Rom J Morphol Embryol 2014, 55(2 Suppl):693696

RJME

CASE REPORT

Romanian Journal of
Morphology & Embryology
http://www.rjme.ro/

Implant overdenture and Locator system in edentulous

patient with severely resorbed mandible a case report
CAMELIA IONESCU1), BOGDAN MIHAI GLBINAU1), HORIA MANOLEA2), ION PTRACU1)
1)

Faculty of Dentistry, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania

2)

Faculty of Dentistry, University of Medicine and Pharmacy of Craiova, Romania

Abstract

Clinical studies have revealed that the main objective of implants in the edentulous jaw is to provide support for fixed prostheses or to
stabilize complete dentures. Various attachment systems were developed for universal use in partially and completely edentulous patients
such as clasps, cone-shape telescope copings, magnets, bar systems, locators. The aim of this case report is to present the Locator
attachment that does not use the splinting of implants. Four implants were placed in the foraminal region and the Locator attachment system
was used to connect overdentures to mandibular dental implants. The results proved that the Locator attachment system offers the
possibility to obtain a higher retention and an improved stability for overdentures in edentulous patients with a severely resorbed mandible
and lack of vertical space between the arches.
Keywords: implant, mandibular overdenture, Locator attachment system.

Introduction
At present, total edentulism is considered a condition
that consists of severe dysfunction of the whole dentomaxillary system, and serious comorbidities involving
the entire body. It is in no instance considered a privilege
of the involution associated with senescence. Primarily,
we consider that chronological age does not correspond
with the biological age anymore.
During the first three years after teeth extraction, the
alveolar bone level decreases considerably, afterwards this
process slows a bit, but it will never stop completely.
The average rate of mandibular ridge resorption, in such
situations, is about 0.2 mm per year [1]. In some cases,
the mandibular alveolar ridge resorption is so severe
that it is almost impossible to make complete denture
that meet all prosthetic requirements.
The literature states that, before the advent of oral
implantology, patients with increased resorption of the
alveolar ridges were treated by different preprosthetic
techniques (soft tissue surgery, ridge augmentation
procedures) in order to solve some of such problems;
however, very often, these treatments did not provide a
permanent solution [24].
In recent decades, with the development of dental
implants, total edentulous ridges can be restored in
various ways. If you insert a sufficient number of dental
implants and the space between the two ridges (maxillary
and mandibular) is favorable both in vertical and horizontal
direction, a fixed denture can be successfully inserted.
Another option is a dental implant overdenture.
Both treatment solutions vary in terms of aesthetics
and hygiene rehabilitation and not least costs. An overdenture on implants is less expensive than fixed dental
prosthesis supported on implants, which is a more
attractive treatment solution to a large number of patients.
ISSN (print) 12200522

Patient, Methods and Results

Patient N.M., aged 53 years, came to the dental office
complaining lack of mandibular denture stability and
inability to properly masticate. The patient was explained
that he required a complex oral rehabilitation, and was
offered to choose between different treatment plans.
Eventually, the patient has expressed a desire that the
dental treatment should begin with the mandibular arch
and later on the rehabilitation should include the other
arch also, this for financial reasons.
At clinical examination, we found a metal-acrylic fixed
prosthesis on the maxillary arch, improperly executed,
and on the mandible a conventional denture that was
highly unstable (Figures 1 and 2).
Aesthetic examination reveals the need for complex
oral rehabilitation: the restoration of the vertical dimension
of occlusion, occlusion compensation curves and buccal
and incisal curves.
Due to favorable prosthetic field in the front and
severe resorption in the lateral region, we chose to insert
four dental implants in the interforaminal region and
attached an overdenture using the Locator attachment
system. The treatment plan was explained to the patient,
he was informed of the benefit of a mandibular overdenture on four implants, and informed consent was
obtained thereof as he agreed with the proposed prosthetic
solution.
Following both clinical-surgical measurements and
radiographic examination (panoramic Rx) of mandibular
interforaminal area and study models, we found that there
is sufficient data to choose the place of insertion of dental
implants. In this way, CT was not performed as the
patient has had such an investigation done in the last
three months.
Four implants were inserted (Dual-Fit Implant, Bio
APHA, APHA-Bio Tec Ltd., Israel) with dimensions of
ISSN (on-line) 20668279

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Camelia Ionescu et al.

3.311.5, 3.311.5, 3.310, and 3.7511.5 mm from the

forth quadrant to the third (right to left).
Postoperatively, the patient was prescribed antibiotics
for five days (Amoxicillin and Clavulanate Potassium),
he received strict instructions on oral hygiene (mouth
rinsing with Listerine mouthwash for 14 days).
All implants had primary stability at 30 Ncm force,
tested in the surgical stage that went on in normal conditions. Healing abutments had been mounted and the suture
wires were suppressed 10 days after the intervention (5/0
polypropylene monofilament) (Figure 3).
The mandibular conventional denture was refurbished
in accordance with the healing abutments using a relining
material based on acrylic resin (GC Tissue Conditioner,
GC America Inc., Alsip, IL, USA).
After three months healing period, which represented
the optimal osseointegration of dental implants, we took
an impression of the prosthetic field using an open individual tray, removable transfer abutments and an elastic

polyester material (Impregum F, 3M ESPE, MN, USA).

For an exact transfer of intermaxillary relations of
occlusion, we used a total facial arch and an adaptable
articulator (Artex, Amann Girrbach, Austria) (Figure 4).
A model for the mandibular prosthesis together with
a wax-up of the upper arch were made in the dental
laboratory and then tried in the oral cavity (Figures 5
and 6).
We analyzed the aesthetics and functionality of the
model and sent it back to the laboratory for transforming
it into the final prosthetic restoration.
We finally analyzed the retention of Teflon gaskets in
accordance with the insertion axis of dental implants and
we chose light and ultra light gaskets for the first eight
months of wearing. Afterwards, these Teflon gaskets will
be replaced with new ones (Figure 7).
Prosthetic restoration was inserted in the mouth after
we previously made a mock-up maxillary restoration
accordingly to the wax-up (Figure 8).

Figure 1 Patients dental and periodontal status at

presentation.

Figure 2 Appearance of the dysfunctional mandibular

denture.

Figure 3 Radiological appearance of the prosthetic

field after insertion of dental implants and their osseous
integration.

Figure 4 Establishing the I.M.R. using the facial arc

for transferring the terminal hinge axis.

Figure 5 Lower denture

model and wax-up done
for the upper arch.

Figure 6 Final
prosthetic restoration.

Figure 7 Final prosthetic

restoration: mucosal
surface appearance.

Figure 8 Intra-oral view: special

attachment devices were mounted
to the implants.

Implant overdenture and Locator system in edentulous patient with severely resorbed mandible a case report

At the end of treatment, the patient was pleased with

the appearance and comfort achieved by the new
mandibular denture on the four individual implants and
the Locator system.
Discussion
A final treatment plan include the number and size
of dental implants, their topography, type of superstructure
and off course financial costs.
Dentists and dental laboratories develop their own
practices, using different attachment techniques, based
on their individual experience and success and costs
variability. When choosing the type of denture attachment,
one must take into account the following criteria [5]:
the degree of retention available (solidity of implants),
adequate restorative space, oral hygiene status, profile
height of the device, possibility of reinforcement of the
structure, easy application and maintenance and costs.
Many factors contribute to promote the use of
individual implants such as: lower costs, improved
access for hygiene and cases with small interarch space
[6]. Thus, an individual approach, i.e., individual dental
implants treatment is more efficient, resulting in the
lowest cost and more effective for most edentulous
patients [6].
There are some attachment devices that improve
denture retention to implants (rods, hooks, magnets,
Locator, telescopes). Studies have shown that all
attachment systems are effective and that one should use
a clinical guide in order to select between these.
Literature divides connecting systems in rigid or
resilient. The rigid ones allow limited torque and improve
the angled insertion, while the resilient devices permit
various rotation and angulation [6]. Where there are
slightly non-parallel implants, a resilient device will
decrease the friction, wear and fracture [6].
In cases of major complications with overdentures,
including the failure of the prosthesis, it is necessary to
adjust or replace the connecting device [7, 8]. This
situation can be significantly minimized by appropriate
selection of the device in question.
A resilient connection between the prosthesis and
implant can reduce the load as far as the degree of
movement is achieved at the expense of resilience of the
mucosa only. In this way, the greatest part of the occlusal
force is thus absorbed directly by the alveolar ridge [9].
Adequate restorative space is another important aspect
in the success of overdentures therapy [10]. In totally
edentulous patients, available restorative space is limited
by the occlusal plane, oral soft tissues, facial tissues
(cheeks and lips), and tongue. For patients with mandibular dentures, this space should accommodate a large
enough base of the prosthesis, proper positioning of the
teeth and implant attachment system. Also, factors such
as minimal space for speech and aesthetics must be taken
into account when defining the available restorative space.
Therefore, during the diagnostic phase of overdenture
therapy, evaluation of available restorative space is critical
[11].
Unfortunately, this important factor is often evaluated
for the first time after placing the prosthetic implants

695

and at that moment alternatives are limited [12]. Attempts

to fabricate prostheses in cases with inadequate space
can lead to insufficient physiological retention and/or
suboptimal stability [10]. To prevent this phenomenon,
some authors highlighted the importance of vertical
restorative space and its management in patients with
overdentures [13]. In this respect, there is a classification
system for ridges [13] namely: arch type Class I
restorative vertical space equal to or greater than 15 mm;
arch type Class II space between 12 and 14 mm, arch
type Class III space between 9 and 11 mm, arch type
Class IV space less than 9 mm. Note that, in the latter
case it is necessary to review procedures to increase the
vertical space available such as alveoloplastia, intentionally
increasing the vertical dimension of occlusion (sizing) and
the management of attachment systems in overdentures
[13]. When the space between arcades is inadequate there
are some problems such as: overcontouring dentures,
excessive growth of vertical dimension of occlusion,
fracture of adjacent teeth, loosening of the overdenture,
denture fracture and general patient dissatisfaction [14].
Other authors consider that restoring the edentulous
arch requires a certain amount of vertical dimension
between the maxilla and mandible to ensure adequate
thickness of restorative material, space for attachment
elements, aesthetics and ease of cleaning [15].
According to the literature, it appears that interarch
space required for the retention of a prosthesis to the
implant (distance from the shoulder of the implant to the
incisal edge) is about 12 to 14 mm as follows: a thickness
of 23 mm of soft tissue is generally present above the
implant, an area of 2 mm from the lining of the edentulous
ridge to the bar needs to be present for suitable cleaning
[15], 4.5 mm bar thickness, 2 mm for the acrylic resin
and the rider [16] and 3 mm for the teeth [17]. Most
attachment systems with staples include height of the
matrix and the abutment, ranging between 56 mm [18].
In conclusion, patients with well-preserved ridge,
who have lost teeth due to caries benefit from reduced
interarch space for an implant overdenture. In addition
to this, the space often limited interferes with the reinforcement of the prosthesis making it hard for the
dentist to use the space required for devices such as
staple systems [18]. Thinning the soft tissue during the
surgical act and the use of internal connection to
implants can help us overcome the problem of limited
vertical space [17].
Due to limited inter-ridge space, one must use low
profile systems that can cause thinning of denture base
with at least 2 mm. In this regard, since 2001, a new
product has been released to the market: the Locator, a
new resilient connector whose abutment and attachment
systems height is only 3.17 mm. The system can be
applied in a limited inter-ridge space [18], and is a
reliable alternative to the staples [19]. It consists of a
metal matrix and a resilient plastic element that is
placed on latch embedded directly into the prosthesis
[18]. The system includes four different colored lining
that gives multiple attachment forces. In this way, the
patient is pleased with the aesthetic result obtained, and
in addition, the system achieves greater retention and
greater stability for the prosthesis.

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Camelia Ionescu et al.

Besides the Locator system, there are other attachment

systems with a low profile that can be used with mandibular overdentures. For instance, the magnet attachment
systems are also used in patients with low interarch
space and important aesthetic requirements [20].
In our case, we chose this kind of treatment because
of insufficient restorative space available, which was less
than 9 mm. At the same time, we considered the fact
that in time it is possible to lose an implant or two,
a condition that can be remedied without much need
of the laboratory help with refurbishing the denture,
accordingly to McGills consensus. Also, there were
financial agreements with the patient that lead to this
treatment plan.
Among other factors that guide the selection of
attachment devices, we include their height, which
significantly contribute to reducing the potential of
fracture of the denture base in the case of insufficient
acrylate thickness.
The advantage of using the Locator attachment
system is that when a gasket replacement is needed it is
not mandatory to remediate the entire device within the
denture base.
Conclusions
The development of oral implantology has lead to a
great improvement of the oral rehabilitation of edentulous
thus improving the quality of life in these patients.
Implant-supported overdenture therapy can provide
stability, support and retention of the prostheses in
edentulous patients with severely resorbed mandible.
Using the Locator attachment system, mandibular implantsupported overdentures are a true alternative to fixed
prostheses in terms of economics, saving time as well.
Acknowledgments
This case report is a part of the PhD Thesis of the
first author who fulfilled requirements for the PhD degree
in Medical Sciences at Carol Davila University of
Medicine and Pharmacy, Bucharest, Romania.
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Corresponding author
Bogdan Mihai Glbinau, Assistant, MD, PhD, Faculty of Dentistry, Carol Davila University of Medicine and Pharmacy,
37 Dionisie Lupu Street, 020021 Bucharest, Romania; Phone +40722352 050, e-mail: [email protected]

Received: February 23, 2014

Accepted: July 16, 2014