Implant Overdentures

AMR ELKHADEM
PROFESSOR-PROSTHODONTICS CAIRO UNIVERSITY
Lecture outline
• Definition advantages and limitations
• Classification according to support
• Classification according to retention elements:
1. Studs
2. Magnets
3. Bars
• Planning for implant overdenture placement
• Prosthetic steps
 What is an overdenture?
Overdenture is any removable dental prosthesis that covers and rests on one or more
remaining natural teeth, the roots of natural teeth, and/or dental implant. It is one of the most
practical measures used in preventive dentistry.
Advantages of Overdenture
versus complete dentures
 Improved retention and stability
The use of implant-retained overdentures allow the use of mechanical retainers
commonly known as attachments instead of depending on the weak physical
means of retention which are usually ineffective with conventional dentures

A direct relationship has been shown between prosthesis retention and stability
and patient satisfaction

In fact, even with otherwise successful conventional complete denture treatment

in the mandible, it has been shown that it is possible to achieve a higher clinical
standard for success with the implant overdenture
 Improved masticatory function
Complete denture patients needed 1.5 to 3.6 times the number of chewing strokes compared with the
mandibular implant-retained overdenture patients

Most patients reported improved eating ability after implant utilization. In addition patients are capable to
chew more hard and fibrous food substrates when compared to conventional dentures
 Preservation of the residual bone
Evidence indicates that physiological residual ridge resorption occurs in the anterior edentulous mandible at
a rate four times greater than bone resorption occurring in the same location when dental implants have been
used

Longitudinal studies have shown that a mean yearly alveolar ridge height reduction of around 0.4 mm can
be expected in the edentulous anterior mandible resulting from physiological changes while 0.1 mm of
annual bone loss is expected around dental implants
 Improvement of oral sensory function
With the extraction of teeth the periodontal ligament containing the main receptors for tactile sensation and
pressure is lost with a subsequent decrease in the oral sensory function for completely edentulous patients

Jang and Kim studied the difference in oral sensory function between patients with natural dentition,
complete dentures and implant-supported prosthesis by detecting the thickness perception threshold and the
threshold to lateral pressure. They concluded that an osseointegrated root form implant helped towards
restoration of the oral sensory function

Jang K, Kim Y: Comparison of oral sensory function in complete denture and implant-supported prosthesis
wearers. J Oral Rehabil 2001;28:220-5
 Reduction of the prosthesis volume
The implant restoration allows for reduction of the prosthesis flanges and palatal coverage especially for
entirely implant-supported prosthesis which is a great benefit for new denture wearers, gaggers and patients
with tori or exostosis. Minimizing soft tissue coverage allows also for improved taste sensation
 Improved patient general satisfaction
Improved retention, masticatory efficiency, smaller prosthesis size contribute greatly to the
overall patient satisfaction

For this reason, the McGill consensus statement considered the 2-implant supported
mandibular overdenture the gold standard treatment for mandibular edentulism
Overdenture versus Fixed
implant prosthesis
 The use of less number of implants
Classical fixed full arch restoration requires minimally six
implants

A routine practice of using two inter-foraminal implants has

been encouraged by many authors. There are some articles
in the literatures that even described the success of
overdentures retained by a single symphyseal implant

The use of a fewer number simplifies the surgical

procedures and reduces the cost of the treatment
 Improved esthetics
Overdentures offer the advantage of obtaining better esthetics than fixed ceramo-metallic
restoration in patients with severe vertical bone loss in terms of reproducing the inter-dental
papilla and placing teeth in their ideal position

Overdentures also allow for restoration of the lost facial contour through its flanges which is not
applicable for cemented restorations
 Improved access to oral hygiene
The ability of the patient to
remove the prosthesis and
perform oral hygiene measures
around the implants and denture
hygiene measures is a major
advantage over fixed restoration
types
 Stress reduction
Overdentures offer the advantage of reducing the stress on the implants via the use of resilient
attachments that allow stress relief.

Furthermore, the ability of the patient to remove his denture at night eliminates the possible
stresses due to nocturnal parafunctions
 Reduced cost
It has long been generally regarded that the 3 modalities for the treatment of the edentulous
mandible [conventional complete denture, implant-retained overdenture and fixed implant-
supported mandibular prosthesis] have a linear cost progression from the least to most costly,
due to the increased number of implants used and the increased prosthodontic complexity
required for the fixed implant supported prosthesis
Drawbacks of overdentures compared to
fixed implant restorations
 Maintenance requirements
Implant-retained overdentures have shown to require frequent maintenance especially during
the first year of service when compared to fixed restorations

The need for maintenance was reported for all attachment types. Maintenance includes
reactivation or replacement of the attachment components, corrosion with subsequent rapid
loss of retention and extreme wear of some magnet systems, and the need for prosthesis
relining in implant-mucosa supported prosthesis
 Space requirement
The mandibular overdenture requires 12 mm or more starting from the implant shoulder to the
level of the occlusal plane

This is required to cross the mucosal thickness, place the abutment and retainer for solitary
attachment or to place the bar at its retainer whether a clip or a stud attachment with sufficient
space between the undersurface of the bar and the mucosa to allow for proper hygiene and
finally to place a prosthesis with sufficient thickness to resist fracture
 Patient desire
It may be the main disadvantage of mandibular overdentures. Patients often require a fixed
prosthesis to feel that the teeth are an integral part of their mouth which can not be achieved
through a removable prosthesis
 Types of overdentures according to support
Implant-supported overdentures:
The entirely implant-supported prosthesis utilizes in most cases four or more implants to provide total
support for the prosthesis. The mucosa does not contribute to any load sharing. A distally extended
cantilever bar had also been advocated to maximize the retention of the distal component.

Implant-mucosa supported (assisted)overdentures:

The implant-mucosa-supported prosthesis depends on the idea of load sharing between the implants and
the mucosa of the distal extension. In most cases it utilizes fewer number of implants usually two
interforaminal implants
 How much load do both implants and
mucosa bear?
It mainly depends on the movement allowance of the overdenture.
As the overdenture is allowed to move vertically and rotate more load
is transferred to the mucosa and less to the implants and vice versa
Misch classified the movement prosthesis movement (PM) and the
consequent load support in to PM0, PM2, PM3, PM4, and PM6
 Types of overdenture according to support

Acc. To Misch
RP4 RP5
Entirely Implant supported Implant mucosa supported
How much load goes to implant and to the soft tissue?

Mainly implant supported??

Non quantified
Mainly mucosa supported?? terms
Implant assisted ??
 Prosthesis movement grading
In PM0 the prosthesis shows no movement under function and it requires implant support
mechanics similar to that of fixed restorations

In PM2 the prosthesis is allowed to perform a hinge like movement in two planes

In PM3 the prosthesis is allowed to perform hinge like movement as well as tissue ward vertical
movement

In PM4 the prosthesis is allowed to move in the mesial, distal, facial and lingual directions

In PM6 the prosthesis is allowed to hinge and move in six directions.

Defining the support type according to the
degree of allowed denture movement
PM0
PM2
PM3
PM4
PM6
 The degree of prosthesis movement does not
depend on the attachment type only but on the
implant distribution
Attachments for implant overdentures
1. Stud attachments
▪ Ball attachments
▪ Low profile attachments
▪ Magnets
2. Bar attachments
3. Telescopic attachments
 What are stud attachments?
Are short projection type of retention mechanism projecting
from a root or implant to retain overdentures
Advantages of studs
1. Ease of fabrication compared to other types
2. Offers universal flexibility when properly distributed
3. Ease of patient handling and oral hygiene around them
4. Ease of maintenance
 Classification
Precision types:
The parts are provided with precisely machined parts that are bonded to the
root structures (with no casting procedure)

Semi precision types:

Provided as castable parts with ready made retention caps. The castable
parts are waxed with tooth coping toobtain a single custom attachment that
is cemented to the teeth
 Common types of studs
1. Ball attachment
2. Intra radicular types
3. Locator/equator
 Ball Attachments
The most common type of radicular
attachments
The male portion is a ball shaped projection
attached to the root with a neck serving as an
undercut for the female that is fixed to the
denture
The female might be:
o Rubber O rings
o A nylon flexible cap
o A split metal cap
 Limitation of ball attachments
Classical ball attachments with o rings are very sensitive to
parallism. The O-rings are relatively stiff and if more than 10
degrees of deviation between attachment exist it becomes difficult
to use it and the wear rate increases significantly

Nylon caps allow for more angular flexibility

Some systems offer the possibility of aligning the caps instead of

making the males parallel to overcome this problem
 Locator attachments
One of the most common attachments nowadays. Manufactured originally by
Zest Anchor
It can be considered as a combined extra and intra radicular type as the female
gain retention from both the outer body an inner hole
The design allow greater angular flexibility than ball attachments
 Magnetic attachments
The magnet system used for overdenture retention incorporates the magnet which is
either a neodymium-iron-boron alloy or a cobalt-samarium alloy (Co5Sm) into the
overdenture.

The second part of the magnet system is the ferromagnetic keeper which is screwed
onto the implant.

Also, the system involves a plastic magnet analogue to be used during the processing of
the denture to avoid loss of magnetism that occurs when magnets are exposed to heat
 Advantages of magnets
The main mechanical advantage of retaining an overdenture with a magnet is that
the horizontal loads acting on the implants during function are eliminated where the
breakaway forces are strongest in the vertical direction, while little resistance is
offered to the lateral forces, thus dissipating potentially damaging lateral forces.

Also, magnets allow some freedom as regards to the path of insertion when the
implants are not parallel

Furthermore, it is much easier for the patients to place the prosthesis in the mouth
and to locate the magnets on the implants which are advantageous for those
patients whose dexterity and eyesight are poor or for handicapped patients
 Disadvantages of magnets
The lack of long term durability due to intra-
coronal corrosion.

Patients with magnetic retention complain from

a clicking noise during eating as the denture
base shifts away from its foundation and then
becomes reseated
 Bar overdentures
A technique to splint implants together for
overdenture constructions

The bar serves mainly for denture support

Bars may be rigid (bar unit) or resilient (bar joint)

The bar may provide direct retention through clips

or may hold a resilient stud attachment on top of
the bar or at its distal part
 Bar attachment
Advantages of bars over solitary attachments:
1. Lower maintenance costs (Walton, 2003; Stoker et al, 2007)
2. Less attachment fatigue leads to better long term retention
3. Can easily accommodate diverging or labially inclined implants
4. Anterior support is provided with the bar extension when the implants are placed to far
posteriorly or when the arch is severely tapered.
5. Since the implants are splinted together there is less chance of implant overload.
 Resilient bar design
In cross section the “Hader” bar is a complete circle and permits the
denture to rotate around it.
This is an implant assisted type tissue bar design. When posterior
occlusal forces are applied, the denture rotates around the bar. As
a result the posterior occlusal forces are supported by the buccal
shelf and retromolar pad.
The anterior forces are supported by the tissue bar. Hence support
is shared between the implants and the denture bearing surfaces.
The bar provides retention and stability for the denture.
Resilient bars (Hader)
 Hader bar design
The anterior, or incisal forces are borne by the implants while the posterior
occlusal loads or born by the primary denture support areas (retromolar
pad and the buccal shelf).
Resilient bars (Dolder bar joint)
Spaced bars with resilient attachment
Rigid bars
Resilient versus Rigid Dolder
bar
Bar with retentive clip (rider)
Bars with studs on bar top
Bars with distal ERA attachment
Bar with combined clips and attachment
Milled bars with pins or locks