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please visit our main website at www.dentalimplantpartnership.com for further information on , surgical and prosthodontics and restorative treatments. dr paul tipton, specialist in prosthodontics president of the british academy of restorative dentistry and dr eugene marais, dental surgeon president of the british academy of dental implantology. bridge design, part ten: removable bridgework on implants in the latest part of his series on bridgework, paul tipton discusses the milled-bar retained removable bridge implant-supported prosthesis. the maxillary overdenture is indicated for patients who have natural teeth or fixed or removable prostheses supported by implants and teeth in the mandible. however, studies by jemt (1996) suggest a high failure rate of over 20% and a high degree of maintenance is required (watson, 1996). overdentures have often been prescribed for failing fixed prostheses (palmquist, 1994), if adequate placement of enough implants to support fixed prostheses was not possible and for cost purposes. oral hygiene procedures are better facilitated by removable prostheses and better aesthetics and phonetics often achievable. this paper will now deal with a rigid bar overdenture design called the ‘milled bar retained removable bridge’ prosthesis. prosthesis design to restore the correct lip support, the maxillary prostheses usually include a prosthesis flange. if such a restoration is fabricated as a direct cemented or screw-retained prosthesis, access for oral hygiene is limited. prosthesis flanges, even if not fully extended, create ridge lap areas that can be cleaned only if they are removable by the patient. the maxillary ridge resorption pattern generally necessitates the fabrication of fully extended labial and buccal flanges in order to retain proper lip support. in a two-piece prosthesis (removable bridge), however, the infrastructure is attached to the implants, either directly or through the abutments, and is removable only by the dentist. it serves as the retentive mechanism for the superstructure – the prosthesis – which is removable by the patient. this style of removable prosthesis can be designed as the traditional bar or ball attached retained overdenture or as a precision-retained milled bar retained removable bridge prosthesis. accurate fit between the infrastructure and superstructure ensures overall rigidity of the milled bar restoration which then functions as a one piece fixed restoration. this can be achieved by fabricating the infrastructure in the form of a milled bar with a similar overcasting (removable bridge) made of metal to fit over the top of the rigid, retentive bar. bar design a minimum of four to six implants is usually required for a maxillary overdenture prosthesis, whilst for the maxillary milled bar removable bridge restoration misch (1993) suggests the minimum is usually six to eight. once seated, the superstructure is secured to the infrastructure with rigid attachments to limit the micromovements during function and minimise the wear between the structures. the infrastructure should be fabricated with a 2° taper as suggested by prieskel (1996) and from an alloy that is biocompatible, has high yield strength, and can be readily sectioned and soldered. the metal component of the superstructure should be as thin as possible to provide space for the rest of the components. the attachments that stabilise the fully seated complex can be of different shapes and forms. simplicity should be a major consideration in selecting the attachments to ensure the uncomplicated fabrication, maintenance and replacement. with multiple implants, the maxillary overdenture becomes most implant supported regardless of the retention devise and bar design. therefore, for multiple implants rigid bars are always recommended and a cast framework must reinforce the denture base to ensure stability and stiffness (mericske-stern, 1998). with multiple implants the overdenture has a horseshoe design, which is well tolerated by patients from a psychological point of view because the feeling of wearing complete dentures is absent. an individually cast metal framework inside the denture is mandatory for the horseshoe design of the milled bar retained removable bridge (mericske-stern, 2000) and provides for adequate stiffness and rigidity of the removable bridge. the palatal seal is cast in metal with female bar retainers not soldered to the cast metal framework, but rather mounted in the acrylic resin base. this facilitates prosthetic services like tightening or renewing retainers. full coverage of the palate becomes necessary only when multiple implants are not used and implant placement is poorly spaces and when support is required from the palatal mucosal tissue. trial dentures once the vertical dimension has been established on trial wax dentures, selection of abutment heights, if required, is completed – usually in the laboratory from a cast poured from an impression of the fixture head. consideration must be given to the inter-implant divergence or convergence. branemark transmucosal standard abutments used in screw-retained implant supported prostheses can accommodate this divergence up to 30-40°. alternatively, if the implants have a reasonable degree of parallelism the restoration can be built directly on to the fixture head of the implant. the impression can be made six to eight weeks following second stage surgery. all prosthetic parts are selected following the mounting of the master cast in the correct vertical dimension, aesthetic try-in and a thorough evaluation of the implant angulation on the master cast. a readily cleaned infrastructure with sufficient bulk for strength can be achieved only by precise utilisation of the available vertical space. the following two case studies illustrate the technique involved in the ‘milled bar retained removable bridge implant supported maxillary prosthesis.’ case study 1 this middle-aged lady was referred to me by her general dental practitioner. her major complaint was one of poorly fitting complete dentures with associated loss of aesthetics and premature aging (figure 1). a trial denture set up was completed in wax as previously described to assess vertical dimension and aesthetics prior to starting treatment (figure 2). the new denture set up not only increased the vertical dimension but also gave better lip support, everting the upper lip and giving it greater fullness (figures 3 & 4) and the patient a better profile and appearance (figures 5 & 6). these trial dentures formed the basis of radiographic guides prior to the ct scan being completed and the surgical guides when implants were placed. implant placement six maxillary and five mandibular implants were placed and after an osseointegration time of six months were uncovered together during the abutment operation. after a period of approximately eight weeks for tissue maturation and stabilisation, prosthetic treatment commenced. the treatment plan was for a milled bar retained removable bridge restoration in the maxilla and a traditional acrylic/gold screw retained implant supported bridge in the mandible. prosthetic technique a pick up impression in a special tray was used to impress the head of the implants in both jaws. klooster (1991) showed that the risk of permanent deformation of the impressions is reduced by increasing the time the impression materials are allowed to remain intraorally, however the inaccuracies of all impression techniques are well documents. soft tissue cast since the implant mating surfaces are subgingival reproduction of this area in dental stone might result in chipping of the master case and so soft tissue simulated casts were utilised instead (wilkinson, 1992). using a material with properties that are different from the one used for the final impression ensures an easy recovery of the master cast from the impression. recording rap mounting the master casts around retruded axis p

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Domain Name: IMPLANTSDENTALCARE.COM
Registry Domain ID: 1664361224_DOMAIN_COM-VRSN
Registrar WHOIS Server: whois.godaddy.com
Registrar URL: http://www.godaddy.com
Updated Date: 2017-06-30T14:12:30Z
Creation Date: 2011-06-29T09:41:19Z
Registry Expiry Date: 2018-06-29T09:41:19Z
Registrar: GoDaddy.com, LLC
Registrar IANA ID: 146
Registrar Abuse Contact Email: [email protected]
Registrar Abuse Contact Phone: 480-624-2505
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Name Server: NS.HOSTZONEDNS.CO.UK
Name Server: NS2.HOSTZONEDNS.CO.UK
Name Server: NS3.HOSTZONEDNS.CO.UK
Name Server: NS4.HOSTZONEDNS.CO.UK
DNSSEC: unsigned
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  REGISTRAR GoDaddy.com, LLC

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  SERVER com.whois-servers.net

  ARGS domain =implantsdentalcare.com

  PORT 43

  TYPE domain

DOMAIN

  NAME implantsdentalcare.com

  CHANGED 2017-06-30

  CREATED 2011-06-29

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  NS.HOSTZONEDNS.CO.UK 87.117.242.51

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  NS3.HOSTZONEDNS.CO.UK 87.117.220.241

  NS4.HOSTZONEDNS.CO.UK 87.117.242.21

  REGISTERED yes

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