Experts Agree: Standard of Care for a Lower Denture Is Two Implants for Retention

The standard of care for the edentulous mandible (no lower teeth) should be the two-implant retained mandibular over-denture (IRMOD).

A survey of U. S. prosthodontic academic experts determined the following opinions:

• Consensus that the IRMOD was superior in 9 of 10 parameters assessed:  retention, stability, speech, chewing efficiency, comfort while eating soft foods and hard foods, confidence in intimate situations, satisfaction and self esteem. 

Conclusions:  An implant retained mandibular overdenture vs. a complete denture only is the first choice of care when restoring an edentulous mandible of a healthy patient or a patient with mild systemic disease.  

Robert G. Tupac, DDS, FACP, Inc., Diplomate, American Board of Prosthodontics
5060 California Ave., #170
Bakersfield, CA 93309
(661) 325-1275 |

17-year Implant Bridge Success

Today I had the privilege of seeing a 63 year old patient I treated 17 years ago.  She had her teeth removed when she was 20 years old, and for the last 30 years before I treated her had been unable to wear a lower denture.  She was very thin, had digestive problems due to a poor diet and had become a recluse because she was reluctant to leave the house and be out in public with a collapsed face. We placed four lower implants and, according to the original Branemark protocol, fabricated a mandibular fixed implant supported bridge.  Now she dances three nights per week and has a healthy glow about her.  She joked that she has to watch her weight because she can eat anything on the menu.


Robert G. Tupac, DDS, FACP, Inc., Diplomate, American Board of Prosthodontics (661) 325-1275 | www.drtupac.com 5060 California Ave., #170, Bakersfield, CA 93309

When Retreatment Is Necessary

For a healthy individual with good oral hygiene, dental implants are predictably successful and survival rates above 90-95% are reported.  This patient reported he was not comfortable wearing an upper denture, so he had four dental implants placed with a screw-retained prosthesis.  Unfortunately, he was not in good health, being a diabetic, having untreated hepatitis-C, and chronic sinusitis.  On a temporary basis, he now wears a temporary denture that holds onto the remaining single implant as his health status improves.  After that, we will examine and discuss his treatment options and alternatives.


Robert G. Tupac, DDS, FACP, Inc., Diplomate, American Board of Prosthodontics (661) 325-1275 | www.drtupac.com 5060 California Ave., #170, Bakersfield, CA 93309

Baby Boomers: Your New Denture Is A Facelift

Teeth vs Denture

People with their natural teeth have all the esthetic advantages over denture patients.  Their jaws are fully developed and their back teeth maintain the height of their bite, therefore keeping the height of the lower third of their face in proportion with their midface and forehead.  Their front teeth supply the lips and corners of their mouth with support.

Bone Loss

When you lose your teeth, all that changes.  The removal of teeth results in loss of half of the bone that supported them in two years or less!  Patients say their gums shrink, but it is really the bone underneath their gums that is receding.  The upper jawbone shrinks up and back, and the front teeth of an upper denture move in the same direction, causing loss of lip support, deteriorating muscle tone and more wrinkles.  The lower jawbone shrinks down and back, and the lower front teeth recede accordingly.  The upper and especially the lower jaws in the back shrink also, and the height of the bite of the dentures becomes "closed."  All of these changes create that characteristic "denture look"--one of facial collapse.  For the denture wearer, looking in the mirror daily, it isn't as noticeable (like watching your hair go gray), but the changes are dramatic and can best be seen in photographs over time.

If this has happened to you, then you are ready for your facelift with a new set of dentures.  A new set of dentures will recapture the height of your bite, place the front teeth where the natural ones used to be in order to reestablish lip and cheek support, eliminate wrinkles. and make the lower third of your face more in proportion with the rest of your face.  The new set of dentures is what makes those looking at you unable to know you wear dentures!

We love to do create new, younger looks for our denture patients!

Robert G. Tupac, DDS, FACP, Inc., Diplomate, American Board of Prosthodontics (661) 325-1275 | www.drtupac.com 5060 California Ave., #170, Bakersfield, CA 93309

All-on-4: Implant-Retained Fiixed Bridge Succes for Denture Patients

Dr. Robert Tupac participated in an All-on-4 presentation at the NobelBiocare headquarters in Yorba Linda, California given by Dr. Ken Parrish.  This technique has been developed to maximize the use of available bone and to allow for immediate function.  Tilted posterior implants are placed to optimize anterior-posterior spread to provide a fixed prosthesis that has enough posterior teeth for bite support and effective chewing.  Dr. Tupac has personally performed this treatment, with great success, on more patients, over the last several years, than any other prosthodontist in the Central Valley.  This technique also allows the patient to go from wearing a removable complete denture to having implants and a temporary fixed bridge in a single appointment.  For more information, visit Dr. Tupac's website www.drtupac.com or call the office at 661-325-1275.

Robert G. Tupac, DDS, FACP, Inc., Diplomate, American Board of Prosthodontics (661) 325-1275 | www.drtupac.com 5060 California Ave., #170, Bakersfield, CA 93309

Why Denture Wearers Want Implants

Reasons denture wearers want implants:  

• They miss eating their favorite foods.  
• They want to order from the entire menu.  
• They are tired of worrying whether their teeth will pop out.  
• They are sick and tired of adhesives.  
• They want to appear younger and have better facial structure.  
• They want more functional teeth.  
• They want the self-confidence from knowing their teeth are secure.  
• They want to preserve their jawbone from further shrinkage. 

Robert G. Tupac, DDS, FACP, Inc., Diplomate, American Board of Prosthodontics (661) 325-1275 | www.drtupac.com 5060 California Ave., #170, Bakersfield, CA 93309

Considerations When Having Your Teeth Removed

People Without Teeth  

In the United States, people without teeth (complete edentulism) make up 26% of the population between the ages of 65 and 74.  Under World Health Organization criteria, these people are considered disabled because of their inability to eat and speak effectively.  

Result of Tooth Loss

The chief result of tooth loss is the diminished quality and quantity of the residual jawbone.  Without a properly functioning masticatory system, nutrition suffers and overall health is likely to decline.  This physical impairment is also associated with systemic factors--including osteoporosis, hypertension and coronary arterydisease, smoking and asthma, diabetes, neuropathy and dementia, rheumatoid arthritis, certain cancers and a decline in one's general satisfaction with life. 

Denture wearers should keep their overall health in mind, particularly their ability to maintain a balanced and nutritional diet.  They should see their prosthodontist often to keep their dentures well-fitting to minimize bone loss, tissue irritation, and functional problems.  

Patients who are contemplating removal of their natural teeth need to be aware of the potential systemic conditions that are associated with tooth removal and tooth loss.  

Robert G. Tupac, DDS, FACP, Inc., Diplomate, American Board of Prosthodontics (661) 325-1275 | www.drtupac.com 5060 California Ave., #170, Bakersfield, CA 93309

Our Procera Laser Scanner Is State-of-the-Art

Procera Laser Scanner

Since getting the latest generation NobelBiocare Procera Laser Scanner two and a half years ago, we have been making custom abutments on all of the dental implants we have placed.  With custom abutments, optimal contours and tissue emergence profile is achieved, far beyond what is possible with stock abutments.  

The Key Benefit of the System

The scanner also has the ability to scan an entire arch, and we do it in a three stage manner.  First the implant positions are scanned, then the soft tissue contours are scanned over the implant positions and finally a diagnostic waxup of the final positions of the teeth is added.  By doing all of this, we are able to design the bars within the shape of the final prosthesis--whether it is a bar around which an All-on-4 fixed prosthesis is to be processed or an overdenture  tissue bar such as this one, to which the denture will snap into the locator attachments incorporated in the bar.  

We have found that the finest and most current computer technology enables us to provide the most accurate and durable prostheses for our patients. 

Robert G. Tupac, DDS, FACP, Inc., Diplomate, American Board of Prosthodontics (661) 325-1275 | www.drtupac.com 5060 California Ave., #170, Bakersfield, CA 93309

Your Sore Palate Under Your Denture

Denture stomatitis is a common and longstanding problem for removable denture wearers.  It is found to a greater or lesser extent in about 45% of the denture wearing population, according to studies.  It is an inflammation of the palatal tissue, that can be localized to slight area, involve the entire area of tissue covered by the denture, or be severe enough to create a bubbly, shiny surface.

While many things may contribute to the condition:  poor oral hygiene, wearing the denture at night, trauma, smoking, systemic conditions, allergic reactions to denture materials, and bacterial and fungal infections, the general consensus is that a denture that shows a lack of adaptation (that has poor retention or poor stability) is a cause always present.  As always, since the bone and soft tissues under dentures are shrinking over time, it is important to keep your dentures relined to fit as well as possible to keep your mouth healthy.

Robert G. Tupac, DDS, FACP, Inc., Diplomate, American Board of Prosthodontics (661) 325-1275 | www.drtupac.com 5060 California Ave., #170, Bakersfield, CA 93309

Prosthodontists Plan the Teeth Before the Implants

Wouldn't it be horrible if you had dental implants successfully placed and then couldn't have teeth on top of them?  You think it couldn't happen, but we've often seen unusable, misplaced implants.  That's why a prosthodontist should be the one to plan your implant therapy, because the final teeth have to be designed first and then the implants placed to facilitate the prosthesis.  Even in the case of a single tooth implant, the restorative requirements come first:  how much vertical space is there for the abutment and the tooth, what are the bite requirements, what does the tissue look like so the implant crown can emerge from the gums like a natural tooth?  These factors dictate where and how the implant must be placed, and also often which implant is most appropriate.  As more teeth become involved, the planning becomes more three dimensional.  What are the forces that will be applied to the new teeth?  How many implants are necessary for replacement of the multiple missing teeth?  How can you be sure implants don't end up between tooth positions?  Implants supporting a full arch fixed bridge, or a denture with a bar or attachments, are the most complicated.  What is the height of your bite?  Where do your teeth come together?  Where do the teeth need to be?  When the tooth position is determined, then how much volume or dimension of the prosthesis is necessary to have a restoration that is durable and long lasting?  How are the implants to be spread out, in what positions, at which angles?  Planning for teeth on implants needs to be made from the "top down", so when you know where the teeth are going to go, the implant foundation can be appropriately established.  Your Board Certified Prosthodontist is best suited to plan your implant treatment. 

Robert G. Tupac, DDS, FACP, Inc., Diplomate, American Board of Prosthodontics (661) 325-1275 | www.drtupac.com 5060 California Ave., #170, Bakersfield, CA 93309

Implant Tissue Bar

LH wanted dental implants to help stabilize and retain his upper denture.  He had the required bone of adequate quality and quantity.  After using radiographic markers to determine implant position with a surgical guide, four implants were placed.  After the implants were ready to restore, according to Osstell Resonance Frequency measurements, they were connected with a tissue bar.  Limited occlusal clearance and the labial position of the anterior teeth required attachments be placed on the palatal aspect of the bar.  Because the overdenture is opposed by natural teeth, a cast superstructure strengthens the overdenture and supplies housings for the nylon attachments.  At 5 year recall, bone levels are excellent and the patient reports he is pleased with his ability to eat, the stability of his appearance and the durability of the prosthesis.

Robert G. Tupac, DDS, FACP, Inc., Diplomate, American Board of Prosthodontics (661) 325-1275 | www.drtupac.com 5060 California Ave., #170, Bakersfield, CA 93309

17-year Implant Bridge Success

Today I had the privilege of seeing a 63 year old patient I treated 17 years ago.  She had her teeth removed when she was 20 years old, and for the last 30 years before I treated her had been unable to wear a lower denture.  She was very thin, had digestive problems due to a poor diet and had become a recluse because she was reluctant to leave the house and be out in public with a collapsed face. We placed four lower implants and, according to the original Branemark protocol, fabricated a mandibular fixed implant supported bridge.  Now she dances three nights per week and has a healthy glow about her.  She joked that she has to watch her weight because she can eat anything on the menu.

Robert G. Tupac, DDS, FACP, Inc., Diplomate, American Board of Prosthodontics (661) 325-1275 | www.drtupac.com 5060 California Ave., #170, Bakersfield, CA 93309

Implant Options for Denture Patients

Bar structure

In the top radiograph, six upper implants (the ones on the sides tilted backwards) and their distribution allows them to be joined by a bar structure that has teeth attached to it and the hybrid bridge is permanently screwed in place.  It can only be removed in the prosthodontic office.  The prosthesis is more like a row of teeth, has minimal soft tissue coverage, and derives all of its support from the implants.  This prosthesis is most like having your natural teeth back again.

Tissue bar

In the bottom radiograph, four upper implants are joined by a tissue bar.  The resulting prosthesis is called a tissue bar overdenture--it is a removable prosthesis that attaches with clips or snaps to the bar for stability and retention when in place, but can be taken out to allow the implants to be brushed and cleaned.  The prosthesis is horseshoe shaped (open in the center of the palate) but does cover the ridge and adequate lateral tissue for additional support.  Sometimes, when there has been a lot of bone shrinkage, the removable prosthesis allows teeth to be better placed for lip and cheek support, esthetics and phonetics.

Implants options

You don't like your complete upper denture and would like to have some implants.  What are your options?  They depend on the amount of available bone you have remaining and the dimensions in your mouth (clearance for your bite, the sizes of the structural components of the prosthesis, and proper arrangement of teeth) that are required.

Robert G. Tupac, DDS, FACP, Inc., Diplomate, American Board of Prosthodontics (661) 325-1275 | www.drtupac.com 5060 California Ave., #170, Bakersfield, CA 93309

Your Prosthodontist Knows About Lupus

Lupus is a chronic inflammatory disease that can affect various parts of the body, especially the skin, joints, blood and kidneys.  Approximately 95% of lupus patients suffer from some form of oral involvement.  The oral complications are either directly related to the disease or come about as a side effect of medical treatment.  Lupus patients may suffer from the following mouth symptoms: dry mouth, cracked lips, bleeding gums, sore jaws, gingivitis (gum disease), cracked or swollen tongue, lesions (ulcers) on any soft tissue surface including the cheeks, lichen planus and yeast infections. Denture wearers are more susceptible to soft tissue irritation and sore spots. Lupus patients should make sure their dentist has experience and knowledge of lupus and autoimmune diseases and takes a full medical history and updates the list of your medications regularly. 

Source:  Lupus Guide to Dental Care by HeatherGalusha-Phillips

Robert G. Tupac, DDS, FACP, Inc., Diplomate, American Board of Prosthodontics (661) 325-1275 | www.drtupac.com 5060 California Ave., #170, Bakersfield, CA 93309

Upper Teeth In A Day

Dr. Tupac has performed "Teeth In A Day" procedures over the last seven years.  In the beginning, with the 3i Implant system DIEM protocol, and presently with the NobelBiocare guide system.

NobelGuide is a treatment procedure which allows a patient to be treated from no teeth to a fixed bridge of teeth in one appointment.  Starting from wearing an upper full denture, this patient had a CT Scan of his upper jaw. By applying NobelGuide Procera software to the scan, the anatomy of his upper jawbone was visualized in three dimensions, allowing virtual placement of dental implants with a computer program. In addition to planning implant placement, the computer program facilitated creation of a clear surgical guide, to be used for "flapless" implant placement. The temporary fixed bridge was fabricated in advance of the surgery also, so the bridge was placed at the same time as the implants.  This technique is predictable because the planning has revealed the anatomy under the soft tissue.  The resulting bridge enables immediate function with a beautiful esthetic result, the patient having gone from a removable complete denture to an implant supported fixed bridge in one appointment.

Robert G. Tupac, DDS, FACP, Inc., Diplomate, American Board of Prosthodontics (661) 325-1275 | www.drtupac.com 5060 California Ave., #170, Bakersfield, CA 93309

Lower Teeth In A Day

Using a surgical guide fabricated from a virtual computer surgery done on a CAT Scan, five dental implants were placed in this lower jaw and the lower denture converted to a temporary screw-retained fixed bridge at the same appointment.  This technique is called "Teeth In A Day," and is one of many dental implant options Dr. Tupac provides his patients.

Robert G. Tupac, DDS, FACP, Inc., Diplomate, American Board of Prosthodontics (661) 325-1275 | www.drtupac.com 5060 California Ave., #170, Bakersfield, CA 93309

Mandibular Fixed Implant Supported bridge

Recently I had the privilege of seeing a 63 year old patient I treated 17 years ago. She had her teeth removed when she was 20 years old, and for the last 30 years had been unable to wear a lower denture.  She was very thin, had digestive problems due to a poor diet and had become a recluse because she was reluctant to leave the house and be out in public with a collapsed face. We placed four lower implants and, according to the original Branemark protocol, fabricated a mandibular fixed implant supported bridge.  Now she dances three nights per week and has a healthy glow about her.  She joked that she has to watch her weight because she can eat anything on the menu.

Robert G. Tupac, DDS, FACP, Inc., 
Diplomate, American Board of Prosthodontics
(661) 325-1275 | www.drtupac.com
5060 California Ave., #170, Bakersfield, CA 93309 (map)