to fit on their respective casts and laboratory putty matrices were created to guide denture tooth set-up (Figure 14).
Immediate denture construction was carried out using conventional techniques.7 Denture tooth set-up matrices were used to guide optimal facial-lingual posterior tooth placement. Metal castings were incorporated into definitive denture bases to reinforce prostheses that would require multiple reline procedures during the postextraction phase of therapy. Immediate dentures were waxed, flasked, processed, finished, and polished. The final prostheses were duplicated in clear acrylic resin to facilitate preimplant radiographic treatment planning procedures. 
 
SURGICAL THERAPY
The patient completed a 30 second preoperative oral chlorhexidine (CHX) rinse. After obtaining satisfactory intravenous general anesthesia, the oral cavity was suctioned free of all secretions and a gauze throat pack placed. Left and right maxillary and mandibular block local anesthesia was administered (8 cc of 0.5% Marcaine with 1:200,000 epinephrine). The maxillary and mandibular teeth were atraumatically removed using elevator and forceps technique. A crestal gingival incision was then made extending from the right tuberosity circumferentially to the left tuberosity. A full-arch, full-thickness mucoperiosteal flap was reflected. The hypertrophic anterior maxillary alveolus was vertically reduced by approximately 7 to 8 mm. Six evenly spaced root form implants (Replace Tapered Groovy [Nobel Biocare]) were then placed in selected extraction sites. All implants demonstrated good primary stability and were seated with 35 to 40 Ncm of rotational torque. Cover screws were then placed on each implant. Osseous voids adjacent to implants and all unutilized extraction sockets were grafted with solvent-dehydrated, mineralized cortical bone allograft (Puros Cortical Particulate Allograft [Zimmer Dental]). After excising redundant gingival tissue, the full-thickness flap was closed using 4-0 interrupted chromic sutures.
Attention was then turned to the mandibular arch. Using an identical surgical technique, the remaining mandibular teeth were removed. The hypertrophic anterior mandibular alveolus was vertically reduced and 4 anterior root form implants (Replace Tapered Groovy) were placed achieving a rotational seating torque of 45 Ncm. Implant socket voids and areas of thin labial cortex were grafted in the same manner as previously described and cover screws were placed on the implants. The full-thickness mucoperiosteal flap was then closed using 4-0 interrupted chromic sutures. The gauze throat pack was removed and the procedure terminated. Postoperative narcotic analgesics, systemic antibiotics, corticosteroids, and oral CHX rinse were prescribed.
Following dental extractions and implant placements, the maxillary and mandibular immediate dentures were adjusted, adapted using a provisional soft liner, and placed. The patient returned for 48-hour post-placement evaluation and management (Figure 15). At this appointment, all surgical sites were closely evaluated for healing progress and denture irritations. The existing provisional liner was replaced with a plasticized acrylic resin liner (PermaSoft [DENTSPLY Prosthetics]). Proper occlusion was evaluated and adjusted. The patient was scheduled for monthly reevaluations (Figure 16).

Five months following implant placement, the patient returned for surgical uncovering of the previously placed maxillary and mandibular implants to the oral cavity. After completing a 30-second preoperative CHX rinse, and then obtaining satisfactory intravenous general anesthesia, the oral cavity was suctioned free of all secretions, and a gauze throat pack was placed. Block local anesthesia was administered (8 cc of 0.5% Marcaine with 1:200,000 epinephrine). A gingival crest incision was made over each of the previously placed maxillary and mandibular implants. Limited split thickness mucoperiosteal flap were elevated to exposing each of the previously placed dental implants. Cover screws were removed and replaced with healing abutments of the appropriate diameter and 3 mm in height. Gingival tissues were then advanced and adapted around the healing abutments using 5-0 chromic suture. The gauze throat pack was removed and the procedure terminated. Postoperative anti-inflammatory analgesics were prescribed.

DEFINITIVE PROSTHODONTIC THERAPY
Four weeks following the patient’s second surgical intervention, new impressions were made to begin fabrication of the definitive maxillary and mandibular implant-supported overdentures. Healing abutments were removed from all maxillary implants and closed tray impression posts were placed (Figure 17a). After carefully estimating the dimensions of the maxillary arch, an appropriate stock impression tray was selected (Strong-Massad Denplant Tray). These clear plastic trays allow one to see through them to help in selecting and fitting the tray as well as to ensure that sufficient room is available between the tray and of the all impression components (Figure 17b).

The polystyrene-based polymer trays used are thermoplastic. Subtle alterations to flange trajectory were made by passing the appropriate portion of the tray quickly through a microflame until the resin softened. Careful manipulation the softened tray was made and the tray was cooled in water. Tray flanges identified to be over extended were subtractively adjusted by grinding with conventional acrylic resin rotary instrumentation.
The definitive impression procedure required multiple placements of the impression tray in the patient’s mouth. In order to achieve consistently repeatable tray placements, tray stops were developed. Using high viscosity VPS (Aquasil Ultra Heavy), three-quarter size circles of material were placed in the tuberosity and midpalate areas. Additional material was dispensed into the anterior tray (Figure 17c). The tray was seated on the edentulous maxilla and centered over the ridge and implant impression components. The objective was to develop an adequate and consistent space between the tray and impression surfaces. Upon material polymerization, the tray was removed and the stops inspected for even thickness. Stops were trimmed with a sharp knife to minimize the area of tissue contact.
A rope of high viscosity VPS (Aquasil Ultra Heavy) was dispensed along the peripheral tray borders to begin the border molding process (Figures 18a to 18c). The tray was placed and centered on the maxilla. The following tissue manipulations were used to define peripheral borders:
• To define the labial notch, the philtrum was grasped close to the vermilion border and pulled downward.
• To form the labial vestibular borders, the patient was instructed to purse her lips forcefully using a sucking action and then smile widely.
• To define the buccal notches and buccal vestibular borders, the cheek was grasped at the corner of the mouth with forefinger and thumb and pulled downward and forward. This process was then repeated on the contralateral side.
• To define the coronomaxillary vestibular border and hamular frenum area, the patient was instructed to open her mouth wide. This caused the coronoid processes to translate through the coronomaxillary spaces, bringing associated muscles to their terminal positions.
• To functionally form the posterior border of the tray, the patient was instructed in the Valsalva maneuver.8-10 The patient’s nostrils were manually occluded while the she forcibly exhaled through her nose. This caused the soft palate to valve downward, forming the VPS along the postpalatal seal aspect of the impression tray.

Figure 18. Definitive maxillary impression with replaced impression posts and implant analogs (a). Resultant maxillary master cast (b) and mandibular master cast (c).	Figure 19. ERA Micro Angulated Female Abutments (Sterngold) rotated to parallelism on the master cast.
Figure 20. ERA Micro Angulated Female Abutments rotated to parallelism in the patient’s mouth prior to cementation.	Figure 21. Maxillary record base with central bearing plate (a) and mandibular record base with central bearing pin (b).
Figure 22. Neutral zone impression illustrating compound rim (a), record base (b), completed registration with designated occlusal plane (c) facial view, and completed registration (d) occlusal view.	Figure 23. Definitive maxillary and mandibular implant overdentures.

Following polymerization of the VPS, the maxillary impression tray was removed and inspected to assure that appropriate anatomic and functional detail was represented. Finally, all borders were relieved approximately one to 2 mm using a scalpel blade and/or rotary instrumentation in preparation for the definitive impression (Figures 18a to 18c).
Prior to making the definitive impressions, soft-tissue conditions across the denture bearing tissues of the maxilla were closely examined. The viscosity of VPS impression material was selected based on relative tissue conditions, ie, the more mobile/ unattached the denture bearing tissues, the lower the viscosity of the impression material used. For the patient described here, a low viscosity material (Aquasil Ultra LV [DENTSPLY Caulk]) was selected to make the definitive impression.
The low viscosity impression material was intraorally injected around the maxillary impression posts and loaded into the tray. The impression tray was then seated and centered on the maxilla using the tray stops as guides. All border molding manipulations were repeated. Upon polymerization of the impression material, the definitive impression was removed and inspected for appropriate anatomic, functional, and surface details. Impression posts were then removed from the mouth, one at a time, attached to implant analogs, and placed into the impression in proper position (Figure 19). The impression was then beaded, boxed, and cast in a suitable vacuum mixed dental stone.
This impression procedure was essentially repeated to make the mandibular definitive impression. Border molding manipulations used in order to customize the mandibular stock tray included:
• To functionally form the lingual and retromylohyoid flange borders, the patient was instructed to place the tip of the tongue forward out of the mouth and then move the tongue side to side. Next the patient was instructed to retract the tip of the tongue to touch the posterior palate.
• To form the labial notch, the lower lip was grasped at the vermilion and pull outward and upward.
• To functionally form the labial and buccal borders, the tray was stabilized with the index and middle fingers on the finger rests with the thumb beneath the chin. The patient was asked to purse the lips using a sucking action and then smile widely.
• To form a buccal notch, a cheek was grasped with the forefinger and thumb at the corner of the mouth and pulled upward and forward. This process was repeated on the opposite side.
Following completion of the mandibular definitive impression, the impression posts were removed from the mouth, one at a time, and implant analogs were attached and placed into the impression in proper position. The mandibular impression was then beaded, boxed, and cast in a suitable vacuum mixed dental stone (Figure 19).
In determining the attachment mechanisms to be used for the planned implant overdentures, consideration was given to relative trajectory of the implants in each arch and available restorative space. Despite aggressive efforts to reduce alveolar projection and improve restorative space conditions, there was not enough restorative space to accommodate a bar attachment system. Additionally, the lack of absolute maxillary implant parallelism required use of a stud-type mechanical attachment system capable of angle correction. For these reasons, the ERA Micro Angled Attachment System (Sterngold) was selected.
Using angle correction diagnostic armamentarium provided by the manufacturer, it was determined that the facial trajectory of the 4 maxillary anterior implants required use of 17° ERA Micro Abutments, and the buccal trajectory of the 2 most posterior maxillary implants required incorporation of 11° EAR Micro Abutments (Figure 20). Because the mandibular implants demonstrated relative parallelism, zero-degree ERA Micro Abutments were selected for the mandibular restoration.
Healing abutments were removed from the maxillary implants and abutment bases were screw fastened to each of the implants. The abutment bases were tightened to 20 Ncm of torque. Angle correction ERA Micro Female Attachments, as described previously, were placed in the abutment bases using alignment handles. Using the alignment handles to assess parallelism, each attachment was rotated until relative parallelism was achieved. A permanent, fine-tipped ink pen was used to mark a line from each abutment base onto its angle correction attachment to record appropriate rotational orientation. One by one, each attachment was removed from its respective base, cement was applied to the base and attachment (ERA Lock Cement [Sterngold], and the attachment was reinserted into the base, being careful to realign the pen marks (Figure 21). Upon polymerization, excess cement was removed.
Healing abutments were removed from the mandibular implants. Four zero-degree ERA Micro Abutments were screw fastened to the implants. Each abutment was tightened to 20 Ncm of torque.
Maxillary and mandibular record bases were fabricated and a central bearing device was attached (Figure 22). As previously described, the central bearing device was used to make and interarch centric relation record at the patient’s proposed OVD. A second mandibular record base was constructed to carry a compound rim in order to accomplish a neutral zone registration (Figure 23). Detailed description of the neutral zone registration technique is provided elsewhere.6 A second maxillary record base with wax rim was adjusted to appropriate contour and used to record repose and high smile maxillary lip positions, record dental midline, and to aid in the face-bow transfer record.
The maxillary definitive cast was mounted in a semiadjustable articulator using the face-bow registration. The mandibular cast was mounted against the maxillary cast in the articulator using the centric relation interarch record. Using the adjusted wax rim, maxillary anterior denture teeth were set to the aesthetic dictates indicated on the wax rim. The mandibular denture teeth were set using facial and lingual matrices fabricated from the neutral zone registration. Posterior maxillary denture teeth were set into a balanced lingualized occlusal scheme.
The wax trial denture was placed in the patient’s mouth and she approved the aesthetic and phonetic results. An external impression was then made to define the precise denture cameo surface contours that resulted in optimal denture stability. A detailed discussion of the external impression procedure is available in the professional literature.11 The definitive implant-supported overdentures were then flasked, processed, finished, and polished (Lucitone 199 [DENTSPLY Prosthetics]). Metal reinforcing frameworks were fabricated and incorporated in the overdentures during the processing sequence (Figure 24).

The definitive prostheses were taken to the patient’s mouth and adjusted for fit, form, and function. ERA retentive elements were placed on each of the implant abutments in preparation for intraoral pick-up procedures. Rubber dam material was used as a means of block-out (Figure 25). The prostheses were seated over the attachments in order to determine if adequate clearance between the denture base and attachment housings was available. This was accomplished by assuring that the patient’s prescribed OVD was maintained and any inadvertent contact was disclosed using VPS and appropriately adjusted. Chemically-activated composite resin material (ERA PickUp Resin [Sterngold]) was used to pick-up the attachments into each of the overdentures (Figure 25). Care was taken to assure that the patient achieved the prescribed centric relation posture at the planned OVD during the attachment pick-up procedure.
Following the clinical attachment pick-up procedure, the overdentures were removed and inspected to completeness. Excess material was eliminated. The definitive attachment female components were placed into the overdentures in accordance with the desired level of prosthesis retention (Figures 25a to 25c). Removal and placement of the overdentures was discussed with and demonstrated to the patient. The patient was then made to demonstrate mastery of the removal and placement of her new dentures.
The following figures will show the patient after the new prosthesis has been placed. Further procedures at the patient’s request were then initialized to enhance the maxillary lip and other areas on the face, which had deprived tissue and severe wrinkling. With the use of several different enhancement materials in the both the upper lip, lower lip, cheeks, nose, earlobes, and infraorbital areas were injected as a filler into the areas bringing the face upward and enhancing both the maxillary and mandibular vermilion borders and decreased the sunken-in appearance. 
 
FACIAL COSMETIC THERAPY
Following placement of the definitive, implant-supported maxillary and mandibular overdentures, the patient expressed interest in learning more about procedures available to improve the cosmetic appearance of her lips, face, and associated structures. The patient was referred to an aesthetic nurse specialist for evaluation and treatment of upper lip vermilion border volume loss compounded by generalized advanced facial volume deficiency and deep rhytids.
The diagnostic findings of generalized adipose facial crevicing contributed to the thread-like upper lip vermilion dimension and deep rhytids requiring volumization of peripheral areas of the face to improve the lip dimension. It was emphasized to the patient that therapy limited to the lips in the presence of a substantially depleted facial canvas would accentuate the lips creating a significant aesthetic deficiency.
Four treatment sessions were accomplished attempting to volumize the entire facial area, including the forehead, below and under the eyebrows, temples, crow’s feet, tear troughs, zygomatic and malar areas of the midface, cheek hollows, lip vermilion borders, white shoulder and body of the lips, oral commissures, mandible, preauricular areas, procerus, chin philtrum, and earlobes. The injectable products used included: Artefill (Suneva Medical); Sculptra Aesthetic (Dermik Laboratories); Radiesse (Merz Aesthetic); Juvederm Ultra XC, Juvederm Ultra Plus XC, and Botox Cosmetic (Allergan); Perlane-L, Restylane-L, and Dysport (Medicus).
The patient also received full face and neck fractional laser treatment during injection therapy. All facial cosmetic treatment was performed over a 6-month period of time. Results are demonstrated in Figures 25a to 25c and 26a to 26c.

Acknowledgement
Dr. Massad would like to acknowledge his prosthetic technician Zarko Danilov of Carmichael, Calif, for his detailed work involving this case.

References

1. Landa JS. The free-way space and its significance in the rehabilitation of the masticatory apparatus. J Prosthet Dent. 1952;2:756-779.
2. Atwood DA. A cephalometric study of the clinical rest position of the mandible: Part III: Clinical factors related to variability of the clinical rest position following the removal of occlusal contacts. J Prosthet Dent. 1958;8:698-708.
3. 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.
4. McHorris WH. Centric relation: Defined. J Gnathol. 1986;5:5-21.
5. Ahuja S, Cagna DR. Classification and management of restorative space in edentulous implant overdenture patients. J Prosthet Dent. 2011;105:332-337.
6. Cagna DR, Massad JJ, Schiesser FJ. The neutral zone revisited: from historical concepts to modern application. J Prosthet Dent. 2009;101:405-412.
7. Seals RR Jr, Kuebker WA, Stewart KL. Immediate complete dentures. Dent Clin North Am. 1996;40:151-167.
8. Laney WR, Gonzalez JB. The maxillary denture: its palatal relief and posterior palatal seal. J Am Dent Assoc. 1967;75:1182-1187.
9. Naylor WP, Rempala JD. The posterior palatal seal—its forms and functions (I)—Diagnosis. Quintessence Dent Technol. 1986;10:417-422.
10. Lavelle WL, Zach GA. The posterior limit of extension for a complete maxillary denture. J Acad Gen Dent. 1973;21:31.
11. Massad JJ, Cagna DR. Vinyl polysiloxane impression material in removable prosthodontics. Part 3: Implant and external impressions. Compend Contin Educ Dent. 2007;28:554-561.

Dr. Massad is adjunct associate faculty, Tufts University School of Dental Medicine, and adjunct associate faculty, Department of Comprehensive Dentistry, University of Texas Health Science Center, San Antonio. He has published articles in the Journal of Prosthetic Dentistry, International Journal of Periodontal and Restorative Dentistry, Compendium of Continuing Dental Education, The Independent Journal England, The Pankey Gram, Bulletin of American Association of Dental Examiners, Journal of the Oklahoma Dental Association, Dentistry Today, Dental Economics, and others. He can be reached at (918) 749-5600 or joe@drjoemassad.com.

Disclosure: Dr. Massad is a stock holder in Global Dental Impression Trays, the parent company, and president. He also was and is an independent paid consultant for many dental companies, such as DENTSPLY Caulk, DENTSPLY Prosthetics, DENTSPLY Tulsa, Massad Jaw Recorder System, Massad & Strong Trays, Nobel Biocare, Sterngold Products, and Zimmer Dental.

Dr. Patterson is a native of Bartlesville, and has practiced oral and maxillofacial surgery in Oklahoma for 32 years. Dr. Patterson’s practice is currently focused upon advanced dental implant procedures, periodontal plastic surgery, bone regeneration techniques, and the “teeth-in-a-day” concept. His professional affiliations are: ADA, American Association of Oral and Maxillofacial Surgeons, International Congress of Oral Implantologists, Institute for Dental Implant Awareness as a Charter Member, and the Oklahoma Dental Association. Dr. Patterson has been recognized nationally for this innovative approach to patient care and has been previously featured in Dental Economics magazine. He can be reached via e-mail at info@suiteoralsurgery.com.

Disclosure: Dr. Patterson reports no disclosures.

Ms. Brewer is the founder and managing consultant at SkinMedic in Tulsa, Okla, which was established in 1998. Ms. Brewer earned a MS degree and BS degree in Nursing from Wright State University in Dayton, Ohio. She is a member of the American Association of Plastic Surgery Nurses, American Academy of Anti-Aging Medicine, American College of Mesotherapy, and Oklahoma Nursing Association, and has appointments on Advisory Boards for the Clary Sage School of Aesthetics, Oklahoma University Continuing Education, and Tulsa Technology Center. She is recognized nationally as a certified trainer of advanced courses for physicians and practitioners in the art of dermal filler injections including Artefill, Juvederm, and BOTOX. She can be reached at (918) 587-7546.

Disclosure: Ms. Brewer reports no disclosures.

Dr. Cagna is associate dean for postgraduate affairs as well as professor and the director of the Advanced Prosthodontics Program in the department of Prosthodontics at The University of Tennessee Health Science Center in Memphis. He received his dental degree from the Medical University of South Carolina, College of Dental Medicine in 1990 and completed residency training in the Department of Prosthodontics at the University of Texas Health Science Center at San Antonio, Dental School in 1994. He also received a MS degree from the University of Texas Health Science Center, School of Biomedical Sciences. Dr. Cagna is a Diplomate of the American Board of Prosthodontics and a Fellow of the American College of Prosthodontists. He holds memberships in the American Academy of Restorative Dentistry, the International Academy of Gnathology, American Association of Dental Research, and the American College of Prosthodontists. He lectures extensively on a variety of topics associated with prosthodontics and dental laboratory science. Dr. Cagna conducts an active private practice in the University of Tennessee Dental Faculty Practice where he manages all phases of clinical and laboratory prosthodontic patient care. He can be reached at (901) 448-6642 or dcagna@uthsc.edu.

Disclosure: Dr. Cagna holds stock in Global Dental Impression Trays (Strong-Massad Denplant Tray).