Implant-tissue supported, magnet-retained mandibular overdenture for an edentulous patient with Parkinsons disease: A clinical report

Frederick C.S. Chu, BDS, MSc,a Fei L. Deng, DDS, MS,b Adam S.C. Siu, BDS, MDS,c and Tak W. Chow, BDS, MSc, PhDd Faculty of Dentistry, The University of Hong Kong, Hong Kong, China; Guanghua College of Stomatology, Sun Yat Sen University, Guangzhou, China
Degenerative neurologic disorders such as Parkinsons disease are becoming more prevalent as life expectancy is improved. Although the use of an implant-supported overdenture is an acceptable treatment modality, the clinician should recognize the indications and maintenance requirements of different attachment systems for individual patients. The use of a magnetic attachment system in an implantsupported mandibular overdenture for an edentulous patient with Parkinsons disease is presented. (J Prosthet Dent 2004;91:219-22.)

arkinsons disease is a neurologic disorder that results from the degeneration of dopamine-producing nerve cells in the brain, specically in the substantia nigra and the locus ceruleus.1 When 80% or more of the dopamine-producing cells are lost, symptoms such as rigidity, tremor and bradykinesia will appear because dopamine is the neurotransmitter that stimulates motor neurons for muscle control.2 When voluntary and involuntary muscle control of the oro-facial-pharyngeal muscles are compromised, difculty in mastication, dysphasia, and tremor of the mouth and chin may be encountered. Oral rehabilitation of the edentulous mandible in patients with symptomatic Parkinsons disease is particularly challenging to the clinician when the orofacial musculature is unable to stabilize the prosthesis. Use of implant-supported mandibular overdentures for edentulous patients with Parkinsons disease has been reported in the literature with satisfactory results.3,4 Although the implants may support the overdenture against occlusal loading, a suitable attachment system may also be used to provide good retention and stabilization of the prosthesis against functional dislodging forces. For patients with Parkinsons disease and with limited manual dexterity, the attachment system should also allow easy insertion and removal of the prosthesis and cleansability around the implant abutments. Although the bar-clip, ball-anchor, and custom-made telescopic system require a more precise path of insertion, the mandibular overdenture with a magnetic attachment may be more easily inserted by the patient or the patients caregiver. A photoelastic

Assistant Professor, Discipline of Oral Diagnosis, Faculty of Dentistry, The University of Hong Kong. b Associate Professor and Head, Department of Oral Implantology, Guanghua College of Stomatology, Sun Yat Sen University. c Private Practitioner, Central District, Hong Kong, China. d Associate Professor, Discipline of Oral Diagnosis, Faculty of Dentistry, The University of Hong Kong.

study demonstrated that when a denture was subjected to different loads, the absence of high foci of stress concentration between the attractive surface of magnet and the keeper resulted in low detrimental lateral stress acting on the implant.5 The effects of 3 attachment systems (bar-clip, ball attachment, or magnet) on peri-implant tissues in patients with implant-supported mandibular overdentures were studied.6 It was found that marginal bone loss and attachment level were not signicantly different among the systems.6 In a recent study, the maximum masticatory force and muscular activity obtained with mandibular overdentures retained by the 3 systems were also found to be similar.7 In terms of maintenance, a study compared ballanchor and magnet attachment systems in 25 patients with implant-supported mandibular overdentures over 4 years.8 The number of visits required per patient (6.8) for the ball-anchor was not signicantly different than the magnet group (8.7).8 In a study of 36 patients, the 5-year prosthetic aspects of mandibular overdentures supported by 2 implants with bar-clips, ball attachments, and magnets were compared.9 Although patient satisfaction was similar among groups during the observation period, the number of prosthetic complications of the magnets (n = 112) was higher than with the ball attachments (n = 81), and bar-clips (n = 22). Wear, corrosion, and exchange of the magnets frequently needed to be rectied. Loosening of abutment screws and exchange of the O-rings and O-ring retainers were encountered for ball attachments. The most common complication for the bar group was the need for reactivation of clips.9 Corrosion of the magnet was also reported to be the primary reason for denture replacement in another 5-year study of implantsupported, magnet-retained mandibular overdentures.10 Breakdown of the encapsulating material and diffusion of moisture and ions through epoxy seal were identied as the reasons for corrosion of the magnets tested.11 To avoid magnet corrosion, a manufacturer
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Fig. 1. Frontal view demonstrates severely resorbed edentulous residual ridges.

Fig. 2. Panoramic radiograph.

Fig. 4. Panoramic radiograph of implants and impression copings.

Fig. 3. Tomographs of anterior mandible with radiographic template in place.

(Aichi Steel Corp, Tokai City, Aichi, Japan) has used microlaser welding to provide a hermetic seal of the casing around the magnet.12 In a 19-month study, ball-anchors supported by 2 implants were found to have similar plaque scores, attachment levels, and bone loss when compared with interconnected bars supported by 2 or 4 implants.13 Although the complex maneuver of oss and gauze are not required for nonsplinted implant attachments, no signicant differences were reported in a study comparing the gingival health between splinted and unsplinted implants.14 However, an accurate impression and casting of a costly gold bar are necessary for the barclip attachment. There is also a high incidence of soft tissue hyperplasia associated with bars.15,16 In addition, although clips may require multivisit reactivation,17,18 the attractive forces of magnets may remain unchanged if well sealed. However, patients should be advised not to wear the overdenture with the magnets and return to the dentist for temporary retrieval of the keepers from the implants should magnetic resonance imaging be
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required, because the keepers are made of magnetizable steel and may interfere with signals.19 The following clinical report describes the treatment planning involved for the use of a magnetic attachment for an implant-supported mandibular overdenture. The essential clinical and laboratory procedures are illustrated.

CLINICAL REPORT
An 83-year-old woman was referred to Prince Philip Dental Hospital of the University of Hong Kong for an implant-supported prosthesis. She was diagnosed with Parkinsons disease 4 months previously and had had a mild stroke approximately a year earlier. Medication was prescribed by her physician for the 2 conditions, and she was medically stable. On examination, the patient presented with severely resorbed edentulous maxillae and mandible (Fig. 1). The existing complete dentures had been fabricated 2 years before, but the patient was unable to masticate with them. The denture extensions, occlusion, and occlusal vertical dimension of the dentures were satisfactory, but the mandibular denture was unstable during function.
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Fig. 6. Intaglio surface of overdenture showing 2 magnets. Fig. 5. Magnetic keepers on standard abutments.

To assess the quality and quantity of the bone in the anterior mandible, a panoramic radiograph and spiral tomographs (Scanora, Soredex; Orion Corp, Helsinki, Finland) were made (Figs. 2 and 3). A radiographic template was constructed for tomography by duplicating the existing mandibular denture and using lead foil as markers. Due to the severity of bone resorption and poor quality of bone, 4 7-mm- long implants of 3.5-mm and 4.0-mm diameter (TiUnite; Noble Biocare, Goteborg, Sweden) were placed under local anesthesia and intravenous sedation with 2 mg of midazolam. A soft diet20 and analgesics (Paracetamol 500 mg every 6 hours, when necessary) were prescribed, and the patient was asked not to wear dentures for 10 days after Stage I surgery. After removal of the sutures, the mandibular denture was regularly lined with a resilient liner (Coesoft; GC America, Alsip, Ill) until Stage II surgery, 3 months later. A vinyl polysiloxane impression (Exaex, GC America) was made 2 weeks after Stage II surgery, and standard abutments of suitable height were selected to allow the placement of magnetic keepers 1 mm above mucosa (Fig. 4). Magnetic keepers (Magt-IP-BF; Aichi Steel Corp) were screwed to the standard abutments with a torque of 32 Ncm, according to the manufacturers recommendation (Fig. 5). A new set of acrylic resin complete dentures was then fabricated with the transparent processed bases using the 2-stage processing technique.21 The patient was asked to return after a 1-week trial period unless a problem arose before the scheduled appointment. Two magnets were then attached to the mandibular denture with an autopolymerizing resin (Unifast Trad; GC America) using a direct transfer technique (Figs. 6 and 7). Wax (Occlusal indicator wax; Kerr, Orange, Calif) was carefully placed around the abutments to prevent the ow of resin into the undercuts. The patient then practiced inserting and removing the mandibular overdenture after the incorporation of magnets. No difculty was encountered. The patient was informed that
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Fig. 7. Frontal view of prostheses.

additional magnets could be attached if retention with 2 magnets was insufcient. However, the patient stated that the retention of the mandibular overdenture was satisfactory and the prosthesis could be removed without assistance. During a 12-month maintenance period, looseness of 1 magnetic keeper was found on 1 occasion. This did not recur after retightening. The patient was satised with the functional improvement achieved by the prostheses, and family members noted an improvement in the patients selection of foods.

DISCUSSION
Implants of 7 mm in length were placed because the severely resorbed mandible prevented the use of longer implants. Four of the short implants were placed to share the occlusal load in the anterior region and to avoid the possibility of further surgery should an implant fail to osseointegrate. According to the specications provided by the manufacturer, each magnet provided approximately 6 N of attractive force and the magnets were placed on the most distal implants. The magnitude of retentive force was adequate for this patient. Should a higher force be required, additional magnets could be added.
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Compared with the higher prole bar-clip or ball attachments, the vertical height required to accommodate a magnet assembly is only 2.3 mm, and this is an advantage for using magnets when the interocclusal space is limited. Magnetic attachments may be useful when the angulation and position of implants are less than ideal. The clinical and laboratory procedures involved are also straightforward.

SUMMARY
The implant-supported, magnet-retained mandibular overdenture may be suitable for edentulous patients, especially when a patients muscular control is adversely affected by a neurologic disorder.
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