Overdenture with Inclusive® Mini Implants

We have previously made the patient a complete set of dentures: a maxillary complete denture and a mandibular complete denture. At the last appointment, the patient said that the maxillary denture was tight and fit well but the lower was still a little bit loose (even after we functioned and refitted twice). Now, we're looking at the option of placing three to four mini implants in the anterior to keep the lower denture stable.

We've really extended the lingual flange borders.

We have a soft liner in this area – a permanent soft liner that grabs a hold of the lingual flange or the submandibular cleft.

That still doesn't quite do it because we have a really, really eroded ridge here, and it's very resorbed. If we are going to place implants in this anterior ridge, it's very important that our denture is already made and that everything is perfect because the denture will become our surgical guide. We need to ensure there's enough room in the "neutral zone" for the attachments of the implants. The patient's tongue is a little big; sometimes factors such as this influence the decision to place implants. That way the denture won't pop up because of tongue movement. I make certain that none of the buccinator muscle movements or borders pop up the denture.

This patient is the perfect candidate for implants. We will perform a CBCT scan to make certain. Using her denture as our radiographic guide, I place four gutta percha little spots, alternating on each side – they are not in the row. This is also used for the radiograph guide in your CT scan.

Everything kind of comes out at once. That's really good to know, and I make sure that everything is where I want it to be.

I make some holes and add some radiopaque markers. We use gutta percha, which is radiopaque. We see that our bite is in really good shape, everything hits. That's very important.

Now we are going to bur some holes into the side of the denture using a #4 round bur at low speed. We want to ensure that the holes are 1 mm to 1.5 mm deep, as well as wide. It's very important to drill these holes in a jagged line, so that you can see the radiopaque markers in the CT scan.

This allows us to place gutta percha into these holes on each side, and I do four holes. Be careful: Make sure the holes are very clean. Don't burn anything, and do not go too far into the denture or you run the risk of cutting a hole in the intaglio surface.

We have now placed the gutta percha into each of the holes. I use a #7 wax spatula with large pieces of orthodontic gutta percha. You want it to make nice and neat, get all the excess off. This is very important because it really makes for a better scan.

You see I take any of the access off. Make sure that the gutta percha is all the way into the hole, at least a 1 mm deep.

Try to make it dense as you can see here. Notice the staggered holes, which is very important. Now we'll put it in the. Because of these undercuts, the denture must be placed kind of in the back of the throat so that it goes right into the lingual flange area, that depression.

CT Scan

We started our case by anesthetizing the patient with bilateral mandibular blocks and local infiltrations. We seated the surgical guide to make sure that it's properly seated for accurate implant placement. One way to verify this is to check for blanching of the soft tissues as our surgical guide is manually seated.

A 1.9 mm drill is used to drill the initial osteotomy sites of all four implants in this case. We use a drill stop to control the depth of our osteotomy.

Drill stops are a great way to prevent damage to vital structures. They are a wonderful tool and give the clinician a higher level of comfort when working near vital structures.

After the drilling sequence is complete, our implant is poised with the implant carry on.

The blue carrier is attached to the top of the implant so that you can manually insert it to the desired depth, depending on the stability reached at this point.

The primary stability for this case was great. We decided to keep this up to act as a vertical guide for parallelism with the other implants.

We stepped up to the 2.4 mm drill with the drill guide at the same depth to slightly widen the osteotomy. This allowed for placement of our 3.0 mm diameter implants. The handpiece is used to deepen the implant into the osteotomy site.

Using a torque wrench, we place the implants and verify primary stability. I prefer using a torque wrench to get a better feel of how the implant fits into the osteotomy site.

We want the depth of the implant to be as seen here, with the top of the collar slightly above the tissue. Once this achieved, we record and check the torque values as a guide for a primary stability of each implant. At this point, we place all four implants. The blue carrier can be rolled off the top when the implant is in its final position. This can be done easily using finger pressure, and you can feel safe that your implant will remain stable as the blue carrier is rolled off.

Bone quality and quantity will dictate the diameter of the implants placed. This is critical to the long-term success and survival of the prosthesis and the implants. Simply put, remember: The more bone you have and the denser it is, the more comfortable you can feel putting in longer diameter implants and wider diameter implants. These are decisions that can be made preoperatively, after reviewing the CBCT scan to determine the bone density (D1, D2, D3 or D4). I place marking material over the implants (Dr. Thompson Color Transfer Applicator; Great Plains Dental Products Co. Inc.).

We place the existing prosthesis denture on top, moving it around so that the marker transfers on to the denture where it needs to be relieved for the attachments.

It's very important that you don't drill through the denture or make it too thin. This will make the denture weak. It's very important that, during the preoperative procedure and diagnosis of these conditions, you have a neutral zone. That is, keep enough room not only for the implant but also the attachment.

Once the initial holes have been drilled, you will have a better idea of where Trusoft™ (Bosworth Company) will come in handy (chairside soft line material). We'll go ahead and clean it up, and put it back in with more marking material. The marking material is purple. It's very important to get the marking material in the area that needs to be relieved. This ensures that nothing touches it. Relieve that area, using the marking material as many times as you need to ensure the denture sits on the ridge — not on any part of that implant or the ball male attachment.

After we confirm that we do not have any rocking and that we're on the ridge, we verify the occlusion is in good shape. We confirm the vertical dimensional of the occlusion hasn't changed because we don't have any high areas where the attachments are hitting the denture.

We go ahead and place this adhesive with Bosworth Trusoft chairside soft lining material. It's important that this material is not too thin or too thick, and that it can be placed using the spatula without problems like air bubbles within those relieved holes. You have approximately one minute to place it. I personally like to keep the material just in the area almost where there are holes. You can, of course, relieve it later. You don't want it everywhere else. I already have made that perfect denture, why do you need to do anything more than that?

You can see the provisional attachment with the Bosworth Trusoft soft lining material. Notice the permanent soft liner for the lingual flanges, and that's why you have to place the denture behind the submandibular depression. It goes right into there and form fits. The other material was permanent material.