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ΙMPLANT-SUPPORTED OVERDENTURES: CLINICAL REVIEW

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ΙMPLANT-SUPPORTED OVERDENTURES: CLINICAL REVIEW

ABU-HUSSEIN MUHAMAD *, CHLOROKOSTAS GEORGES, ABDULGANI AZZALDEEN

*Department of Pediatric Dentistry, University of Athens, Greece, Corresponding author: Abu-Hussein M, D DS, MScD, MSc,
MDent Sci (PaedDent), FICD, 123Argus Street, 10441 Athens, Greece, E-mail:abuhusseinmuhamad@gmail.com

ABSTRACT
Aim: The aim of this literature review is to evaluate the various studies and systemic reviews conducted on maxillary and
mandibular implant-supported overdentures.
Background: Conventional complete dentures were the common treatment modality for edentulous patients. However, the
advent of implant-supported overdentures has replaced conventional dentures as a better standard for rehabilitation.
Review results: Mandibular implant-supported overdentures have a higher success rate than maxillary implant-supported
overdentures. Maxillary implant-supported overdentures tend to be a form of “rescue treatment,” than being the first modality
of treatment for edentulous patients.
Conclusion: To improve the success rate of implant-supported overdentures, careful case selection is an important criterion.
Further research needs to be conducted to improve the success for maxillary implant-supported overdentures.
KEY WORDS: Review, overdenture, implant, retention

INTRODUCTION conventional complete denture, especially with regard to

Edentulism is considered a poor health outcome and may mandibular denture .These problem include: difficulty
compromise quality of life. The prosthetic management of with prosthesis retention, stability and comfort .this in
the edentulous patient has long been a major challenge for turn may negatively affect functional ability such as
dentistry. 1 The classical treatment plan for the edentulous speech, aesthetic and mastication 6. Fig.1
patient is the conventional complete removable maxillary
and mandibular denture. However, this treatment has
several drawbacks specially that of the lower denture. 2
Treatment of edentulous patients with implant-retained
removable prostheses has been shown to provide a
predictable and successful outcome that overcomes the
functional deficiencies that are associated with
conventional dentures.3 recently the most basic restoration
for the edentulous mandible should be an implant retained
overdenture with two implants placed in the anterior
mandible. In completely edentulous patients, implants can
be used in conjunction with attachments to enhance the
retention and stability of the overdentures. Different types
of attachment systems had been suggested for retaining
implant supported overdentures including stud (ball and
socket, locator), bar, telescopic and magnetic attachments. Table.1; Treatment plan for patients with complete
[4]All these types of anchorage systems had different missing teeth
retentive capacities. Thus, the present study is designed to The edentulous patients with a severely resorbed
compare the retention of two different implants mandible often encounter problems with their mandibular
attachments.4 The factors that adversely affect successful complete dentures. The main complaints of these patients
use of a complete denture on the mandible include: are lack of optimal stability and retention of their
mobility of the floor of the mouth, thin mucosa lining the mandibular dentures, together with decreased chewing
alveolar ridge, reduced support area and the motion of the ability.7
mandible.5 Edentulous patients with severely resorbed The problems of conventional complete dentures can be
mandible often experience problems with their summarized as continued alveolar bone loss leading to
403
Muhamad et al. IEJDTR, 2017; 6(2): 403-411
lack of stability and retention especially of the lower
denture which in turn causes lack of self-confidence and
reduction in biting force and chewing efficiency, so most
difficulty with complete denture prostheses arises from
the inability to function with the mandibular prostheses.8,9
Fig.2
The aim of this literature review is to evaluate the various
studies and systemic reviews conducted on maxillary and
mandibular implant-supported overdentures.
Implant-supported Overdenture
Dental implant is a prosthetic device made of alloplastic
material(s) implanted into the oral tissues beneath the
mucosal or/and periosteal layer, and on or within the bone
to provide retention and support for a fixed or removable
dental prosthesis; a substance that is placed into or/and
upon the jaw bone to support a fixed or removable dental.
There are many classification that are related to dental
implant including types of implant , material of implant ,
time of implantation and others .However, the
classification of implants according to the time of loading
is relevant in this review. Overdentures improve phonetics
patient psychological outlook and quality of life.
Conventional dentures rely upon residual alveolar ridge
and mucosa for support and retention. Patient finds
implant supported overdenture significantly more stable
and rate their ability to chew a wide variety of food as
significantly easier, this improves the nutrition state
implant-supported overdentures may reduce the amount
of soft-tissue cover age and extension of the prosthesis
which is especially important for new dentures or those
who have low gagging thresholds, less bone resorption,
greater prosthesis stability, better esthetic, improved
maintenance. The effect of tooth loss is two-fold which
may affect the patients psychologically and clinically.10
Fig.3
Clinically, the effects of tooth loss are important. Alveolar
bone resorption could be considered condition and can
pose a prosthodontic dilemma for the restoration of
edentulous mandible. Tallegren reported that mean
decrease in anterior mandibular ridge height was four
times greater than that of the maxilla. Alveolar bone loss
can be reduced by provision of implants, studies have
shown that implant supported mandibular over dentures
can preserve bone height in areas where implants are
located.11 Fig.4
Psychologically, edentulism has been quoted as having
charac teristic of a chronic illness as it is incurable and
functionally and physiologically disruptive. Reduced self
confidence, taboo and the feeling of premature ageing have
been also been reported by patients.12
According to time of loading Implants can be classified
into: Delayed implant loading and immediate implant
loading;
A-Delayed Implant Loading:
Conventional implant treatment protocols involved the
placement of implants followed by a healing period of
three to six months in a submerged or nonsubmerged
placement . These periods were necessary to allow for
Muhamad et al. IEJDTR, 2017; 6(2): 403-411
complete osteogenesis and woven bone remodeling into
load-bearing lamellar bone prior to any occlusal loading.13
The disadvantages of delayed implant loading is the need
to remove the conventional denture for two weeks after
implant placement to promote healing in addition to
postoperative changes in the soft tissues during the
healing period can result in discomfort and often
necessitates frequent prosthesis adjustment. Moreover,
additional surgery to expose the implant fixtures is
another disadvantage of the delayed loading protocol.
These concerns have commonly caused physiological,
psychological or sociological challenges for patient who
underwent implant treatment. 14 Fig.5
B – Immediate implant loading:
Implant placement and prosthetic loading for edentulous
patients at the same clinical visit or separated by two to
four weeks was proposed.15 This approach was primarily
applied in the mandible where excellent primary implant
stability can be achieved in the interforaminal region.16
Bone formation has been shown to be enhanced by
adequate mechanical stimulation. Initially, the attachment
of the implant to the bone is purely mechanical (primary
stability) this, primary stability depends on the implant
(dimension and design) and the implant bed (bone
density). Over the course of bone healing, both mechanical
and biological factors are important in implant anchorage
(secondary stability).17
Several timings have been proposed for immediate
implant loading some authors reported that, the implants
should be functionally loaded by the prosthesis within 72
hours following implant placement.[18] Others report
loading within 48 hours , 24 hours or at the same visit
following implant placement However , suggested that
immediate loading up to one week following implant
placement was acceptable.[19]
Many authors discussed that there is no significant
difference in the clinical and radiographic state of patients
treated with implant supported mandibular overdentures
loaded either 1 week or 3 months after surgery.20
The results of 1-year study of the mandibular
overdenture treatment using single-stage surgery and
immediate prosthetic loading of implant indicated that
immediate loading to retain a mucosa-borne overdenture
is a safe, reliable, and cost-effective treatment.21
In concrescence mentioned that the immediate loading of
two implants by means of ball attachment-retained
mandibular denture is a predictable treatment option that
offers increased stability and comfort, while keeping a high
implant success rate.22
Advantages of immediate loading
The advantages of immediate loading are numerous; the
positive effect on bone response; reduced numbers of visit,
monitoring implants during healing and cost effectiveness
are viewed here.
One-stage implant treatment, by the use of either
nonsubmerged implants or modified two-stage submerged
treatment using a one-stage surgical protocol, has recently
become more popular. The placement of implants in a one-
stage procedure has some advantages; only one surgical
404
intervention is needed, treatment time is shorter, costs are
lower, and clinical monitoring of the implants is possible
during the osseointegration period.
Immediate occlusal loading provides many advantages
where the implant and prosthesis are placed in the same
day, thereby providing the patient with an esthetic and
stable replacement for the missing tooth/teeth in one
appointment. Moreover, the use of the immediate loading
concept significantly reduces the total treatment period
which has positive social and psychological effects for the
patient and increase significantly the patient comfort.23
During the osseointegration period, the implants are
accessible for clinical monitoring added that immediate
loading of implants would not only reduce the risk of Fig.3 The majority of mandibular overdentures
development of fibrous tissues, but also minimize the Performed by dentists are with two implants
development of immature bone and promote a faster
maturation of the immature bone to lamellar bone by
accelerating bone remodeling at the bone/implant
interface by inducing bone cells stimulation.24
Immediate loading within physiologic limits stimulates
bone formation as result of the bone adaptation to loading.
The benefits of an immediately loaded implant-supported
prosthesis in edentulous patients reduce surgical and
prosthetic visits along with improved function and patient
comfort in addition functional prosthesis delivered
immediately after surgery.
Immediate loading eliminates the need for numerous and
long appointments that may require great demands on
practitioner time for adjustment of provisional prostheses Fig.4; Rehabilitation of an Edentulous Patient
delivered to the patients during the healing period of with Implant Supported Overdenture
delayed loaded implants.25

Fig.5; Loctor abutments attached to implants

Disadvantages of immediate loading
Fig.1 Preoperative OPG This approach cannot be applied to every implant patient.
In comparison to conventional implant therapy, the
immediate occlusal loading procedure requires more chair
time at the time of implant placement for both the patient
and the restorative practitioner. Immediate loading also
requires effective communication and coordination among
the surgical and restorative teams, as there is a degree of
flexibility involved in the delivery of the prosthesis.26
The main disadvantage of this technique is the risk of
implant failure with subsequent multiple appointments to
remove the implant, graft bone and replace a new fixture.
In this case, the second implantation does not follow the
immediate loading protocol. As well as, the immediate
loading technique in completely edentulous patients
Fig.2 Post operative OPG
405
Muhamad et al. IEJDTR, 2017; 6(2): 403-411
requires usually many implants which increases the fee
and makes patient's acceptance less likely.
Indications
 Severe morphologic compromise of denture
supporting areas that significantly undermine denture
retention
 Poor oral muscular coordination
 Low tolerance of mucosal tissues • Para functional
habits leading to recurrent soreness and instability of
prosthesis • Unrealistic prosthodontic expectations
 Active or hyperactive gag reflexes, elicited by a
removable prosthesis, e.g. roofless maxillary denture
 Psychological inability to wear a removable prosthesis,
even if adequate denture retention or stability is
present
 Unfavorable number and location of potential
abutments in residual dentition. Adjunctive location of
optimally placed osseointegrated root analogs would
allow for provision of a fixed prosthesis.
Contraindications
 Chemical dependency (like phenytoin)
 Uncontrolled systemic disorders
 Psychological (schizophrenia, dysmorphophobia).
Treatment modalities for the restoration of edentulous
mandible include: mandibular complete denture
preprosthetic surgery with mandibular complete dentures
and implant supported mandible overdentures and
implant supported fixed bridge. Classic treatment for the
edentulous mandible is a mandibular complete denture;
the pattern of bone loss associated with the complete
dentures can result in dentures bearing area becoming
compromised. Redford demonstrated that more than 50%
of CD wearers have problems with the retention and
stability of these mandibular complete dentures. When the
patient experiences poor retention and stability, patient
satisfaction, confidence and comfort will suffer. The
implant-supported mandibular overdentures have been
investigated by Van Steerbergh being one of first authors
to purpose the placement of two implants in mandible to
support an overdentures. Within 52 months, a 98%
success rate was achieved. Implant supported overdenture
requires frequent maintenance, especially during their
first year.26 Atterd et al concluded that cumulative survival
rate of over dentures was 100% at 15 years with longevity
of prosthesis being 10.39 ± 5.59 years. Albrektsson et al
have argued that state of almost ‘restitution and integrum’,
can be achieved with dental implants.27
Selecting an adequate ISO attachment
Clinicians have selected different attachment systems
based on factors such as durability, patient demand, cost
effectiveness, technical simplicity, and retention.
Attachments can be classified depending on its function as
a) rigid, if they do not allow any denture dislodgements, or
b) resilient, when they allow translation, rotation, axial or
hinge over posterior axes movements or a combination of
them because of their flexibility. With rigid attachments,
the implant will receive 100% of occlusal load, whilst, with
resilient attachments, occlusal load will be supported by
Muhamad et al. IEJDTR, 2017; 6(2): 403-411
implant, denture or fibromucous. Currently, the most used
attachments are:
“O” Ring or Ball attachment
Ball attachment is considered the simplest type of
attachment for clinical application with tooth or implant
supported overdentures. It has a screw-retained male
abutment in the implant with a spherical shape on its
occlusal portion, and a prosthetic anchored female part
that can be metallic or covered with nylon having a
different retention range. These attachments do not need a
great prosthetic space and they allow hinge and rota tion
dislodgements. However, the specific design of the ball
attachment may influence the amount of free movement
thereby limiting its resiliency. However, these attachments
cannot be used with non-parallel implants.28
Magnetic attachment
Basically, they consist of one magnet attached to the
denture and another to the implant. They constitute a
simple and comfortable system for the patient as magnet
attraction guides the denture insertion. On the other hand,
they have a weaker lateral stability and retention in
comparison with mechanic attachments as ball or bar
devices. In addition, they are susceptible to corrosion by
saliva, explaining why they are clinically less often used.29
However, a new generation of rare-earth magnetic
attachments could improve their properties and be
clinically more often utilized These new attachments may
still be a useful treatment option for edentulous patient
with weak muscle disease such as Parkinson’s disease
patients, because they not only keep the denture stable,
but also need less force to insert and remove the denture. 30
Bar attachments. .
Bar constitute an excellent anchorage system that
provides greater retention, enabling better force balance
by its splinting effect and it can also correct severe
unparalellisms. The retention elements or clips are
interchangeable and can be reactivated. The main
disadvantages of bar attachments are the need for a large
prosthetic space and the risk of mucositis due to an
inadequate oral hygiene under the bar. Bars need to be
parallel to the rotation axis, be straight and be positioned
1-2 mm to the alveolar crest. There are some different bar
designs as Ackermann Bar (spherical shape), Dolder Bar
(ovoid or “U” shape) and Hader Bar (keyhole shape).Also,
there are implant-supported milled bars overdentures.
They are bars with precision attachments and rigid
anchorage, made by casting, electroerosion or CADCAM.
They need a larger prosthetic space because of its volume
and necessitate a good implant anchorage to support
functional forces. They have double retention: by wall
convergence of two degrees and by using other
attachments systems anchored to the bar as Locator or ball
attachments it will be indicated that the implant be
splinted with bar attachments. According to Adell et al.
improve the success rate of implant-supported
overdentures, careful case selection is an important
criteria. Further research needs to be conducted to
improve the success for maxillary implant-supported
overdentures. Clinical Significance: Implant-supported
406
overdentures have improved the masticatory efficiency
and the quality of life of patients. Therefore, this treatment
modality should be considered as a primary treatment
option for edentulousness in future, there were more
failures (24%) in implants less than 10 mm long.
Depending on implant location if implants are placed quite
far from each other, it will not be indicated to use bar
attachments due to increase of bone stress.
-Locator attachments
The male part consists of an implant screw-metallic
abutment and the female part of a metallic cap lined with
nylon of different colors depending on their retention
capacity, which is anchored to the denture. There are two
types of nylon: a) those with internal and external
retention for well-positioned implants (from more to less
retention: transparent, pink, blue) and b) with external
retention for parallel implants (from more to less
retention: green, orange, red).31, 32 Finally, there is a yellow
nylon for laboratory use that can also be used as
temporary nylon. These attachments do not need a large
prosthetic space and they can correct unparalellism up to
40 degrees. The attachments allow for rotation
dislodgement and their utilization is widely endorsed in
the current literature.
-Telescopic attachment
Telescopic crowns are also known as a double crown,
crown, and sleeve coping. These crowns consist of an inner
or primary telescopic coping, permanently cemented to an
abutment, and a congruent detachable outer or secondary
telescopic crown, rigidly connected to a detachable
prosthesis.32, 33 The use of telescopic retainers has been
expanded to include implant retained prostheses to make
use of their enormous advantages. These retainers provide
excellent retention resulting from frictional fit between the
crown and the sleeve.34 They also provide better force
distribution due to the circumferential relation of the outer
crown to the abutment which makes the axial transfer of
occlusal load that produce a less rotational torque on the
abutment by improving the crown root ratio so preserving
the tooth and alveolar bone.35
According to wall design telescopic retainers can be
classified into parallel sided crowns, tapered (conical-
shaped) crowns, and crowns with additional
attachments.36 Telescopic retained restoration has the
advantage of the ease of removability. This encourages the
patient for repeated cleaning and maintenance purposes.
Moreover, the overdentures self finding mechanism in
telescopic constructions facilitated prosthesis insertion
considerably. This construction seemed to be an effective
treatment modality for geriatric patients with serious
systemic diseases as in Parkinson’s diseases.37
Peri-implant findings and prosthetic complications
Peri-implant tissue evaluation criteria vary between
studies. Evaluation often includes plaque index, bleeding
index, probing depth, amount of keratinized attached
mucosa and marginal bone level, and possible exudation of
peri-implant pockets is recorded if seen. There are varying
opinions regarding the importance to and impact on peri-
implant health of a zone of keratinized attached mucosa
Muhamad et al. IEJDTR, 2017; 6(2): 403-411
surrounding dental implants. It has been reported that
healthy marginal mucosa around implants could be
achieved in good oral hygiene conditions also in situations
when no keratinized mucosa is present.38,39
Complications seen with implant overdentures are usually
biological and technical or mechanical and more mucosal
hyperplasia has been noticed with bars than with ball
attachments. It has been supposed that an insufficient
space beneath the bar–which prevents proper cleaning–
may cause a soft-tissue inflammatory response under the
bar attachment. Another reason for mucosal hyperplasia
with bars could be the less precise settling of the denture
base to the mucosa compared with ball overdentures. 40
Periimplant mucositis is rather often seen around
implants. The incidence (an average of 19 %) associated
with implant overdentures is greater than with fixed
implants.41 It has been found that peri-implant tissue
health is not related to the retention system used.42 The
most common technical complications with implant
overdentures are loosening of the retentive mechanism,
usually seen in about 30 % of cases.43 In addition, fracture
of the retentive anchor, occlusal screw loosening with bars,
fracture of the acrylic base material or broken teeth and
fractured bars are common findings. Resilient
attachments were observed to more frequently have
broken, loose, or lost female parts and a need for repairs
and relining of the denture base, whereas rigid bar
attachments more typical need tightening of the bar
retainers.44
It has been shown that attachments wear over time and
lose their retention force. Several studies have been
published concerning the need for corrections and
adjustments of overdentures after delivery of the
prostheses. Prosthetic maintenance is needed with all
attachments, but barsupported overdentures have been
observed to need it less.45 A rigid milled bar attachment
on four-implant overdentures has been shown to cause
less prosthetic maintenance compared with resilient
denture attachments with ovoid bars.46 On the other hand,
Gotfredsen and Holm (2000) presented that the frequency
of technical complications was higher with bars than with
ball attachments with two implants and an overdenture. 47
Recent studies conclude, however, that there is no
correlation between attachments and prosthetic
complications. Only bars with distal extensions have been
seen to have more. Maxillary overdentures have been
found to have more prosthetic complications than
mandibular overdentures , but the surveys vary.
DISCUSSION
Implant-supported and -retained overdentures have
become a widespread and predictable treatment option for
edentulous mandibles. Comparatively low costs and simple
treatment compared with fixed structures, easiness of
hygiene and sometimes also better esthetic results when
lost hard and soft tissues need to be replaced are factors
that account for the success. A sufficient amount of bone is
usually available in the interforaminal area of the
mandible to enable implantation. The number of implants
needed for a mandibular overdenture is smaller than for a
407
fixed implant bridge–usually two to four implants–and this
is advantageous when the amount of jawbone is reduced.
Numerous studies confirm good treatment results with
two mandibular implants also in the long term. It is
generally stated that for an edentulous mandible,
twoimplant overdenture treatment should be the standard
of care relative to conventional denture treatment.48
Marx et al presented a technique in 2002 in which dental
implants were used as “tent poles” in combination with
bone grafts to maintain the bone volume This surgical
procedure use autogenous bone grafts from the iliac crest
and implantation is performed extraorally underneath the
tip of the mandible at the chin during the same operation.
This technique has been called soft tissue matrix
expansion and has also been used as a modified technique
in Oulu University Hospital.49
This treatment modality was developed primarily for cases
with extreme alveolar resorption of the mandibular bone,
with typically approximately six mm or even less of ridge
height left, and has helped alleviate severe problems with
conventional complete dentures. During the past decades
several different attachment systems have been presented
and compared with each other in terms of retentive force,
easiness to use and hygiene, tendency to breakage and
economic factors. It has been noted that when the
attachment system or the number of implants is varied,
there is no clear differences in satisfaction among patients
with mandibular overdentures.50
Cordioli G et al in 1997, conducted a five-year study which
evaluated a treatment option by using a single implants
over denture in the midline of the mandible of 21 geriatric
patients according to the protocols of standard surgical
technique in two stages. Improvement in oral comfort,
function and health of the peri-implant soft tissues, and the
marginal bone levels interproximally were evaluated for 5
years after over denture delivery. Results showed a
remarkable improvement in comfort and function without
any failures of the implants placed.51
Krennmair G et al in 2001 nine patients with a mean age
of 82.2 years underwent placement of a single symphyseal
endosseous implant and anchorage of complete denture
using ball attachments. Standardized recall examinations
were carried out at intervals of 3-6months for a period of
18 month. The anchorage with single implant led to the
improvement of both patients' subjective satisfaction and
reduction in reported discomforts.12
Wolfart S et al in 2008 reported two clinical cases of a
single implant in the middle of the mandible with ball
attachment and with a screw activated matrix for the
stability and retention of the prosthesis. The result showed
improvement in the chewing ability and quality of life in
old patients.
Walton JN et al in 2009 conducted randomized clinical trial
of 86 subjects using conventional complete dentures were
given either one midline or two bilateral mandibular
implants. Patient satisfaction was similar and the single-
implant patients had the benefit of significantly lower
component costs, reduced time of surgery, postsurgical
Muhamad et al. IEJDTR, 2017; 6(2): 403-411
maintenance and besides in the 2 implant group five
implants had failed in four patients.52
Liu J et al. In 2013 conducted a study on the influence of
number of implants on the biomechanical behaviour of
mandibular implantretained over dentures and concluded
that, Single implant retained over dentures showed no
damaging strain concentration in the bone surrounding
the implant.53
Grageda E et al in 2014 published a report that single
implant retained over denture had an additional advantage
which was less expensive and invasive compared to that of
the over dentures supported by two implants.54
Bryant SR et al. In 2015 compared use of single or two
implants for implant over dentures in a five year
randomized clinical trial. It showed no significant
difference in the satisfaction or survival of edentulous
subjects.55
Alsabeeha N et al. In 2010 did an in vitro retention force
investigation on different designs of attachment systems
used for single-implant retained mandibular over
dentures. Here, two ball attachments (prototype) of
greater dimension and four commercially available
attachments (ball and stud) of normal dimension were
compared. They found that attachment systems of larger
dimensions provided higher retentive forces for
mandibular single implant over dentures. Alsabeeha NH et
al. in 2010 did a study on the clinical performance and
material properties of single-implant over denture
attachment systems and concluded that large ball
attachment systems reflected favourable wear behaviour
and clinical performance.56
Cheng T et al in 2012 conducted a study on patient
satisfaction and masticatory efficiency of mandibular over
dentures retained with single implant using the
attachments( stud and magnets) and found that there
were no statistically significant differences in overall
patient satisfaction, speech, and retention between the
above mentioned attachments.57
Kono K et al in 2014 conducted a study on in-vitro
assessment of mandibular single/two implant over
dentures using stress-breaking ball attachments and
conventional ball attachment. Strain surrounding the
implant, pressure at 5 different soft tissue areas, and
displacement of the denture base were measured and
found that the pressure at each region of the stress
breaker ball attachment was less than that compared with
the conventional ball and it also provided optimal stress
distribution.58
Nascimento JF et al. In 2015 conducted a study on the
photo elastic stress distribution produced by different
retention systems for a singleimplant mandibular over
denture in photo elastic model of a resilient edentulous
ridge. They concluded that the load transmitted to the
implant was equally distributed over the implant with low
stress concentration.59
Maeda Y et al conducted an in-vitro study and came to an
conclusion that over dentures using single implant with
dome-type magnet or ball attachments had biomechanical
effects similar to the two-implant over dentures in terms
408
of lateral forces transmitted to the abutment and denture
base movements under molar functional loads.60
Liu J et al. conducted a three-dimensional finite element
analysis on the influence of number of implant on the
biomechanical behaviour of periimplant bone, implants,
abutments and over dentures and were recorded. They
concluded that single implant retained mandibular over
dentures do not show damaging strain concentration in
the bone around the only implant and that it was a cost-
effective treatment option for edentulous patients. The
placement of a third implant between the original two in
patients rehabilitated by two-implant over dentures
showed improvement in the constant and obvious denture
rotation around the fulcrum line showed.53
When selecting an attachment system the dentist must
take into consideration the long term results. The selection
criteria for the attachment system are the following:
1. The number, the position and the angulation of the
implants. There can be used a minimum of two implants,
unsplinted or splinted by bar. Thus, their number depends
on the prosthetic factors, but also on the number of
implants that must be The choice of the attachment
systems must take into consideration also the inclination
of implants, ball attachments imposing a divergence of
maximum 30 degree, and locator allowing up to 20 degree
divergence on each implant, meaning a divergence of the
long axis of implants of up to 40 degree. [10,26]
2. The prosthetic features: the vertical prosthetic space,
the resilience of the oral mucosa, occlusal loading, the
overdenture retention and stability requirements analysed
in conjunction with patient’s anatomical and functional
particularities.[1,2,5,26,31]
3. The manual dexterity of the patient influences his
ability to properly manipulate the overdenture, as its
insertion and removal. In patients with decreased manual
dexterity, relatively frequently encountered in elderly, it is
more appropriate to chose a less retentive attachment
system[13,31].
4. Biological conditions and therapeutic expectations.
Splinting the dental implants by choosing bar as
attachment system provides a more uniform distribution
of occlusal forces, but has the disadvantage of higher costs
for addressing the complications – loss of one implant may
be accompanied by the need of replacement of the entire
bar system and also the prosthesis. [5,7,10,26,31]
5. Financial and time resources of the patient. The cost of
fabrication of the bar attachments in contrast to stud
abutments will be much higher in most instances.
Treatment options should never solely be based on
finances. [3]
Choosing the attachment systems for the implant
overdentures must take into consideration long term
results concerning retention, stability, mechanical
complications, and selection criteria related to the number,
inclination of implants, prosthodontic conditions, the
dexterity of the patient, biological conditions, and
therapeutic expectations, financial and time resources of
the patients, overall costs and usage technique.
CONCLUSIONS
Muhamad et al. IEJDTR, 2017; 6(2): 403-411
Mandibular implant-supported overdentures have a
greater success rate than maxillary implant-supported
Overdentures. To improve patient quality of life, careful
case selection should be incorporated for the Success of
both maxillary and mandibular implants upported
overdentures. Further research needs to be conducted to
improve the success for maxillary implant-supported
overdentures.
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