CLINICAL REPORT

Prosthetic management of an existing transmandibular

implant: A clinical report
Ramtin Sadid-Zadeh, DDS, MS,a Antigoni Stylianou, DDS, MS,b and Ruth Aponte Wesson, DDS, MSc

Transmandibular implants ABSTRACT

(TMIs) were developed in the
This report describes the prosthetic management of a fractured Dolder bar on a transmandibular
Netherlands by Dr Hans implant system. The patient declined surgical removal of the implants. Therefore, to repair the
Bosker during the mid-1970s. superstructure, a cast Dolder bar was fabricated and luted onto the existing transmandibular im-
TMIs were designed to over- plants. An implant-retained bar overdenture was then fabricated to rehabilitate the mandibular
come the difficulties associated arch. (J Prosthet Dent 2017;-:---)
with the reconstruction of
extensively atrophied mandibles (with bone heights less majority of reports.4,6,8,9 A few studies have directly
than 12 mm) without bone-grafting surgical proced- compared the TMI system with other implant systems.
ures.1-4 The TMI reconstruction system allows implant For example, results from a clinical trial of implant-
placement in the anterior interforamina region using an retained mandibular overdentures in patients with
extraoral and submental approach.5 Reconstruction with severely atrophied mandibles showed no statistically
TMIs is primarily indicated in patients with severe significant differences between the TMI, IMZ, and Brå-
mandibular atrophy; Type IV bone quality of the nemark implant systems after 1 year.10 In contrast, 6-year
mandible; a history of fracture or resection of the results from a multicenter clinical trial revealed that a
mandible; previously irradiated mandibular bone; or higher survival rate and clinical implant performance
previous failure and removal of other implant types, such were associated with the IMZ and Brånemark implant
as endosseous or subperiosteal implants.6 systems compared with the TMI system.11 Similarly,
TMIs are generally supported by a box-frame struc- short endosseous implants have been shown to perform
ture comprising a superstructure, baseplate, transosseous
posts, and cortical screws. Specifically, the baseplate is
secured to the inferior border of the mandible using 5
cortical screws with 4 transosseous struts that pass
through the alveolar crest and oral mucosa (Fig. 1).3,4 An
intraoral Dolder bar with 2 distal cantilevers is used to
connect the 4 transosseous posts. The overdenture is
secured to the Dolder bar segments of the superstructure
with retentive sleeves.3,7 TMI components are fabricated
from a corrosion-resistant alloy consisting of 70% gold,
5% platinum, 12.8% silver, and 12.2% copper (Implator;
Cendres et Métaux).4
Overall success rates of the TMI system have been
reported to range between 95.8% and 97.8% in the Figure 1. Transmandibular implant system.

a
Assistant Professor, Department of Restorative Dentistry, University at Buffalo School of Dental Medicine, Buffalo, NY.
b
Private practice, Paphos, Cyprus.
c
Associate Professor, Department of Head and Neck Surgery, Section of Oral Oncology and Maxillofacial Prosthetics, The University of Texas MD Anderson Cancer
Center, Houston, Texas.

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Figure 2. Presentation before treatment. A, Intraoral. B, Panoramic radiograph.
better than TMIs in patients with severely resorbed
mandibles.12
The incidence of reversible complications associated
with the TMI system has been reported to vary between
7.8% and 22.2%, and the number of complications has
been reported to be correlated with the level of experi-
ence of the surgeon or restorative dentist. Complications
reported included soft tissue hyperplasia around the
transosseous posts, loss of osseointegration, infrabony
pockets, postoperative infection related to skin grafts,
fenestration of implant threads, partial loss of integration
due to premature loading, and fracture of the posts.4,6,8,13
As a result of recent advances in implant systems and
bone grafting procedures, TMIs are rarely used. Thus,
management of complications associated with these
implant systems has not been adequately reported.
However, because of the high survival rate of this system,
failures and complications are likely to present a chal-
lenge to clinicians in the future. This clinical report il-
lustrates a step-by-step prosthetic approach for
managing a failed TMI superstructure through retreat-
ment of the superstructure and the implant-retained
prosthesis.
CLINICAL REPORT
An 80-year-old white woman presented to the Maxil-
lofacial Prosthetic Clinic at the University of Alabama at
Birmingham (UAB) School of Dentistry with a removable
implant-retained prosthesis. The patient had a fractured
bar on a TMI system (TMI Bosker) (Fig. 2) supporting an
ill-fitting mandibular overdenture and opposing a con-
ventional complete denture. Clinical and radiographic
evaluations revealed that the locknut and superstructure
thread were worn for 2 TMI implants, that the locknut
and sleeve were lost for the rest of the implants, and that
the superstructure of the TMI Bosker was fractured.
However, the fastener remained intact for all of the
implants, and the surrounding hard and soft tissues
were healthy. The implants had been placed in early
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1994 in the Oral and Maxillofacial Surgery Department
at UAB.
The patient was informed that the TMI Bosker parts
were no longer available. She was then given the option
of either having the existing implants removed with or
without placement of endosseous implants or of main-
taining the current implants with a newly customized
cast framework. The patient declined any surgical inter-
vention and consented to the fabrication of cast metal
housings connected by 3 Dolder bars. Therefore, the
definitive treatment plan included a maxillary conven-
tional complete denture and a new mandibular bar-
overdenture. The assembly was designed to be luted
onto the superstructure thread of the transosseous posts
and then onto the fasteners.
Preliminary impressions were recorded using irre-
versible hydrocolloid (Jeltrate; Dentsply Sirona) for the
fabrication of study casts in Type IV stone (Microstone;
Whip Mix Corp). The study casts were then used to
fabricate a custom open tray from light-polymerizing
acrylic resin (Triad; Dentsply Sirona) to facilitate defini-
tive impression procedures.
Before the definitive impression, a polyvinyl siloxane
(PVS) putty impression was used to record the super-
structure thread of the transosseous posts and fasteners.
Dowel pins and autopolymerizing acrylic resin (Pattern
Resin LS; GC America Inc) were used to fabricate replicas
of each transosseous post superstructure. A passive fit
custom impression cap was fabricated for each trans-
osseous post using autopolymerizing acrylic resin (SR
Ivolen; Ivoclar Vivadent AG) to serve as an impression
tray (Fig. 3). A circumferential retentive groove was
engraved on the superior portion of each cap to ensure
retention of the housings in the impression material.
Separate interconnecting bars were also fabricated to
connect the housings intraorally.
The open custom tray was used for border molding
with modeling plastic impression compound (GC America
Inc). The acrylic resin customized impression caps
were then connected intraorally with interconnecting
Sadid-Zadeh et al
- 2017
Figure 3. Custom impression cap for transosseous post.
Figure 5. A, Resin pattern on transosseous post linked with Dolder bar pattern. B, Cast bar on definitive cast.
bars using autopolymerizing acrylic resin (Pattern Resin
LS; GC America Inc). During this step, it was critical to
ensure passive fit of the assembly to control for possible
bending of the post during the recording of the
impression. A recording impression of the transosseous
posts was made using the assembled housing caps, and
PVS impression material (Monophase Aquasil;
Dentsply Sirona) was used according to the manufac-
turer’s recommended instructions. PVS impression
material (XLV Aquasil; Dentsply Sirona) was then
injected below the assembled housing cap (Fig. 4), and
the definitive impression was recorded (LV Aquasil;
Dentsply Sirona).
The dowel pins and autopolymerizing acrylic resin
(Pattern Resin LS; GC America Inc) were used to mold
the transosseous post on the definitive impression. The
definitive cast was then fabricated using Type IV dental
stone (Microstone; Whip Mix Corp), while the dowel pin
and resin were in the definitive impression. In order to
fabricate a cast bar on the posts, a separating agent was
applied to each post, and autopolymerizing acrylic resin
(Pattern Resin LS; GC America Inc) was applied to form a
Sadid-Zadeh et al
3
Figure 4. Recording impression from transosseous posts.
cap for each post. Dolder bar patterns (Attachments Intl)
were then used to connect the housings. The resulting
pattern was cast using a noble alloy (Lodestar; Ivoclar
Vivadent AG) (Fig. 5). A well-adapted closed impression
tray was fabricated on the definitive cast using an auto-
polymerizing acrylic resin (SR Ivolen; Ivoclar Vivadent
AG) to enable the pickup impression of the inter-
connected bar assembly.
In order to optimize the fit, the bar framework was
evaluated intraorally, sectioned, and laser welded
(Compact Laser Welding Machine; LaserStar Technolo-
gies Corp) in the dental laboratory. Three Dolder bar clips
(Attachments Intl) were placed on the bar. The bar was
then luted onto the transosseous posts with an interim
luting agent (Temp-Bond; Kerr Dental). The undercut
below each post was blocked with a light-polymerizing
material (Kool Dam; Pulpdent Corp), and the pickup
impression was recorded (LV Aquasil; Dentsply Sirona),
as shown in Figure 6. The impression material below the
Dolder bar was removed in the laboratory, and a second
definitive cast was fabricated using Type IV gypsum
(Silky-Rock; Whip Mix Corp) with the bar and clips on
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Figure 6. A, Bar luted with interim cement and ready for pickup impression. B, Pickup impression.

Figure 7. A, Bar luted intraorally. B, Processed base with Dolder riders.

the cast. A laboratory-processed base (Lucitone Clear; DISCUSSION

Dentsply Sirona) was fabricated, and the clips were
As a result of the relatively high success and survival
picked up in the base during the processing.
rates of the TMI system, clinicians are likely to encounter
The next clinical step required intraoral luting of the
failures and complications of these systems in the years
bar. First, the transosseous posts were isolated with a
ahead, likely involving prosthetic parts and superstruc-
rubber dam, and both the posts and the intaglio surface
tures. As a result of surgical and technical advances and
of the housings were airborne-particle abraded chairside
the subsequent successes of contemporary endosseous
with 50 mm Al2O3. Next, an alloy primer (Panavia F2;
implants, manufacturers may no longer produce parts
Kuraray Noritake Dental Inc) was applied to the abraded
for older implant systems, such as TMIs. As a result, for
surface, and the bar was luted to the post (Panavia F2;
this patient, we were faced with an interesting predic-
Kuraray Noritake Dental Inc) according to the manu-
ament. Considering the potential trauma and detri-
facturer’s instructions. Subsequently, the processed base
mental effects associated with surgical removal of these
was fitted intraorally and adjusted as needed for proper
implants, the patient instead consented to an individu-
fit and border extension (Fig. 7).
alized prosthodontic plan to repair the failing prosthetic
The maxillary complete denture and mandibular
parts.
implant-retained overdenture were fabricated using
conventional methods, and the teeth were set in bilateral
CONCLUSIONS
balanced occlusion. At the completion of treatment, oral
hygiene instructions were provided. The patient was This clinical report presents a description of a custom-
recalled at 48 hours and after 1 week with no further ized approach for repairing the superstructure of a
adjustments needed at that point. The patient was then TMI. No complications were observed after 1 year of
scheduled for recall visits every 6 months. follow-up.

THE JOURNAL OF PROSTHETIC DENTISTRY Sadid-Zadeh et al

- 2017
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Corresponding author:
Dr Ramtin Sadid-Zadeh
University at Buffalo School of Dental Medicine
3435 Main St, 215K Squire Hall
Buffalo, NY 14214
Email: rsadidza@buffalo.edu
Copyright © 2017 by the Editorial Council for The Journal of Prosthetic Dentistry.
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