Implant assisted

mandibular overdenture

McGill Consensus Statement, Int J

Oral Maxillofacial Implants

2002;17(4):601-2

Implant Overdenture Delphi Study

JADA 2012

Adv. Of mandibular over denture

versus conventional complete
denture

esthetics
speech

stability

occlusion

Improved

prosthesis
support

prosthesis
retention

chewing
efficiency
occlusal
efficiency

In a study by Awad et al.,6

implant overdenture (IOD)
patients were able to chew
different types of food
significantly better than patients
with complete dentures (CDs).
(Data from Awad MA, Lund JP,
Dufresne E, et al: Comparing the
efficacy of mandibular implantretained overdentures and
conventional dentures among
middle-aged edentulous
patients: satisfaction and
functional assessment,

Adv. Of over denture versus the

fixed restoration Fixed Prosthesis

Improved
periimplant
probing

Easy
repair
Improved
esthetics

Hygiene
bone
grafting

Fewer implants
(RP-5)

Stress
relief
attachment

specific implant
placement
Lower cost and
laboratory cost
(RP-5)
Reduced stress

Philosophy for Implants

in the
Edentulous Mandible

 In the case of multiple

extractions, this often means a
4-mm vertical bone loss within
the first 6 months.

This bone loss continues over

the next 25 years, with the
mandible experiencing a
fourfold greater vertical bone
loss than the maxilla.

As the bony ridge resorbs in

height, the muscle
attachments become level with
the edentulous ridge which
affect the retantion, stability

 To the contrary, the anterior bone

under an overdenture may resorb as
little as 0.6 mm vertically over 5
years, and long-term resorption
may remain at less than 0.05 mm
per year.

the dental professional should

educate the patient about the
bone loss process after tooth loss.
In addition, the patient should be
made aware the bone loss process can
be arrested by a dental implant.

dental implants to maintain

Classification of
Prosthesis Movement
(PM)

 An overdenture is by definition removable, but

in function or parafunction, the prosthesis may
not move.

If the prosthesis does not have movement

during function, it is designated PM-0 and
requires implant support similar to a fixed
prosthesis.

A prosthesis with a hinge motion is PM-2, and

a prosthesis with an apical and hinge motion is
PM-3.

A PM-4 allows movement in four directions,

and a PM-6 has ranges of PM in all directions.

Implant site
selection

 Anatomical reasons:
more bone anterior increase the
length and width of the
implant..increase the implant
stability.

 Biomechanical consideration:
Overdentures with posterior
movement gain better acceptance
than removable restorations with
anterior movement. The anterior
denture teeth are most often slightly
anterior to the edentulous ridge. As
a result, although the prosthesis is
more stable with anterior implants,
horizontal or vertical forces to the
mandibular anterior teeth cause the
prosthesis to rock down in the front
(and up in the back

The available bone in the anterior mandible

(between the mental foramina) is divided
into five equal columns of bone serving as
potential implant sites, labeled A, B, C, D,
and E, starting from the patients right .
Regardless of the treatment option being
executed, all five implant sites are mapped
at the time of treatment planning and
surgery. There are reasons for this
treatment approach.

A B C DE

Give the
patient the
chance to
change his
treatment
plan.

A patient may
desire a
completely
implantsupported
restoration (e.g.,
RP-4 or FP) but
cannot afford the
treatment all at
once.

If an implant
complication
occurs, the
preselected
option sites
permit
repeatable
corrective
procedures.

 The mandibular overdenture requires at least 12 mm

between the soft tissue and the occlusal plane to provide
sufficient space (15 mm from bone level to occlusal plane) for
the bar, attachments,
and teeth.

OD-1

Patients needs
and desires are
minimal,
primarily related
to lack of
prosthesis
retention

Posterior
ridge form is
an inverted U
shape

Edentulous
ridge not square
with a tapered
dentate arch
form

Opposing
a maxillary
full
denture

Anatomical
conditions are
good to excellent
(division A or B
anterior and
posterior bone

Patient
selection
criteria for:
OD-1

Cost is the
primary
factor

Additional
implants will
be inserted
within 3
years

Independent implants
in the A and E positions
allow a greater anterior
rocking of the
restoration and place
greater
leverage forces against
the implants.

OD-2
OD-2

Patient selection
criteria for: OD-2

The dentate
arch form is
square to
ovoid.
The mandibular
residual ridge
form is square to
ovoid, and

Anatomical
conditions are good
to excellent (division
A or
B bone in anterior
and posterior
regions).

Opposing
arch is a
maxillary
denture.

Posterior
ridge
forms an
inverted
U shape.

When the patient is

unable to insert
additional implants
within a short time
frame (within 3
years), an OD-2 is
safer
than an OD-1
independent implant
approach

Patients
need and
desires are
minimal,
primarily
related to
lack of
retention.

implants in the B and D positions,

and a bar joins the implants.
Attachments such as an O-ring (A)
or a Hader
clip (B), which allow movement
of the prosthesis, can be added
to
the bar. The attachments are placed
at the same height at equal
distances off the midline and
parallel to each other.

Bar splinting the A and

E positions will flex five
times more than a bar
connecting implants in
the B and D positions.
As a consequence,
screw loosening risk is
increased

The connecting bar between

implants B and D
should not be cantilevered to the
distal.

The Hader clips in the

prosthesis do not allow
prosthesis movement.
Hence, this is a
PM-0 implant overdenture
and will cause repeated
biomechanical
complications.

Implants in A and E positions

never be splinted
Implants joined with straight bar are
lingual to ridge:
Difficulty with speech
Anterior tipping of overdenture
Five times greater bar flexure than B
and D positions.

Implants are joined with anterior curved bar.

Greater bar flexibility (nine times the
B and D positions)
Increased screw loosening
Increased moment forces on anterior

aspect of
prosthesis

Splinted Implants in the A

and E Positions lead to:
Implants joined
with straight bar
are lingual to
ridge result in
Difficulty with
speech and
anterior tipping
of the denture

When O-rings are

used for OD-2, the
attachments
are placed parallel
to each other and
at the same
occlusal
height.

OD-3

The mandibular
residual ridge form
is square to ovoid,
and

Anatomical conditions
are good to excellent
(division A or
B bone in anterior and
posterior regions).

Opposing
arch is a
maxillary
denture.

Cost a
moderate
factor

Patient may
have moderate
force factors
(e.g.,
parafunction)

Patients
needs and
desires require
improved
retention,
support, and
stability

Advantages of Splinted A, C,
and E Implants
Less screw loosening
Less metal flexure
Less stress to each implant compared with A
and E implants
More implants
Greater surface area
Less prosthesis movement
One implant failure still provides adequate
abutment support

The connecting bar between

implants in A, C and E
positions

The attachments
should be positioned
to allow movement of
the distal section of the
prosthesis.(o-ring is
recommended)

OD-4

Patient selection
criteria for:
OD-4

Ch bone
volume

Opposing
natural
teeth

Patients
needs and
desires
require
improved
retention,
support,
and
stability

Increase

Unfavorable
force factors
(parafunction
, age, crown
height space
>15 mm)

the CHS

OD-4
four implants are
placed in the A, B, D,
and E positions. The
implants provide
sufficient support for a

distal
cantilever.

OD-5

Patient selection
criteria for:
OD-5

Ch bone
volume

Opposing
natural
teeth

Unfavorable
force factors
(parafunction
, age, crown
height space
>15 mm)

Patients
needs and
desires
require
improved
retention,
support,
and
stability

Increas
e the

CHS

implants are placed

in the A, B, C, D, and
E positions. A bar
splints the implants
together
and is distally
cantilevered. The
length of the

cantilever depends
on
the anteroposterior
distance and the force
factors.

OD-5

A-P spread rule for cantilever

A-P spread
It is the distance
from the middle of
the most anterior
abutment to the
distal aspect of the
most posterior
abutment.

A tapered arch
form has the
greatest A-P
distance, larger
than 8 mm in
comparison with
ovoid and square
arch form

Abutments designed
for attachmentretained restorations

magnets

Locator abutment
components and
instruments

Locator
abutment with
different
gingival height.

Processing cap

Locator inserts that

is color coded come
with five different
retentive holding
force levels

Locator
abutment
pick up
Locator
Analog

Locator Core
Tool

1. Locator Abutment Driver

for tightening of
abutment.
2. Locator Insert Seating
Tool for seating an insert
into the titanium processing
cap.
3. Locator Insert Removal
Tool for catching and pulling
the used insert out of the
permanent metal housing.

Block out spacer

Torque wrench

Clinical and
Laboratory procedure
for locator abutment

Abutment selection
The highest level of tissue
measured with the Abutment
Depth Gauge. This will allow
the retention groove to be at
the appropriate supra gingival
height.

Abutment selection
Please use extreme caution
when measuring that you
do not add any additional
height to your
measurement.Order
exactly what you measure.
Measure 1mm = order
1mm cuff

Abutment installation
Install the Locator
Abutment into the
implant manually.

Manually seat the abutment

using the Locator Abutment
Driver part of the Locator Core
Tool.

Final tightening

With torque
wrench
with
recommend
ed torque
25 N/cm

attach the Locator

Abutment Pick-up to
each Locator Abutment.
The pick-up should have
stable friction retention.

Take the abutment-level impression

in a customized impression tray
with an elastomeric impression
material.
Remove the impression once the
impression material has set.

The black processing inserts of the

pick-ups should be clearly visible
within the impression. Send the
impression to the laboratory.

Place the abutment locator replica in

the locator abutment pick up then
pour the impression with stone to
have the working model

Place the spacer over the head of each Locator

Abutment Replica providing primary soft tissue
support and a resilient situation. process and cure
it into the overdenture.
Remove the overdenture and discard the spacer after
the acrylic has cured.

Send the final overdenture with the

Locator Processing Cap and insert to the
clinician.

Converting an
existing denture chair
side

Place the spacer over the head of each

Locator Abutment providing primary
soft tissue support and a resilient
situation. Firmly attach the Locator
Processing Cap.

Mark the top of the Processing Cap

using indelible denture pencil,
pressure-indicating paste, etc.

Use an acrylic laboratory burr to

relieve the denture base in the
indicated areas

Vents are important to allow the

escape of excess material

1st
Pt. to close
gently to align
occlusion

2nd Pt. to remain open till

complete curing

Evaluate the pick up

1- check that
both attachment
are picked-up
2-No voids
3- voids are
correctable if
the attachment
does not move
4-trim the excess

Remove Spacer from the Locator

Abutment. Remove the Processing
Insert from the Processing Cap in the
overdenture using the Locator Insert
Removal Tool.

Press the preferred Locator insert into the

Processing Caps metal housing, using the
Insert Seating Tool.
Gradual loading is always recommended.

Components of ball attachment

Components of ball attachment

May be straight or angled

zest anchors develop
new saturno narrow
diameter implant
system that have
straight and angled ball
attachment.

Magnetic attachment
Magnet assembly
placed in denture and
flat keeper on
abutment.

Advantages for magnetic

retainer
1. Not affecting the
denture path of
insertion
2. Self-seating
denture
3. Maintenance is
simpler

disadvantages
1. Less retention
intra oral
2.corrosion(which is
can be treated be
electroplating)

Plastic pre-milled bar system(PPM)

The color coded PPM Bar patterns are premilled in 0 degree,
2 degree and 4 degrees.
The PPM plastic bar patterns burn
out clean without residue. 0, 2 or 4 degree
mandrels are used to place the
PPM Bars in the desired path of insertion.
Corresponding carbide burs
are used to finish the casting. The Titanium
PPM 0 or 2 degree bars were designed
for laser welding.

Hader-EDS Bar System

The Bars plastic bars,
Titanium Bars for laser
welding and Gold Bars
for soldering or laser
welding
are now available.

The Housings: The Clips: The durable

Hader-EDS Clips are
The gold-plated
machined metal Hader- interchangeable with standard
EDS Housing simplifiesHader Clips and are available
clip replacement and in three color-coded levels of
retention.
prevents looseness
caused by acrylic
breakdown.

The Analogs and

Impression Clips:
Plastic Hader-EDS
Impression Clips
aluminum Hader-EDS
Bar Analogs are available
for the fabrication of
processing Models.

Clinical and
Laboratory procedure
for Bar abutment

Abutment height
selection

Remove the
healing abutment

Screwing the
abutment

Tighten the
uniabutment
pick up

Take the
impression

Screwing the
abutment
analoge to
have the
master model

Place the SemiBurnout Cylinder on

the replica and
tighten it with a
Laboratory Bridge
Screw. The plastic
part of the cylinders
are cut back to
appropriate
dimensions.

Reduce the bar height, leaving a minimum of

2.5 mm to ensure a proper fit of the inserts.

Note: Do not grind the retention surface

of the bar.
Attach the bar to the plastic sleeve with a
material that has a low polymerization
shrinkage.(duralay)

Processing
Apply casting sprues
outside the functional
areas of the bar.
Invest, burnout and cast
with an appropriate metal
alloy according to
standard working
procedures.

If we have metal bar

Investing

then

soldering

Finish and thoroughly

polish the bar. Protect the
margins of the cylinders
during grinding and
polishing by using the
Polishing Protectors.

Single screw test for passive fit

Spacing and blocking

Place the bar restoration on the
UniAbutment Replicas and tighten with
the Laboratory Bridge Screws. Press the

green plastic spacer onto the bar.

The spacer is used to enable positioning
of the Profile Bar Insert after
polymerization of the overdenture.

Block out the undercuts and

leave the spacers free. Cover the upper
free areas of the bar and the
Semi-Burnout Cylinders

denture processing
Place the housings on the
spacers before investing of the
overdenture. Make sure the
housings are fully seated.
Process the acrylic resin and
finish the prosthesis as usual.

Inserting
Install the Profile Bar
Insert into the housing
with the supplied
Insertion Tool. The
Profile Bar Insert should
snap in audibly.

Matainance the bar