6 OCTOBER 2016

Patient: Mrs. Anna S
Dentist: Dr. Tim Struwig

Reason for visit
Anna wanted to have a better fitting upper denture but most of all she wanted to know about dental implants that could stabilize her terribly loose lower denture as she had heard of this option from a friend who recently had it done.

History of present complaint

Anna had lost all her teeth due to periodontal disease roughly 40 years ago and told me that although her upper full denture was slightly too loose her main problem was that every time she ate her lower full denture would move around as if it was in a tumble dryer and she would often hurt herself when she bit down on it whilst it was out of position, not to mention all the food that would accumulate under it all the time.

Medical History

Anna was 73 years old at the time of her initial consultation with me and she was in relatively good health besides being treated by her medical doctor with Aspovor for her higher than normal cholesterol levels as well as being treated with Eltroxin for her slightly elevated blood pressure. She informed me that she did not have any allergies. She also said that she did not have any prosthesis in her body, was not on any other medication and had not been hospitalized in the last 5 years.

Dental History

Roughly 40 years prior to her first visit with me Anna had a full dentectomy (due to periodontal disease) under general anesthetic after which immediate dentures were placed. She recalled having made 5 sets of new full upper and lower dentures from about 3 different dentists in the last 40 years.

Patient attitude and expectation

Anna was a very nervous as well as serious patient and took a while to come out of her shell and warm up to me but once this had taken place and she started to trust me we got along really well.

Anna’s expectation was to have a lower denture that did not move around as much or hurt her while she was eating and she also asked me to please help her so that less food would accumulate under her dentures. She also expected her new upper full denture not to be as loose as the one she had presently.

Full extra oral and intra oral examination and charting

Upon completion of the extra oral examination it became clear that there was a presence of Angular Cheilitis (fungal infection) in the corners of her mouth due to an insufficient vertical height of occlusion to keep the skin folds in that area from touching and continuously collecting saliva and remaining moist. There were no extra oral sings of pathology detected.

Intra-orally I noticed that there were some traumatic ulcers along the attached gingiva covering the alveolar ridge in the lower jaw which were caused from when the ill- fitting lower denture would move out of place and be compressed onto these areas while she was eating. Besides this no further abnormalities/ pathologies were detected intra-orally. It was also noted that her oral hygiene was of a high standard.

Charting: Not applicable due to her mouth being edentulous.

Special test reports

Not applicable

Problem list/ diagnosis

- Extremely loose full lower denture due to extensive alveolar ridge resorption over time ( roughly 40 years)
- Loose full upper denture due to slight alveolar ridge resorption
- Fungal infection (Angular Cheilitis) in the corners of her mouth.

Treatment planned and treatment provided

Fortunately the treatment planned and the treatment provided were the same in this case.

Anna’s treatment plan revolved around us placing two dental implants in her anterior mandible which would both be attached to ball abutments which would in turn slot into receiving sockets on her existing lower denture. The upper denture would be remade.

Anna let me know from the outset that she did not have a lot of money and asked me to try to save on costs for her wherever I could. Due to the fact that there was not a lot of occlusal wear on her lower denture (made roughly 2 years previously) we decided to try to “recycle it” as well as use it as our surgical stent/guide when placing the implants. We did discuss options that involved more than 2 implants for example an “all on 4 fixed prosthesis” but Anna quickly told me that if only 2 implants could keep her lower denture from moving around then she only wanted 2 implants and nothing more.

The treatment plan was as follows:

- Make a new upper denture that would fit better but also increase the vertical height of occlusion with this denture by 3mm in order to help rid Anna of her Angular Cheilitis we also prescribed the use of Clotrimazlole Cream 1% to help ease her symptoms until she received her new upper denture after which the Angular Cheilitis should disappear spontaneously as a result of the skin in the corners of the mouth no longer folding over each other and continuously collecting saliva and becoming inflamed and infected with fungi such as Candida.
- Placement of the two dental implants in the anterior mandible using her existing lower denture as a surgical guide/stent by drilling two holes just lingual of the lower anterior denture teeth in the regions between T32 and T33 and T42 and T43 and then stitching the attached gingiva above the alveolar ridge back over the implants and leaving them undisturbed for 3 months for osseointegration to take place. The holes drilled into the existing lower denture were covered up afterwards with Viscogel (tissue liner).
- Anna then continued to wear her existing full lower denture and was healing well at her 2 week follow up. 3 months after the surgical placement of her implants Anna returned for us to surgically expose her dental implants and placed healing abutments that were just above the gingiva in order to allow her to continue wearing her lower denture.
- 2 weeks later Anna had healed beautifully so we removed her healing abutments in the morning and placed the final ball abutments on the implants and torqued them to 20 Ncm, we then immediately proceeded to take the final Impregum Impression over her newly placed ball abutments using her existing full lower denture as a special tray. Anna received her final implant supported full lower denture modified from her existing denture (to save on cost) that same day and she was overwhelmed with joy once I placed the final product and it was no longer moving around in her mouth.

Follow up visits

Anna returned for a follow up visit roughly 3 months later because one of her ball abutments had started to loosen. I re-tightened it for her and she was on her way again.

Another 6 months later Anna returned due to a pressure ulcer that had formed in her right maxillary sulcus from where her denture was rubbing up against it. Anna informed me that she had lost about 5kg in a matter of weeks due to a diet she was on and I reasoned that this might have been the reason for her upper denture loosening slightly and then forming the ulcer. I ease her denture flange in that area and she assured me that it immediately felt much better. I informed her that if the upper denture remained loose we might have to reline it again due to her sudden weight loss.

Roughly 4 months later she returned after losing even more weight and asked us to reline her full upper denture. We took a reline impression for her in the morning and returned her newly relined denture the same afternoon.

Pantomogram before treatment (OPG)

Pantomogram after placing implants (OPG)

Pantomogram after placing ball abutments (OPG)