Fixed prosthesis with a milled bar for correcting misangled implants:

A clinical report
Jae-Hoon Lee, DDS, MS,a Val Frias, DDS, MS,b Changwoo Woo, CDT,c and Roman Maiberg, CDTd
Dental Hospital, Yonsei University, Seoul, Korea; Millennium Dental Center, Great Neck, NY

The fabrication of fixed implant-supported prostheses for edentulous maxillae may result in esthetic and
functional problems due to the unfavorable angulations of the supporting implants. This article presents
a technique that uses a metal mesosubstructure prepared with a conventional milling technique and pal-
atal set screws to compensate for an unfavorable implant position, thereby providing a more esthetically
acceptable and functional result. (J Prosthet Dent 2007;97:129-32.)

T he design of an implant prosthesis is often deter-

mined by the position and angulation of the supporting
osseointegrated implants. Adequate presurgical pros-
thetic design is essential to the accurate placement of
implants for an esthetically acceptable and functional
result, as inadequate treatment planning and miscom-
munication with the surgeon may result in prosthetic
complications. These complications include misangu-
lated or unfavorably positioned implants and lack of
parallelism between implants, resulting in a compromise
in esthetics, phonetics, and function.
Various solutions have been proposed to correct
unfavorable implant placement during the prosthetic
phases of treatment. The most common methods in-
clude the use of angulated1,2 or custom3 abutments,
which allow for correction of misangulated implants. Fig. 1. Implant position in maxillary arch.
However, when implants are severely angulated, even
the use of a prefabricated angulated abutment may still and mandibular dentures. On examination it was noted
result in the location of the screw-access opening being that both the mandible and maxilla evidenced signs
positioned in the buccal surface of the prosthesis. of moderate to severe atrophy. Six implants had been
For the completely edentulous patient, milled bars previously placed in the maxillae and the mandible,
have been used as substructures for implant-supported respectively.The surgery had been performed without
prostheses. Milled bars can be fabricated by precision adequate prosthodontic treatment and planning, and
milling conventionally cast frameworks,4,5 and the matri- ridge augmentation procedures had not been attempted
ces can be fitted using electric discharge machining6 or a prior to implant placement. The resulting angulations
computer-aid design/computer-assisted manufacturing of the implants in the atrophic maxillae compromised
(CAD/CAM) procedure.7 In this clinical report, a con- the fabrication of a conventional implant-supported
ventionally milled bar with palatal set screws was used to prosthesis (Fig. 1). Additionally, the previously relined
correct implant angulation in a completely edentulous dentures exhibited signs of poor retention and fit.
patient. Impressions were made with implant level impression
copings (Nobel Biocare Inc, Yorba Linda, Calif) and a
polyether impression material (Impregum; 3M ESPE,
CLINICAL REPORT
St. Paul, Minn) to evaluate parallelism and select abut-
A 60-year-old woman presented to the Division of ments. It was determined that a conventional framework
Prosthodontics at Columbia University with a chief was not indicated due to severe buccal inclination of
complaint of dissatisfaction with her complete maxillary the implants and their lack of parallelism. Treatment
options, including an overdenture or a fixed prosthe-
sis with buccal position of the screw-access openings,
a
Full-time Lecturer, Department of Prosthodontics, Dental Hospital, were presented to the patient. The patient rejected
Yonsei University. both of these options and requested a fixed option that
b
Private practice, Buffalo, NY.
c
Dental technician, Dental Laboratory, Dental Hospital, Yonsei
would provide optimal function and avoid the placement
University. of the screw-access openings in the buccal surface of the
d
Dental technician, Millennium Dental Center. prosthesis. A treatment plan was developed to fabricate a

MARCH 2007 THE JOURNAL OF PROSTHETIC DENTISTRY 129

THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 2. Recording of incisal edge position of existing denture
with vinyl polysiloxane occlusal index.
Fig. 4. Arrangement of artificial teeth on definitive prosthesis
verified with occlusal vinyl polysiloxane index.
mesostructure to compensate for the poor implant
placement. The patients existing dentures were clini-
cally acceptable; therefore, they were connected to
the implants with plastic temporary cylinders (Nobel
Biocare Inc). Occlusal vertical dimension, occlusal plane,
esthetics, and phonetics were clinically verified.
The cast was used to select the appropriate 17- and
30-degree angulated abutments (Nobel Biocare Inc).
The abutments were placed intraorally, and an abut-
ment level impression was made with polyether impres-
sion material (Impregum; 3M ESPE). The casts were
mounted in an articulator (Whip Mix 2240; Whip Mix
Corp, Louisville, Ky), and a wax trial denture was cre-
ated according to the index from the existing denture
to maintain the teeth position. An index of the facial
contour and incisal edge position of the denture teeth
was created in a vinyl polysiloxane material (Reprosil
putty; Dentsply Intl, York, Pa) to visualize the position
of the maxillary teeth during the fabrication of the metal
130
LEE ET AL
Fig. 3. Occlusal view of framework mesostructure.
Fig. 5. Occlusal view of waxed prosthesis. Note location of
palatal screws on superstructure framework.
framework (Fig. 2). A palatal index was also created from
the trial prosthesis to maintain the vertical dimension
of occlusion on the articulator. The framework for the
prosthesis was then fabricated on a working cast poured
from the abutment-level impression. A conventional
milling process4,5 was used to create the mesostructure,
and then a metal superstructure connected by 5 lingual
screws8 (Tube screw; Attachments Intl, San Mateo,
Calif) was also fabricated as described below (Fig. 3).
The mesostructure connected to the implant was pre-
pared with acrylic resin (Pattern resin; GC Corp, Tokyo,
Japan). Metal tubes to create threads for lingual screws
were then placed 0.10 mm more lingually over the lingual
surface of the mesostructure of the pattern for the phos-
phate-bonded investment material (GC Fujivest II,
Leuven, Belgium) to hold up the tube during the burn-
out procedure and to prevent overflow of melted gold
during the casting procedure. An oxidized titanium screw
pin (Tube screw; Attachments Intl) with antiflux (Stopor;
VOLUME 97 NUMBER 3
LEE ET AL
Fig. 6. Facial view of definitive prostheses.
Metalor Dental AG, Oensingen Switzerland) was inserted
into the tube with a hand torque driver (Tube screw;
Attachments Intl) to prevent oxidization of the screw
threads during the divesting procedure. The screw pin
was then unscrewed from the tube to reduce the length
to the surface level after investing and casting (Ceram
54; Dentrex, Cherry Hill NJ). The finished structure was
then milled with a 2-degree milling bur (Milling bur;
Busch, South Plainfield NJ) and evaluated intraorally.
The Sheffield test was used to verify the fit.9
Next, the superstructure was fabricated with acrylic
resin (Pattern resin; GC Corp) to cover the screw area,
creating a smooth access opening on the superstructure.
The screw was then removed from the structures after
investing and casting of the acrylic resin superstructure
pattern. The fit between the mesostructure and super-
structure was then adjusted with a tungsten carbide
bur (Bredent Medical, Senden, Germany), and the max-
illomandibular relationship was recorded for complete
denture fabrication by using an occlusal wax rim on
both arches. The tooth arrangement on the trial den-
tures was transferred on the superstructure framework
with the prepared index (Figs. 4 and 5). The prostheses
were remounted on the articulator after polymerization,
and the occlusion was adjusted on the articulator. The
prosthesis was inserted, and phonetics, esthetics, func-
tion, and comfort were clinically verified (Figs. 6 and
7). Postoperative instructions were given to the patient,
and no complications have occurred in the 4 years since
insertion of the prosthesis.
DISCUSSION
The fabrication of a 2-piece framework with palatal
screws to correct the angulation of implants for a maxil-
lary edentulous patient was described. The framework
allowed for a stable functional base for a removable
prosthesis while masking the screw-access openings.
This allowed an improvement in contour, esthetics, and
MARCH 2007
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 7. Occlusal view of definitive maxillary prosthesis.
phonetics. The framework was created as a precision-
milled mesostructure with screw retention positioned
on the palatal surface of the framework. The superstruc-
ture connects to the mesostructure as a corresponding
matix sleeve, is secured to the mesostructure with the
palatal screws, and has retentive elements for the reten-
tion of artificial teeth and acrylic resin. The creation of a
superstructure sleeve that connects precisely to the mes-
ostructure bar allows for masking of the implant screw-
access openings, which exit on the labial surface of the
mesostructure. The use of palatal screws for retention
of the suprastructure then allows the retentive elements
to be placed in a position where there will be minimal in-
terference with the contouring of the framework and
prosthesis. Placing the set screws from an occlusal aspect
could simplify the insertion of the screws. However, this
often interferes with the placement of the artificial teeth
and requires that the buccolingual width of the frame-
work be increased. This approach may result in thicker
contours and may affect comfort and phonetics and
was, therefore, not used in this patient situation. The
risk of screw aspiration may increase from the palatal ap-
proach, but this risk can be minimized by placing gauze
in the posterior part of the mouth.
A superstructure fitted with electric discharge ma-
chining and equipped with precision attachments
may be an alternate treatment for the retention and
stability of a complete-arch prosthesis, but the in-
creased expense involved may limit its use. A conven-
tional milling technique to produce the mesostructure
and conventional casting and fitting of the superstruc-
ture provided a cost-effective and functional option
for the patient, who presented with improperly angu-
lated implants.
SUMMARY
In the situation where prosthetic design must be
modified to compensate for implant angulation, the
131
THE JOURNAL OF PROSTHETIC DENTISTRY LEE ET AL

most common methods have been to use an angulated 6. Eisenmann E, Mokabberi A, Walter MH, Freesmeyer WB. Improving the fit
of implant supported superstructures using the spark erosion technique.
or custom abutment. However, in extremely angulated Int J Oral Maxillofac Implants 2004;19:810-8.
implant situations, the location of the screw-access 7. Besimo C, Jeger C, Guggenheim R. Marginal adaptation of titanium frame-
opening may still compromise esthetics, even with the works produced by CAD/CAM techniques. Int J Prosthodont 1997;10:
541-6.
use of angulated abutments. In this article, a prosthesis 8. Galindo DF. The implant-supported milled-bar mandibular overdenture.
consisting of a bar-and-sleeve framework with lingual J Prosthodont 2001;10:46-51.
screw retention has been illustrated as a viable treatment 9. Jemt T. Three-dimensional distortion of gold alloy casting and welded tita-
nium frameworks. Measurements of the precision of fit between completed
option for extremely angulated implants in an implant- implant prostheses and the master casts in routine edentulous situations.
supported restoration for a completely edentulous J Oral Rehabil 1995;22:557-64.
patient.
Reprint requests to:
DR JAE-HOON LEE
DENTAL HOSPITAL, YONSEI UNIVERSITY
REFERENCES PROSTHODONTIC DEPARTMENT
1. Balshi TJ, Ekfeldt A, Stenberg T, Vrielinck L. Three-year evaluation of Brane- 134 SHINCHON-DONG, SEODAEMUN-GU
mark implants connected to angulated abutments. Int J Oral Maxillofac SEOUL, KOREA
Implants 1997;12:52-8. FAX: 82-2-312-3598
2. Sethi A, Kaus T, Sochor P, Axmann-Krcmar D, Chanavaz M. Evolution of the E-MAIL: jaehoon115@hotmail.com
concept of angulated abutments in implant dentistry: 14-year clinical data.
Implant Dent 2002;11:41-51. 0022-3913/$32.00
3. Lima Verde MA, Morgano SM, Hashem A. Technique to restore unfavor- Copyright 2007 by The Editorial Council of The Journal of Prosthetic
ably inclined implants. J Prosthet Dent 1994;71:359-63. Dentistry.
4. Brudvik JS, Chigurupati K. The milled implant bar: an alternative to spark
erosion. J Can Dent Assoc 2002;68:485-8.
5. Ercoli C, Graser GN, Tallents RH, Hagan ME. Alternative procedure for
making a metal superstructure in a milled bar implant-supported overden-
ture. J Prosthet Dent 1998;80:253-8. doi:10.1016/j.prosdent.2007.01.003

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