TOWNIE CLINICAL: Removable Revolution: Fast, Predictable, Easy! By: Ara Nazarian, DDS

The Removable Revolution is taking place, especially now that people are living longer these days. The majority of these patients still have some teeth or some form of removable appliance, but cannot afford traditional implants or fixed restorative options to meet their demands of aesthetics and function. You can send them away to other specialists and dentists or keep them in your office by providing alternatives that will satisfy these needs. This article demonstrates how to provide patients options that are economical, efficient, and comfortable using mini-implants from the IMTEC Corporation!

Case Presentation
A patient presented to the practice with broken off anterior teeth from her precision-bar partial denture (Figs. 1-2). She said that they were breaking off all the time and was ready for something new. Upon clinical examination, the splinted crowns on #5, #6 and #11 were loose with open margins and recurrent decay. All RBA were reviewed with the patient. She had limited funds, but wanted something that would look nice, make her look younger, not artificial looking, and would not fall out every minute. Since she still had #5, #6 and #11 present, we would utilize these teeth after caries removal for retention. An overdenture system would be used in #6 and #11 after root canal therapy.

Impressions were taken at this point to make a record base. The lab just made some indentations where the little stumps were of #5, #6 and #11. Since the crowns were loose on her exiting crown/partial combination, I was able to use them as a temporary with composite built front teeth to get her through the stages of denture fabrication. Standard protocol was used for setting the denture teeth in a wax-rim. Special attention was given to her midline, smile, and phonetics. Blue Line teeth from Ivoclar Vivadent were selected for their natural looking aesthetics and their resistance to wear (Figs. 4-5). In fact, Blue Line teeth are fabricated from DCL Material (Double Cross-Linked). The density of DCL Material provides; high wear resistance, plaque resistance, shade stability, resistance to breaking or cracking, and superior bond to denture base materials. On the day of delivery, the denture was tried in for fit and comfort. Two IMTEC mini-implants were placed inside teeth #6 and #11, a technique I learned from Dr. English at the IMTEC course I attended (Figs. 6-7). They were cemented in with a resin cement (Variolink II) to get a nice tight seal. The denture was then retrofitted using IMTEC’s protocol for mini-implants with cold cure acrylic. Any excess acrylic material was removed and the denture polished.

 

In Conclusion
General dentists can prepare themselves for the Removable Revolution with techniques and materials that allow them to correct a variety of dental frustrations. By doing so, they can restore dental function and confidence to their patients and provide clinical and economic benefits to their practices. The advent of the mini dental implant has given general dentists an easy, less costly and rapid way of solving many of the difficult problems that arise in dental practice. Over 36 million patients in the United States have lost their teeth; however, only one-half of 1 percent have received implant therapy. This striking disparity signifies a huge untapped market for implants. Are you ready for the Removable Revolution?

		Figure 1 Preoperative facial photo
		Figure 2 Preoperative smile view
		Figure 3 Occlusal wax-rim try in
		Figure 4 Blue Line denture teeth from Ivoclar Vivadent
		Figure 5 Closer look at denture; note aesthetics
		Figure 6 IMTEC mini-implant and retainer cap
		Figure 7 IMTEC mini-implants placed in teeth #6 and #11
		Figure 8 Internal view of denture with retainer caps
		Figure 9 Postoperative facial photo

 

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Ara Nazarian DDS, is a graduate of the University of Detroit-Mercy School of Dentistry. Upon graduation he completed an AEGD residency in San Diego California with the United States Navy. Currently, he maintains a private practice in Troy, Michigan with an emphasis on comprehensive and restorative care. In 2002, he received the Excellence in Dentistry Scholarship and Award. His articles have been featured in many of today’s popular dental publications. Dr. Nazarian also serves as a clinical consultant for the Dental Advisor, testing new products on the market. He is a member of the Academy of General Dentistry and the American Academy of Cosmetic Dentistry. He can be reached at (248) 457-0500 or at ara20002@comcast.net.

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Townie Comments

fmn1116	9/3/2003 11:56:58 PM
Nice service doc. What was the total fee?
desert_rat	9/4/2003 12:52:00 AM
Nice job with this. Do you do polyvinyl impressions, alginate or what? Do you do a facebow transfer? This is awesome. How many visits?
drnaz	9/4/2003 6:41:17 PM
Thanks for the compliments! The breakdown for this case is; upper denture–$1250, endo for #6 and #11–$600 each, mini-implant posts–$625 each, retrofit denture & adjustments included. Total=$3,700; I first took alginate impressions had custom trays made and then used Virtual Monophase (blue color-Ivoclar Vivadent) for final impression. It has a great scent, sets pretty quickly and makes impression taking for dentures easy! I did not use a facebow for this case. Total visits 5: 1) alginate impressions, 2) final impressions with Virtual monophase, 3) occlusal rim and guidelines for teeth set-up, 4) wax try-in of teeth, 5) delivery and retrofit once mini-implant posts placed. I do think we need to see more removable cases for all dentists so that we can have the confidence to provide a great service and be productive. If I can do it (this being my first overdenture case) anyone can do it. So, yes I would like to see more of these or be happy to share these tips with my peers.
mcallister	9/5/2003 5:37:37 PM
Are you concerned about recurrent decay on the residual roots? Do you have the patient place fluoride in her denture before placing it? I would be interested in seeing the post op x-ray.
drnaz	9/9/2003 7:29:37 PM
As mentioned earlier, this patient had two crowns that were rocking back and forth due to the force on them with the precision bar partial. Because of this the margins were opened allowing a great place for food and plaque to accumulate. Now, she has two small ball heads to keep clean that are mostly sealed under the denture. I am confident that she can keep these two areas clean that there is no need to place fluoride under her denture, but it is a suggestion I never thought of.
hack2	9/10/2003 12:53:22 AM
In the maxilla, even standard implants when it’s only two do not have a good track record for an upper implant supported denture. From a surface area standpoint, these should be a bit worse. Did you discuss this with the patient?
drjcann	9/10/2003 6:35:59 AM
Hack brings up a good point. Studies on only 2 implants in the maxilla have not been stellar. I would think about placing a few more in the future to try and prolong the case. Heck it may be fine but I am not sure about only 2 in the maxilla. Great service though, I need to go to the IMTEC class and see what it is all about.
drnaz	9/10/2003 12:14:33 PM
Hack2; when you say “good track record” how do you evaluate that? Does that mean 3 years, 5 years, the rest of the patient’s existence? Are the studies on separate implants, implants with a bar, or posts (implant used as a ball post) in already existing teeth? I would love to see your data! The patient’s previous restorations and combination lasted over 8 years and before that it was just a partial attached to the coronal portion of these teeth. If we can get that much time using this technique without having to take teeth out, do a bone graft, cost X amounts of money, and do it in a quick amount of time, I consider the Track Record a SUCCESS. Please remember the title of this article was Removable Revolution: Fast, Predictable and Easy not Expensive, 9 months and Ideal! Seriously if you haven’t gone to one of IMTEC’s courses your missing out. They are full of information to help you service your patients and build your practice. They have a website where they post each different course. Ask for a free video tape, you’ll definitely want to learn more.
hack2	9/10/2003 1:59:46 PM
It is based on literature and experience that most of us have learned from with conventional implants. Two implants to support a denture in the maxilla is not a predictable procedure. You can look it up. As far as expensive and ideal...yeah, it would be more expensive. What if yours fails within 5 years or less? Was it really a money saver? Also in regard to expensive and ideal, how can you say 9 months for the ideal? A wait in the maxilla is more commonly 4 months right now. I expect it to decrease more as we continue to play around. I’m also unsure of what grafting you are referring to aside from the sockets during placement. I don’t have the luxury of seeing a PAN to see if a sinus graft would be required, but the ridge looks adequate, and even if not, you can expand the maxilla rather easily. I have no idea how long your case will last, but I don’t think you do either. Based on what is known about conventional implants in the maxilla (2 for a removable) caution should be recommended and anticipation of a good long-term result (greater than 5 years) is perhaps too optimistic. Citing a lack of evidence to refute your claim of this being a successful procedure is not evidence. The burden of proof is on you. Do you have any 3-5 year data giving the success of this procedure? OK, how about 2-year data?
drnaz	9/10/2003 4:39:15 PM
Again this case was to illustrate what could be done using these implants (as a post system) in teeth to give my patient a great result. These teeth have been in her mouth with strong bone so far and have held up to partials. Again we as dentists have to look at the needs and wants of the patient. She has limited funds, not very much bone in the posterior region (she would need sinus grafts–sorry I can’t scan a PAN on my scanner) and wanted something immediately. I wish she would say, “Yes,” to multiple implants, sinus grafts, fixed... But that’s not the real world. We came up with something that met her demands and made her very pleased. As far as two supporting implants in the maxilla, (again this is not totally the case here) the McGill study out of Toronto on the contrary to your generalization states that it’s a standard of care designation to have only 2 implants supporting a denture in the maxilla. Please feel free to contact IMTEC for a copy of this independent study.