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An Interocclusal Recording Method for the Fabrication of Full-Arch Implant-

Retained Restorations

Article  in  Journal of Oral Implantology · April 2012

DOI: 10.1563/AAID-JOI-D-11-00232.1 · Source: PubMed

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CLINICAL

An Interocclusal Recording Method for the Fabrication of

Full-Arch Implant-Retained Restorations
Gregory-George Zafiropoulos, DDS, Dr.Dent, Dr.habil1*
Aiman Abdel Galil, Dipl.Dent.Techn2
Giorgio Deli, DDS, MD3

The prosthetic rehabilitation of full arches with implants requires exact impression and bite registration. In this
report, we describe the application of a simple method that uses a duplicate of the full denture as a mounting
guide, which allows the accurate recording of the maxillomandibular relationship and bite registration while
expediting this process for the treating dentist. Case reports of 2 patient are used to illustrate this method,
which is independent of the implant system used, can be applied for both fixed and removable restorations, and
reduces chair time.

Key Words: implant denture, interocclusal distance, maxillomandibular relationship, implant

prosthodontics, implant prosthetic

INTRODUCTION interocclusal relationship, occlusal recording, and

esthetic factors used initially to produce the full

A
full denture is usually delivered after
tooth extraction or implant insertion in
a fully edentulous arch and is used
until the final restoration is performed.
A well-designed full denture should
fulfill the following criteria: (1) correct vertical height
and maxillomandibular relationship; (2) accurate
occlusion; (3) appropriate choice of teeth with
regard to shape, length, width, and position; (4)
adequate lip support; and (5) proper function and
esthetics that meet the patient’s expectations. The
final restoration should fulfill or surpass these
requirements. Obtaining a correct impression and
accurately evaluating the interocclusal relationship
(eg, interocclusal distance, occlusal recording, and
determination of the exact position of the placed
implants) are often challenging and time-consum-
ing tasks.1,2
In this case report, we describe the use of an
easy and reproducible technique that allows the
1 1; Figure 2b), and the appropriate retention element
Dental Center Blaues Haus, Dusseldorf, Germany, and Division
of Periodontology, Catholic University, Rome, Italy.
2
Dental Center Blaues Haus, Dusseldorf, Germany.
3
Division of Periodontology, Catholic University, Rome, Italy.
* Corresponding author, email: zafiropoulos@prof-zafiropoulos.de
DOI: 10.1563/AAID-JOI-D-11-00232
denture to be transferred as a template for the
fabrication of the final full-arch implant retained
fixed or removable restoration.
CASE REPORTS
Case 1
An 80-year-old male nonsmoker in good general
health, who was not regularly taking any medica-
tion or drug, was referred for implant placement
and mandibular prosthetic restoration in February
2010. After extraction of multiple mandibular teeth
that had been rendered unsalvageable by advanced
periodontal disease, a denture was fabricated
(Figures 1a through b and 2a). Tooth 18 was
temporarily retained until the fabrication of the final
restoration to stabilize the denture through an
Akers clasp (Figure 1c). For additional stabilization
of the denture, 2 provisional implants with ball
attachments were placed in areas 22 and 24 (Table
was embedded into the denture’s base.
Four months after the extraction sites had
healed and denture sores were eliminated, the
function and esthetics of the denture were opti-

Journal of Oral Implantology 357

Interocclusal Recording for Full-Arch Implant-Retained Dentures

FIGURES 1 AND 2. FIGURE 1. Case 1: full denture in situ. (a) Front view. (b) Right view. (c) Left view showing Akers clasp. FIGURE 2.
Case 1. (a) Orthopantomograph before implant placement. (b) Orthopantomograph after implant placement.

FIGURES 3 AND 4. FIGURE 3. Case 1. (a) Duplicate denture (DentDu). (b) DentDu in situ during try-in. FIGURE 4. Case 1 impression
system. (a) Left: titanium impression post (mounted on the implant) and Right: plastic impression sleeve. (b) Impression
sleeve left in the impression material. (c) Composite-embedded in vitro section of the impression system.

358 Vol. XL /Special Issue / 2014

 Zafiropoulos et al

TABLE 1
Implant characteristics
Case Position Diameter (mm) Length (mm) Implant Placement Design / Line*
1 20 3.75 11.5 Axial Screw cylinder / soft bone line
1 21 3.75 11.5 Axial Screw cylinder / soft bone line
1 22 2.8 13 Axial Provisional with ball attachment
1 24 2.8 13 Axial Provisional with ball attachment
1 25 3.3 11.5 Axial Screw cylinder / soft bone line
1 28 3.75 11.5 Axial Screw cylinder / soft bone line
1 29 3.75 11.5 Axial Screw cylinder / soft bone line
1 30 4.5 11.5 Axial Screw cylinder / soft bone line
2 4 3.75 13 Angulated 358 angle from the vertical axis Screw cylinder / soft bone line
2 6 3.75 11.5 Axial Screw cylinder / soft bone line
2 7 3.75 11.5 Axial Screw cylinder / soft bone line
2 9 3.75 11.5 Axial Screw cylinder / soft bone line
2 11 3.75 11.5 Axial Screw cylinder / soft bone line
2 14 3.75 13 Angulated 358 angle from the vertical axis Screw cylinder / soft bone line

*Dentegris, Duisburg, Germany.

FIGURE 5. Case 1. (a) Ball attachments mounted on implants 20 and 29. (b) Ball attachment 1 week after implant ucovering.
(c) Positioning the duplicate denture (DentDu) over the ball attachments and retention elements. (d) Retention element
embedded in the DentDu.

Journal of Oral Implantology 359

Interocclusal Recording for Full-Arch Implant-Retained Dentures
FIGURES 6 AND 7. FIGURE 6. Case 1. (a) Bite registration using the duplicate denture. (b) Buccal view and (c) Interior basal view
of the element embedded in the patient’s denture base. FIGURE 7. Case 1. (a) Master cast. (b) Laboratory ball attachment
mounted on the implant analog in the master cast. (c) Placement of the duplicate denture on the articulator.
mized. The angulation, shape, and color of the
denture teeth and the shape of the denture base
were corrected where necessary. Six screw-cylinder
dental implants (Dentegris, Duisburg, Germany;
Table 1) were placed in positions 20, 21, 25, and
28–30 using a 2-stage protocol. The patient used
the resulting denture until the final restoration was
delivered. In this case, a fixed, cemented, implant-
retained denture was planned for the final restora-
tion of the mandible.
Two months after placement, the implants were
uncovered, the healing abutments were placed, and
the denture was modified to allow sufficient space
for the healing abutments. A duplicate denture
(DentDu) was fabricated from clear resin (Paladur,
Heraeus, Hanau, Germany) and tested; minor
occlusal discrepancies were corrected, and the
DentDu was modified carefully in the area of the
healing abutments to create internal clearance
(Figure 3a and b).
The closed-tray impression technique was used
in the present case. The impression was made using
a polyether material (Impregum, 3M ESPE, St Paul,
Minn) and a transfer system consisting of a titanium
impression post and a plastic impression sleeve
(closed-tray system, Dentegris; Figure 4a through c).
360 Vol. XL /Special Issue / 2014
At the same clinical session, 2 ball attachments
(Dentegris) were positioned on implants 20 and 29
and torqued to 35 Nm (Figure 5a and b). A window
was carefully created on the buccal side of the
DentDu in the area of implants 20 and 29 to provide
access to the ball attachments (Figure 5c). The
retention elements (matrices) were mounted on the
ball attachments and fixed to the DentDu with
modeling resin (Pattern Resin, GC, Alsip, Ill; Figure
5d), and bite records were taken in centric occlusion
(Figure 6a). The ball attachments were left mounted
on the implants, and retention elements were fixed
onto the patient’s denture as described previously
(Figure 6b and c). Provisional implants 22 and 24, as
well as tooth 18, were then extracted, so that the
denture was retained on the 2 ball attachments.
A master cast was then fabricated, and 2
laboratory ball attachments were positioned on
implant analogs 20 and 29 on the master cast
(Figure 7a and b). The DentDu was placed on the
master cast and retained with the laboratory ball
attachments and retention elements (matrices) at
positions 20 and 29. The casts were mounted on an
articulator using the DentDu with the bite records
as a mounting guide (Figure 7c). A silicon key from
the DentDu was then fabricated using a matrix of C-
 Zafiropoulos et al

FIGURE 8. Case 1. (a) Fabrication of a silicon key. (b) Silicon key for the selection of the implant abutments. (c)
Orthopantomograph showing the mounted implant abutments.

silicone (Zetalabor, Zhermack SpA, Badia Polesine,
Italy). The dental technician used this key to
determine the parallelism, angulation, position,
and shape of the implant abutments (Figure 8a
and b). The metal framework was milled from a titan
5 alloy (Zenotec Ti Disc, Wieland, Pforzheim,
Germany) and veneered with microceramic com-
posite (Ceramage, Shofu, Ratingen, Germany).
During the next clinical session, the 2 ball
attachments at positions 20 and 29 were removed
and the implant abutments were positioned on the
implants and torqued to 35 Nm (Table 2). The
denture was fixed using provisional cement (Im-
plant Provisional, Alvelogro Inc. Snoqualmie, Wash;
Figure 8c and Figure 9a through d).
Case 2
A 52-year-old male nonsmoker in good general
health, who was not regularly taking any medica-
tion or drug, was referred for implant placement
and maxillary prosthetic restoration in June 2010.
The patient’s maxillary teeth had been extracted by
a restorative dentist due to advanced periodontal
disease, and a full denture had been mounted
(Figure 10a). The patient had undergone surgical
and periodontal treatment of the mandible 1 year
previously, and the mandibular teeth, for example,
implants, had been restored with fixed partial
dentures. For the restoration of the maxilla, the
fabrication of a removable, implant-retained, pala-
tal-free denture with telescopic crowns as attach-
ments was scheduled.1
Six screw-cylinder dental implants (Dentegris;
Table 1) were placed in positions 4, 6, 7, 9, 11, and
14. A 2-stage protocol was used for implants 6, 7, 9,
and 11, and a 1-stage protocol was used for
implants 4 and 14. Because the patient refused
sinus augmentation, implants 4 and 14 were placed
at a 358 angle from the vertical axis. System-specific
prefabricated titanium abutments (DAAS angulated
abutment, Dentegris) were mounted on implants 4
and 14, torqued to 35 Nm, and covered with
system-specific healing caps (DAAS healing cap,
Dentegris). The denture was modified carefully in
the areas 4 and 14 to create internal clearance
(Figure 10b and c).

TABLE 2
Flow of procedures for the full-arch restoration with an implant retained denture using a duplicate denture (DentDu)
Clinical Laboratory
Step Treatment Session Session
1 Implant uncovering and impression taking for DentDu fabrication 1
2 DentDu fabrication 1
3 a. Try-in of DentDu 2
b. Impression taking
c. Positioning of the ball attachments on the implants and fixation of the
matrices into the denture
d. Fixation of the matrices into the DentDu and taking of bite records
4 Fabrication of the framework and the attachments (in cases of removable denture 2
design)
5 Try-in of the framework 3
6 Veneering 3
7 Mounting of the final restoration 4

Journal of Oral Implantology 361

Interocclusal Recording for Full-Arch Implant-Retained Dentures

FIGURE 9. Case 1. Final restoration of the mandible in situ and old maxillary telescopic denture with new veneering. (a) Front
view. (b) Right view. (c) Left view. (d) Orthopantomograph.

Five months after the placement and uncovering
of implants 6, 7, 9, and 11, a DentDu was fabricated,
2 ball attachments were mounted on implants 6
and 11 (Figure 11a and b). All subsequent clinical
steps were performed as described previously
(Figures 12 through 14).
DISCUSSION
The reconstruction of a fully edentulous arch with
implant-retained dentures requires thorough plan-
ning and precise estimation of the interocclusal
relationship. Accurate recording of the maxilloman-
dibular relationship is a prerequisite for achieving
proper occlusion and a successful treatment out-
come.2,3 In the cases described here, the initially
delivered denture allowed for the correction of the
interocclusal relationship, tooth shape and color,
and angulation throughout the healing period. In
this way, the patient could become acclimated to
the function and esthetics of the denture. By using a
duplicate of this denture to take bite records and
use as a mounting guide, the maxillomandibular
relationship was recorded and transferred accurate-

FIGURE 10. Case 2. (a) Full denture in situ. (b) Duplicate denture in situ during try-in. (c) Orthopantomograph after implant
placement.

362 Vol. XL /Special Issue / 2014

 Zafiropoulos et al

FIGURES 11–14. FIGURE 11. Case 2. (a) Ball attachments mounted on implants 6 and 11. (b) Retention element embedded in
the duplicate denture. FIGURE 12. Case 2. (a) Bite registration using the duplicate denture (DentDu). (b) DentDu mounted on
the articulator. FIGURE 13. Case 2 final restoration in situ. (a) Front view. (b) Right view. (c) Left view. FIGURE 14. (a)
Orthopantomograph showing the mounted implant abutments. (b) Orthopantomograph showing the mounted implant
abutments.

Journal of Oral Implantology 363

Interocclusal Recording for Full-Arch Implant-Retained Dentures
ly, and the esthetic outcome previously accepted by
the patient was achieved. Thus, it was not necessary
to repeat the usual clinical recordings (eg, centric
relation, occlusal vertical dimension, tooth position,
and esthetics, wax try-in) at the time the final
restoration was fabricated.4 Additionally, the com-
bined use of the DentDu and the silicon key allowed
for the selection of implant abutments (prefabricat-
ed or customizable) that were the optimal angula-
tion and shape and facilitated the fabrication of an
esthetically pleasing implant-supported restoration.
In case 1, mandibular reconstruction with a fixed
cemented denture was scheduled. One tooth was
temporarily retained, and a provisional implant was
placed; both increased the stability of the mandib-
ular denture and the patient’s comfort. The use of
provisional implants is not mandatory, depends on
the anatomic situation, and is the responsibility of
the treating dentist.
In case 2, maxillary reconstruction with a
removable denture using telescopic crowns as
attachments was scheduled.1,5 The 2 posterior
implants were placed at an angle of 358 from the
vertical axis. This angulation should not be consid-
ered a limitation of the method presented here;
axially placed implants may also be used. Of course,
the number of implants used will vary depending
on the design of the scheduled removable denture.
Because this report was focused on the clinical
recording technique and the transfer of the
template to the final restoration, the surgical
protocols, impression techniques, and laboratory
procedure for denture fabrication were not de-
scribed and/or discussed. The selection of impres-
sion technique (open or closed tray), final restora-
tion design (fixed screw-retained, fixed cemented,
removable), and implant system is the responsibility
of the surgical/restorative team and is not influ-
364 Vol. XL /Special Issue / 2014
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enced by the method described in this report. The
disadvantages of this technique include the re-
quired skill level of the dental technician and the
additional cost of the ball attachments for the
patient. However, in addition to the benefits
described here, the use of this technique reduced
overall cost (because clinical recordings and labo-
ratory procedures were not repeated) and required
chair time (Table 2). The main factors influencing
the final outcome are the accuracy of the first
denture fabrication after tooth extractions and its
adjustment for optimal restoration during the
healing period.
CONCLUSION
The method described herein allows for the
accurate transfer of the occlusal relationship,
vertical dimensions, and implant position while
facilitating the full-arch restoration process and
reducing the amount of chair time needed.
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2. Ghazal M, Albashaireh ZS, Kern M. The ability of different
materials to reproduce accurate records of interocclusal relation-
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3. Ganddini MR, Schejtman N, Ercoli C, Graser GN. Prosth-
odontic application for implant carriers. J Prosthet Dent. 2004;92:
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4. Kaufman M, Cranin AN, Sayed A, Ley J, DeGrado J, Banton B.
A modified occlusal registration and implant transfer technique. J
Oral Implantol. 1996;22:258–262.
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