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Overdenture Compendium
Overdenture Compendium
Abstract: While most implant-based treatment has his- for a fixed prosthesis may be limited because of inadequate
torically focused on fixed prosthetic tooth replacement, quantity and structure of the bone. Enhancement of esthet-
the multitude of benefits to the edentulous population ic appearance and facial morphology through replacement
from implant overdentures is overwhelming in improved of lost hard and soft tissues may be proven easier, if not
function, emotional stability, physical health, and esthet- more effective, with removable overdentures than with con-
ics. Although there still remains a lack of consistency in ventional fixed prosthesis, with possibly decreased costs and
techniques, prosthetic design, and attachment systems, less surgical intervention.
these aspects have been proven less important to suc- Generally, more implants are required to support a fixed
cessful outcomes than once thought. This article presents prosthesis than an overdenture. Other factors to consider
a simplified approach to patient evaluation, treatment include the health of the patient, his or her ability to under-
planning decisions, attachment selection, and technique. go grafting procedures, and cost.4 There has been an abun-
dance of literature presenting a variety of treatment options,
case reports, and clinical techniques over the past 20 years,
Learning Objectives: but more recently there has been general agreement about
After reading this article, the reader should be able to: the treatment protocols and long-term documented benefits
evaluate a patients hard and soft tissues as they of implant overdentures. This treatment option has become
relate to overdenture design. the most rewarding care provided in this authors clinical
practice, and with increasing life expectancy, its full impact
determine the most ideal position and number of on clinical practice is yet to be realized. Although there still
implants for maintaining each patients overdenture. remains a lack of consistency of techniques, prosthetic de-
select the best attachment to help minimize wear, sign, and attachment systems, these aspects have been proven
breakage, and maintenance. less important to successful outcomes than once thought.
What are agreed upon are the specific indication for this
treatment and the benefit derived. This article presents a
While most implant-based treatment has historically fo- simplified approach to patient evaluation, treatment plan-
cused on fixed prosthetic tooth replacement,1 the multi- ning decisions, attachment selection, and technique.
tude of benefits to the edentulous population from implant First, there is a need to appreciate the sequelae of tooth
overdentures is overwhelming in improved function, emo- loss, and associated benefits of implant overdentures, fol-
tional stability, physical health, and esthetics. Proper evalua- lowed by patient evaluation, treatment protocols, and clinical
tion and treatment planning of the fully edentulous patient technique. For many years clinicians realized that placement
has been shown to result in an improved quality of life for of endosseous osseointegrated implants under a removable
patients2,3 and predictable clinical success. The indication prosthesis would provide the definitive advantages of bone
preservation,5 prosthetic retention, stability, and a degree of soft tissue support of the lips and associated structures will
occlusal support resulting in improved function, facial es- become an initial guideline to treatment options. If hori-
thetics, and comfort. More recently, comprehensive and zontal loss of hard and soft tissue through resorption, dis-
ongoing studies conducted at McGill University have docu- ease, or trauma is so advanced that teeth need to be placed
mented the improved nutrition, psychosocial status, and far anterior to the residual ridge to provide adequate facial
quality of life that have been gained through the use of over- support, then an overdenture (ie, acrylic base and flanges)
denture treatment.6,7 The use of implants also provides a can provide replacement of these structures (Figure 3). Al-
predictable solution for patients and practitioners to the ternatively, bone grafting procedures can be performed to
problems associated with conventional dentures by resolving augment the missing tissues, but limitations must be evalu-
functional and esthetic compromises. ated. Limiting factors in grafting procedures include ade-
The sequelae of tooth loss and an edentulous arch is re- quate blood supply, patient health, and finances. When
sidual ridge resorption both in the horizontal and vertical evaluating vertical loss of hard and soft tissues, the resultant
direction. This ongoing loss of hard and soft tissue is most interarch space must be determined to see if excessive crown-
noticeable in the loss of orofacial support: facial esthetics, to-implant ratio and biomechanical forces will preclude a
phonetics, and collapse of vertical dimension. This leads to conventional implant-supported fixed restoration (Figure 4).
an aging appearance due to the lack of lip support and de- While grafting procedures have radically changed how cli-
creased facial height (Figure 1 and Figure 2). Concurrent nicians treat patients, there are limitations to the amount of
with these changes in facial structures are impaired oral vertical augmentation possible.
function, pain, insufficient retention, and instability of con- Any successful overdenture treatment begins with the un-
ventional dentures, as well as nutritional and psychological derstanding that conventional full-denture fabrication princi-
changes. Many patients seeking resolution to chronic sore- ples must be followed. These include ideal border adaptation
ness of load-bearing tissues and nonstable or retentive den- and extension and full-denture occlusion.10 Through proper
tures will enjoy increased esthetics, function, comfort, and articulation and denture tooth setup, all parameters of final
psychological benefits from implant overdentures, without treatment success can be evaluated. A try-in of the proposed
the need for more extensive fixed restorations.8,9 tooth setup will allow evaluation of esthetics, phonetics, and
support, as well as the critical determination of ridge position
PATIENT EVALUATION: relative to the proposed prosthesis before surgery. The setup
MAXILLOFACIAL RELATIONSHIP then will be used to guide ideal implant position because the
Upon evaluation of the edentulous (or soon to be edentu- most critical factor in overdenture implant placement is that
lous) patient, facial esthetics and the amount of extraoral implants emerge well within the confines of the denture.
Figure 1 Extensive resorp- Figure 2 Ongoing loss of max- Figure 3 The patient seen Figure 4 Excessive interarch space
tion of the maxilla caused illary and mandibular basal in Figure 1 after place- caused by advanced bone loss is
by tooth loss results in a lack bone leads to decreased ver- ment of a maxillary over- evaluated through articulation
of adequate horizontal sup- tical dimension and height denture. Note the return before ideal esthetic and functional
port of the orofacial soft tis- of face from overclosure in a of facial esthetics through setup of the denture teeth.
sues in a male patient. female patient. support of the soft tissues.
also will prevent premature wear and breakage. Clearly the of the mucosa. The greatest portion of the occlusal forces
major overdenture complication and maintenance concern are thus absorbed directly by the alveolar ridges.17 There are
relates to attachment adjustment and replacement,14,15 as attachment systems that allow angulation correction of up to
well as fracture from the prosthesis. These issues can be sig- 20 per implant (40 for two divergent implants) within a re-
nificantly minimized through proper attachment selection silient range (LOCATOR, Zest Anchors, Escondido, CA).
and use of resilient attachments.16 A resilient connection Other factors in attachment selection include height of
between the denture and implants should allow reduced the attachment to minimize space required inside the den-
loading of the abutments in so far as the degree of move- ture (to decrease potential fracture caused by inadequate
ment takes into account the compressibility (ie, resilience) acrylic thickness) and housings with replaceable matrices.
Figure 7A Four Regular Neck implants Figure 7B Abutments (LOCATOR) were Figure 7C Block-out rings were placed
(Straumann USA, LLC, Andover, MA) selected based on the depth of the peri- to prevent material from flowing into
were placed anterior to the mental implant sulcus, which was obtained by undercuts. Special attention must be
foramen with ideal distribution. measuring the distance from the top of given to block out any additional un-
the implant to the highest point of soft dercut areas to prevent locking into
tissue (eg, transmucosal cuff heights of these areas.
1 mm to 6 mm were available).
Figure 7D Housings (LOCATOR) were Figure 7E The final prosthesis was pre- Figure 7F Vent holes were placed in the
placed to verify the full seating of the pared for incorporation of the housings. area of the attachments to allow the
final prosthesis, without interference escape of excess material and prevent
from attachments or housings. complete seating on the tissues.
Figure 7G Housings with black processing Figure 7H Any voids around the hous- Figure 7I The prosthesis after being
males, which were tacked in place with ings were filled in extraorally, and black polished and having the occlusion
acrylic by means of the patient maintain- processing males were replaced by final checked; it is ready for final delivery
ing a medium biting force in centric occlu- retentive inserts (available in various and hygiene instruction.
sion while the material cured. amounts of retention).
This will allow the clinician to evaluate full seating on the of three implantsis more favorable to prevent the anterior-
tissues and minimize distortion caused by curing of a bulk posterior rock and provide a tripod of support. The implants
of acrylic during processing, as well as to evaluate and cor- can be placed in a one-stage or nonsubmerged approach be-
rect the attachment position before the delivery appoint- cause esthetic soft-tissue contours are not critical in overden-
ment. Less than ideal attachment position can be corrected ture therapy. This also will allow a more incisal position of
at this time through such means as a reline impression in the implantabutment connection and hygiene access. The
the trial base with the patient in full occlusion to assure specific arch position in relation to tooth and embrasure loca-
intimate contact with the underlying tissues. tion also is not critical with a removable prosthesis.
Techniques have been developed to simplify chairside
incorporation of attachments.22 The most important con- CONCLUSION
cerns are blocking out any undercuts that acrylic may flow Through proper patient evaluation, adherence to conven-
into (preventing removal of the denture) and ensuring that tional denture techniques, and ideal communication among
the prosthesis can fully seat on the tissues without being surgical, laboratory, and restorative colleagues, implant over-
held up by interference with the attachments. dentures provide simple, predictable, and cost-effective treat-
ment to edentulous patients. Additionally, they provide the
DESIGN CRITERIA benefits of esthetics, phonetics, bone preservation, increased
The only rationale for incorporation of a metal framework comfort, better psychosocial state, and enhanced nutrition,
or lingual reinforcing bar is to prevent potential fracture of all resulting in an improved quality of life (Figure 9).
the appliance caused by minimal acrylic thickness or exces-
sive occlusal forces.21 The downside of this process is the REFERENCES
additional cost and laboratory procedures involved. In sit- 1. Branemark PI, Zarb GA, Albrektsson T. Tissue-Integrated
uations of high potential fracture of the appliance, such as Prostheses: Osseointegration in Clinical Dentistry. Chicago, IL:
the extreme occlusal forces seen in patients with opposing Quintessence; 1985.
full-arch implant-supported restorations or areas of mini- 2. Awad MA, Locker D, Korner-Bitensky N, et al. Measuring
mal acrylic bulk, a metal frame will serve to resist flexure the effect of intra-oral implant rehabilitation on health-related
and potential fracture. An important consideration for the quality of life in a randomized controlled clinical trial. J Dent
laboratory is to allow open space in the framework for in- Res. 2000;79(9):1659-1663.
corporation of the attachments. 3. Awad MA, Lund JP, Shapiro SH, et al. Oral health status and
treatment satisfaction with mandibular implant overdentures
and conventional dentures: a randomized clinical trial in a se-
SURGICAL CONSIDERATIONS
nior population. Int J Prosthodont. 2003;16(4):390-396.
While two individual implants provide outstanding, well-
4. Mericske-Stern R. Prosthodontic management of maxillary
documented clinical results, three or four implants will pro-
and mandibular overdentures. In: Feine JS and Carlsson GE,
vide greater retention and level of implant support and min-
eds. Implant Overdentures: The Standard of Care for Edentulous
imize anterior-posterior rocking from the unsupported long
Patients. Chicago, IL: Quintessence Pub. Co.; 2003:83-98.
extension of the denture base. Extreme distal implant place-
5. Jemt T, Chai J, Harnett J, et al. A 5-year prospective multicenter
ment will decrease anterior support by allowing an anterior
follow-up report on overdentures supported by osseointegrated
lever arm in function (Figure 8). A more stable result will be implants. Int J Oral Maxillofac Implants. 1996;11(3):291-298.
obtained through implant placement with greater anterior- 6. Feine JS, Carlsson GE. Implant Overdentures: The Standard of Care
posterior spread that can decrease rocking, or through the for Edentulous Patients. Chicago, IL: Quintessence Pub. Co.; 2003.
placement of an additional implant in the anterior segment. 7. Morais JA, Heydecke G, Pawliuk J, et al. The effects of man-
While the cuspid position has traditionally been the site of dibular two-implant overdentures on nutrition in elderly eden-
choice for the two-implant overdenture, there is much merit tulous individuals. J Dent Res. 2003;82(1):53-58.
in placing the implants closer to the lateral incisor position to 8. Quirynen M, Alsaadi G, Pauwels M, et al. Microbiological and
minimize rock and allow for potential additional implant clinical outcomes and patient satisfaction for two treatment
placement in the future. In a larger ridge, consideration of options in the edentulous lower jaw after 10 years of func-
two cuspid and one additional incisor implantfor a total tion. Clin Oral Implants Res. 2005;16(3):277-287.
1. When evaluating vertical loss of hard and soft tissues, 6. In situations where implants are even minimally non-
the resultant interarch space must be determined to parallel, a resilient attachment will consistently show:
see if which ratio will preclude a conventional a. less friction.
implant-supported fixed restoration? b. increased breakage.
a. implant-to-ridge c. no rotational movement.
b. crown-to-implant d. all of the above
c. smile line-to-crown
d. papillae height-to-crown scallop 7. An advantage of splinting through the use of a bar or
telescopic copings is to:
2. The risks of proceeding with implant placement a. distribute the forces to more implants.
before trying in the tooth setup include: b. increase denture base thickness.
a. compromised space for overdenture c. decrease laboratory costs.
attachments. d. improve access for hygiene.
b. inadequate acrylic thickness.
c. laboratory and component costs necessary to 8. Maintaining partial palatal coverage to assist in the
correct poor angulation. potential reduction of load to the implants may be
d. all of the above recommended in instances of reduced implant
support because of the:
3. Individual, nonsplinted implants can provide ideal a. quality of integration.
retention of the prosthesis to prevent: b. number of implants.
a. vertical and lateral displacement. c. compromised implant positioning.
b. bone remodeling. d. all of the above
c. any load to the residual ridge.
d. inadequate blood flow under the prosthesis. 9. The most important concerns when incorporating
attachments chairside include:
4. Traditional overdentures are classified as: a. blocking out undercuts acrylic may flow into.
a. implant-retained and implant-supported. b. being able to remove the denture.
b. implant-retained and tissue-supported. c. ensuring that the prosthesis can fully seat on
c. nonretentive and nonsupportive. the tissues.
d. tissue-retained and tissue-supported. d. all of the above
5. All overdenture attachments are classified as: 10. In a larger ridge, which implant configuration should
a. open or closed. be considered to prevent anterior-posterior rock?
b. round or square. a. one cuspid and two incisor
c. rigid or resilient. b. one cuspid and one incisor
d. indexed or nonindexed. c. two cuspid and one bicuspid
d. two cuspid and one incisor
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