PRACTITIONER SECTION

Guidelines for treatment planning of mandibular

implant overdenture
Siddharth Bansal, Meena A Aras, Vidya Chitre

ABSTRACT

Implant overdenture (OD) is the common treatment modality for the rehabilitation of complete
mandibular edentulism with dental implants. The purpose of this review was to collect the data
regarding various factors contributing to the selection of implant OD design and to provide
comprehensive guidelines for the clinicians in planning the OD design.

KEY WORDS: Attachments, implant overdenture, implant retained prosthesis, implant supported
prosthesis

INTRODUCTION design are grouped under the following subheadings:

indications, biomechanical principles, prosthetic space
Edentulous patients with severely resorbed maxillary analysis and type of attachment (interconnected vs.
and mandibular arches commonly experience problems solitary implants), optimum number of implants
with retention, stability and support and the related required, prosthesis design, implant location, prosthesis
compromise in chewing ability with conventional maintenance, patient satisfaction and success rate.[3]
complete dentures. As the successful use of dental
implants in the treatment of mandibular edentulism is INDICATIONS
well-documented in the literature[1] for both fixed and
removable prosthetic rehabilitations,[2] these problems IRP with 2 implants is contraindicated in younger patients
can be easily solved by using implant retained prosthesis or those who are edentulous for <10 years due to anterior
(IRP)/implant supported prosthesis (ISP). IRP achieves posterior rotation of prosthesis, which causes increased
support from both implants and tissues whereas ISP bone resorption in posterior edentulous region [Table 1].[4-6]
achieves support only from implants.
BIOMECHANICAL PRINCIPLES
The purpose of the review was to collect the data
regarding factors contributing to the selection of implant According to Misch, as ISP is stabilized on multiple bars
overdenture (OD) design and to provide comprehensive between implants, the attachment clips located on each bar
guidelines for the clinicians in planning the OD design. are frequently not parallel to one another or perpendicular
Factors which contribute to the determination of the OD to the posterior ridges. Therefore, the clips can bind in
function, limiting prosthesis movement. This can produce
Department of Prosthodontics, Goa Dental College and Hospital, Panaji,
Bambolim, Goa, India
Address for correspondence: Dr. Siddharth Bansal,
Table 1: Indications of ISP and IRP
Department of Prosthodontics, Goa Dental College and Hospital, Panaji, ISP IRP
Bambolim, Goa - 403 202, India.
E-mail: siddharthbansal42@gmail.com Patient with severe ridge Patient with good
resorption posterior ridge anatomy
Access this article online
Superficially placed mental Moderate to good
Quick Response Code: nerve retention and stability of
Website:
www.jdionline.org
the denture
High muscle attachments Financial limitations
Knife edge ridge
DOI: Sharp mylohyoid
10.4103/0974-6781.131014 projections
ISP: Implant supported prosthesis, IRP: Implant retained prosthesis

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 Bansal, et al.: Implant overdenture treatment planning
a reduced range of motion between the prosthesis and
bar attachment, increased prosthesis support from the
implants and increased applied torsional forces to the
implants.[6] In clinical situations involving poor posterior
ridge form, reducing posterior mucosal support in this
manner may be advantageous as it prevents rotational
movements of the prosthesis. Similar to a fixed prosthesis,
it creates a stable occlusal plane and prosthesis position
reducing possible jaw resorption in posterior mandibular
and anterior maxillary regions.[7,8]
IRP with ball or bar and clip attachments design allows
a significant amount of rotation and vertical movement
due to soft-tissue resiliency and leads to residual ridge
bone loss. Therefore for the functional success of an IRP,
an optimal extension and fit of the denture is important.
PROSTHETIC SPACE ANALYSIS
For successful implant OD treatment planning prosthetic
space analysis should be taken under consideration for
selection of the prosthetic components of the implant
attachment system. At least 13-14 mm interocclusal space
is required for bar supported OD considering teeth size,
denture base thickness, bar thickness for the rigidity, the
space from the mucosa to the bar for hygiene and the
soft-tissue thickness.[9] Minimum space requirement[10,11]
for ball attachment is 10-12 mm and for locators is 8.5 mm.
Inadequate space for prosthetic components can result in
an overcontoured prosthesis, excessive occlusal vertical
dimension, fractured teeth adjacent to the attachments,
attachments separating from the denture, fracture of the
prosthesis and overall patient dissatisfaction.
TYPE OF ATTACHMENTS (INTERCONNECTED VS
SOLITARY IMPLANTS)
Next is to decide which type of attachment is to be used,
whether to splint implants with a rigid bar fixation or
an independent implant attachment system is to be
used. Guidelines to assist with this treatment decision
are also limited and controversial in the literature. The
attachment selection is affected by the implant number,
distribution and alignment, bone quality, arch shape,
retention, and denture design.[12]
The attachments used for implant ODs are mainly
divided into the bar type and the solitary type and into
the resilient type and the rigid type, depending on the
movement allowance. Popular OD attachments used are:
1. Ball attachments with rubber o-rings and/or metal
housings
2. Bar attachments with clips
3. Locators
4. Magnets
5. Bar with locators cast or tapped into the framework.
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Abutment parallelism is very critical for the solitary
implants as abutment non parallelism leads to faster
wear of the matrix. Therefore with increase in number
of implants, splinting should be done as abutment
parallelism becomes more difficult.
In a V shaped anterior mandibular ridge, if bar is placed
at canine locations, it encroaches on the tongue space
and if placed anteriorly, length of the bar becomes
inadequate. Therefore in such cases, ball attachments
or 3-4 implants with a connecting bar supported OD is
indicated.[13]
Use of a bar may complicate the procedure, increase
the cost of the prosthesis, is more technique sensitive[14]
and generally require more space than individual
attachments. One perceived advantage of the bar is that
it can accommodate divergent implants.[4] However
individual attachments can also be used for divergent
implants.[15]
The available data supports the use of independent
implants for a mandibular OD.[16-18] Stress transmitted
to implants by ball attachment or bar attachment is
controversial in the literature.
A study by Kenney and Richards[19] evaluated the photo
elastic stress patterns produced by implant-retained
ODs. They found that independent O-ring attachments
transferred less stress to implants than the bar-clip
attachments when their model was subjected to posterior
vertical load.
Celik and Uludag[20] in their study have reported that
more stress was observed in the solitary type than in
the bar splinting type when the photoelastic stress
distribution was assessed in ODs with three mandibular
implants according to the retention mechanism.
Wismeijer et al.[21] studied 110 patients who had received
mandibular implant OD treatment. Subjects received
either 2 implants with ball attachments, 2 implants with
an interconnecting bar, or 4 interconnected implants.
Subjects completed questionnaires designed to elicit
opinion regarding individual treatment outcome.
Sixteen months after treatment, almost all subjects were
generally satisfied. No significant difference was found
between the 3 treatment strategies.
Meijer et al.[22] using three-dimensional finite-element
analysis, studied the stress distribution in the anterior
mandibular bone around implants under conditions in
which either 2 or 4 implants were used. They concluded
that there was no reduction of the principal stresses in
bone when the occlusal load was distributed over an
increasing number of implants.
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 Bansal, et al.: Implant overdenture treatment planning
OPTIMUM NUMBER OF IMPLANTS
Next question comes about what is the optimum number
of implants required for removable IRP/ISP. The answer
to this question is controversial because adequate data
to address this concern is lacking. Some practitioners
believe that using more implants for OD treatment
results in a better treatment outcome, but supporting
evidence is limited.
Zarb and Schmitt et al.[23] support the concept that fewer
implants can be equally effective for the OD prosthesis.
However, the placement of additional implants for the
proposed prosthodontic treatment probably provides
a means for contingency planning against the loss of
implants, if tissue integration fails.
Sadowsky suggested multiple implants for mandibular
OD when sensitive jaw anatomy, increased occlusal
forces, or high retention needs are present or when
implant length <8 mm or implant width <3.5 mm are
employed.[4]
One of the most recent studies is by Thomason et al.
The study aimed to present the current evidence and
rationale to support the McGill (2002) and York (2009)
consensus statements.[38,39] The conclusion was that there
is overwhelming evidence to support the proposal that
a two-implant OD should become the first choice of
treatment for the edentulous mandible. No information
was, however, given regarding the various options in
attachment systems, i.e. bars, ball attachment, locator
and/or possible adjunctive benefits with the use of
additional implants.[24]
Four to six implants for Implant-supported ODs splinted
with a bar, are usually prescribed to achieve a sufficient
amount of support, stability and retention. In this type
of prosthesis, more support is derived from the implants
than the alveolar ridge mucosa eliminating the need for
extension of denture base.
According to Wismeijer et al.,[21] Timmerman et al.[40],
Visser et al.[41], Meijer et al.[42], increase in number of
implants did not significantly improve the patient
satisfaction.[25]
LOCATION OF IMPLANT PLACEMENT
According to Taylor,[26] for a 2-implantretained mandibular
OD, placement of implants in the lateral incisor area rather
than the canine position offers a mechanical advantage,
providing better stability for the OD.
The implants act as a fulcrum with 2 potential lever
arms: (1) From the fulcrum to the posterior extension of
88
the denture and (2) from the fulcrum anteriorly to the
incisal edge. Forces on either lever arm will produce
rotation. However, the primary and secondary bearing
areas of the OD will resist occlusal forces placed on the
posterior lever arm, but forces on the anterior lever arm,
such as incisive movements, may cause more noticeable
rotation. By moving the implants from the canine to the
lateral incisor position, the effective anterior lever arm
is reduced, thus minimizing the tipping forces on the
OD. Various implant overdenture prostheses designs
are described based on number of implants and type of
attachments [Table 2].[13]
PROSTHESIS DESIGN
Maintenance and complications
One of the main problems with implant ODs is the
potential complication associated with the attachment
mechanisms. Controversy persisted as to whether
the ball or bar design requires more maintenance.
Some studies suggest that a bar attachment requires
less maintenance [27,28] whereas others suggest the
opposite.[29,30] However in recent literature, studies have
shown that bar supported ODs requires less prosthetic
maintenance than ball attachments.[31,32]
In one of the study, Walton et al. [33] found a high
complication rate with a ball attachment matrix which
could be due to misaligned implants. Most common
prosthetic maintenance and complications occurred
with magnetic attachments are due to wear and
corrosion.[34] Various complications are loss of retention,
clip or attachment fracture, opposing prosthesis fracture,
acrylic resin base fracture, prosthesis or abutment screw
loosening and implant fracture.[35]
Success rate
Success rates (as measured by the continual
osseointegration of implants) of 1-10 years which
supported the ODs in the mandible, ranged from 91.7% to
100% and the mean implant survival rate was over 98%,
both of this supports the presumption that this treatment
Table 2: Prosthesis design
Location in No. of Type of prosthesis
mandibular implants
arch
Interforaminal 2 Overdenture bar/ball anchor/
region locator/magnet attachment
with complete denture design
3-4 Overdenture bar/ball anchor/
locator/magnet attachment
4-6 Fixed detachable hybrid
prosthesis or bridge with
distal cantilever
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 Bansal, et al.: Implant overdenture treatment planning
has a good prognosis in a long-term perspective.[34,36] No
difference has been found among the success rates of the
different attachment mechanisms.[37] However, direct
comparisons of these reports are difficult owing to the
variety of attachment mechanisms and different implant
manufacturing systems employed.
SUMMARY
Following objectives should be taken into considerations
for planning of ISP/IRP:
Determine the optimum location and number of
implants in the context of the morphological aspects
of the residual ridge.
Design a favorable distribution for occlusal stresses
on the implants and the prosthesis bearing tissues.
Avoid discrepancies among the design of the
dentures, the implants location and the attachment
system.
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How to cite this article: Bansal S, Aras MA, Chitre V. Guidelines for
treatment planning of mandibular implant overdenture. J Dent Implant
2014;4:86-90.
Source of Support: Nil, Conflict of Interest: None.
Journal of Dental Implants | Jan - Jun 2014 | Vol 4 | Issue 1
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