Repair of a fractured implant overdenture gold bar: A clinical and laboratory technique report
Identifieur interne : 000158 ( Pmc/Corpus ); précédent : 000157; suivant : 000159Repair of a fractured implant overdenture gold bar: A clinical and laboratory technique report
Auteurs : Fahim Vohra ; Amani Al FawazSource :
- European Journal of Dentistry [ 1305-7456 ] ; 2013.
Abstract
This clinical report explains a convenient, efficient, yet effective alternative for management of fractured substructure cast bars for implant-retained overdentures. The technique allows the fracture to be repaired at low cost and short time without remaking the substructure and the denture and further allowing the patient to keep their denture. The report sketches the clinical and laboratory procedures involved in the repair.
Url:
DOI: 10.4103/1305-7456.115428
PubMed: 24926222
PubMed Central: 4053631
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PMC:4053631Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Repair of a fractured implant overdenture gold bar: A clinical and laboratory technique report</title><author><name sortKey="Vohra, Fahim" sort="Vohra, Fahim" uniqKey="Vohra F" first="Fahim" last="Vohra">Fahim Vohra</name><affiliation><nlm:aff id="aff1">Department of Prosthetic Science, SDS, College of Dentistry, King Saud University, Kingdom of Saudi Arabia</nlm:aff></affiliation></author><author><name sortKey="Al Fawaz, Amani" sort="Al Fawaz, Amani" uniqKey="Al Fawaz A" first="Amani" last="Al Fawaz">Amani Al Fawaz</name><affiliation><nlm:aff id="aff1">Department of Prosthetic Science, SDS, College of Dentistry, King Saud University, Kingdom of Saudi Arabia</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">24926222</idno><idno type="pmc">4053631</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4053631</idno><idno type="RBID">PMC:4053631</idno><idno type="doi">10.4103/1305-7456.115428</idno><date when="2013">2013</date><idno type="wicri:Area/Pmc/Corpus">000158</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000158</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Repair of a fractured implant overdenture gold bar: A clinical and laboratory technique report</title><author><name sortKey="Vohra, Fahim" sort="Vohra, Fahim" uniqKey="Vohra F" first="Fahim" last="Vohra">Fahim Vohra</name><affiliation><nlm:aff id="aff1">Department of Prosthetic Science, SDS, College of Dentistry, King Saud University, Kingdom of Saudi Arabia</nlm:aff></affiliation></author><author><name sortKey="Al Fawaz, Amani" sort="Al Fawaz, Amani" uniqKey="Al Fawaz A" first="Amani" last="Al Fawaz">Amani Al Fawaz</name><affiliation><nlm:aff id="aff1">Department of Prosthetic Science, SDS, College of Dentistry, King Saud University, Kingdom of Saudi Arabia</nlm:aff></affiliation></author></analytic><series><title level="j">European Journal of Dentistry</title><idno type="ISSN">1305-7456</idno><idno type="eISSN">1305-7464</idno><imprint><date when="2013">2013</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>This clinical report explains a convenient, efficient, yet effective alternative for management of fractured substructure cast bars for implant-retained overdentures. The technique allows the fracture to be repaired at low cost and short time without remaking the substructure and the denture and further allowing the patient to keep their denture. The report sketches the clinical and laboratory procedures involved in the repair.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Pjetursson, Be" uniqKey="Pjetursson B">BE Pjetursson</name></author><author><name sortKey="Bragger, U" uniqKey="Bragger U">U Bragger</name></author><author><name sortKey="Lang, Np" uniqKey="Lang N">NP Lang</name></author><author><name sortKey="Zwahlen, M" uniqKey="Zwahlen M">M Zwahlen</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Stellingsma, C" uniqKey="Stellingsma C">C Stellingsma</name></author><author><name sortKey="Vissink, A" uniqKey="Vissink A">A Vissink</name></author><author><name sortKey="Meijer, Hj" uniqKey="Meijer H">HJ Meijer</name></author><author><name sortKey="Kuiper, C" uniqKey="Kuiper C">C Kuiper</name></author><author><name sortKey="Raghoebar, Gm" uniqKey="Raghoebar G">GM 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Eur J Dent</journal-id><journal-id journal-id-type="iso-abbrev">Eur J Dent</journal-id><journal-id journal-id-type="publisher-id">EJD</journal-id><journal-title-group><journal-title>European Journal of Dentistry</journal-title></journal-title-group><issn pub-type="ppub">1305-7456</issn><issn pub-type="epub">1305-7464</issn><publisher><publisher-name>Medknow Publications & Media Pvt Ltd</publisher-name><publisher-loc>India</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">24926222</article-id><article-id pub-id-type="pmc">4053631</article-id><article-id pub-id-type="publisher-id">EJD-7-382</article-id><article-id pub-id-type="doi">10.4103/1305-7456.115428</article-id><article-categories><subj-group subj-group-type="heading"><subject>Short Communication</subject></subj-group></article-categories><title-group><article-title>Repair of a fractured implant overdenture gold bar: A clinical and laboratory technique report</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Vohra</surname><given-names>Fahim</given-names></name><xref ref-type="aff" rid="aff1">1</xref><xref ref-type="corresp" rid="cor1"></xref></contrib><contrib contrib-type="author"><name><surname>Al Fawaz</surname><given-names>Amani</given-names></name><xref ref-type="aff" rid="aff1">1</xref></contrib></contrib-group><aff id="aff1"><label>1</label>Department of Prosthetic Science, SDS, College of Dentistry, King Saud University, Kingdom of Saudi Arabia</aff><author-notes><corresp id="cor1"><bold>Correspondence:</bold> Dr. Fahim Ahmed Vohra Email: <email xlink:href="fahimvohra@yahoo.com">fahimvohra@yahoo.com</email></corresp></author-notes><pub-date pub-type="ppub"><season>Jul-Sep</season><year>2013</year></pub-date><volume>7</volume><issue>3</issue><fpage>382</fpage><lpage>386</lpage><permissions><copyright-statement>Copyright: © European Journal of Dentistry</copyright-statement><copyright-year>2013</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-sa/3.0"><license-p>This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p></license></permissions><abstract><p>This clinical report explains a convenient, efficient, yet effective alternative for management of fractured substructure cast bars for implant-retained overdentures. The technique allows the fracture to be repaired at low cost and short time without remaking the substructure and the denture and further allowing the patient to keep their denture. The report sketches the clinical and laboratory procedures involved in the repair.</p></abstract><kwd-group><kwd>Dolder bar</kwd><kwd>implant-supported overdenture</kwd><kwd>soldering</kwd></kwd-group></article-meta></front><body><sec sec-type="intro" id="sec1-1"><title>INTRODUCTION</title><p>Improved predictability and better success rates[<xref rid="ref1" ref-type="bibr">1</xref>] for osseointegrated implant-retained restorations have resulted in acceptance[<xref rid="ref2" ref-type="bibr">2</xref>] of implant-retained overdentures (IOD) to facilitate improvement in denture support, stability, and retention.[<xref rid="ref3" ref-type="bibr">3</xref><xref rid="ref4" ref-type="bibr">4</xref><xref rid="ref5" ref-type="bibr">5</xref>] McGill consensus (McGill University, Montreal) stated in light of evidence that 2-implant retained overdenture should become the standard of care for treatment of the edentulous mandibles.[<xref rid="ref6" ref-type="bibr">6</xref>] Studies have evidently revealed improved masticatory efficiency, quality of life, patient satisfaction, implant and prosthesis survival rates for IOD's compared to conventional complete dentures.[<xref rid="ref7" ref-type="bibr">7</xref><xref rid="ref8" ref-type="bibr">8</xref><xref rid="ref9" ref-type="bibr">9</xref><xref rid="ref10" ref-type="bibr">10</xref>] However, implant overdentures, particularly in the maxilla, require greater maintenance,[<xref rid="ref11" ref-type="bibr">11</xref>] and stomatitis,[<xref rid="ref12" ref-type="bibr">12</xref>] mechanical fractures,[<xref rid="ref13" ref-type="bibr">13</xref>] clip loosening, clip fracture and replacement,[<xref rid="ref14" ref-type="bibr">14</xref>] relining and rebasing[<xref rid="ref15" ref-type="bibr">15</xref>] are the common complications reported. Fractured substructure for overdenture prosthesis conventionally indicates remaking of the retainer and the prosthesis, needing three to four patient visits, additional financial cost and also leaving the patient without a functional and esthetic prosthesis. This short communication will present the clinical and laboratory steps for an efficient yet accurate procedure for a maxillary implant overdenture fractured bar repair avoiding the prosthesis and the metal substructure to be remade.</p></sec><sec id="sec1-2"><title>CASE REPORT</title><p>A 59-year-old female presented at the prosthodontic department as an emergency. Patient reported looseness of the maxillary implant-retained tissue-supported overdenture (IOD) from four weeks and increased mobility specifically on chewing at the left side from last 72 hours. The removable maxillary prosthesis and the bar retainer have been in function from the last 50 months; during this period, the patient was seen for review of prosthesis retainer at 1, 6, 12, and 18 months postoperative. During the service of prosthesis, patient has had complains of repeated screw loosening and soft tissue inflammation and growth around the distal left maxillary implant.</p><p>The patient was wearing a loose implant-retained maxillary overdenture on a gold bar retainer splinting four implants, the bar retainer had no cantilever extensions. The implants (Straumann<sup>®</sup>, 4.1Ø, RN Standard) were positioned at tooth number 15, 13, 21, 24 in the maxilla and connected by three gold U-shaped Dolder bars (H 3.0 mm, regular, Elitor<sup>®</sup> Straumann<sup>®</sup>) soldered to gold copings, made to fit passively. The framework-reinforced overdenture prosthesis incorporated three corresponding riders/clips (Straumann<sup>®</sup>, Dolder matrix, regular) acting as matrices on the intaglio surface providing attachments to the bar retainer [<xref ref-type="fig" rid="F1">Figure 1</xref>]. It was clear that the gold bar fractured mesial to the gold coping at implant 24 but was not displaced [<xref ref-type="fig" rid="F2">Figure 2</xref>]. The maxillary implant overdenture prosthesis was found to be satisfactory with regards to fit, occlusion, aesthetics, and phonetics, however, was unstable due to the fracture in the supporting gold bar. The treatment plan suggested to the patient included the fabrication of a new bar retainer and maxillary IOD prosthesis. However, due to the patient's time restraint and after discussion of benefits and risks, an informed consent was developed and the decision was taken to retain the prosthesis and repair the gold bar using gold solder.</p><fig id="F1" position="float"><label>Figure 1</label><caption><p>Intaglio surface of the metal framework reinforced maxillary implant overdenture with reduced palatal coverage showing three metal riders</p></caption><graphic xlink:href="EJD-7-382-g001"></graphic></fig><fig id="F2" position="float"><label>Figure 2</label><caption><p>Gold bar fracture mesial to implant coping at tooth position no. 24, near the solder joint</p></caption><graphic xlink:href="EJD-7-382-g002"></graphic></fig></sec><sec id="sec1-3"><title>REPAIR PROCEDURE</title><p>Following were the procedural steps in the repair of the fractured implant overdenture gold bar:</p><p><list list-type="order"><list-item><p>Complete seating of the gold copings on the implant platform was verified using periapical radiographs after the screws were torqued at 30 Ncm. The fracture on the Dolder bar, which was approximately 4 mm mesial to the coping on the most distal left maxillary implant, was found to be undisplaced [<xref ref-type="fig" rid="F2">Figure 2</xref>].</p></list-item><list-item><p>Intra-orally, the fracture was initially stabilized using sticky wax (Sticky wax, Ainsworth Dental Company, Marrickville, Australia) and fixated using chemically cured inlay pattern resin (Duralay, Reliance Dental Mfg. Co, Worth, Illinois, USA). Employing the bead-on method, both the ends of the fracture line and few millimeters beyond was covered by the pattern resin [<xref ref-type="fig" rid="F3">Figure 3</xref>].</p></list-item><list-item><p>Once the pattern resin had completely polymerized (5-7 minutes), the Dolder bar retainer was unscrewed and removed from the mouth using a SCS screw driver (Straumann, Basel, Switzerland) [Figures <xref ref-type="fig" rid="F4">4</xref> and <xref ref-type="fig" rid="F5">5</xref>]. Regular neck healing abutments (Straumann 4.5Ø, 2 mm height) were placed on the top of implants to prevent the soft tissues from collapse.</p></list-item><list-item><p>Four implant analogs (Straumann RN syn Octa) were secured to the gold copings [<xref ref-type="fig" rid="F6">Figure 6</xref>] on the overdenture Dolder bar, and the assembly was mounted in dental stone (Vel-Mix, Kerr Co, Orange, CA, USA) in the laboratory [<xref ref-type="fig" rid="F7">Figure 7</xref>] to provide positioning stability.</p></list-item><list-item><p>Next, the complete assembly was embedded in the solder investment material (Heravest L, Heraeus Kulzer, Germany) excluding the resin-covered portion [<xref ref-type="fig" rid="F8">Figure 8</xref>].</p></list-item><list-item><p>The pattern resin was removed and cleaned. It was ensured that the solder gap (0.05-0.2 mm, Heraeus Kulzer, Germany) and the edge surface dimension (Blasted with 50m Corundum, Al<sub>2</sub>O<sub>3</sub>, Heraeus ulzer, Germany) were optimally prepared and primed by application of a soldering flux (Hera UL 99- Universal flux, Heraeus Kulzer, Germany) prior to any heat treatment.</p></list-item><list-item><p>Flame soldering (gas/oxygen flame) was performed using precious metal solder strip (Hera solder 800, Heraeus Kulzer, Germany) at an elevated temperature (850-950°C).</p></list-item><list-item><p>After bench cooling, the assembly is divested [<xref ref-type="fig" rid="F9">Figure 9</xref>] using sandblasting and the gold solder was adjusted using coarse rubber disc and polishing was completed using a burlew/gold lustre blue disc (Shofu Dental Corp, St Marcos, CA, USA) [<xref ref-type="fig" rid="F10">Figure 10</xref>].</p></list-item><list-item><p>The repaired bar and coping assembly was removed from the implant analogs and placed intra-orally after adequate disinfection and were found to connect passively on all four implants.</p></list-item><list-item><p>The maxillary implant overdenture prosthesis was stable on fit, and the patient was delighted with the excellent result. The repaired Dolder bar/gold coping assembly was fitted the same day, and the patient was able to wear a stable overdenture within just four hours.</p></list-item></list></p><fig id="F3" position="float"><label>Figure 3</label><caption><p>Intra-oral splinting of the fracture ends using chemical cured pattern resin (Duralay, Reliance Dental Mfg. Co.)</p></caption><graphic xlink:href="EJD-7-382-g003"></graphic></fig><fig id="F4" position="float"><label>Figure 4</label><caption><p>Splinted gold bar and coping assembly removed from the mouth to undertake laboratory procedure</p></caption><graphic xlink:href="EJD-7-382-g004"></graphic></fig><fig id="F5" position="float"><label>Figure 5</label><caption><p>Intra-oral occlusal view of the maxilla after removal of the gold bar retainer</p></caption><graphic xlink:href="EJD-7-382-g005"></graphic></fig><fig id="F6" position="float"><label>Figure 6</label><caption><p>Compatible implant analogs (replica) secured to the gold copings on the bar retainer prior to mounting</p></caption><graphic xlink:href="EJD-7-382-g006"></graphic></fig><fig id="F7" position="float"><label>Figure 7</label><caption><p>The gold bar retainer and implant analog assembly mounted in dental stone for positioning stability of fractured segments</p></caption><graphic xlink:href="EJD-7-382-g007"></graphic></fig><fig id="F8" position="float"><label>Figure 8</label><caption><p>The mounted assembly of gold bar is invested (embedded in investment material), except the resin covered area around the fracture line for performing soldering</p></caption><graphic xlink:href="EJD-7-382-g008"></graphic></fig><fig id="F9" position="float"><label>Figure 9</label><caption><p>The soldered and divested gold bar assembly, prior to finishing and polishing</p></caption><graphic xlink:href="EJD-7-382-g009"></graphic></fig><fig id="F10" position="float"><label>Figure 10</label><caption><p>Repaired, finished, and polished gold bar retainer assembly, ready for intra-oral fit</p></caption><graphic xlink:href="EJD-7-382-g010"></graphic></fig></sec><sec sec-type="discussion" id="sec1-4"><title>DISCUSSION</title><p>In the present report, a simple, efficient, yet accurate technique for the repair of fractured bar retainer for a maxillary implant-retained overdenture is described. These fractures can be the outcome of inherent weakness of the metal alloy, inadequate dimensions and design of the bar retainer, magnitude of occlusal forces and the antagonist[<xref rid="ref16" ref-type="bibr">16</xref>] (fixed, removable prosthesis or natural dentition), inferior solder joints,[<xref rid="ref17" ref-type="bibr">17</xref>] and fatigue failure.[<xref rid="ref18" ref-type="bibr">18</xref>] The fracture was located at the solder joint mesial to the left distal maxillary implant coping. Repeated complain of loose bar retainer and soft tissue inflammation indicates incomplete seating of the coping on the implant platform,[<xref rid="ref19" ref-type="bibr">19</xref><xref rid="ref20" ref-type="bibr">20</xref>] i.e., a non-passive implant coping connection. Also, a diagonal discrepancy in approximation of the fracture line was observed, reinforcing the potential for non-passive fit. The problem was compounded further by comparatively apical placement of left distal maxillary implant. The continuous stress at the implant/coping connection due to non-passive fit, apical position of implant, high occlusal forces, and inferior solder quality resulted in fatigue failure.</p><p>Initially, the patient was presented with an option of remake of both the bar retainer and the prosthesis, this would employ the conventional technique increasing the chairside time and overall cost. The alternative repair option involved re-soldering, which in order to give optimum results needs controlling several factors[<xref rid="ref21" ref-type="bibr">21</xref>] (solder method, surface preparation, levels of porosity, filler diffusion, and voids as crack initiators). On the contrary, the repair technique allowed for same day fit of the bar retainer and prosthesis, avoided any impressions, resulted in passively fitting retainer substructure (as splinted intra-orally and picked-up), current prosthesis was kept and used, and saved time and cost.</p><p>The passively fitting substructure, which was fabricated, resulted in reducing the risk of future fracture as it alleviated the consistent stress on both the solder joint and implant/coping interface. It further decreased the possibility of a loose retaining screw and incidence of soft tissue inflammation at the implant site.</p></sec><sec sec-type="conclusion" id="sec1-5"><title>CONCLUSION</title><p>In summary, the clinical and laboratory technique illustrates a simple, precise, and cost-effective way of repairing a fractured implant overdenture bar retainer on the same day using a gold solder and allowing the patient to keep the prosthesis during the repair. 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