Oral rehabilitation of a patient with

bruxism and cluster implant failures in

the edentulous maxilla: A clinical report
Wei-Shao Lin, DDS,a Carlo Ercoli, DDS,b Roxanne Lowenguth,
DDS, MS,c Lisa M. Yerke, DDS,d and Dean Morton, BDS, MSe
School of Dentistry, University of Louisville, Louisville, KY; East-
man Institute for Oral Health, University of Rochester, Rochester,
NY; School of Dental Medicine, University of Buffalo, Buffalo, NY
For most patients with failed dental implants, the placement of new implants is the only option that allows for re-
treatment with a fixed dental prosthesis. This clinical report describes the rehabilitation of a patient with a history of
bruxism and cluster implant failures in the edentulous maxilla 10 years after the insertion of a milled bar overdenture.
Seven failed implants were removed and simultaneous bone grafting was performed. After an 8-month healing period,
8 dental implants with new surfaces were placed. These supported a metal ceramic fixed complete denture with a
metal occlusal surface. The prosthesis was retained with 3 sections of milled bars and 3 set screws. This clinical report
describes the details of the treatment with an emphasis on prosthetics. (J Prosthet Dent 2012;108:1-8)

Studies have shown predictable
long-term clinical success with im-
plant-supported or implant-retained
fixed or removable prostheses in the
edentulous jaw, and dental implants
have become an important part of
modern dentistry.1-3 The preponder-
ance of evidence suggests that typi-
cal survival rates for dental implants
are in the 80% to 95% range over 10
or more years and less than 0.1 mm
annual mean crestal bone loss may
be expected.4-6 In completely eden-
tulous patients, a systematic review
has suggested that implant survival
and success might not be affected
by the design of the implant prosthe-
sis.4 However, a higher failure rate has
been reported for implant treatment
in the edentulous maxilla than in the
mandible, implying that the implant
treatment outcome is less predictable
in the edentulous maxilla.7-9 When
there is an early implant failure before
loading the implant with the definitive
restoration, an attempt at reimplan-
tation with a larger diameter implant
or a bone graft before implant place-
ment may increase the chance of suc-
cessful osseointegration.10 A late im-
plant failure, which is often referred
to as periimplantitis, is characterized
by the loss of bone around integrated
implants and is a more difficult clini-
cal situation to manage. Bone loss
from late implant failure is usually
progressive in nature. The removal of
failing implants or periimplant pocket
elimination surgery are often treat-
ment options for periimplantitis.10,11
Patients and clinicians should be
aware of the challenge of decreased
hard/soft tissue volume caused by
periimplantitis when reimplantation
is considered. The success of reim-
plantation may be increased by using
wider implants or implants with im-
proved surface characteristics.12-15
Implant failures are not randomly
distributed in all patients, and im-
plant loss in clusters (more than 1
implant failure per patient, not neces-
sarily in the same area or quadrant)
can be observed in specific high-risk
individuals who experience a so-
called “cluster phenomenon.”16-19
These patients with multiple failing/
failed implants have been described
as “cluster patients.” Although cluster
patients seem to be random, they of-
ten share certain individual character-
istics and risk factors that distinguish
them from patients with successful
implants.8
Common risk factors for implant
failures are poor bone quality, un-
treated chronic periodontitis, system-
ic diseases, smoking, unresolved car-
ies or infection, advanced age, short
and/or small implants, eccentric oc-
clusal loading, an inadequate number
of implants, and parafunctional hab-

a
Assistant Professor, Department of Oral Health and Rehabilitation, School of Dentistry, University of Louisville.
b
Associate Professor, Chair and Program Director, Division of Prosthodontics, Eastman Institute for Oral Health, University of
Rochester.
c
Clinical Associate Professor, Department of Periodontology, Eastman Institute for Oral Health, University of Rochester.
d
Private practice, Rochester, New York. Assistant Professor, Department of Periodontics, School of Dental Medicine, University of
Buffalo.
e
Professor, Chair, and Director, Advanced Education in Prosthodontics, Department of Oral Health and Rehabilitation, School of
Dentistry, University of Louisville.
Lin et al
2 Volume 108 Issue 1
its.20,21 Among these risk factors, some
studies have concluded that there are
certain specific dominating factors re-
lating to the cluster phenomenon of
implant failures, such as lack of bone
support or bone quality, heavy smok-
ing, short implants, existing periodon-
titis, and bruxism.22-30 There is no con-
sensus on or scientific evidence for the
etiology of clustering failure phenom-
ena. Therefore, future studies are indi-
cated to determine the risk factors and
propose proper treatment protocols
for future implant patients.24,25,29-33
This clinical report describes the reha-
bilitation of a patient with cluster im-
plant failures in the edentulous maxilla
10 years after the loading of dental im-
plants with previously restored milled
bar overdentures.
CLINICAL REPORT
A 72-year-old white man present-
ed at the Division of Prosthodontics
at the University of Rochester, East-
man Institute for Oral Health, Roch-
ester, NY with the chief complaint of
fractured mandibular anterior teeth
(Fig. 1A). The patient did not report
any relevant medical history contra-
indicating routine dental treatment
or implant surgery, but self-reported
a dental history of bruxism with mul-
tiple fractured denture teeth on his
maxillary implant-supported milled
bar overdenture. The chipped porce-
lain on the mandibular fixed dental
prosthesis and the fractured denture
teeth on the maxillary overdenture
coincided with the self-reported his-
tory of bruxism. The clinical and ra-
diographic examination revealed a
fractured mandibular anterior fixed
dental prosthesis and defective poste-
rior crowns with recurrent caries and
fractured veneering porcelain. The
maxillary milled bar overdenture was
supported by 7 dental implants (Re-
place Select taper; 13 mm in length,
4.3 mm or 5.0 mm in diameter; No-
bel Biocare, Zürich-Flughafen, Swit-
zerland) placed and integrated 10
years before this visit. The periimplant
soft tissue demonstrated significant
inflammation characterized by red,
swelling gingiva (Fig. 1B). The prob-
ing depths for the 7 dental implants
were 7 mm to 11 mm with bleeding on
probing. The periapical radiographs
showed generalized 30% to 40% bone
loss (Fig. 1C).
The maxillary dental implants and
mandibular right and left canines had
a poor prognosis, and the decision
was made to remove all maxillary im-
plants and mandibular canines after
discussing treatment options, includ-
ing endodontic treatment on canines
and flap surgery for periimplantitis,
with the patient. Conventional com-
plete dentures and implant-support-
ed or implant-retained overdentures
were excluded as treatment options
because the patient had no need for
lip support and preferred a fixed pros-
thesis. In the maxilla, the patient ac-
cepted the definitive treatment plan
of 8 dental implants and an implant-
supported metal ceramic fixed com-
plete denture with metal occlusal
surface. In the mandible, the patient
accepted the definitive treatment plan
with a fixed dental prosthesis sup-

A B

C
1 A, Preexisting condition with failed mandibular anterior fixed partial dental prosthesis and maxillary implant-
supported milled bar overdenture. B, Periimplant soft tissue demonstrated signs of inflammation and swelling. C,
Periapical radiographs demonstrated generalized 30% bone loss around existing 7 dental implants. Implant at maxil-
lary left premolar area showed radiolucency enclosing entire implant length.

The Journal of Prosthetic Dentistry Lin et al

July 2012
ported by 4 implants for the anterior
region and defective posterior crown
replacement. The patient signed the
consent form and fully understood
the advantages and disadvantages of
the different treatment options.
The removal of the maxillary im-
plants was performed under local
anesthesia. One day before the sur-
gery, the patient began taking anti-
biotics (amoxicillin 500 mg, 3 times
daily for 7 days) and using a 0.12%
chlorhexidine gluconate mouthwash
(CHG Oral Rinse; Xttrium Laborato-
ries, Chicago, Ill) for oral disinfection.
All implants were easily removed with
a counterclockwise motion, and the
extraction sites were debrided and
irrigated with sodium chloride (0.9%
sodium chloride; Baxter Health Cor-
poration, Deerfield, Ill). Graft mate-
rial containing a demineralized bone
matrix and cancellous bone mix (Dy-
nablast Putty; Keystone Dental, Burl-
ington, Mass) was molded to restore
a desirable alveolar ridge anatomy,
and collagen membranes (Bio-Guide;
Osteohealth, Shirley, NY) were placed
over the graft material. Flaps were
coronally repositioned and primary
closure of the flap was obtained.
The provisional complete denture,
relined with soft reliner (Lynal; Dent-
sply Caulk, Milford, Del), was pro-
vided immediately after the surgery.
The patient was instructed to follow
a soft diet, avoid excessive force on
the grafted site, and continue the
chlorhexidine gluconate mouthwash
regimen for 7 days. Two weeks after
surgery, the sutures were removed.
After a 1 month healing period, a
surgical template duplicated from a
diagnostic waxing was fabricated to
allow the placement of 4 implants in
the anterior mandible (at the area be-
tween the mandibular canines). Four
implants (Straumann Standard Plus;
diameter 4.1 mm, length 12 mm,
Institut Straumann AG, Basel, Swit-
zerland) were placed. A provisional
removable partial dental prosthesis re-
lined with a resilient liner (Lynal; Dent-
sply Caulk) was provided immediately
after surgery. Similar postsurgical in-
Lin et al
structions were given to the patient.
After a 3-month healing period,
the defective crowns on the mandib-
ular right first premolar and left first
and second premolars were removed
and interim restorations fabricated
with autopolymerizing acrylic resin
(Jet Tooth Shade Acrylic; Lang Den-
tal). A definitive mandibular implant
level impression was made by using a
transfer, open tray impression tech-
nique with polyether impression ma-
terial (Impregum Penta; 3M ESPE, St
Paul, Minn). The mandibular definitive
cast was mounted against the maxillary
edentulous diagnostic cast with a face-
bow transfer record and semiadjustable
articulator (Hanau Modular; Water Pik
Inc, Fort Collins, Colo). The implant-
supported provisional fixed partial
dental prosthesis on the mandibular
anterior implants was made with au-
topolymerizing acrylic resin (Jet Tooth
Shade Acrylic; Lang Dental) and interim
abutments (Institut Straumann AG). A
pink shade light-polymerizing compos-
ite resin (Sinfony Indirect Lab Com-
posite; 3M ESPE) was applied on the
areas with soft tissue defects to achieve
proper contour on the provisional fixed
prosthesis. The maxillary diagnostic
tooth arrangement and mandibular im-
plant-supported interim fixed prosthe-
sis were inserted intraorally to evaluate
the occlusal vertical dimension, esthet-
ics, phonetics, and occlusion (Fig. 2).
Four prefabricated straight cementable
implant abutments (Institut Straumann
AG) were then selected for the definitive
mandibular prosthesis. Using the maxil-
lary diagnostic waxing as the opposing
dentition, the mandibular definitive cast
and abutments were sent to the dental
laboratory for the fabrication of the de-
finitive prosthesis. The insertion of the
definitive prosthesis (3 single crowns
on the mandibular right first premolar
and left first and second premolars;
mandibular anterior implant fixed par-
tial dental prosthesis) was achieved by
using a resin cement (Multilink Auto-
mix; Ivoclar Vivadent, Schaan, Liechten-
stein). The excess cement was removed
and oral hygiene instructions were given
to the patient (Fig. 3).
3
The maxillary diagnostic tooth ar-
rangement was then duplicated with
transparent autopolymerizing acrylic
resin (Orthodontic Resin; Dentsply
Caulk) and barium sulfate as a ra-
diographic guide for the computed
tomography (CT) scanning (Fig. 4A).
With the information obtained from the
cone beam computed CT scanning and
volumetric imaging software (Invivo5
Anatomy Imaging Software; Anatom-
age Inc, San Jose, Calif ) (Fig. 4B), the
digital 3-dimensional (3-D) surgical
treatment plan was determined. The
radiographic guide was converted to
a surgical template by opening the ac-
cess with an acrylic resin trimming bur
(E-Cutter Staggered Toothing; Brasseler
USA, Savannah, Ga) to allow for ap-
propriate implant placement based
on the surgical treatment plan and
prosthetic design.
The maxillary implant surgery was
performed 8 months after the removal
of the failing implants and bone graft
procedure to allow for complete heal-
ing. A presurgical antibiotic regimen
was followed. Under local anesthesia
(Ultracaine D-S Forte; Aventis Phar-
ma Deutschland GmbH, Frankfurt am
Main, Germany), 8 implants (Strau-
mann bone level implant RC; diam-
eter 4.1 mm and 4.8 mm, length 10
mm and 12 mm, Institut Straumann
AG) were placed with the guidance
provided by the surgical template.
The provisional maxillary complete
denture was relined with resilient liner
(Lynal; Dentsply Caulk) and immedi-
ately inserted. The postsurgery proto-
col was reviewed with the patient.
A definitive maxillary implant-
level impression was made by using
a transfer open tray impression tech-
nique with polyether impression ma-
terial (Impregum Penta; 3M ESPE)
after the 6-month healing period. The
corresponding implant analogs (RC
analog; Institut Straumann AG) were
connected to the impression cop-
ings, and the impression was poured
with Type IV dental stone (ResinRock;
Whip Mix Corp, Louisville, Ky) to fab-
ricate a definitive cast. A verification
index was fabricated on the defini-
4 Volume 108 Issue 1

2 Maxillary diagnostic tooth arrangement and existing 3 Definitive anterior mandibular implant fixed partial
mandibular implant-supported provisional fixed partial dental prosthesis (from right canine to left canine posi-
dental prosthesis. tion) and existing metal ceramic crowns on mandibular
right first premolar, left first, and second premolars.

A B
4 A, Maxillary diagnostic tooth arrangement was duplicated as radiographic guide for computed tomography scan-
ning. B, Digital 3-D surgical treatment plan was determined by using volumetric imaging software.

tive cast with temporary abutments
(RC D7; Institut Straumann AG) and
autopolymerizing resin (GC Pattern
Resin; GC America, Alsip, Ill) and
connected with autopolymerizing
resin (GC Pattern Resin) intraorally
to verify the accuracy of the definitive
cast. Definitive maxillary and oppos-
ing mandibular casts were mount-
ed in a semi-adjustable articulator
(Hanau Modular; Water Pik Inc),
and a complete diagnostic tooth ar-
rangement was made and confirmed
intraorally for function and esthetics.
The facial matrix was then made with
laboratory vinyl polysiloxane (VPS)
putty material (Sil-tech; Ivoclar Viva-
dent, Schaan, Liechtenstein) around
the facial surface of the maxillary diag-
nostic tooth arrangement to preserve
spatial orientation. The mounted casts
The Journal of Prosthetic Dentistry
and facial putty matrix were sent to the
dental laboratory for the fabrication of
the definitive prosthesis.
Eight implant abutments (0022.4742;
Institut Straumann AG) and gold cop-
ings (023.4741; Institut Straumann
AG) were selected for the implant-
supported metal ceramic fixed com-
plete denture. The facial matrix was
used as a reference for the milled bar
fabrication (Fig. 5A). Three segments
of the milled bar were made over 8
dental implants. An occlusal taper of
2 degrees was achieved on the buccal
and lingual surfaces of milled bars,
and a 1.5 mm space was reserved un-
der the bars for the purposes of oral
hygiene. Set screw access was provid-
ed on each segment of the bar (Fig.
5B). The Sheffield 1-screw test34 and
radiographs were used to confirm the
seating of the bars intraorally (Fig.
5C). The facial matrix was used again
as a reference to fabricate the 1-piece
metal ceramic fixed complete denture
over the milled bars (Fig. 6). Because
of the patient’s history of bruxism,
all occlusal contacts were positioned
in metal to minimize potential por-
celain chipping (Fig. 7A). The inser-
tion of the definitive prosthesis con-
sisted of placing 3 sections of milled
bars into place with a torque of 35
Ncm; then the prosthesis was evalu-
ated intraorally over the milled bars
(Fig. 7B). VPS indicator material (Fit
Checker; GC America, Alsip, Ill) was
used to indicate the binding areas at
the intaglio surface on the metal ce-
ramic fixed complete denture, and
these were adjusted until an even fit
was achieved. The set screws were
Lin et al
July 2012
5 A, Facial matrix was made around facial surface of diagnostic tooth arrangement to preserve spatial orientation
of denture teeth and used as reference for bar fabrication. B, One set screw access was made on lingual aspect at
each segment of bar. Three sections of bars were in place. C, Panoramic radiograph confirmed seating of bars.
tightened to a torque of 15 Ncm. The
desired occlusal contacts were con-
firmed with dental articulating paper.
A hard stabilization splint for nightly
use was provided to the patient to
prevent nocturnal teeth grinding and
clenching. The patient was given pos-
tinsertion oral hygiene instruction
and enrolled in a 6-month recall pro-
gram. The patient demonstrated the
ability to maintain good oral hygiene
and to wear an occlusal splint. No
clinical complications were observed
at the 18-month follow-up examina-
tion, and the patient remained satis-
fied with the function and esthetics of
the restoration.
DISCUSSION
Although studies have shown fa-
vorable clinical results for dental im-
plants in partially and completely
edentulous patients, an estimated
Lin et al
A B
200  000 to 250  000 failing implants
are recorded annually worldwide.18-20
Failed implants often significantly
challenge the clinician. The reduced
bone volume from periimplantitis at
implant sites requires further soft/
hard tissue augmentation to allow for
reimplantation; however, reimplanta-
tion is often the only treatment op-
tion available to satisfy patients who
request a fixed dental prosthesis.12
Both patient and clinician should be
aware of the difficulties and poten-
tial risks of reimplantation before any
attempt is considered.14 It has been
recommended that a failing/failed
implant should be removed as soon
as is practical or when diagnosed as
hopeless. The use of wider and longer
implants with improved surfaces was
proposed to improve the chances of
successful reimplantation.15
In the current clinical report, the
existing failing implant (Replace Select
5
C
taper; Nobel Biocare) with TiUnite
surface was removed, and a different
implant system with SLActive surface
(Straumann Bone Level Implant RC;
Institut Straumann AG) was chosen
for reimplantation. The hydrophilic
SLActive surface was introduced in
2006 and animal experiments26 have
suggested that this surface has shown
a stronger bone response than con-
ventional SLA surface. By using ex-
perimental ligature-induced periim-
plantitis in animal models, Berglundh
et al27 investigated 4 commercially
available dental implant surfaces: the
machined surface (ICE MicroMini-
plant; Biomet 3i, Palm Beach, Gar-
dens, Fla), the SLA surface (Standard
Plus Implant NN; Institut Straumann
AG), the TiOblast surface (Micro-
Thread; Astra Tech AB, Mölndal, Swe-
den), and the TiUnite surface (MkIII
Narrow Platform; Nobel Biocare).
This study suggested that ligatures
6 Volume 108 Issue 1

6 Wax pattern for 1-piece metal ceramic implant fixed

complete dental prosthesis supported by milled bars. One
set screw access was made on superstructure at each cor-
responding section of bar to provide additional retention.

A B
7 A, Metal occlusal surface of metal ceramic implant fixed complete denture. B, Facial view of definitive maxillary
and mandibular prostheses.

induced the spontaneous progress
of experimental periimplantitis with
additional bone destruction. Among
the 4 implant surfaces chosen for the
study, the TiUnite surface showed
the most pronounced periimplantitis
progression. Although this result im-
plied the TiUnite implant surface is
more susceptible to periimplantitis,
the cause of this susceptibility is not
fully understood and may be related
to other characteristics of the implant
surface modifications.27
Little research has focused on the
occlusion of implant-supported and
implant-retained restorations, and
the scientific evidence is primarily
limited to in vitro, animal, and ret-
rospective studies. In recent review
articles32,33 mutually protected occlu-
sion with shallow anterior guidance
The Journal of Prosthetic Dentistry
was recommended for the implant-
supported complete arch fixed dental
prosthesis when opposing a natural
dentition. Bilateral and anterior-pos-
terior simultaneous contacts in cen-
tric relation and maximum intercuspal
position were also proposed to evenly
distribute occlusal force during excur-
sions.32,33 This clinical report adapted
the previously mentioned concepts
by using mutually protected occlu-
sion as the choice of occlusal scheme
for a definitive prosthesis. Aside from
the designated occlusal scheme, the
esthetic outcome was confirmed by
both the clinician and patient dur-
ing the trial insertion of the diagnos-
tic tooth arrangement. The maxillary
posterior teeth were arranged in such
a way as to fulfill the patient’s wish to
have a broader smile and with suffi-
cient horizontal overlap to decrease
the risk of cheek biting.
Few publications have suggested
clinical guidelines for reducing com-
plication risks and implant failures
for patients with a history of brux-
ism. Because of the lack of scientific
evidence, these clinical guidelines are
not evidence-based. They are usu-
ally experienced-based and primarily
opinions derived from publications
related to implant treatment and
bruxism.30 Although there is no de-
finitive scientific evidence to identify
bruxism as a dominating risk factor
for the overload of dental implants
and the superstructure, treatment
guidelines have been adapted in the
current clinical report to compensate
for possible complications from para-
functional movement.28-30
Lin et al
July 2012
In this clinical report, the patient
presented with a history of repeated
fracture of natural teeth, a fixed par-
tial dental prosthesis, conventional
complete dentures, and an implant-
supported overdenture. During the
treatment planning process, the pa-
tient was offered treatment for his
maxillary periimplantitis and the
reimplantation of 8 new dental im-
plants. The patient provided informed
consent after being made aware of the
benefits and risks of treatment op-
tions. After the decision to provide im-
plants, the following precautions were
used to minimize risk. In consideration
of the previous failed dental implants
and the restorations, the maximum
number of longer and wider implants
was used within anatomic limitation
for reimplantation.  The metal occlu-
sal surfaces were recommended to
minimize potential porcelain fracture.
In addition, cross-arch stabilization
was achieved with a splinted implant
prosthesis. Splinting was intended to
distribute the applied forces favor-
ably among the implants to minimize
the transfer of horizontal load to the
bone-implant interface and to in-
crease bone surface area.31 Although
the 1-piece, cross-arch splinted im-
plant prosthesis may increase the dif-
ficulty of home oral hygiene care, the
design was chosen because of the
potential biomechanical advantages.
A screw-retained prosthesis was cho-
sen for better retrievability and for
easier maintenance. The potential
difficulty with conventional prosthe-
ses of this type (1-piece cross-arch
screw-retained metal ceramic implant-
supported fixed dental prosthesis with
a metal occlusal surface) is achieving
passive fit between the framework and
dental implants. Although the frame-
work can be sectioned and soldered to
achieve better passivity, the soldering
procedure will change the occlusion
on the framework. An alternative pros-
thesis design with 3 sections of milled
bars and 3 lateral screws was used.
With 3 sections of milled bar, the pas-
sive fit between the dental implants
and milled bars was easier to achieve
Lin et al
because of the shorter span. The im-
plants can be mechanically splinted to-
gether with 1-piece superstructure and
lateral screws. The intaglio surface of
the superstructure (implant supported
metal ceramic fixed complete denture)
can be easily adjusted to achieve a bet-
ter fit between the superstructure and
milled bars and to prevent the need
for soldering the superstructure. A hard
autopolymerizing acrylic resin occlusal
guard was fabricated after the definitive
prosthesis was inserted to distribute the
eccentric occlusal force associated with
nocturnal tooth grinding.
Poor oral hygiene could have been
a factor contributing to the inflam-
mation and swelling at the periim-
plant soft tissue of the 7 failed dental
implants with 1 piece milled bar. The
importance of the home oral hygiene
protocol was carefully explained to
the patient. The combination of pow-
ered water irrigating devices (Water
Flosser; Water Pik Inc) and manual
interdental cleaning devices (inter-
dental brushes) was recommended to
the patient to facilitate effective daily
oral hygiene. The patient demonstrat-
ed high compliance and effectiveness
in home oral hygiene care during the
18-month follow-up period.
SUMMARY
This clinical report described the
rehabilitation of a patient with clus-
ter implant failures in the edentulous
maxilla 10 years after loading with
a milled bar overdenture. Clinical
guidelines for treating patients with
bruxism derived from previous ar-
ticles were followed to minimize the
risk of complications and implant fail-
ure in the retreatment. Eight dental
implants were placed in the previously
failed implant sites, and an alternative
design for implant supported metal
ceramic fixed complete denture with
metal occlusal surface retained with
3 sections of milled bars and 3 lateral
screws was implemented. A hard stabili-
zation splint for nightly use was provid-
ed to prevent nocturnal parafunction.
The patient demonstrated the ability to
7
follow home care protocol and enrolled
in the 6-month recall program with sat-
isfactory clinical results.
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Corresponding author:
Dr Wei-Shao Lin DDS
Department of Oral Health and Rehabilitation
University of Louisville, School of Dentistry
501 S. Preston Street
Louisville, KY 40202
Fax: 502-852-1317
E-mail: WeiShao.Lin@Louisville.edu
Copyright © 2012 by the Editorial Council for
The Journal of Prosthetic Dentistry.

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