Periodontal disease, tooth extractions, rehabilitation of the oral cavity, installation of implants, preparation of a bar denture and a full-arch denture (false teeth)

Our male patient aged 62 reported to our clinic with the following complaints:

  • He had not reported for a dental check-up in years and suspected a problem with his old bridges.
  • Some of his teeth were sensitive while others were decidedly sore on bite.
  • He felt the bridges under his teeth were loose.
  • He complained of foul breath.
  • He was genuinely frightened and wanted to come to grips with problem was and see how it could be tackled.

Images on the initial condition:

At the first consultation session a panoramic radiograph was produced and the condition of the teeth thoroughly assessed.

Unfortunately his teeth proved beyond repair and had to be removed due to a large extent of horizontal and vertical bone resorption. The natural teeth, or preps, beneath his old bridges were “awash” with pus (chronic periodontitis) and became dental foci. Had his periodontal disease been treated several years earlier and the sub- and supragingival tartar removed at least twice a year, his gums, teeth and jawbone would not have fallen into such a state of disrepair.

During the first treatment session all 16 of his teeth were extracted and his mouth was cleansed of all dental foci. The gums were sealed with sutures, the removal of which was due 7 to 10 days after the intervention. An immediate denture was prepared in order for the patient to have teeth, be able to smile and eat, and have self-confidence without his quality of life being compromised during the healing period of at least 3 months.

What to know about immediate dentures?

Thorough cleaning is also important with immediate dentures. The denture should be removed after each meal and cleaned with a denture brush and food remains stuck beneath should be removed. The oral cavity should also be rinsed gently but thoroughly.

  • Patients are advised to remove dentures overnight, clean them and store them in a well-ventilated area, ensuring that the wound in the mouth can “breathe” and heal.
  • In the course of healing the anatomic relations are constantly changing. A few weeks on the denture will not fit the same way, it may swing or go loose seeing as the initial swellings recede in a few days causing the denture to go loose. Such instances may necessitate a reline at our clinic as the denture is also at a risk for breakage.
  • If wearing the denture causes your gum to crack see our clinic immediately as this may easily be helped. The treatment may continue after 3 to 4 months’ healing.

Pictures of the extracted teeth

The extracted teeth, only one third of which was in the bone. The unappealing, black tartar beneath the gums (subgingival tartar) is readily seen

The removed bridge together with the teeth and the enormous pocket of pus (dental focus). His old bridges came off along with the teeth with nothing to hold them, they were “swamped” with pus. Huge amounts of tartar have appeared on the root apex with a pocket of pus

A molar following extraction, covered in tartar up to the root apex. This is the kind of tartar that builds up underneath the gums, if the bone is resorbed and periodontal pockets form around the root canal.

A molar following extraction, covered in tartar up to the root apex. This is the kind of tartar that builds up underneath the gums, if the bone is resorbed and periodontal pockets form around the root canal.

The mandible immediately after the extraction of teeth and the “cleansing” of the bone with tensionless sutures placed in


Following tooth extractions the patient leaves with an upper and lower immediate denture.

The immediate dentures in the mouth following tooth extractions

Second treatment phase, implant surgery (3 workdays)

Following 4 months’ healing time a CBCT (Cone beam computed tomography) scan was recorded to examine the residual bone mass prior to implant surgery. Our patient’s financial means only allowed for 4 implants to be installed in the mandible which would support a bar-retained denture whereas the upper jaw would accommodate a complete removable overdenture without implants. The upper jaw was perfectly suited for a stable and well-fitting complete overdenture owing to the vacuum effect induced between the palate and the denture. With the mandible there is no sufficiently large surface to induce an adequate vacuum effect. Owing to the constant movement of the tongue, masticatory muscles, mimic muscles a stable denture can only be achieved by means of implants.

The upper jaw ridge following 4 months’ healing

The lower jaw ridge following 4 months’ healing

CT scan in which the residual bone mass of the lower jaw bone can be examined in 3 dimensions, based on which the size and location of the implants can be assigned. The height of the bone in the lower region exceeded 15 mm and its width measured almost 7 mm, which qualify as very good parameters.

Following instalment the stability of the implants exceeded 30 Ncm, the exposed gum was therefore sealed with gingiva formers straight away. The provisional denture was relined as per the altered anatomic relations to ensure comfortable wear.

It is important to minimise the wearing time of provisional dentures following a bone graft and/or the placement of implants. Patients are advised only to wear the provisional dentures at work or at places where they are supposed to talk and smile. At home provisional dentures should be removed immediately. Please keep the denture and the mouth clean and see that the implanted/bone grafted area is not exposed to pressure and that the provisional denture does not “wiggle” on the implants.

Pressure exerted by the denture decreases blood circulation, hinders healing and may cause cracking, infection or, worst of all, the rejection of the implant, however well the implant was installed.

Follow-up radiograph following the placement of the 4 implants, with gingiva formers (aka. healing abutments)


The soft reline of the provisional denture:

Step 1: Roughening the surface of the dentures in contact with the gums with a drill to achieve the best possible adhesion of the reline material to the denture. In case of gingiva formers the denture has to be milled at the location of the gingiva formers to prevent it from wiggling and exposing the gingiva formers to pressure.

Step 2: Degreasing the surface of the dentures.

Step 3: Spreading glue on the roughened surfaces

Step 4: The admeasurement, mixture and filling of the reline material into the denture

Step 5: The denture filled with reline material is placed inside the mouth and the patient is requested to bring the denture into occlusal position until the reline material bonds (approx. 5 minutes)

Step 6: With the reline material having bonded the dentures were removed from the mouth. It is readily seen in the pictures below that the material perfectly blends in with its environment without contrasting with the colour thereof. The denture is now fully in line with the altered anatomic relations, comfortable to wear and stable. The material having spilt over the edges of the denture can easily be trimmed away with a pair of scissors.

In the process of healing the anatomic relations constantly change. The reline made at the time of the operation will not provide the same stability several months later as it did initially. It is important to make sure that the denture does not wiggle on the implants and gingiva formers (healing abutments) as this puts the denture at a risk for injury, let alone the fact it adversely affects the healing process. The pressure exerted by a loose denture may dislodge the implant in a few weeks. In such cases patients are advised to wear the denture for as short a time as possible. If a new reline is feasible, that may help, but it means repairs and additional costs to be incurred by the patient. As a temporary fix, denture glues may also be considered.

Unfortunately there is a contingency that very big lobes need to be formed with a lot of bone drilled away, and hence the reline of the old denture becomes unfeasible following bone graft or implant surgery. In such instances a new provisional denture is recommended.

The fabrication of the permanent tooth repalacements (10 workdays)

This was the longest of all treatment sessions. Precision impressions were taken of the implants using closed tray impression copings. An impression was taken of the maxilla with oroplastic impression material (EX 3N Gold) in order to fabricate the most stable and most accurate denture. This material softens in response to mouth temperature and assists in the ideal edge contouring of dentures whilst the patient is making movements with their mouth. Following impression taking a gnathological treatment was due in which bite registration was performed with an articulator for the dental technician to see the appropriate joint position of the jawbones on occlusion and design the dentures accordingly.

During the framework trial fitting the finished bar is put in position, that is, screwed onto the implants to verify the accuracy of the framework.

Denture trial fitting is performed to verify aesthetics and proper occlusion of the teeth.

Our patient was content with the treatments, participates in regular check-ups and tartar removal, which is condition for warranty. A few weeks on, eating, speech and smile would be perfectly restored and self-confidence regained, and the patient would feel free to mingle with people. The first 8 days following hand-over of the finished work is a difficult period during which the patient should read out aloud, talk and eat so that the natural function of the muscles, tongue and the temporomandibular joint is restored at the earliest. This process usually takes two months.

It is supremely important to keep the denture clean. You are advised to remove it after each meal and clean it thoroughly. The implant and the bar too have to be cleaned thoroughly with a tooth brush and toothpaste, Super Floss and an interdental brush.


Implant tooth replacement need the same, if not more attention, care and follow-up as crowns and bridges retained by natural teeth do. Regular follow-up is also a condition for warranty. Oral hygiene and the longevity of the implants are closely related.

Picture of the implant deep inside the bone and the beautiful gum contour formed by the gingiva formers/healing abutments.

Closed tray impression copings inside the mouth by means of which precision impressions were taken of the implants.

Follow-up panoramic radiograph with the closed tray impression copings.

Function impression taken with a custom impression coping using oroplastic material Ex 3 N Gold of the edentulous maxilla

Closed tray precision impression of the lower implants

Gothic arch registration procedure with the asymmetrical arrow point clearly indicating an inhibition of the forward movement of the left mandibular condyle

Face bow transfer from the maxilla

The plastering of the upper master cast into the articulator with the help of a facebow transfer for the dental technician to see the position of the maxilla

Adjustment of the articulation of the master cast of the mandible into the correct joint position using the Gothic arch tracing

With the use of wax templates the length of the teeth and occlusal height are determined. The middle line, the position of the lips in a steady state and smiling position, and the width of the nose are marked

The finished wax templates following the adjustment of occlusal height, the determination of the middle line and smile line in the articulator

The bar designed for 4 implants and the artificial gum on the master cast.

During the denture trial fitting, teeth are embedded in red wax to examine aesthetics and the appropriate occlusion of teeth. At the denture trial fitting the dentist can move around the teeth at the patient’s request and can perform whatever slight aesthetic modification is necessary. Following the denture trial fitting the patient “nods in approval” and the dental technician may begin the fabrication of the permanent denture

Bottom view of the bar denture at the denture trial fitting with the dolder bar clasps

The finished upper metal plate overdenture (removable denture) with a unique rim finish

The permanent lower bar-retained denture for 4 implants on the master cast

Part of the bar of the lower bar denture on the gypsum cast

Bottom view of the finished lower bar denture with dolder bar retention

The finished upper full denture (false teeth) and the lower bar denture in the mouth:

Follow-up panoramic radiograph of the lower bar