Q U I N T E S S E N C E I N T E R N AT I O N A L

PROSTHODONTICS

Yeon-Wha Baek

Restoration of a partially edentulous patient with

an implant-supported removable partial denture:
A case report
Yeon-Wha Baek, DDS, MSD1/Young-Jun Lim, DDS, MSD, PhD2/Jong-Ho Lee, DDS, MSD, PhD3/Hyo-Sook Ryu, DMD1
The aim of this report is to present and discuss the clinical procedure of an implant-supported removable partial denture for
a partially edentulous patient who exhibited a severely
resorbed ridge and a collapsed vertical stop. The 67-year-old
partially edentulous patient presented with a lack of vertical
stop and an advanced transverse arch discrepancy. For the
maxilla, an implant-supported removable partial denture was

fabricated on bilateral distal implant abutments. The mandibular arch was restored with an implant-supported xed partial
denture, since it was expected to function more properly than
a removable partial denture. This clinical report demonstrates
a successful treatment approach to restore oral function and
appearance for the patient. (Quintessence Int 2014;45:307312;
doi: 10.3290/j.qi.a31334)

Key words: customized titanium abutment, implant-supported removable partial denture, transverse arch
discrepancy, zirconia crown

Implant-supported prostheses are the preferred restorative method over conventional removable partial
dentures (RPDs) for partially edentulous areas opposed
by natural teeth without a vertical stop, because it is
dicult to acquire the stability and support of RPDs in
this situation.1,2 However, placing implants into all
edentulous sites is occasionally limited by anatomical
or nancial barriers, or patients concerns about extensive surgical procedures. In these cases, implant-supported RPDs (ISRPDs), which generally require fewer
1

Graduate Student, Department of Prosthodontics and Dental Research Institute,

School of Dentistry, Seoul National University, Seoul, Korea.

Associate Professor, Department of Prosthodontics and Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Korea.

Professor, Department of Oral Maxillofacial Surgery and Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Korea.

Correspondence: Dr Young-Jun Lim, Department of Prosthodontics,

School of Dentistry, Seoul National University, 101 Daehak-ro, Jongnogu, Seoul 110-749, Korea. Email: limdds@snu.ac.kr

VOLUME 45 NUMBER 4 APRIL 2014

implants, can be considered as a treatment option.

Their inherent nature as removable prostheses can also
compensate for a transverse arch discrepancy and provide easier access for oral hygiene and maintenance.
In recent decades, implant-supported RPDs have
been developed as a treatment modality for partially
edentulous patients to obtain desirable treatment outcomes.3-7 Grossman et al5 reviewed a total of 44
implants in 23 partially edentulous patients who were
treated with implant-supported RPDs, for a mean follow-up time of 31.5 months after implant placement.
The overall implant survival rate was 95.5%, and all the
patients were satised with their prostheses. Bortolini
et al7 conducted a retrospective study on 32 patients
restored with the same type of prosthesis, which
included 64 implants for over 8 years. The study
reported that the implant success rate was 93.75% and
concluded that an implant-supported RPD was a pre-

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dictable treatment solution at reduced biologic and

economic costs while maintaining the benets of both
implants and removable prostheses.7
In the patient presented in this clinical report, both
arches were partially edentulous and the edentulous
areas were occluded with natural opposing teeth without a vertical stop. Severe alveolar bone resorption and
an advanced transverse arch discrepancy were also
observed. This report describes the clinical procedure
of an implant-supported RPD to restore masticatory
function and appearance.

CASE PRESENTATION
A 67-year-old man presented to the graduate Prosthodontic Clinic at Seoul National University Dental Hospital; his chief complaint was that he could not eat with
his RPDs. A clinical examination revealed a lack of
retention and stability of the current dentures for both
arches due to the loss of the maxillary left lateral incisor
as an abutment tooth of the RPD. The remaining maxillary teeth were the left canine and rst molar; teeth on
the right side of the mandible were present while the
entire left dentition of the mandible was missing. The
edentulous parts of both arches were opposed by natural teeth, which aected the stability of the patients

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Figs 1a to 1d Initial intraoral views. (a)

Maxillary occlusal view. (b) Mandibular
occlusal view. (c) Frontal view. (d) Left lateral view; note a severe transverse arch
discrepancy.

current prostheses. The residual ridge in the maxillary

anterior and right posterior regions was severely
resorbed and the patient had a signicant discrepancy
in the transverse interarch dimensions (Fig 1). The
patients medical history was noncontributory.
The maxillary left rst molar and the mandibular
right central and lateral incisors exhibited grade 2
mobility and pain on percussion, and they were
planned to be extracted. Several treatment options for
the mandible were discussed with the patient: a conventional RPD, an implant-supported RPD, or an
implant-supported xed partial denture (FPD). Since
xed prostheses generally provide better function in
the mandible than removable prostheses, an implantsupported FPD was selected. For the maxilla, two treatment options were presented: an implant-supported
FPD or an implant-supported RPD. It was unfavorable
to place implants in all of the edentulous sites due to
the severe resorption of the anterior ridge and nancial
limitations. Furthermore, a removable prosthesis was
preferred as it could compensate for a transverse arch
discrepancy and provide anterior lip support.
Five implants were placed in the mandible using a
nonsubmerged surgical procedure as follows; two
implants (3.5 11.0 mm, Neobiotech) in the right central incisor and left canine region, one implant

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Baek et al

Fig 2 Panoramic radiograph after

implant placement.

(4.5 11.0 mm) in the left rst premolar region, and

two implants (5.0 8.0 mm) in the left rst and second
molar region (Fig 2). Likewise, four implants were
inserted in the maxilla as follows; two implants
(5.0 11.0 mm) in the right rst and second molar
region, and two implants (4.5 11.0 mm) in the left rst
and second premolar region. Provisional removable
prostheses for both arches were fabricated over the
healing abutments. The tissue surface of the prosthesis
was relieved and relined with a soft relining material
(Coe-Comfort, GC America) to avoid xture loss due to
excessive loading. The pick-up type impression copings
were secured to the xtures after a healing period of 6
weeks. An open tray impression was taken using a silicone material (Exane putty type, GC; Express Regular
Body, 3M Espe) with a custom acrylic resin open tray
(Quicky, Nissin Dental Products). The impression copings were removed from the mouth together with the
set impression. The vertical dimension was determined

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Figs 3a to 3d Occlusal plane modication procedure. (a) Broadrick ag. (b) Jig on
cast. (c) Jig in the mouth. (d) Intraoral view
after occlusal plane modication.

with the Willis method.8,9 The casts were mounted in a

semi-adjustable articulator with a centric relation
record and a facebow record. After a diagnostic waxup, the mandibular occlusal plane was established by
using a Broadrick ag (Fig 3a) and occlusal interferences during lateral and protrusive movements were
removed. Teeth on the stone cast were trimmed
according to the curve of Spee and a resin jig (Duralay,
Reliance Dental Manufacturing Company) was used as
a guide to alter the mandibular occlusal plane in the
patients mouth (Figs 3b to 3d). The maxillary left
canine was prepared for a crown after caries removal
and endodontic treatment were performed. Provisional
xed prostheses were cemented onto the temporary
implant abutments and the maxillary canine, and a
maxillary provisional RPD was fabricated (Fig 4).
Another 6 weeks were allowed before denitive restorative procedures began. The CAD/CAM (computeraided design/computer-assisted manufacture) system

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Figs 4a to 4d Intraoral views after temporary prostheses fabrication. (a and b)

Occlusal views after temporary xed prostheses fabrication. (c and d) Maxillary
occlusal view and frontal view after temporary removable partial denture fabrication.

Fig 5 CAD (computer-aided design) procedure.

was used to fabricate customized titanium abutments

for all of the implants. With the same method, the zirconia xed prostheses were designed and milled for the
mandible (Fig 5). However, the metal framework for the
maxillary xed prosthesis was made of gold using the
lost wax technique. After the framework try-in, the porcelain layer was added to the framework and the denitive porcelain-fused-to-gold (PFG) xed prostheses
were cemented with a temporary implant cement (Premier Implant Cement, Premier Dental Products), with

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the exception of the PFG crown for the maxillary left

canine, which was permanently cemented with a resinmodied glass-ionomer (RMGI) cement (FujiCem, GC)
(Fig 6). For the maxillary RPD, a stick modeling compound (Peri Compound, GC) was used for border molding on a custom tray, and a functional impression was
taken with a regular bodied silicone material (Express
Regular Body, 3M Espe). The maxillary major connector
was a full palatal plate, and an Akers clasp and an RPA
clasp were used on the right rst molar and the left

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Figs 6a to 6d Intraoral views after denitive xed prostheses fabrication. (a and b)

Occlusal views after customized titanium
abutments connection. (c and d) Occlusal
views after denitive xed prostheses
cementation.

Figs 7a to 7e Intraoral views after denitive prostheses fabrication. (a and b)

Occlusal views. (c and e) Lateral views. (d)
Frontal view.

second premolar respectively. Mesial and cingulum

rests were added to the abutment prostheses to provide support for the RPD. A relatively esthetic wrought
wire clasp was also soldered onto the maxillary RPD
framework at the left canine region. The metal framework was tried in the mouth and checked for accuracy.
A wax rim was constructed to replicate the appropriate
lip support, arch form, and occlusal plane. Jaw relations
were recorded, and the casts were mounted on a semiadjustable articulator. Denture teeth (Duracross Physio,

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Nissin Dental Products) were set in the wax rim to

establish simultaneous bilateral even contacts in centric occlusion and group function contacts in the working side. After wax denture try-in, the denture was
processed with a heat-polymerized acrylic resin (Rapidsimplied, Vertex Dental). The case was remounted in
the laboratory to compensate for error caused by resin
polymerization shrinkage.
The denitive RPD was delivered, and the patient
was satised with appearance and masticatory function

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(Fig 7). After the initial assessment, the patient was

seen once every 3 months for a 12-month period without any complications.

DISCUSSION
The patient described in this report presented with a
loss of vertical stop and a severe jaw discrepancy. In
addition to the abovementioned treatment plans for
the maxilla, a complete denture with the extraction of
the left canine was also considered as a treatment
option. However, the left canine did not exhibit mobility or response to percussion, and the patient wanted
to preserve the tooth. Therefore, an RPD was a more
favorable option than a complete denture for retention,
support, and stability. Moreover, posterior implantsupported xed prostheses could establish the posterior occlusion and the optimal vertical dimension. Even
compared to the restoration of implant-supported
xed prostheses alone, implant-supported RPDs provided the advantages of labial support, hygiene, maintenance, and nancial saving.6
Although previous studies reported on various
kinds of implant-supported RPDs, there is a signicant
lack of studies on posterior implant-supported xed
prostheses surveyed and used as abutments of RPDs.3-7
The RPD presented in this case was designed to distribute occlusal loads evenly throughout the implant-supported xed prostheses and the denture. Bilateral even
contacts and group function occlusion were established in order to avoid occlusal overload to the maxillary xed prostheses. Continuous follow-ups will be
essential for a good prognosis in order to periodically
evaluate the peri-implant condition and the need to
reline the maxillary RPD.

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CONCLUSION
This clinical report demonstrates the treatment method
for using an implant-supported RPD to restore a maxilla
that exhibited a severely resorbed ridge and a collapsed vertical stop. The mandibular arch was restored
with an implant-supported FPD.

ACKNOWLEDGMENT
This work was supported by the Korea Health R&D Project (HI12C0064),
granted by Ministry of Health and Welfare, Republic of Korea.

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