Prosthodontics CLINICAL

Implant-supported overdentures: part 2

Jaymit Patel*1 and David Gray1

Key points
Outlines the key factors to assess in a patient’s Summarises information on the prosthetic space Summarises the maintenance requirements for
history and examination when considering requirements for commonly available implant implant-supported overdentures.
implant-supported overdentures. attachment systems.

Abstract
The ability to provide high-quality complete dentures is a key skill for the general dental practitioner. The introduction
of new implant attachments and dental technologies has opened the possibility of a wide variety of treatment options
when considering implant-supported overdentures (ISODs).
A thorough understanding of the advantages and disadvantages of ISODs is essential to ensuring appropriate
treatment planning, consent and maintenance. Part one of this paper discussed the role of ISODs and the different
attachment systems available. This second part will explore the relevant treatment planning considerations and
maintenance requirements.

Introduction
This article is the second of a two-part series
exploring the treatment options, planning
considerations and maintenance requirements
for implant-supported overdentures (ISODs).
Part one has described ISODs, their relative
advantages and disadvantages, and commonly
used implant attachment systems. Part two
focuses on the treatment planning of ISODs
including the diagnostic process, the optimal
number and distribution of implants, planning
the implant-supported prosthesis, as well as the
long-term maintenance requirements.
There is a professional consensus supporting
the notion that ISODs can help to improve
quality of life in edentate patients when
compared to a conventional prosthesis.1,2
Furthermore, ISODs have improved retention
and stability when compared to conventional
complete dentures,3,4 with retention being a key
factor influencing patient satisfaction.5 ISODs
are associated with a reduction in alveolar ridge
1
Leeds Dental Institute, The Worsley Building, Clarendon
Way, LS2 9LU, UK.
*Correspondence to: Jaymit Patel
Email address: jaymit.patel@nhs.net
Refereed Paper.
Accepted 3 December 2020
https://doi.org/10.1038/s41415-021-3278-3
resorption, and improvements in chewing
function, nutritional status and patient-reported
confidence.6 Additionally, the York1 and McGill2
consensus statements suggest that a mandibular
denture retained by two implants is a cost-
effective treatment for individuals in the United
Kingdom and Canada. Treatment planning on
an individual basis should, however, consider
factors relevant to the specific patient. These may
render an ISOD, or a particular type of ISOD,
inappropriate in certain scenarios. Additionally,
both of these consensus statements focus on
a mandibular complete denture retained by
two implants as an overarching ‘first-choice
treatment’ for edentulous patients rather
than the optimal treatment for any particular
case. Consideration should always be given to
patient-specific factors to determine feasible
and appropriate treatment options to restore
edentate spans.1
A conventional denture of good technical
quality is required before the provision of an
ISOD. An ISOD relies upon all aspects of the
conventional denture being optimised in order
to provide maximum benefit to the patient. This
facilitates the assessment of patient compliance
and motivation, anatomy in relation to tooth
position and the potential challenges in the
provision of a successful ISOD. The assessment
process outlined below presumes that a
conventional denture of good technical quality
has already been provided. The case-specific
aims of an ISOD (aligned with the limitations of
the conventional prosthesis) should be clear at
this point. Additionally, all principles of history
and examination for edentate patients still apply,
as outlined in recently published articles.7,8
History
A thorough history and examination will enable
the assessment of the potential challenges with
denture provision and determine the likelihood
of success. The presenting complaint may
relate to various challenges in the construction
of dentures including anatomical, clinical,
technical and patient-related factors.7
For many individuals, tooth loss results from
preventable dental diseases. It is important to
consider the individual’s ability to maintain
dental implants from a similar risk-oriented
perspective, as dental implants are often more
challenging than the natural dentition both
in terms of preventing and treating disease.7,9
These risk factors include the patient’s previous
oral hygiene standards, their medical health
(including the influence of medical conditions
on oral health and dexterity), smoking
history, bruxism and previous diagnoses of
periodontal/peri-implant disease. All of these
factors are associated with a higher risk of
implant-related complications.10,11

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 CLINICAL Prosthodontics

Fig. 1 a) The working cast with the wax rim. The incisive papilla has been outlined. The distance between the incisive papilla and the planned
labial surface of the upper incisors is greater than 10 mm. This patient will therefore require a removable prosthesis with a flange to provide
adequate lip support. This is also evident from extraoral views of the peri-oral tissues, b) without and c) with the upper denture in situ

An initial prevention-oriented course of
treatment may be required to optimise patient-
related factors before treatment planning of
implant-supported prostheses.
Additionally, it is vital to evaluate the patient’s
motivation for seeking treatment, along
with their commitment to undergo implant
rehabilitation. In some cases, patients may
attend with expectations for treatment that are
unrealistic and/or rooted in misinformation
on the viability of implant-supported
rehabilitations. A thorough and open treatment
planning discussion outlining all of the available
options along with what the patient can expect
in terms of aesthetics, chewing ability, comfort
and stability of the prosthesis is essential.
It is important to consider that whilst an ISOD
will be beneficial to a significant proportion of
edentate patients, it is not the best treatment for
all patients; for example, individuals who are
unable to maintain implants or are unable to
undergo surgical/augmentation procedures.
Examination
Zitzmann and Marinello12 described the factors
that should be considered when planning
implant-supported restorations. These include
the volume and quality of bone at prospective
implant placement sites, the lip line and lip
support, and aesthetic demands. It is important
to consider all relevant factors before deciding
on an implant-supported rehabilitation.
Lip support
In dentate patients, lip and face support is
provided by the labial/buccal contour of teeth
as well as the shape of the alveolar ridge. In
edentate patients, this support is provided by
the position and shape of the prosthetic teeth,
as well as the labial/buccal flange. Resorption
of the maxillary alveolus occurs in an apical
and posterior direction,13 often necessitating
the use of a prosthesis with a flange to provide
support for the lip.
Lip and face support should be assessed both
with and without any pre-existing dentures,
and with the patient facing forwards and in
profile.14 In cases of advanced alveolar ridge
resorption, the support provided by removable
prostheses significantly contributes to the soft
tissue profile of the lower facial third.
One method of assessing this involves
duplicating the denture and removing the
anterior flange to assess the amount of lip
support provided by the teeth alone.5 It
has been suggested that if resorption in the
anteroposterior direction exceeds 10 mm, then
a removable prosthesis is indicated.15 This can
be measured between the labial surface of the
upper incisors and the centre of the incisive
papilla (Fig. 1). This distance is normally 8–10
mm before any alveolar resorption.16
There is a tendency for patients to prefer
fixed over removable prostheses; however, fixed
prostheses are unable to provide the same degree
of soft tissue support owing to the lack of a flange.
If lip support is inadequate without a flange, a
removable prosthesis will be required.
Mouth opening
A reduced oral aperture can make the provision
of conventional removable prostheses more
challenging.8 These factors also influence
the ability to place dental implants and to
accommodate implant attachment systems
within a restricted space.
The available space to accommodate implant
drills, abutment drivers and attachment
housings should be considered. This is
influenced by the anticipated position of dental
implants, and it is therefore often useful to
consider mouth opening in conjunction with
inter-arch space and bone volume.
In some cases, a compromise in implant
angulation may be accepted to overcome
challenges with reduced mouth opening.
This typically involves a slight anterior tip of
implants with either angulated screw access
or an angle-correcting abutment. It should
be noted that some of these solutions require
additional prosthetic space, thus necessitating
careful planning, typically within a specialist
environment. From a mechanical standpoint,
there is an increased risk of complications
when angle correcting, including an increased
risk of screw loosening, screw fracture and
implant failure.17
Smile line
The smile line, movement of the upper lip in
social circumstances and the character of peri-
oral muscle attachments should be considered
to define the prosthetic envelope, as well as the
complexity of the case. A high smile line can be
challenging to manage as the implant/mucosal/
prosthesis junction may be visible. The smile
line should be assessed with and without the
dentures in situ.14 If the alveolar mucosa is
visible during smiling, then a flange (as part
of a removable prosthesis) may be required to
mask this junction; this will be based upon the
aesthetic challenges specific to the case.
In cases where there is a well-formed
edentate ridge, there may be limited space to
accommodate implant components without
alveolar ridge reduction. Insufficient space may
also render some prosthetic options unviable.
As such, an awareness of the prosthetic space
requirements of different attachment systems
is of paramount importance.
Inter-arch space
The available inter-arch space dictates the
feasibility of implant components and the
prosthesis, and is determined by the occlusal
vertical dimension and required freeway space.
These can be determined during the construction
of a conventional denture (as outlined by Patel

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 Prosthodontics CLINICAL

et al., 2018)7 and will be influenced by the alveolar

anatomy, skeletal relationship18 and the patient’s
adaptive capacity.5
AbuJamra et al. (2000)19 described a technique
for assessing the inter-arch space during implant
planning. This assessment requires a silicone
index to be made of the complete denture while
seated on a stone cast. The silicone index can
then be used in conjunction with the stone cast
to measure the available space to accommodate
implant components (see Figure 2).
The space required to house the prosthetic
rehabilitation will vary based on the type of
attachment planned. While this is specific to
the manufacturer of each component type, a
guide on the required space for various implant
Fig. 2 A sectioned putty index of the denture which is used to measure space for acrylic around
rehabilitations is summarised in Table 1. In each locator housing
some cases, certain attachments may not be
feasible due to the available prosthetic space,
particularly if implant positioning is not ideal.

Radiographic assessment

Radiographic assessment and follow-up

are essential for both implant planning and
long-term care. Two-dimensional imaging
(most commonly periapical radiographs)
can be used for both of these purposes.
Periapical radiographs taken using a parallel
Fig. 3 Lower complete radiographic stent with mid-labial gutta-percha markers. The markers
imaging technique are useful to obtain crude
have alternating heights to facilitate navigation through cross-sectional slices on a CBCT
measurements of periradicular space. They
are also essential for monitoring bone levels
at implant sites, in a similar manner to that justify and interpret cone beam computed When planning an implant-supported
utilised for the natural dentition. tomography (CBCT) images.20 rehabilitation, radiographic exposure can
Three-dimensional imaging offers further A consensus report published in 2012 be undertaken with a radiographic stent in
insights into patient anatomy but must be suggested that CBCT in implant dentistry situ. The radiographic stent is often based
prescribed and interpreted appropriately. The can be used for diagnostics, implant on an idealised wax-up or denture and
European Academy of DentoMaxilloFacial planning, surgical guidance and post-implant contains radiopaque material (commonly
Radiology (EADMFR) recommend that evaluation.21 The present article will focus on barium sulphate or gutta-percha [GP]) to
additional training is required to prescribe, the use of CBCT for implant planning. indicate the position of teeth. Figure 3 shows

Table 1 The space requirements for different implant attachment systems

Milled bar with acrylic

Locator Ball abutment Bar and clip-supported denture
Conventional over-casting
Space requirement (Zest Anchors, (Dalbo, Siscon, (Dolder, Cendres Metauz, Switzerland)
denture (Atlantis, Dentsply Sirona,
Inc./CA, USA) Switzerland) (Hader, MA, USA)
NC, USA)
Denture acrylic >2–3 mm >3 mm >3 mm >3 mm >3 mm
Implant abutment (minimum > 5mm + 2 mm gingival Dolder: >3–5 mm + >2 mm gingival clearance
- 1.5 mm >3.7 mm
supragingival component) clearance Hader: >4.5 mm + 2 mm gingival clearance
Dolder: >3–4 mm
Retentive housing - 3.2 mm >2.4 mm -
Hader: >2.5 mm
>8–9 mm + 1 >9 mm + 1 mm
Occlusal space required >3 mm >10 mm + 1 mm for bruxists >12 mm + 1 mm for bruxists
mm for bruxists for bruxists
Bucco-lingual width required >3 mm 10 mm 10 mm - 11 mm
Buccal and lingual width
required from centre of - 3 mm 4 mm - 4 mm
implant screw hole

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 CLINICAL
a radiographic stent based on a complete
denture, which contains radiopaque GP
on the mid-buccal aspects of the teeth. All
GP points start at the gingival margin on
the denture and are of alternating lengths;
this provides information on the idealised
position of teeth in three-dimensional
space including their tip and proclination.
GP markers of alternating heights can also
facilitate navigation of axial cross sections
and thus the interpretation of the CBCT.
CBCT enables the anatomy of the maxilla
and mandible to be evaluated in relation to
the idealised tooth positions on a denture
(in a three-dimensional manner), and thus
provides information on the ideal position
for dental implants. Therefore, CBCT used
in conjunction with a radiographic stent can
facilitate this prosthetically driven treatment
planning process.22
Surgical planning
Surgical planning is critical when considering
the number of dental implants, the relative
distribution of implants and the attachment
type. 23 While numerous studies have
investigated the influence of implant number
and position on force distribution, there is
limited data investigating clinical outcomes
and long-term success rates of different
implant configurations. 5,24,25,26,27 This may
be the result of the wide array of factors
which influence the success of removable
prostheses, many of which are challenging to
measure objectively.14,28 Nonetheless, it has
been suggested that removable prostheses
in the maxilla should be supported by more
implants than a similar prosthesis in the
mandible. This relates to reasons discussed
in part one of this series. Additionally,
removable prostheses supported by a single
implant have significantly poorer outcomes
when compared to those with two or more
implants.29,30,31 Published literature involving
simulation of force distribution during
loading suggests that four implants in the
mandible may be favourable mechanically
when compared to two implants; however,
this is associated with comparatively limited
improvement in implant survival or patient
satisfaction.32,33 Similar findings have been
suggested in the maxilla when deciding
between four and six dental implants.34,35
Various studies suggest a minimum of two
implants in the mandible and four implants
in the maxilla.5,14
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Prosthodontics
Fig. 4 The first method of ISOD provision is adopted in such cases where a pre-existing
denture is to be utilised, or where the clinician favours incorporating the free-standing
implant attachments only once denture construction is complete. It should be noted that
there is a risk of locking a denture in place when utilising this technique. The clinician should
therefore have a thorough knowledge of the attachment system and materials being utilised
Assess the pre-existing Create a space in the Fit the locator Cold-cure pick-up of
denture to ensure denture overlying housing onto the locator housing
sufficient space the implant implant abutment
• See Figure 2 • The locator abutment • Ensure an appopriate • Ensure removal of
should not contact the spacer is placed prosthesis prior to
denture between the abutment complete material set
• If creating a new and the housing
denture, this may be
done by the technician
Fig. 5 Alternatively, the denture can be processed with the denture housings in situ. This
technique requires a new denture to be constructed, but avoids the risks associated with
cold-curing housings into a denture and ensures that the entire denture is constructed
from heat-cured acrylic
Primary impressions Secondary impressions Jaw registration, wax trial
• The laboratory constructs • Locator abutments are fitted and denture fit
a special tray with (if not already completed) • A heat-cure base plate is
sufficient spacing to • Impression copings are seated constructed with attachment
accomodate abutment onto the abutments housings in situ
level pick-up impressions • A secondary pick-up impression • This facilitates assessment of
is taken the denture base as well as
attachments
• Remaining stages are
completed following
conventional principles7
Surgical planning should follow a structured such as component wear, acrylic fracture, screw
format, with the below sequence being loosening, screw fracture and soft tissue trauma.5
published in the literature:36 A well-fitting prosthesis should be constructed
1. Prosthesis design/type before implant placement to enable appropriate
2. Patient force factors surgical implant planning. This section will
3. Bone density focus on the delivery of an ISOD retained by
4. Key implant positions (distribution and key stud attachments (for example, Locator) as this
positions) is likely to be the most common rehabilitation
5. Implant number required for the planned managed within the primary care environment.
restoration There are two methods for delivering an ISOD.
6. Implant sizes These are both summarised in Figures 4 and  5.
7. Available bone
8. Implant design. Assessing soft tissue height
Following an appropriate healing time, healing
Delivery of ISODs abutments can be removed from the implant
and the height of the soft tissue above the
All of the key principles of denture provision implant head can be measured (Fig. 6). This
apply to the construction and delivery of facilitates selection of an implant abutment
ISODs. While an ISOD will benefit from the of an appropriate height to achieve the lowest
additional retention provided by the implant possible profile while ensuring that the soft
attachment assembly, this will not compensate tissue margin remains at or slightly below the
for a poorly fitting, unretentive or unstable engaging component of the abutment. Healing
denture. Indeed, a poorly fitting denture can abutments should be replaced following the
lead to complications associated with the ISOD selection of appropriate abutments.
 Prosthodontics CLINICAL

Fig. 6 a, b) Measuring soft tissue height to determine c) the correct abutment height. This measuring tool can be used to determine soft tissue
height in 1 mm increments from 1 mm to 8 mm

Fig. 7 A single tooth implant analogue, a, b) with and c) without the corresponding impression coping in situ. The laboratory cast the impression
with both components attached and remove the impression coping during removal of the impression material from the set casting stone

Primary impressions
Primary impressions for ISODs should follow
the same principles as those for conventional
dentures.
Secondary impressions
Secondary or definitive impressions should
follow the key principles of conventional
denture impressions to record the important
anatomic landmarks, functional soft tissue
space, but crucially also to record the position
of the dental implants in three-dimensional
space. This impression must accurately
record the position of all dental implants;
any distortion in this recording will result in
an inability to fully seat the denture. A rigid
special tray is recommended for this process
to optimise the recording of soft tissues and
minimise any flexure caused by distortion of
the impression tray. Secondary impressions
for free-standing stud-type attachments are
typically taken with an impression coping in
conjunction the definitive abutment seated and
torqued onto the implants, while for splinted
attachment systems, the secondary impression
is typically undertaken with impression
copings attached directly to the implant. A
baseline radiograph is recommended following
insertion of the implant abutment to assess
correct abutment seating as well as record
baseline anatomy/bone levels.37
A ‘pick-up’ of the corresponding abutment
impression copings is made during this process
(see Figure 7). These impression copings seat on
to the implant abutment and more accurately
record implant positioning. Corresponding
implant lab analogues are placed into these
copings following removal of the impression
to enable the laboratory to work to an accurate
representation of the dental implant when
fabricating the definitive denture.
Impressions should be taken with a rigid
setting stable material such as polyether or
polyvinylsiloxane (PVS). This minimises
movement of impression copings during
removal of the impression material or
impression casting. A systematic review of the
accuracy of implant impressions reports that
10 out of the 11 articles reviewed identified
no difference between the accuracy of PVS
and polyether impressions. 38 The same
systematic review reported that the accuracy
of these impressions was greater (with both
abutment and implant-level impressions)
when the impression copings were splinted
intraorally with pattern resin or an alternative
rigid setting material before impression
taking. This is reported to minimise flexure
and displacement of implant copings during
impression taking.
Occlusal registration and wax trial
Occlusal registrations should ideally be
performed on a heat-cured acrylic baseplate
with the retentive implant housing in situ. This
enables assessment of the fit of the definitive
denture base, as well as the accuracy and fit of
the retentive housings within the denture base
on to the implant abutments.
Occlusal registration is performed as
recommended for conventional dentures.
Prosthetic space for implant housings as well
as the prosthesis can be assessed at this point
(as outlined previously).
A wax trial should also be completed in a
similar manner to a conventional denture wax
trial. There is a lack of evidence relating to the
optimal occlusion for an ISOD.
Fit
Delivery of an ISOD should follow routine
steps for conventional dentures, including the
assessment of processing errors and acrylic
deformities. Many implant housings are
integrated into the denture base using specific
processing inserts. These may become damaged
during the denture processing and finishing

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Table 2 A summary of the common complications associated with ISODs

Complication Possible aetiology Management

Worn insert Replace insert

Loss of retention
Deactivated insert Activate insert to desired force
Tighten abutment to manufacturer’s recommended torque value
Loose abutment
Identify factors potentiating screw loosening
Attempt retrieval of abutment screw
Poor stability Replace abutment
Abutment screw fracture*
Identify factors potentiating screw fracture
Consider remake of overdenture
Ridge resorption Consider reline/remake of existing ISOD
Assess static and dynamic occlusion
Occlusal discrepancy
Adjust chairside if able to identify discrepancy
Painful fit surface/
ulceration Fit surface not smooth or impression error Adjust and polish denture with use of pressure indicating paste as required
Ridge resorption/poorly adapted denture base Consider reline/remake of existing ISOD
Occlusal discrepancy Denture repair and occlusal assessment/adjustment at fit
Fractured teeth A remake may be required with an increased occlusal vertical dimension or selection
Insufficient inter-occlusal space*
of a lower-profile retention system
Oral hygiene at implant site In-depth assessment of peri-implant health including relevant indices26
Peri-implantitis* Unhygienic prosthesis design Oral hygiene instruction
Risk factors for peri-implant disease Periodontal debridement
Key:
* = indicates complications that may require referral to a relevant specialist.

stages. Adjustments are made to achieve
satisfactory denture fit using normal protocols,
while also being aware of the thickness of acrylic
that remains over attachment housings. If the
denture is deemed satisfactory for delivery, then
the processing inserts are removed and replaced.
Manufacturers typically provide a range of inserts
with varying retentive values. The least retentive
inserts are trialled first, with optimal denture
retention representing a balancing of retention
and the patient’s ability to remove the prosthesis.
Implant angulation,39,40 distribution,40 insert
material,40,41,42 shape40,41 and retentive value40
can all influence the wear rate of attachment
inserts. Thus, appropriate insert selection is key
to minimising the maintenance requirements
for ISODs.
Maintenance
While the procedures for maintaining ISODs
are usually straightforward, close monitoring is
essential to maintain optimal functioning. Recall
is, thus, generally found to be more frequently
required than with conventional dentures.
The complications associated with
ISODs can be categorised as mechanical
and biological. The most common causes
of failure vary depending on the type of
implant attachment system and prosthesis.
It is, nonetheless, understood that there is a
high reported incidence of mechanical43,44 and
biological45 complications relating to ISODs.
These are outlined in Table 2.
Indeed, many clinicians advocate pre-planning
a ‘minimum’ maintenance schedule from this
early stage, both to maintain peri-implant health
as well as ensure maintenance of the prosthesis
and patient-reported outcomes.46,47
Biological complications
Routine monitoring of peri-implant health is
recommended as per the current British Society
of Periodontology guidelines.48 This involves
detailed four- or six-point pocket charting at
implant sites at all recall appointments, along
with assessments for bleeding and suppuration.
Further assessment and treatment should, in the
first instance, be provided within the primary
care environment as per this available guidance.48
It is reported that 28% of patients will develop
peri-implantitis.49 The maintenance of oral
hygiene is imperative to the prevention of peri-
implant disease.50 Patients should be educated in
adequate oral hygiene measures around dental
implants and bars.51 Oral hygiene levels should be
monitored regularly and reinforcement provided
where necessary. Patients should be informed to
carry out oral hygiene measures twice daily.
Mechanical plaque control around
lone-standing implant attachments can be
adequately performed with a small electric
toothbrush head, single tufted brush, an
interspace brush or a combination of aids.
Bars require additional use of floss and/or
interspace brushes between the implants to
ensure adequate plaque control. The patient’s
dexterity should be considered from the outset
and oral hygiene measures need to be tailored
to the individual. Dentures should be brushed
with a toothbrush or dedicated denture brush
at least once a day to remove plaque biofilm.
Chemical plaque control with an oral rinse
should be considered as a supportive measure
for individuals who are unable to maintain oral
hygiene with mechanical control alone.
There is a lack of high-quality published
literature reporting on the required frequency
of professional debridement at implant sites
to maintain peri-implant health. Despite this,
there is evidence to suggest good outcomes in
achieving resolution of peri-implant mucositis
with periodontal therapy.51
Mechanical complications
When comparing ISOD abutment systems,
there is little evidence of differences in
incidence of mechanical complications. With
regards to lone-standing systems, Cristache
et  al. identified that over five years, the
prosthodontic success varied between magnets
(82.6%), locators (78.2%), titanium matrix
ball abutments (72.7%) and gold matrix ball
abutments (50%).52 This study allowed for up
to five replacements of the insert and one reline
within the five years to be defined as prosthetic

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success. The most common complications were
deactivation/replacement of insert, loosening
of abutment screw, relining the ISOD, fracture
of denture teeth and peri-implant mucositis or
tissue hyperplasia. Less frequent complications
included fracture of the abutment screw,
remake of the ISOD and fracture of the ISOD.
The Locator attachment system is a common
system used routinely for ISODs. A retrospective
study identified that the most common reasons
for patients making unplanned returns to the
dentist regarding their dentures were for denture
adjustments, inadequate retention and loosening
of the implant abutments.53 This is comparable to
the maintenance of other attachment systems and
can usually be remedied chairside.42
While the majority of complications associated
with ISODs are straightforward to manage,
additional training may be required. Vere et al.
identified that general dental practitioners were
not familiar with a common attachment system
(Locator system) and were reluctant to maintain
implant-retained overdentures. 54 Further
support is recommended to ensure dentists in
general practice are comfortable and confident
in the routine maintenance of ISODs.
Conflict of interest
The authors declare no conflicts of interest.
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