Implant supported overdentures/dental courses

Implant supportedImplant supported
overdenturesoverdentures
INDIAN DENTAL ACADEMYINDIAN DENTAL ACADEMY
Leader in continuing Dental EducationLeader in continuing Dental Education
www.indiandentalacademy.comwww.indiandentalacademy.com

IntroductionIntroduction
The dental profession and theThe dental profession and the
public are more aware of thepublic are more aware of the
problems associated with aproblems associated with a
removable complete dentureremovable complete denture
(mandibular). The insertion of(mandibular). The insertion of
implants for retention stability &implants for retention stability &
support of an overdenturesupport of an overdenture
contributes a more favorablecontributes a more favorable
environment for restoration.environment for restoration.

IntroductionIntroduction
This is also an ideal treatment modality toThis is also an ideal treatment modality to
begin a learning curve in implant dentistry.begin a learning curve in implant dentistry.
There is more lenience in implantThere is more lenience in implant
positioning or prosthesis fabrication with apositioning or prosthesis fabrication with a
implant overdenture. Hence one of theimplant overdenture. Hence one of the
most beneficial treatments rendered tomost beneficial treatments rendered to
patient is also the best introduction for apatient is also the best introduction for a
dentist into the discipline of implantdentist into the discipline of implant
dentistry.dentistry.

TREATMENT CONSIDERATIONS
On the basis of the available literature, the following
clinical treatment concepts should be considered:
1. The mandibular overdenture
retained by implants in the
interforaminal region appears to
maintainbone in the anterior
mandible.
2. In younger patients or those
edentulous for less than 10 years, a
fixed implant denture may preserve
posterior bone better than an implant
overdenture in the mandible.

3. Although reports are conflicting,
patients with mandibular implant
overdentures may experience
a loss of fit of their antagonist denture.
Occlusal schemes with no anterior
contact in the centric
relation position and minimal anterior
contact in excursions may reduce the
combination syndrome effect.
Frequent recalls to assess.

4. It appears that retention, stability,
and chewing ability improve only
slightly with an implant supported
mandibular overdenture as compared
with an implant-mucosa–supported
overdenture.
5. Multiple implants can be
recommended for the mandibular
overdenture when sensitive jaw
anatomy, increased occlusal forces,
or high retention needs are present
or when implant length is <8 mm or
implant width is <3.5 mm.

6. When 2 implants are used in the
anterior mandible to retain an
overdenture, solitary ball attachments
appear to be less costly, less
technique sensitive, and more
accommodating of tapered arches.
However, ball attachments seem to
be less retentive
than the bar design.www.indiandentalacademy.comwww.indiandentalacademy.com

7. The use of immediately loaded implants
in the anterior mandible for the overde
nture design is a promising treatment
concept.
8. Overdentures retained by 2 implants in
the anterior mandible appear to
demonstrate a higher burden of
maintenance during the first year than in
subsequent years. Controversy persists
as to whether the ball or bar design
requires more maintenance.

9. There appears to be no
statistical difference when long-
term maintenance is compared
among mandibular implant
overdentures retained by 2
implants in contrast to those
retained by 3 or more implants.

10. Mandibular implant overdentures
appear to show higher patient satisfaction
scores than complete dentures, even with
patients who have undergone
preprosthetic surgery.
11. Patients appear to be similarly
satisfied with a fixed implant complete
denture or a removable implant
overdenture on the mandible. Patients
who rate stability more important than
hygiene tend to choose a fixed
prosthesis. www.indiandentalacademy.comwww.indiandentalacademy.com

12. When the anchorage system
or number of implants is varied,
there may be no significant
differences in satisfaction with
moderately resorbed edentulous
patients restored with mandibular
implant overdentures.

Effect of aging poplationEffect of aging poplation
The increase in life expectancy hasThe increase in life expectancy has
drastically increased the population ofdrastically increased the population of
elderly people . It is projected that in nextelderly people . It is projected that in next
50 years the 65 yr old individual50 years the 65 yr old individual
population would be more than 20% of thepopulation would be more than 20% of the
population.population.
The age is the indicator of tooth lossThe age is the indicator of tooth loss

Anatomic consequences ofAnatomic consequences of
edentulismedentulism
 Decreased width & height of supporting boneDecreased width & height of supporting bone
 Prominent mylohyoid & internal oblique ridgeProminent mylohyoid & internal oblique ridge
 Progressive decrease in keratinised mucosaProgressive decrease in keratinised mucosa
 Forward movement of prosthesis from anatomicForward movement of prosthesis from anatomic
inclinationinclination
 Thinning of mucosa,with sensitivity to abrasionThinning of mucosa,with sensitivity to abrasion
 Loss of basal boneLoss of basal bone
 Increase in size of tongueIncrease in size of tongue

Esthetic consequencesEsthetic consequences
Prognathic appearancePrognathic appearance
Decrease in horizontal labial angleDecrease in horizontal labial angle
Thinning of lipsThinning of lips
Deepening of nasolabial grooveDeepening of nasolabial groove
Facial wrinkle increaseFacial wrinkle increase
Decrease in facial heightDecrease in facial height
Loss of muscle toneLoss of muscle tone
Witch’s chin appearanceWitch’s chin appearance

Advantages of implant supportedAdvantages of implant supported
overdenturesoverdentures
Prevents bone lossPrevents bone loss
Maintain facial estheticsMaintain facial esthetics
Reduce or eliminate prosthesis movementReduce or eliminate prosthesis movement
Eliminates soft tissue abrasionEliminates soft tissue abrasion
Improve chewing efficiencyImprove chewing efficiency
Increase occlusal forcesIncrease occlusal forces
Improves prosthesis stability,retentionImproves prosthesis stability,retention
Improved speechImproved speech

Reduce denture sizeReduce denture size
Require fewer implants comparedRequire fewer implants compared
to fixed prosthesisto fixed prosthesis
Eliminates extensiveEliminates extensive
surgeries,grafting etcsurgeries,grafting etc
Requires less specific implantRequires less specific implant
placementplacement
Esthetics better than fixedEsthetics better than fixed
prosthesisprosthesis

Better hygeineBetter hygeine
Removable by patientRemovable by patient
Repair easyRepair easy
Require short appointments,Require short appointments,
reduced laboratory fees, fewerreduced laboratory fees, fewer
implantsimplants
Overall cost reducedOverall cost reducedwww.indiandentalacademy.comwww.indiandentalacademy.com

DisadvantagesDisadvantages
Patients desire for fixed prosthesisPatients desire for fixed prosthesis
Difficult to fabricate in reduced inter archDifficult to fabricate in reduced inter arch
space situationsspace situations

Diagnosis and treatmentDiagnosis and treatment
planningplanning

Medical evaluationMedical evaluation
Thorough general medical evaluation isThorough general medical evaluation is
absolute necessary before implantabsolute necessary before implant
treatment.streatment.s
Cvs, Cns, respiratory system,digestive ,Cvs, Cns, respiratory system,digestive ,
endocrine, hemopoietic,allergies, bones &endocrine, hemopoietic,allergies, bones &
joints, neoplasm,joints, neoplasm,
Pt with debilitating sysytemic disordersPt with debilitating sysytemic disorders
are contraindicated.are contraindicated.

Diagnostic imaging and techniquesDiagnostic imaging and techniques
Preprosthetic implant imaging-identifyPreprosthetic implant imaging-identify
diseae,determine bone quality quantity,diseae,determine bone quality quantity,
implant position and orientationimplant position and orientation
Surgical and interventional implantSurgical and interventional implant
imaging- to determine the position ofimaging- to determine the position of
implant placed,graft siteimplant placed,graft site
Post prosthetic imaging - to evaluate thePost prosthetic imaging - to evaluate the
status of the implant , adjacent bonestatus of the implant , adjacent bone

Imaging modalitiesImaging modalities
Periapical radiographyPeriapical radiography
Panoromic radiographyPanoromic radiography
Occlusal ‘’ ‘’Occlusal ‘’ ‘’
Cephalometric ‘’ ‘’Cephalometric ‘’ ‘’
TomograpyTomograpy
ComputedComputed

tt

Division of available boneDivision of available bone
Available bone height , width,Available bone height , width,
length, angulation, crown –length, angulation, crown –
implant body ratioimplant body ratio
A-A- abundant , >5mm width,abundant , >5mm width,
13mm ht, 7mm lt, <30 deg angle,13mm ht, 7mm lt, <30 deg angle,
C/I = <1C/I = <1
Root form wide diameter implantRoot form wide diameter implant

BB
2.5-5 mm width, 1o-13 mm ht,2.5-5 mm width, 1o-13 mm ht,
>12mm lt <20 angulation,>12mm lt <20 angulation,
C/I = <1C/I = <1
Osteoplasty, augmentation,Osteoplasty, augmentation,
narrow implant,narrow implant,

CC
Unfavourable width, ht ,length,Unfavourable width, ht ,length,
Osteoplasty, augmention, narrow implantOsteoplasty, augmention, narrow implant
DD
Severe atrophy , basal bone loss, flatSevere atrophy , basal bone loss, flat
maxilla, pencil thin mandiblemaxilla, pencil thin mandible
augmentationaugmentation

Bone densityBone density
A key determinant for success.A key determinant for success.
Strength of bone = bone densityStrength of bone = bone density
Bone contact amnt, modulus of elasticityBone contact amnt, modulus of elasticity
and axial stress contours are affected byand axial stress contours are affected by
bone density.bone density.
Treatment plan , implant no & size , shoudTreatment plan , implant no & size , shoud
be modified according to bone densitybe modified according to bone density

BONE TYPEBONE TYPE

Treatment sequenceTreatment sequence
Initial appointmentInitial appointment
Medical ,dental history, dental & x-rayMedical ,dental history, dental & x-ray
evaluation, diagnostic casts , CT scan etcevaluation, diagnostic casts , CT scan etc
Confirmation appointmentConfirmation appointment
Diagnostic wax up, final Rx plan, consentDiagnostic wax up, final Rx plan, consent
forms, picture of existing conditionforms, picture of existing condition
Presurgical restorative appointmentPresurgical restorative appointment
Caries removal, periodontal therapy, try in ofCaries removal, periodontal therapy, try in of
transitmplational denture, surgical guidetransitmplational denture, surgical guide
templatetemplate www.indiandentalacademy.comwww.indiandentalacademy.com

Implant surgery- stage 1 implantImplant surgery- stage 1 implant
placementplacement
Healing phase-Healing phase-
Stage 2- secondary permucosal extensionStage 2- secondary permucosal extension
,initial loading,initial loading

PROSTHODONTIC PHASEPROSTHODONTIC PHASE
Initial abutment preperation andInitial abutment preperation and
impressionimpression
Try in dentureTry in denture
Final denture deliveryFinal denture delivery
MAINTENANCEMAINTENANCE
Radiographs, examination, homeRadiographs, examination, home
instructions, mediactions etcinstructions, mediactions etc

Classification of completeClassification of complete
edentulous arches in implantedentulous arches in implant
dentistrydentistry

TypeType 11
In the Type I edentulous archIn the Type I edentulous arch
the division of bone is similarthe division of bone is similar
in all three anatomicin all three anatomic
segments. Therefore foursegments. Therefore four
different categories of Type Idifferent categories of Type I
edentulous arches areedentulous arches are
present.present. www.indiandentalacademy.comwww.indiandentalacademy.com

Type I Division AType I Division A
 The ridge hasThe ridge has
abundant bone inabundant bone in
all three sections.all three sections.
The patient mayThe patient may
use as many rootuse as many root
forms as needed,forms as needed,
and whereverand wherever
desired, to supportdesired, to support
the final prosthesis.the final prosthesis.

It is more unusual to haveIt is more unusual to have
enough posterior height inenough posterior height in
either the maxilla or mandibleeither the maxilla or mandible
to permit osteoplasty toto permit osteoplasty to
improve the division. Thereforeimprove the division. Therefore
if posterior implants areif posterior implants are
needed, narrow implants areneeded, narrow implants arewww.indiandentalacademy.comwww.indiandentalacademy.com

Type I Division BType I Division B
 The edentulous ridgeThe edentulous ridge
has adequate bone inhas adequate bone in
all 3 sections in whichall 3 sections in which
to place narrowto place narrow
diameter root formdiameter root form
implants. It isimplants. It is
common practice tocommon practice to
change the anteriorchange the anterior
section of bone bysection of bone by
osteoplasty to a Div Aosteoplasty to a Div A
and to place full-sizeand to place full-size
root form implants inroot form implants inwww.indiandentalacademy.comwww.indiandentalacademy.com

Type I Division C-wType I Division C-w
 Type I Division C-wType I Division C-w
edentulous archesedentulous arches
have inadequatehave inadequate
bone width forbone width for
implantation. If theimplantation. If the
patient desires anpatient desires an
implant-supportedimplant-supported
removable prosthesis,removable prosthesis,
an osteoplasty mayan osteoplasty may
convert the ridge toconvert the ridge to
C-h. The treatmentC-h. The treatment
plan then follows aplan then follows awww.indiandentalacademy.comwww.indiandentalacademy.com

Type 1 div C-hType 1 div C-h
 requires anrequires an
autogenous onlayautogenous onlay
graft in the C-w archgraft in the C-w arch
to restore the ridge toto restore the ridge to
Division A. Type IDivision A. Type I
Division C-hDivision C-h
edentulous arches doedentulous arches do
not present all thenot present all the
essentialessential
requirements forrequirements for
predictable long-termpredictable long-term
implant support forimplant support for
fixed prostheses . Anfixed prostheses . An
implant-supportedimplant-supported
removable prosthesisremovable prosthesis
is often indicated tois often indicated towww.indiandentalacademy.comwww.indiandentalacademy.com

Type I Division DType I Division D
the mostthe most
challenging tochallenging to
traditional andtraditional and
implant dentistry .implant dentistry .
If implant fail? in aIf implant fail? in a
Type I Division DType I Division D
patient, pathologicpatient, pathologic
fractures or almostfractures or almost
unrestorableunrestorable

 Yet these are the patients whoYet these are the patients who
need the most help for support ofneed the most help for support of
their prosthesis. The benefitstheir prosthesis. The benefits
versus risks must carefully beversus risks must carefully be
weighed for each patient.weighed for each patient.
Endosteal implants may beEndosteal implants may be
placed in the anterior mandible.placed in the anterior mandible.

Type 2Type 2
In the Type 2 completely edentulousIn the Type 2 completely edentulous
arch, the posterior sections of bonearch, the posterior sections of bone
are similar but differ from the anteriorare similar but differ from the anterior
segment. The most common archessegment. The most common arches
in this category present less bone inin this category present less bone in
the posterior regions, under thethe posterior regions, under the
maxillary sinus, or over themaxillary sinus, or over the
mandibular canal than in the anteriormandibular canal than in the anterior
segment in front of these Structures.segment in front of these Structures.www.indiandentalacademy.comwww.indiandentalacademy.com

 These types ofThese types of
edentulous ridges areedentulous ridges are
described in thedescribed in the
completely edentulouscompletely edentulous
classification with twoclassification with two
Division letters followingDivision letters following
Type 2, with the anteriorType 2, with the anterior
segment being listed firstsegment being listed first
because it oftenbecause it often
determines the overalldetermines the overall
treatment plan.treatment plan.

 Therefore a mTherefore a maandiblendible
with Division Bwith Division B
between foraminabetween foramina
and Division c distaland Division c distal
to the mandibularto the mandibular
foramen is calledforamen is called
Type 2 DivisionB,CType 2 DivisionB,C
arch. The anteriorarch. The anterior
region is often theregion is often the
only segment used foronly segment used for
implant support.implant support.

 The Type 2 DivisionThe Type 2 Division
A, B arch hasA, B arch has
posterior sections thatposterior sections that
may be treated withmay be treated with
narrow-diameternarrow-diameter
implants, whereas theimplants, whereas the
anterior section isanterior section is
adequate for largeradequate for larger
diameter root formdiameter root form
implants to supportimplants to support
the prosthesisthe prosthesis

Type 3 ArchType 3 Arch
In this the posterior section ofIn this the posterior section of
maxilla or mandible differ frommaxilla or mandible differ from
each other . Less commoneach other . Less common
condition. Found more frequentlycondition. Found more frequently
in maxilla than mandiblein maxilla than mandible
Anterior bone volume is firstAnterior bone volume is first
listed then rt post followed by leftlisted then rt post followed by left
posteriorposterior www.indiandentalacademy.comwww.indiandentalacademy.com

Type 3 Div A,B,DType 3 Div A,B,D
 Has abundantHas abundant
anterior bone (A),anterior bone (A),
moderate bone inmoderate bone in
post rt (B), severepost rt (B), severe
atrophy in the left postatrophy in the left post
region (D)region (D)
 Sinus graftingSinus grafting
required in maxilla.required in maxilla.
 In mand additionalIn mand additional
implant in ant sectionimplant in ant section
with cantilever .with cantilever .

Type 3 Div C,D,CType 3 Div C,D,C
 Ant section C, severeAnt section C, severe
atrophy on one sideatrophy on one side
of postof post
 In mand subperiostealIn mand subperiosteal
implant indicated.implant indicated.
 In maxilla sinus graftIn maxilla sinus graft
& subnasal elevation& subnasal elevation
indicatedindicated

OVERDENTUREOVERDENTURE TREATMENTTREATMENT
OPTIONSOPTIONS
There are 5 treatment optionsThere are 5 treatment options
for mandibular overdenturefor mandibular overdenture
patient. They range frompatient. They range from
primarily soft tissue support andprimarily soft tissue support and
implant retention to aimplant retention to a
completely implant-supportedcompletely implant-supported
prosthesis with rigid stability.prosthesis with rigid stability.
The patient's complaints,The patient's complaints,
anatomy, desires, and financialanatomy, desires, and financial
commitment determine thecommitment determine the
amount of implant supportamount of implant support
required to predictably addressrequired to predictably address
these conditions. The amount ofthese conditions. The amount of
implant support designed in theimplant support designed in the
restoration is related therestoration is related the
number and position of thenumber and position of the
implants .implants .

OverdentureOverdenture OptionOption OneOne
 The first treatment option for mandibular overdenturesThe first treatment option for mandibular overdentures
(OD-I) is indicated primarily when cost is the most(OD-I) is indicated primarily when cost is the most
significant patient factor. However, the patient's desiressignificant patient factor. However, the patient's desires
must be minimal. The posterior ridge form should be anmust be minimal. The posterior ridge form should be an
 inverted U shape, with high parallel walls for good-to-inverted U shape, with high parallel walls for good-to-
excellent anatomic conditions for conventional dentureexcellent anatomic conditions for conventional denture
retention, support, and stability'. The problem associatedretention, support, and stability'. The problem associated
with the existing denture relates only to the amount ofwith the existing denture relates only to the amount of
retention. Under these conditions, two implants may beretention. Under these conditions, two implants may be
inserted in the B and D positions. The implants remaininserted in the B and D positions. The implants remain
independent of each other and are not connected with aindependent of each other and are not connected with a
superstructure. The most common type of attachmentsuperstructure. The most common type of attachment
used in OD-I is an O-ring design.used in OD-I is an O-ring design.
 It is a much better prosthetic option in OD-I to have theIt is a much better prosthetic option in OD-I to have the
implants in the B and D positions rather than in the Aimplants in the B and D positions rather than in the A
and E regions.and E regions. www.indiandentalacademy.comwww.indiandentalacademy.com

OD 1OD 1
 Advantage- economicAdvantage- economic
 Existing prosthesis canExisting prosthesis can
be rebasedbe rebased
 In conditions of poor ridgeIn conditions of poor ridge
& insuffecient space& insuffecient space
 Dis adv-Dis adv-
 Relatively poor implantRelatively poor implant
support & stabilitysupport & stability
 Cant prevent posteriorCant prevent posterior
bone loss.bone loss.

Option 2Option 2
 Implants in B & DImplants in B & D
position, joined rigidlyposition, joined rigidly
by a bar.by a bar.
 Used only when idealUsed only when ideal
posterior ridge form isposterior ridge form is
present.present.
 More economicMore economic
 Retention & minorRetention & minor
stability is provided.stability is provided.

O D 3-1O D 3-1
 Implants in positionImplants in position
A,C,E positions ,A,C,E positions ,
rigidly joined by a barrigidly joined by a bar
if posterior ridge formif posterior ridge form
is good.is good.
 This providesThis provides
retention & moderateretention & moderate
stabilitystability

O D 3-2O D 3-2
 Implants in B,C ,DImplants in B,C ,D
position & rigidlyposition & rigidly
joined by bar whenjoined by bar when
posterior ridge is poorposterior ridge is poor
 Div C-h anterior boneDiv C-h anterior bone
volume is presentedvolume is presented
 Retention & minorRetention & minor
stability present.stability present.

O D - 4O D - 4
 Implants in A B D EImplants in A B D E
positions rigidly joinedpositions rigidly joined
by bar rigidly &by bar rigidly &
cantilevered distallycantilevered distally
about 10 mmabout 10 mm
 Indicated whenIndicated when
desires majordesires major
retention, stabilityretention, stability

O D - 5O D - 5
 Implants placed inImplants placed in
A,B,C,D,E positionsA,B,C,D,E positions
rigidly joined by a barrigidly joined by a bar
cantilevered distallycantilevered distally
about 15mmabout 15mm
 Indicated when ptIndicated when pt
demands highdemands high
retention ,stability &retention ,stability &
supportsupport

End of part 1End of part 1

.




To the left you can see a clinical picture of aTo the left you can see a clinical picture of a
toothless lower jaw. Many patients are alltoothless lower jaw. Many patients are all
too familiar with this type of situation. Thetoo familiar with this type of situation. The
traditional method of replacing teeth in thistraditional method of replacing teeth in this
scenario was to make a fullscenario was to make a full denturedenture, which, which
usually never quite satisfies a patient who isusually never quite satisfies a patient who is
used to having teeth. On a ridge like the oneused to having teeth. On a ridge like the one
on the right, a patient would have a lot ofon the right, a patient would have a lot of
trouble with actually retaining the denture,trouble with actually retaining the denture,
let alone chew with it at a satisfactorilylet alone chew with it at a satisfactorily
level.level.






==

Prosthodontic phaseProsthodontic phase

Implant supported overdentures/dental courses

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