INTRODUCTIONAttachment-retained implant overdenturesare functionally superior to conventionaldentures and are effective and cost-savingalternatives to fixed implant dental prosthe-ses. In the mandible, the 2-implant overden-ture is the least costly implant option,1 itoffers a significant increase in retention andstability over a complete denture,2 anddemonstrates a considerable improvementin quality of life.3 For these reasons, themandibular 2-implant overdenture has beendescribed as a standard of care for edentu-lous mandibles.4-6 Furthermore, solitaryattachments have been shown to be as effec-tive as bars for overdenture retention; thereis no difference in implant prognosis,7 barsincrease the cost of overdentures,8 theyrequire more space,9 they do not improveretention or stability,10 and hygiene is moredifficult with bars.11 The cost of 4 implantsand a bar approaches that of a fixed dentalprosthesis with no significant improvementin bone preservation or patient comfortcom pared with a mandibular overdenturewith 2 implants.12

Short-term data also indicate high suc-cess rates for the 4-implant maxillary over-denture with solitary attachments. Cava -llaro and Tarnow,13 on an admittedly smallsample of 5 patients over a period of 48months, documented 100% success withmaxillary overdentures on 4 implants. Ec -cel lente et al14 demonstrated high successrates even after immediate loading proto-cols. These data indicate that solitary at -tachments for both mandibular and maxil-lary overdentures provide an acceptable im -plant prognosis and predictable retentionwhile simplifying implant treatment proto-cols and reducing costs, making im plantdentistry available to a larger segment ofthe population. Use of solitary implantattachments is therefore likely to becomean established and regularly used restora-tive protocol.

Dentists now require materials and sys-tems that facilitate the use and placement ofthe vast assortment of available implantattachments. The following patient presen-tation demonstrates chairside placement ofat tachments in an edentulous maxilla with5 implants. The illustrated technique is alsoapplicable to mandibular overdentures.

CASE REPORTDiagnosis and Treatment Planning

A 63-year-old male patient presented to theoffice of the prosthodontist with a loosemaxillary tooth-borne fixed dental prosthe-sis and discomfort in the area of the left sec-ond molar (Figure 1). Clinical and panoram-ic radiographic examination revealed thatthe mandibular teeth and prostheses wereintact. Three implants with 3 splintedcrowns replaced the premolars and firstmolar in the maxillary right posterior quad-rant. Five endodontically treated and peri-odontally involved teeth retained a fixeddental prosthesis from the maxillary rightcanine to the left second molar (Figure 2).The second molar abutment was deeply car-ious and the retainer was loose. To relievethe patient’s discomfort, the prosthesis had

been sectioned distal to the canine abut-ment by the prosthodontist (Figure 3) andthe molar extracted by the treating peri-odontist (Figure 4).

Definitive treatment options consid-ered and discussed were: (1) retention ofthe 4 remaining maxillary teeth and aremovable partial denture adjacent to theexisting implant prosthesis; (2) extractionof the remaining teeth, additional implantplacement with placement of a ceram o -metal fixed dental prosthesis; and (3) ex -traction of the remaining teeth and a barretained removable overdenture or; (4) animplant overdenture retained by solitaryattachments.

Primarily due to financial restraints,the patient, prosthodontist, and periodon-tist agreed upon 2 additional implants in

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George Priest,DMD

Efficient Placement of ImplantOverdenture Attachments

IMPLANTS

Figure 1. A 63-year-old malepatient presented with a failingmaxillary fixed dental prosthesisthat extended from the maxillaryright canine to left secondmolar.

Figure 3. The tooth-supportedprosthesis was sectioned distalto the left canine abutment bythe prosthodontist.

Figure 4. The painful and failing left second molar wasimmediately extracted.

Figure 6. After removal of theremaining teeth and prostheses,an interim denture was placed.

Figure 7. Locator abutments(Zest Anchors) were seated onthe 2 newly integrated and the 3 previously placed implants.

Figure 5. Two additionalimplants were placed distal tothe maxillary left canine.

Figure 2. Five endodontically treated teeth supported the failingprosthesis and 3 implants retained a fixed prosthesis in the maxillary right quadrant.

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the maxillary left quadrant and an implant overden-ture retained by 5 individual implant attachments.Due to a severe gag reflex, an open-palate prosthesiswas planned.

Initial Surgical and Prosthodontic TreatmentTwo dental implants were placed by the periodontist,with minimal divergence in relation to the existingimplants, distal to the sectioned fixed dental prosthesisin the areas of the left first premolar and first molar(Figure 5). The patient continued to wear the existingfixed dental prosthesis during the integration period of3 months. The prostheses were then removed from theteeth and existing implants, the remaining 4 endodon-tically treated teeth were extracted, healing abutmentswere placed on the 3 previously placed implants and aninterim denture was seated over the 5 implants duringhealing of the extraction sites (Figure 6).

Definitive Prosthodontic Therapy After a 3-month integration period, definitive prostho-dontic therapy began with depth measurements fromthe implant platforms to the most coronal aspect of thesurrounding gingival levels. Locator Implant Abut -ment (Zest Anchors) selection was predicated on these

measurements. Selection of the shortest Locator At -tachments (Zest Anchors) while maintaining theretention ring supragingival to the highest point of thegingival crest is advisable for several reasons: less hol-low grinding of denture teeth is required, the denturebase is not unduly weakened, and shorter attachmentsfacilitate chairside seating of attachment housings.

Locator Abutments were seated on the implantsand tightened to specified torque values (Figure 7).Locator Processing Spacers (Zest Anchors) were placedover the Locator Abutments to provide relief in thedenture for chairside attachment of the Locator titani-um caps (Zest Anchors) and males (Figure 8), and thenthe final impression was made. The cast was pouredand the palatal extent of the open-palate prosthesiswas demarcated (Figure 9). Denture teeth (SR Phonares[Ivoclar Vivadent]) were selected and arranged for awax try-in (Figure 10), and the approved waxing wasthen processed with gingival characterization (Figure11). The palate was reinforced with a metal subframe,and 5 recesses for chairside seating of the Locator Capswere provided by the incorporation of the processingspacers (Figure 12). Prior to attachment placement,complete basal seating of the prosthesis was ascer-tained with pressure indicating paste (Figure 13) andthe occlusion was refined (Figure 14). Locator block-out spacer rings (Zest Anchors) were placed on theabutments followed by titanium caps with processingmales (Figure 15).

Use of solitary implant attachments istherefore likely to become an establishedand regularly used restorative protocol.

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Chairside AttachmentA novel gingival-colored compositeresin luting system (Quick Up [VOCOAmerica), ideal for the chairside place-ment of implant attachments, was usedto complete the implant overdenture.The kit (Figure 16) also includes Fit TestC&B, a silicone for checking interfer-ences and for blocking out undercuts;Quick Up Adhesive to enhance reten-tion between the denture base andQuick Up resin; and Quick Up LC, alight-cured flowable composite resinfor filling voids in the cured material.

Another important applicationfor Quick Up is inexpensively retro-fitting existing dentures and rejuve-nation of implant overdentures thatrequire replacement of attachments.The method described below can beused when relining an overdentureor replacing misaligned or wornattachments.

First, Quick Up Test C&B siliconewas injected into the overdenture re -cesses (Figure 17), the overdenture wasseated over the attachment caps and theQuick Up Test C&B was allowed to set

before the overdenture was removed(Figure 18). Potential interferences thatwere detected be tween the denture baseand attachments were checked andeliminated. Next, a No. 8 round bur wasused to place undercuts in the recesses(Figure 19) to provide mechanical reten-tion between the denture base materialand the Quick Up composite resin. Ad -ditionally, the same bur was used toplace vent holes from the attachmentrecesses through the palatal surface ofthe overdenture to allow escape of ex -cess resin (Figure 20).

Quick Up Adhesive was paintedinto the overdenture recesses to en -hance retention between the denturebase and the composite resin (Figure21). Petroleum jelly was ap plied tobasal surfaces of the denture to pre-vent unwanted adherence of excessresin (Figure 22). Using the smallenclosed cartridge tip, Quick Up TestC&B was injected around potentialundercut areas of the attachmentsthat could impede removal of theprosthesis after the resin cured (Fig -

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Figure 8. Locator Processing Spacers (ZestAnchors) were placed over the abutments toprovide relief for chairside attachment of theLocator caps (Zest Anchors).

Figure 9. After an impression was made,the cast was poured and the palatal extent of the open-palate prosthesis was demarcated.

Figure 10. A denture tooth set-up was prepared for a wax try-in.

Figure 11. The patient-approved waxing wasthen processed with characterized gingivalresin.

Figure 12. Five recesses for chairside seating of the Locator caps were incorporated into the open-palate, metal-reinforced overdenture.

Figure 13. Complete basal seating of theprosthesis was ascertained with pressureindicating paste.

Figure 14. Occlusion was refined prior toseating the attachments.

Figure 15. Locator block-out spacer ringsand titanium caps were placed on the (ZestAnchors) abutments.

Figure 16. Quick Up (VOCO America) wasused for chairside placement of implantattachments.

Figure 17. Quick Up Test C&B silicone wasinjected into the overdenture recesses tocheck for impediments to complete seating.

Figure 18. Following setting of the silicone,the overdenture was removed and no interferences were detected.

Figure 19. Mechanical undercuts wereplaced into the attachment recesses with aNo. 8 round bur.

Figure 20. The same bur was used to placepalatal vent holes to allow excess resin toescape.

Figure 21. Quick Up Adhesive was paintedinto the overdenture recesses.

Figure 22. Petroleum jelly was applied tosurfaces where adhesion of the resin wasunwanted.

Figure 23. Potential undercuts around theattachments were blocked out with Quick UpTest C&B silicone.

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ure 23). Quick Up luting resin wasthen injected about two thirds of theheight of each recess and the overden-ture was seated (Figure 24). Onemethod of seating the overdenture isto instruct the patient to gently close,but the author has found this ap -proach to result in varied amounts ofclosing force for each individual pa -tient, and some older patients havecompromised motor control or slighttremors that might affect the accura-cy of the registration. The author,thus, prefers to gently hold the pros-thesis in place by hand (Figure 25) and

has found this technique to result inmore predictable control of the fit andretention of the attachments. After atotal of 3 minutes, the overdenturewith the incorporated caps was re -moved (Figure 26). Slight voidsaround the caps or in the access open-ings were filled with Quick Up LC, amatching light-cured flowable com-posite resin (Figure 27). Excess resinaround the attachments was removedand refined with a No. 8 round bur.Quick Up resin that extruded through

the palatal openings was smoothedand polished. This gingival coloredcomposite resin blends nearly seam-lessly with most denture resins. Ap -propriate Locator males that providedadequate retention, yet easy re moval,were seated into the overdenture(Figure 28). In just a few days follow-ing seating, the patient was able toovercome his exaggerated gag reflexwith the aid of the open palate pros-thesis (Figure 29). The implant re -tained overdenture met the patient’saesthetic objective of age appropriatedenture teeth (Figure 30) that blendedwith his existing mandibular crownsand teeth, and his functional andcomfort goals of improved occlusionand mastication. (Figure 31).

CONCLUSIONAttachment retained implant overden-tures have become a routine alterna-tive to traditional removable denturesand a lower cost alternative to morecomplex fixed dental implant prosthe-ses. As demonstrated, new materialscan assist in efficient chairside seatingof a myriad of implant attachments(such as studs, o-rings, clips, and oth-ers). An obvious advantage to placingattachments, as described in the casereport above, is cost savings by decreas-ing laboratory fees and reducing chairtime, but more importantly, it may be amore accurate method of attachmentplacement by giving the clinician com-plete control of attachment placementand elimination of inaccuracies causedby laboratory transfers.

Innovative dental materials andtechniques which simplify the techni-cal processes involved in restorativeimplant dental treatment present cli-nicians another incentive to offerthese valuable services to a greaternumber of patients who would bene-fit from implant dentistry.�

AcknowledgementDr. Priest would like to thank theteam of dental technicians at GeorgiaDental Lab for their consistent excel-lence and assistance with the workpresented here.

References1. Takanashi Y, Penrod JR, Lund JP, et al. A cost com-

parison of mandibular two-implant overdentureand conventional denture treatment. Int JProsthodont. 2004;17:181-186.

2. Heydecke G, Thomason JM, Awad MA, et al. Domandibular implant overdentures and conven-tional complete dentures meet the expectationsof edentulous patients? Quintessence Int.2008;39:803-809.

3. Allen PF, McMillan AS. A longitudinal study of qual-ity of life outcomes in older adults requestingimplant prostheses and complete removable den-tures. Clin Oral Implants Res. 2003;14:173-179.

4. Feine JS, Carlsson GE, Awad MA, et al. The McGillConsensus Statement on Overdentures.Montreal, Quebec, Canada. May 24-25, 2002. IntJ Prosthodont. 2002;15:413-414.

5. Thomason JM, Feine J, Exley C, et al. Mandibulartwo implant-supported overdentures as the firstchoice standard of care for edentulouspatients—the York Consensus Statement. BrDent J. 2009;207:185-186.

6. ADA Council on Scientific Affairs. Dentalendosseous implants: an update. J Am DentAssoc. 2004;135:92-97.

7. Naert I, Quirynen M, Hooghe M, et al. A compar-ative prospective study of splinted and unsplint-ed Brånemark implants in mandibular overden-ture therapy: a preliminary report. J ProsthetDent. 1994;71:486-492.

8. Walton JN, MacEntee MI, Hanvelt R. Cost analy-sis of fabricating implant prostheses. Int JProsthodont. 1996;9:271-276.

9. Misch CE, Goodacre CJ, Finley JM, et al.Consensus conference panel report: crown-

height space guidelines for implant dentistry—part 1. Implant Dent. 2005;14:312-318.

10.Naert I, Alsaadi G, van Steenberghe D, et al. A10-year randomized clinical trial on the influenceof splinted and unsplinted oral implants retainingmandibular overdentures: peri-implant outcome.Int J Oral Maxillofac Implants. 2004;19:695-702.

11.den Dunnen AC, Slagter AP, de Baat C, et al.Professional hygiene care, adjustments and com-plications of mandibular implant-retained over-dentures: a three-year retrospective study. JProsthet Dent. 1997;78:387-390.

12.Visser A, Raghoebar GM, Meijer HJ, et al.Mandibular overdentures supported by two orfour endosseous implants. A 5-year prospectivestudy. Clin Oral Implants Res. 2005;16:19-25.

13.Cavallaro JS Jr, Tarnow DP. Unsplinted implantsretaining maxillary overdentures with partialpalatal coverage: report of 5 consecutive cases.Int J Oral Maxillofac Implants. 2007;22:808-814.

14.Eccellente T, Piombino M, Piattelli A, et al.Immediate loading of dental implants in theedentulous maxilla. Quintessence Int.2011;42:281-289.

Dr. Priest has maintained a private prostho-dontic practice devoted to aesthetic, ad -vanced restorative and implant dentistry formore than 25 years. In 2008, Dr. Priest relo-cated his practice from Atlanta, Ga to HiltonHead Island, SC. He is a Diplomate of theAmerican Board of Prosthodontics, a Fellow ofthe American College of Prosthodontists and aFellow of the International College of Dentists.Dr. Priest is a former professor in graduateprosthodontics at Emory University and aninnovator and teacher of implant and aesthet-ic dentistry for more than 20 years. He lec-tures internationally on topics including im -plant dentistry, advanced restorative dentistryand aesthetic excellence. He is a regular con-tributor to many acclaimed dental journalsincluding the International Journal of Oral andMaxillofacial Implants, the Journal of Prostho -dontics, and the International Journal of Perio -dontics and Restorative Dentistry. He has beennamed one of Dentistry Today’s Leaders inContinuing Education for the past 7 years. Hecan be reached at (843) 342-8890, atoffice@georgepriest.com, or at the Web sitepriestpros.com.

Disclosure: Dr. Priest is a paid consultant forVOCO America and is an unpaid consultant forIvoclar Vivadent.

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Figure 24. Quick Up luting resin was theninjected about two thirds the height of eachrecess and the overdenture was seated.

Figure 25. The prosthesis was gently heldin place during curing of the resin.

Figure 26. After 3 minutes, the overdenturewith the incorporated caps was removed.

Figure 27. Slight voids around the caps andin the access openings were filled withQuick Up LC flowable composite resin.

Figure 28. Appropriately retentive Locatormales were seated into the overdenture.

Figure 29. The open palate prosthesishelped the patient overcome his gag reflex.

Figure 30. The implant-retained overdenturemet the patient’s aesthetic objective of ageappropriate denture teeth (SR Phonares[Ivoclar Vivadent]).

Figure 31. The patient’s functional goals ofimproved occlusion and mastication werealso realized.

Attachment retained implantoverdentures have become aroutine alternative to tradi-tional removable dentures....