INTRODUCTION

The goal of modern dentistry is to restore normal contour, function,

comfort, esthetics, speech and health, regardless of the atrophy, disease or

injury of the stomatognathic system.

Throughout history, humans have attempted to replace missing or

diseased tissue with natural or synthetic substances. There are two elements

in tooth replacement – materials for the replacement of tooth and some form

of attachment mechanism. Various materials have been used for replacement

of missing teeth, including carved ivory, bone and also natural extracted

teeth.

An alternative attachment mechanism was discovered by means of an

accidental finding by Prof.Per Ingvar Branemark and his colleagues during

1950s – 1960s. The metallic structure becomes incorporated in living bone,

Branemark called it Osseointegration.

Osseointegration is a direct bone anchorage to an implant body which

can provide a foundation to support the prosthesis and it has the ability to

transmit occlusal forces directly to the bone. Since then, there is vast

research and innovation in the implant systems1.

Overdentures supported by implants are a comparatively new arrival

in the prosthodontic scene. It is found to have increasing application in

1
prosthodontics, which may be a reflection on population trends and the

demand for better treatment.

Overdenture treatment is a notion which precludes the inevitability of

“floating plastic” in edentulous mouths. It has always offered a sensible and

prudent appeal for dental practitioners, and numerous patients have

benefited from this prescription.

Several prosthodontists around the world chose to develop the notion

of implant supported overdentures. As a result a new standard of

prosthodontic services for the edentulous patients has emerged2.

According to 10-year survival surveys of fixed prosthesis on natural

teeth, decay of abutment teeth indicated as the most frequent reason for

replacement; survival rates are approximately 75%. Implant supported

prosthesis preserves adjacent natural teeth, further limiting the

complications such as decay or porcelain fracture and poorer esthetics,

which are the most common causes of fixed prosthesis failure. A major

advantage of the implant – supported prosthesis is that the abutments cannot

decay.3

Chewing efficiency with implant prosthesis is greatly improved

compared with that of a soft tissue-bone restoration. The masticatory

performance of dentures, overdentures, and natural dentition was evaluated

2
by Rissin et al.4 The traditional denture showed a 30% decrease in chewing

efficiency, other reports indicate a denture wearer has less than 60% of the

function of people with natural teeth. The implant supported overdenture

loses only 10% of chewing efficiency compared with natural teeth. These

finding are similar with implant-supported overdentures. In addition, rigid,

implant-supported fixed bridges may function the same as natural teeth. 5

Beneficial effects such as a decrease in fat, cholesterol and the carbohydrate

food groups have been reported as well as marked improvement in eating,

enjoyment and social life.6

Manal A Awad, et al. compared the efficacy of mandibular implant-

retained overdentures and conventional dentures among middle-aged

edentulous patients. They found mandibular two-implant overdenture

opposed by a maxillary conventional denture is a more satisfactory

treatment than conventional dentures for edentulous middle-aged adults.7

Overdentures have been shown to improve the quality of life for

edentulous patients and contribute significantly to the patient’s

psychological well-being. Patients reported increased satisfaction with the

implant-retained overdenture rather than conventional complete denture.8 In

a randomized clinical trial comparing the efficacy of these overdentures and

conventional dentures in diabetic patients, patients reported that the

overdentures provided better masticatory function than conventional

3
complete dentures and there was improved general satisfaction. 9 Moreover,

Takanashi et al.10 estimated that the time required to fabricate a mandibular

overdenture retained by implants with ball attachments was not significantly

different than the time needed for conventional denture treatment.

The implant-retained overdenture is a treatment option for edentulous

patients in the following situations: poorly retained and unstable mandibular

dentures, poor bone quality or insufficient available bone to accommodate 4

or more implants, as the original Branemark protocol suggests.11

The success rate of implant prostheses varies, depending on a host of

factors that change for each patient. However, compared with traditional

methods of tooth replacement, the implant prosthesis offers increased

longevity, improved function, bone preservation, and better psychologic

results.

4
 HISTORICAL BACKGROUND

Throughout history many clinicians have attempted to use dental

implants as a solution to edentulism. Unfortunately much of this work has

resulted in failure, but without the work of the early investigators to build

upon, we would not enjoy the success that we now have. It is critically

important to understand how oral implantology has evolved in order to

understand where we have been and where we are going.12

Man has attempted to solve the problems associated with the failing

dentition. Earliest evidence that exists is of ancient Egyptians in 2500 B.C.,

when they attempted stabilization of periodontally compromised teeth with

the use of gold ligature wire.

5
 Another evidence of approximately 500 B.C., the Etruscan population

utilized soldered gold bands incorporating pontics from animals to restore

masticatory function as a bridge.

1st evidence of the use of implants dates back to 600 A.D. in the

Mayan population. In this illustration, implantation of pieces of shell to

replicate three lower incisor teeth is shown.

In 1800’s transplantation became popular, but was soon rejected as

transmission of various diseases, including syphilis, were major problems.

6
 In 1809, Maggiolo described the process of fabricating and inserting

gold roots to support teeth.

In 1911 Greenfield described the fabrication and insertion of

endosteal implant. An iridioplatinum basket, soldered with 24 carat gold,

was then inserted into the prepared site.

In mid 1950’s, Lee introduced the use of an endosseous implant with

a central post and circumferential extensions.

In early 1960’s Linkow developed the ventplant implant. This was a

self-tapping type of endosseous screw implant.

Mid 1960’s Linkow introduced the blade vent implant. This “plate”

type of endosseous implant was designed for “Knife edge” ridge.

In 1980’s Niznick introduced the core-vent implant early. This is a

hollow basket implant with a threaded component to engage bone,

recommended for use in posterior mandible.

The screw vent implant – use of this implant is in anterior mandible.

Screw-vent implant is also manufactured with a hydroxyl apatite

coating that allows quicker osseous adaptation to implant surface.

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 Screw-vent implant, also manufactured by the Core-Vent

Corporation, is an endosseous screw type implant prepared with an external

hexagonal interface to engage the abutment.

Another variation of the screw type implant is the self-tapping screw

vent implant. The conical polished collar was intended for use in areas

where significant bone resorption might ensure, such as in stabilizing a bone

graft.

A hydroxylapatite-coated bio-vent implant was designed to be placed

with a “tap in” surgical protocol. The primary indication for the use of this

implant, as advocated by the manufacturer, is in the anterior mandible.

The micro-vent implant, by Core-vent Corporation is a

hydroxylapatite coated implant “tap in/screw in” type surgical protocol. The

primary indication for this implant, as suggested by the manufacturer, is

anterior and posterior maxilla.12

The Development of Overdenture:

The idea of leaving roots of natural teeth to support an overdenture is

not new. In 1856, Ledger described a prosthesis resembling an overdenture.

His restorations were referred to as “Plates covering fangs”. Later this

became the title of a paper published by Atkinson.

8
 In 1861 a conference held in Connecticut, increased the awareness of

the value of such roots in supporting a covering denture.

In 1888 Evans had described a method of using roots actually to retain

restorations.

In 1896 Essing had prescribed a telescopic like coping. At the same

time Peeso also described a removable telescopic prosthesis.

In 1909 a great blow was delivered by William Hunter by way of his

“focal sepsis theory”.

His views were widely accepted on both sides of the Atlantic, but

continental Europe did not share the enthusiasm of Hunter, so overdentures

continued to be made.

In 1976 Rothman stated that Hunter’s comments gave dentistry a

black eve. The reasons for retaining the root were not always specified but it

is likely that denture retention and stability must have been upper most in

the clinicians mind. Gilmore was looking for both denture retention and

stability, whereas peeso suggested that he was interested primary in denture

support.

The main aim of this new upcoming treatment option was to provide

support, stability and retention.2

9
PROSTHETIC OPTIONS IN IMPLANT DENTISTRY:1

In completely edentulous patients, a prosthodontist should inquire

about the patient’s desires. Some patients have a strong psychological need

to have a fixed prosthesis as similar to natural teeth as possible, while some

patients are not seriously concerned whether the restoration is fixed or

removable.

To assess the ideal final prosthetic design, the existing anatomy is

evaluated to determine if fixed or removable restoration is required.

In the completely edentulous patient, a removable implant-supported

prosthesis offers several advantages over a fixed restoration:

1. Fewer implants are required.

2. Prosthodontic appointments are shorter, component costs are

decreased, prosthesis is less complicated, and treatment is less

expensive for the patient.

3. Long-term professional maintenance and treatment of complications

is facilitated.

4. Daily home care is easier.

5. Facial esthetics can be enhanced with labial flanges and denture teeth

compared with customized metal or porcelain teeth. The labial

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 contours can replace lost bone width and height and support the labial

soft tissue without hygienic compromise.

6. The prosthesis can be removed at night to manage parafunction.

The patient should not be encouraged to accept a fixed prosthesis if a

removable prosthesis can predictably satisfy the patient’s needs and desires.

However, some completely edentulous patients require a fixed restoration

because of desire or because their oral condition makes the fabrication of

teeth difficult if a superstructure and removable prostheses are planned. For

example, when the patient has abundant bone and implants have already

been placed, the lack of interarch space will not permit a removable

prosthesis.1

In 1989, Misch reported five prosthetic options available in

implant dentistry.

Type Definition

FP-1 Fixed prosthesis; replaces only the crown, looks like a natural tooth.

FP-2 Fixed prosthesis; replaces the crown and a portion of the root; crown contour
appears normal in the occlusal half but is elongated or hypercontoured in the
gingival half.

FP-3 Fixed prosthesis; replaces missing crown and gingival color and portion of
the edentulous site; prosthesis most often uses denture teeth and acrylic
gingiva, but may be porcelain to metal.

RP-4 Removable prosthesis; overdenture supported completely by implant.

RP-5 Removable prosthesis; overdenture supported by both soft tissue and

implant.

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Fixed Prosthesis:

FP-1:
-
Appears to the patient to replace only the anatomic crowns of missing

natural teeth.
-
Minimal loss of hard and soft tissues.
-
The volume and position of the residual bone often permit ideal

placement of the implant in a location similar to the root of a natural

tooth.
-
Most often desired in the maxillary anterior region.
-
Due to lack of interdental papillae in edentulous ridges, gingivoplasty

is required to prevent “black triangular spaces”.

-
The final FP-1 restoration appears to the patient to be similar to a

crown on a natural tooth.

FP-2:
-
Fixed prosthesis appears to restore the anatomic crown and a portion

of the root of the natural tooth.

-
Gingival 3rd of the crown is overextended, usually apical and lingual

to the position of the original tooth.

-
These restorations are similar to teeth exhibiting gingival recession

and periodontal bone loss.

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FP-3:
-
Replace the natural teeth crowns and a portion of the soft tissue.
-
The original available bone height has decreased by natural resorption

and osteoplasty at the time of implant placement is required.

The addition of gingival tone acrylic or porcelain for a more natural

appearance is often indicated because bone loss is common.

Removable Prosthesis:

There are two types of removable prostheses, depending on the

amount of implant support.

RP-4:-

Is a removable prosthesis completely supported by the implants. The

restoration is rigid when inserted; overdenture attachments usually connect

the removable prosthesis to a low-profile tissue bar or superstructure that

splints the implant abutments.

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 Usually five implants in mandible and six to eight implants in the

maxilla are required to fabricate completely implant-supported prosthesis in

patients with favorable dental criteria.

The implant placement for a RP-4 prosthesis is different than for a

fixed prosthesis. Denture teeth and the acrylic bulk are required for the

restoration. In addition, a superstructure and overdenture abutments must be

added to the implant abutments. This requires a more lingual and apical

implant placement in comparison with the implant position for an FP-1 and

FP-2 prosthesis. The implants in an RP-4 prosthesis should be placed in the

mesiodistal position for the best biomechanical and hygienic situation. On

occasion the position of an attachment on the superstructure or prosthesis

may also affect the amount of spacing between the implants.

RP-5:-

Is a removable prosthesis combining implant and soft tissue support.

The amount of implant support is variable. The completely edentulous

mandibular overdenture may have two anterior implants, independent of or

splinted in the canine region to enhance retention, three splinted implants in

the premolar and central areas to provide lateral stability, or four implants

splinted with a cantilevered bar to reduce abrasions and to limit the amount

of soft tissue coverage needed for support. The primary advantages of an

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RP-5 restoration is the reduced cost. The prosthesis is very similar to

traditional overdentures.

A preimplant treated denture may be fabricated to ensure the patient’s

satisfaction. The implant dentist can also use the treatment denture as a

guide for implant placement. The patient can wear the prosthesis during the

healing stage. A rebase procedure then adapts the premade acceptable

restoration to the connecting bar and soft tissue.

Relines and occlusal adjustments every few years are required for

maintenance of an RP-5 restoration. However, bone resorption with RP-5

may occur 2 to 3 times faster than the resorption found with full dentures.

This can be a factor when considering this type of treatment in young

patients despite the lesser cost and low failure rate.1

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INDICATION/ CONTRAINDICATION:

Indications for implant supported overdenture treatment:12

 Severe morphologic compromise of denture supporting areas that

significantly undermine denture retention.

 Poor oral muscular coordination

 Low tolerance of mucosal tissues

 Parafunctional habits leading to recurrent soreness and instability of

prosthesis.

 Unrealistic prosthodontic expectations

 Active or hyperactive gag reflexes, elicited by a removable prosthesis

for example roofless maxillary denture.

 Psychological inability to wear a removable prosthesis, even if

adequate denture retention or stability is present.

 Unfavourable number and location of potential abutments in residual

dentition. Adjunctive location of optimally placed osseointegrated

root analogues would allow for provision of a fixed prosthesis.

 Single tooth loss to avoid involving neighboring teeth as abutments.

Contraindications of implant supported overdenture Treatment:

 Psychological (schizophrenia, dysmorphophobia)

 Chemical dependency

 Uncontrolled systemic disorders

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Absolute Contraindication:13

Absolute contraindication relates to health conditions that have the

potential to jeopardize the patient’s overall health and safety and seriously

compromise the survival of implanted systems causing residual chronic

complications. The absolute contraindications are listed as follows:

1) Recent myocardial infarction – because patient is using potent

anticoagulants, -adrenergic blocking agents, hypotensive drugs.

2) Valvular prosthesis:- It is important not to plan any implant surgery

until the patient is in stable condition, usually between 15 to 18

months after cardiac surgery, because oral cavity is the principle

gateway to infection.

3) Severe renal disorder:- It is the single most important contraindication

to any form of implant or bone graft surgery. This can occur from a

number of causes, of which the most common are:-

i) Nephritis

ii) Malignancy or tumors

iii) Uncontrolled diabetes

iv) Complication arising from kidney stones

4) Treatment-resistant diabetes

5) Generalized secondary osteoporosis – in this there is significant loss

of bone mass and volume.

17
 6) Chronic and severe alcoholism – Patient with severe alcoholism often

present retarded healing aggravated by malnutrition, psychologic

disorder, inadequate hygiene and major infection risk.

7) Treatment – resistant osteomalacia

8) Radiotherapy in progress – disruption of defence mechanisms, a

compromised endosseous vascular system and inhibition of

osteoinduction.

9) Severe hormone deficiency – the endocrine systems most affected are

thyroid, parathyroid, pancreas, adrenal, pituitary and gonads.

10) Drug addiction – leads to low resistance to disease, predisposition to

infection, malnutrition, psychological disorder.

11) Heavy smoking habits – Main problems that occur are, early stage

poor healing; disorders related to poor oral hygiene.

Relative Contraindications:

These are related directly to nature and severity of the systemic

disorders. They require a meticulous screening of the patient’s medical

records. If the disorder is adequately corrected, carry out the treatment plan;

otherwise, postpone the procedure until optimal conditions prevail.

1) AIDS and other seropositive diseases (HIV-positive)  These

contraindicate any form of surgery.

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2) Prolonged use of corticosteroids :- It is often associated with retarded

healing; disorders of phosphocalcific metabolism (osteoporosis), and

medullary aplasia. It inhibits bone formation.

3) Disorders of phosphocalcific metabolism.

4) Hematopoietic disorder.

5) Buccopharyngeal tumours.

6) Chemotherapy in progress – administration of anticancer drugs.

7) Mild renal disorders.

8) Hepatopancreatic disorders – Gall stones and infectious and viral

hepatitis (severe B, C & E).

9) Multiple endocrine disorders, these include,

-
glucocorticosteroid disorders (Cushing’s syndrome, Addison’s
disorder).
-
Mineralocorticosteroid syndrome (Conn’s syndrome)
-
Parathormone (PTH)
-
Vitamin D3
10) Psychological disorders.

11) Unhealthy life-style.

12) Smoking habits.

13) Lack of understanding and motivation.13

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ADVANTAGES AND DISADVANTAGES:

Advantages of Implant-Supported Prosthesis:1

The use of dental implants to provide support for the prosthesis offers

a multitude of advantages compared with the use of removable soft-tissue-

borne restorations. These are:-

 Minimum anterior bone loss; prevents bone loss

 Improved esthetics

 Improved stability (reduces or eliminates prosthesis movement)

 Improved occlusion (reproducible centric relation occlusion)

 Decrease in soft tissue abrasions

 Improved chewing efficiency and force

 Increased occlusal efficiency

 Improved retention

 Improved support

 Improved speech

 Reduced prosthesis size (eliminates palate flanges)

 Improved maxillofacial prosthesis

Implant prosthesis may offer a more predictable treatment course than

traditional restorations. Tremendous research has been done to achieve

maximum functional service of the implant in the rehabilitation of the

patient.

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 Chewing efficiency with an implant prosthesis is greatly improved

compared with that of a soft tissue-borne restoration. The maximal occlusal

force of a traditional denture wearer ranges from 5 to 50 lb. Patients with an

implant-supported fixed prosthesis may increase their maximal bite force by

85% within 2 months after the completion of treatment.

A mandibular denture may move 10 mm during function. Under these

conditions, specific occlusal contacts and the control of masticatory forces

provides stability of the prosthesis, and the patient is consistently able to

reproduce a determined centric occlusion. Soft tissue abrasions and

accelerated bone loss are more symptomatic of horizontal movement of the

prosthesis under lateral forces. An implant-supported overdenture may limit

lateral movements and direct more longitudinal forces.14

Mericke-Sten et al. compared mastication between root overdentures

and implant overdentures. The former was more discriminative, whereas the

latter developed slightly harder chewing strokes and tended to masticate

more vertically.15

The stability and retention of an implant-supported prosthesis are

great improvements over soft-tissue borne dentures. Mechanical means of

implant retention are far superior to the soft tissue retention provided by

dentures or adhesives and cause fewer associated problems.

21
 The implant support of the final prosthesis is variable, depending on

the number and position of implants. This treatment option offers significant

improvements.

The goal of modern dentistry is to return patients to oral health in a

predictable fashion. The partial and completely edentulous patients may be

unable to recover normal function, esthetics, comfort or speech with a

traditional removable prosthesis.

The patient’s function when wearing a denture may be reduced to

60% compared with that experienced with natural dentition; however an

implant prosthesis may return the function to near normal limits. The

esthetics of the edentulous patient are also affected as a result of bone

atrophy. Continued resorption leads to irreversible facial changes. An

implant stimulates the bone and maintains its dimensions in a manner

similar to healthy natural teeth.1

Disadvantages of Overdentures:

The primary disadvantage of an overdenture is that it does not satisfy

the psychologic need of these patients to feel that the prosthesis is part of

their body.

There are a few drawbacks, even after the construction of a properly

designed and well constructed overdenture.

-
It requires proper plaque control and denture hygiene.

22
 -
It is more costly compared to complete dentures.
-
They are bulkier than many other restorations.
-
Patient’s wearing overdentures may apply more load to their

prosthesis than complete denture wearers, yet the inherent strength

may be less due to the space occupied by the root preparation.

-
The lack of sufficient interarch space makes an overdenture system

more difficult to fabricate and more prone to component fatigue and

fracture.1

DIAGNOSIS/ TREATMENT PLANNING

Ten minutes of frank discussion at the beginning of treatment is worth

more than hours of explanations and excuses at the end. It is an excellent

means of establishing a good rapport between the operator and patient.

Make the patient aware that the structure of the mouth will change

with time, so readaptation of the denture base is required at regular time

intervals and maintenance of overdenture is also essential.2

Overview of Treatment Planning:

 Medical evaluation

 Dental evaluation

 Formulation of treatment plan

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Medical Evaluation:
-
Medical history (like heart disease, hepatitis, AIDS)
-
Vital signs
-
Complete blood count
-
Urinalysis
-
Chest X-ray
-
Electrocardiogram

Dental Evaluation:
-
Dental history
-
Clinical evaluation and charting
-
Diagnostic records
-
Patient expectations

Dental History:- Among the points of information to be gleaned from the

patient are the following:-

-
Why did the patient lose teeth?
-
What was the success or failure of earlier prosthesis?
-
What did the patient expect from previous prosthesis?
-
Is the patient presently wearing a denture?
-
Is there any history of craniomandibular disorders?
-
Are there any home care difficulties?

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Formulation of Treatment Plan:16

One special consideration during the planning stages is the necessity

for proper positioning of the implants under the overdenture.

Treatment sequence is as follows:-

-
Diagnostic records
-
Transitional prosthesis
-
Surgical/fixture placement
-
Surgical / fixture connection
-
Definitive restoration
-
Maintenance

Procedures:

1) Preoperative Procedures:
-
Quantity of available bone
-
Select ideal implant configurations
-
Select overdenture retention configuration
-
Fabricate implant positioning stent
-
Prescribe preoperative medication16

2) Diagnostic Method:

Examination:- A visual examination should be the first step, view a level of

lip line, the edentulous areas and conceptualize the height, width and length

of the proposed operative sites. The amount of attached and keratinized

gingivae. Any localized areas of pathologic change.

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Manual Palpation: With thumb and index finger, assess the firmness and

thickness of the soft tissue. Detect convexities and concavities that might not

be evident on visual or digital examination.

For close examination: Give local anesthesia to labial and lingual aspect of

the edentulous ridge at the potential implant site. Then use a sharp

periodontal probe to make soft tissue thickness measurements. Next use a

sterilized boley gauge with sharpened beaks to puncture the soft tissues by

squeezing the calipers directly through tissues to bone. This presents a

measurement of bone width at varying ridge sites. By doing this repeatedly

from superior to inferior and from medial to distal at 5mm intervals,

develops topographic map of the soft and hard tissue dimensions of the areas

into which implants have to be placed.13

Study Casts:13

Make full arch alignment impression of tooth arches. Pour the

impressions immediately with dental stone and make a second cast of the

arch that is to be restored with implants.

Mount the casts to a semiadjustable articulator (whip mix, Hanau) in

centric relation position with the help of face bow, after recording the proper

vertical dimension.

If the articulation indicates crossbite or ridge procumbency, it is

necessary to determine that the angulation of the implant will permit the

26
final prosthesis to be in functional position. Implant at greater than 35

degree angulation from the long axis of the ridge presents significant

aesthetic and functional problems. If an angle greater than this is created,

forces will be exerted that may be detrimental to the longevity of implant

host sites. Therefore some excellent ridges may be considered questionable

if angulated implants are placed in compromised positions. In addition,

some implant design are available having angles of 15 degrees or even 30

degrees (i.e., stereo-oss, paragon). Setting these to the proper alignment

requires special skills.

Diagnostic Imaging:

The objectives of diagnostic imaging depend on a number of factors,

including the amount and type of information required and the time period

of the treatment rendered.

There are three phases for diagnostic imaging:1

Phase One:- Preprosthetic implant imaging. The objectives of this phase of

imaging include all necessary surgical and prosthetic information to

determine the quantity, quality and angulation of bone; the relationship of

critical structures to the prospective implant sites; and the presence or

absence of disease at the proposed surgery sites.

Phase Two:- Surgical and interventional implant imaging. The objectives of

this phase of imaging are to evaluate the surgery sites during and

27
immediately after surgery, assist in the optimal positioning and orientation

of dental implants, evaluate the healing and integration phase of implant

surgery, and to ensure that abutment position and prosthesis fabrication is

correct.

Phase Three:- Post-prosthetic implant imaging. It is the first step after the

prosthesis placement. Objectives of this phase of imaging are to evaluate the

long-term maintenance of implant rigid fixation and function, including the

crestal bone levels around each implant and to evaluate the implant

complex.

The purpose of surgical imaging is to evaluate the depth of implant

placement, the position and orientation of implants/ osteotomies and to

evaluate donor or graft sites.

A three dimensional imaging technique ideally identifies at each

prospective implant site, the amount of bone width, the ideal position and

orientation of each implant, its optimal length and diameter, the presence

and amount of cortical bone on the crest, the degree of mineralization of

trabecular bone, and the position or relationship of critical structures to the

proposed implant sites.17

Three-Dimensional Imaging Modalities:

 Computed tomography

 Magnetic resonance imaging

28
  Interactive computed tomography

Radiology:

Next step in the diagnostic sequence is a radiologic survey. The

following radiographs and their purposes are listed.

1) Panoramic radiograph:- Presents an overall view of both the maxilla

and mandible. Normal anatomy and existing pathologic conditions of

the dentoalveolar complex and adjacent structures can be noted.

The remaining natural teeth are visualized. Unpredictable distortions

of distance (25% or more) are a constant characteristic of these films.

Advantages:

a) Opposing landmarks are easily identified

b) The vertical height of bone initially can be assessed

c) The procedure is performed with convenience, ease and speed in

most dental offices.

d) Gross anatomy of the jaws and any related pathologic finding can

be evaluated.

2) Periapical:- A periapical radiograph gives a view of higher resolution

and greater accuracy and indicates medullary and cortical bone

density. Often, measurements may be made directly from these films.

3) Lateral cephalometric:- Radiographs are helpful for the patient with

completely edentulous arches.

29
The cross-sectional morphology of the residual anterior ridge can be

visualized along with its angle of inclination.

-
Skeletal jaw relationships may be studied
-
Allows an estimate of labiolingual dimension13

Radiographic ball-bearing template:

Prepare a clear template using the second or surgical planning cast.

Take the 5mm diameter, standardized metal marking spheres which should

be counter-sunk into the cast of the ridge at potential implant site to a depth

of 1 mm and stabilize it with sticky wax.

Then use an Omnivac machine, mould a piece of 0.02 inch gauge,

clear, plastic material to the cast, which incorporates the sphere within it.

After proper trimming, the template produced should be seated intraorally.

Now take periapical radiographs with the template in place, record the

diameter of the spheres on the film.

If they are found to be 5 mm in diameter, the height and length of

available bone is measured, directly on the radiograph. If this is not correct,

use the following algebric equation for determining actual bone

dimensions:-

rs = rm
5 rx

where, rs = X-ray sphere measurement

30
 rm = X-ray bone measurement

rx is the actual bone measurement being sought, and 5 is actual

sphere measurement.

Later this template is used as an implant site locator.13

CT Scanning:13

Three-dimensional imaging enables the user to visualize any area

within the parameters of scan. It provides a variety of views by making 1.5

mm slices through the bone. These slices are stacked by the program’s soft

ware.

Its advantages are:-

1) The amount of available bone may be plotted to the millimeter.

2) The amount of bone width and height can be recorded.

3) Density of bone may be observed and reported in Hounds field

numbers.

4) In mandible, exact location of the mandibular canal in its most

tortuous course may be plotted.

5) It helps the clinician to plan the proper implant types, numbers, sizes

and locations.

Currently, software and hardware (DentaScan) systems are available

that allow the dentist to reformat axial images directly in the office and

superimpose approximately sized implants on them.

31
Tomography:1

Tomography is a generic term, formed from the Greek words tomo

(Slice) and graph (picture) to describe all forms of body section radiography.

Body section radiography is a special x-ray technique that enables

visualization of a section of the patient’s anatomy by blurring regions of the

patient’s anatomy above and below the section of interest. Complex

tomography is useful in determining bone quality or identifying dental and

bone disease. It also aid in identifying critical structures such as the inferior

alveolar canal.

Interactive Computed Tomography:1

This technique was developed to bridge the gap in information

transfer between the radiologist and the clinician. This technique enables the

radiologist to transfer the imaging study to the clinician as a computer file

and enables the clinician to view and interact with the imaging study on

their own computer. An important feature of ICT is that the clinician and

radiologist can perform “electronic surgery” (ES) by selecting and placing

arbitrary size cylinders that simulate root form implants in the images.

Before referring the patient to the radiologist, intraoral splint designed

to immobilize the lower jaw is fabricated. While fabricating the splints with

the following objectives in mind:-

1) Immobilization

32
 2) Disocclusion

3) Orientation

This appliance should allow the jaws to be in the resting position so

that the mandible remains immobilized for up to a 30 minute period.

Method of Splint Fabrication:

For Edentulous Arch:-
Make an alginate impression and pour a diagnostic cast

Fabricate the acrylic base plate with wax occlusal rims

Adjust correct vertical dimension, centric relation, lip length and
prominence

Arrange the teeth to final functional satisfaction and esthetic appearance

Records the patient’s centric relationship position at the resting vertical
dimension, and mount the trial denture on the articulator

Complete the dentures and replicate them in clear self-curing acrylic using a
long denture duplicator flask

Curing is done in a pressure pot for 30 to 35 min.

Seat the replicated clear acrylic trial dentures on the original cast, and fill the

space between them [freeway space, by mounting casts at the resting vertical

33
 dimensional position] with additional self-curing acrylic resin, creating an

inter-arch index.

In single complete edentulous situation the duplicated trial denture

may be luted to an opposing acrylic replica of the arch at the patient’s

resting vertical dimension.

Cut a 1mm deep, 1mm wide, and 10 mm long groove in the labial

acrylic facings of each of the teeth, pack these grooves with well-condensed

gutta percha. This help to create evenly reproducible radiopaque markers.

VISIT-BY-VISIT TREATMENT OBJECTIVES16

Visit 1, Day 1: Implant insertion and immediate impressioning:-

 Confirm use of prophylactic antibiotic

 Set up instrumentation

 Administer anaesthesia

 Target osteotomy locations

 Make incision

 Reflect tissue

 Reconfirm osteotomy lesions

 Prepare osteotomies

 Evaluate suitability of osteotomies

 Insert implant

34
  Perform direct bone impressioning

 Install healing collars

 Perform interarch occlusal registration

 Provide soft-tissue treatment

 Suture

 Select shade

 Provide provisional prosthesis

 Provide home care instructions

 Schedule follow up visit.

To control edema  corticosteroid (Decadron 8mg) is administered with

LA.

Visit 2, Week 1: Suture removal and interim evaluation:-

-
Perform general evaluation
-
Remove sutures
-
Evaluate soft-tissue healing
-
Check and adjust removable prosthesis as required

Visit-3 to 6; Weeks 3 to 12: Overdenture fabrication:-

-
Make preliminary impression
-
Make final impression

35
 -
Counter model and interarch occlusal registration
-
Select shade
-
Select teeth
-
Try in overdenture
-
Prepare retention mechanism clearance within overdenture
-
Complete overdenture

Visit 7, Week 16:- Implant Exposure and Overdenture Retention Mechanism

Fixation
-
Confirm use of prophylactic antibiotic
-
Set up instrumentation
-
Administer anaesthesia
-
Identify implant location, if submerged
-
Expose implant or removal of healing collars
-
Perform trial seating of overdenture retention mechanism
-
Fix overdenture retention mechanism
-
Suture if required
-
Seat provisional prosthesis
-
Provide home care instruction
-
Schedule follow-up visit

Visits 8 to 10, Weeks 17 to 18:- Adapting the overdenture to the retention

mechanism and case completion

36
 -
Remove sutures, if necessary
-
Seat retention clips on clip bar assembly
-
Take impression for removal of clips in overdenture
-
Send impression to laboratory to incorporate clips into overdenture
-
Seat complete overdenture for patient

Laboratory Procedure to attach clips to new or existing overdenture:

-
Place overdenture retention clip into sites recorded in reline

impression.
-
Pour model, allow to set, and trim.
-
Perform separation (retention clips remain on model).
-
Remove impression material and clean overdenture.
-
Carefully cover occlusal side of each clip with a thin layer of wax (0.5

to 1mm) to allow vertical displacement of denture while seating and

during mastication.
-
Cover model with two coats of separating medium, rinse lightly, and

allow to dry.
-
Seat denture on model to ensure that enough of tissue surface has

been relieved.
-
Mix cold cure reline material according to manufacturer’s instructions

after brushing a thin layer of monomer into the relieved area in the

overdenture.

37
 -
Reline overdenture on model using conventional technique,

incorporate retention clips within the overdenture.

-
Finish and polish, check and relieve as necessary around the clips to

ensure correct path of insertion.

IMPLANT SYSTEMS
Implant types and their uses:13

General classification:- A dental implant is a device of biocompatible

materials placed within or against the mandibular or maxillary bone to

provide additional or enhanced support for a prosthesis or tooth.

1) Endosteal Implants:

38
 -
Root form implants
-
Crete mince (thin ridge) and other mini-implant
-
Blade implants
-
Ramus blade and ramus frame

2) Transosteal implants

3) Subperiosteal implants

4) Other implants
-
Endodontic stabilizers
-
Intramucosal inserts
-
Bone augmentation materials

Root form Implants:

With sufficient width and height of bone available, root forms

(submergible, two-stage, and single stage, one piece) are 1st choice.

Following types are available:-

a) Press-fit [unthreaded but covered with a roughened

hydroxyapatite (HA) or titanium plasma spray coating (TPS).

b) Self-tapping (threaded)

c) Pre-tapping (threaded)

Prosthetic options:- Prosthesis may be supported by fixed, fixed-detachable,

overdenture and single tooth prosthesis.

Required bone:-

39
 >8mm vertical bone height

>5.25 mm bone width (buccal to lingual)

>6.5 mm bone breadth (mesial to distal)

Crete Mince (Thin Ridge) and Other Mini Implants:

Crete mince implants are:-

-
threaded
-
self-tapping
-
titanium spirals

Prosthetic Option:-

They add retention to long-term fixed bridge prosthesis by pinning

them through their pontics to the underlying bone, or they may be used to

support transitional prostheses.

Blade Implant:
-
Submergible
-
Two stage
-
Single stage
-
One piece devices
-
Pre-fabricated
-
Custom-cast
-
Alterable (by cutting, bending and shaping at chairside)

Prosthetic Option:-
-
Single or multiple abutment

40
 -
For fixed bridge prosthesis in combination with natural tooth

abutments
-
Also used in multiples for full arch edentulous reconstructions
-
Also used in adequate height but inadequate width
-
Maxillary/ mandibular completely or partially edentulous

Required bone:-

>8mm vertical bone height

>3mm bone width (buccal to lingual)

>10 mm bone breadth (mesial to distal except for single tooth design)

Ramus blade and Ramus frame: Is one piece-blade made for use in the

posterior mandible when insufficient bone exists in the body of jaw.

Ramus frame is a three piece blade, use for atrophic mandibles.

Prosthetic Option:
-
Overdenture
-
Only completely edentulous mandible

Transosteal Implant:

One piece, transmandibular.

Complex Implants:

Advantage is predictable longevity.

Several Designs Available:-

41
 -
Single component
-
Multiple component

Prosthetic option:-
-
Used to support overdenture
-
Fixed bridge may be alternative

Suitable arch – Anterior Mandible

Required bone:-

>6mm height

>5mm width

Sub-periosteal implants:
-
Complete
-
Universal
-
Unilateral

Prosthetic Option:-
-
Extreme mandibular atrophy exists
-
They are custom made
-
They may be used in any part of either jaw.
-
Overdenture and fixed bridges

Suitable arch:- Maxillary and mandibular, completely or partially

edentulous.

Required bone:-

42
 -
>5mm or mandibular augmentation is required.
-
Extremely thin mandible and maxillae may permit

Other Implants:

Endodontic Stabilizers:- Are highly successful, tooth root lengthening

implants.

Their success rate is because they have no site of permucosal

penetration, they are placed into bone through the apices of natural teeth.

Intramucosal Inserts:- Are button like, non-implanted retention devices that

can be used to stabilize full and partial maxillary and mandibular removable

denture prostheses.

Prosthetic Options:- Removable dentures, full or partial.

Suitable arch:- Maxillary completely or partially edentulous arch and

mandibular partially edentulous only.

Required bone:- None; required mucosa, 2.2 mm thick.

Table – Implant selection chart based on available bone and bone density.13
Width (A) Ridge Depth (B) Length (C) Implant Type
Recommended
Available Bone 0-3mm 0-6 mm 0-7 mm Subperiosteal
3-5 mm >8 mm >10mm Blade
>5mm >8 mm 6-25mm 1 root form
>10 mm 16-25mm 2 root forms
24-31mm 3 root forms

43
 >31mm 1 root form for
each additional
7mm of ridge

The mandibular overdenture requires at least 12 mm space between

the soft tissue and the occlusal plane to provide sufficient space (15 mm

from bone level to occlusal plane) for the bar, attachments, and teeth.1

Implant Systems for Overdenture:13

Name Character Primary Length Diameter

/mode retention
1. 3i implant
innovations
micro mini implant Threaded Threading 8.5, 10, 11.5, 13, 15, 3.25
screw 18
Implant Cylinder Surface 8.5, 10, 13, 15 3.3
texture 8.5, 10, 11.5
Miniimplant Threaded Threaded 13, 15, 18, 3.25
implant screw 8.5, 10, 11.5, 13, 15
Cylinder Surface 8.5, 10, 13, 15 3.3
texture
Standard Implant Threaded Threading 7, 8.5, 10, 13, 15, 18 3.75, 4
screw
Cylinder Surface 7, 8.5, 10, 11.5, 13, 4
texture 15, 18
Wide diameter Threaded Threading 7, 8.5, 10, 13 5,6

44
 implant screw
2. ACE Surgical Threaded Threading 8, 10, 13, 15 3.75
supply co. screw
Cylinder Surface 4.0
texture
3. Astra Threaded Threading 8, 9, 11, 13, 15, 17, 19 3.5, 4.0
screw
4. Bicon Threaded Threading 8, 11, 14 3.5, 4.0, 5.0
screw
5. Biohorizons
Division A Threaded Threading 9, 10 4, 5
screw
Division B 12, 13 3.5, 3.5
Division C-H Threaded 9, 10 4, 5
6. Dental Implant Tapering Threading 11 (not for 4.5), 13, 15 3.5, 4.0, 4.5
Systems Inc. cylinder
7. Friatec Stepped Stepped 11, 13, 15 3.8, 4.5, 5.5
cylinder surface 8, 10, 13, 15
8. IMCOR Screw Threading 8.5, 10, 11.5, 13, 15, 3.75, 4.0
18
8, 10, 12 5
9. IMTEC Threaded Threading 8, 10, 13, 15, 20 3.75
Corporation screw 5, 8, 11, 13 5.25
Cylinder press Surface 8, 10, 13, 15 3.3, 3.4, 4,
jit texture 4.75
10. Innova Surface 7, 9, 12 3.5, 4.1, 5
texture

Mandibular Implant Site Selection:

The greatest available height of bone is located in the anterior

mandible, between the mental foramina or anterior loops of the mandibular

canal when present. This region also usually presents the optimal density of

bone for implant support.

45
 The available bone of the anterior mandible is divided into five equal

columns of bone serving as potential implant sites, labeled A, B, C, D and E,

starting from the patient’s right.

Three implants in the A, C and E positions and an overdenture may be

provided now, and in the future two implants may be added in the B and D

locations.1

46
(PM – Prosthesis Movement)

To determine the degree of mandibular atrophy, the following

characteristics were assessed (a simplification of the criteria described by

Atwood and Branemark et al.):18

Class 1: Moderate atrophy, resorption of the residual ridge not pronounced,

only minimal reduction in bone height.

Class 2: More advanced atrophy with thin residual ridge buccolingually.

47
Class 3: Pronounced atrophy, almost complete resorption of the alveolar

ridge, advanced reduction in bone height, but most often favourable shape

for implantation.

Class 4: Extreme atrophy, complete resorption of the alveolar ridge, marked

reduction of bone height, less favourable shape for implantation.18

48
 IMPRESSION MAKING FOR OVERDENTURES

Fabricate a custom tray. This tray should have full-flange extensions

as if it were designed for a conventional denture impression. The tray must

be capable of accommodating the implant abutments and impression

copings. Insert the custom tray over the abutments and impression copings

and adjust its borders. Manipulation of the tray should not be limited by the

presence of the copings. Complete the border molding, and perform final

seating of the tray.

On completion of the impression, place protective caps over the

abutments, using either square or tapered abutment transfer copings. Relieve

the provisional denture and reline it with a soft tissue liner; reseat it and

check for proper occlusion.

If individual attachment abutments are planned, use the impression

copings as the portions of the attachments that are affixed to the denture

base. If adopting this technique, coat the attachments with adhesive and

place them on the abutments. Pick them up with the impression into which

the individual attachment abutment analogs will then be placed.

Now make a master cast. Bead, box and pour the final impression in

dental stone.

49
Verification jig; Vertical Dimension and Centric Relation:

Once the master cast has been trimmed, make a verification jig by

placing square/locking impression copings on top of the abutments or

implant analogs on the cast. Use a stable acrylic resin to lute them into a

unit.

Use a traditional base-plate made sufficiently large to accommodate

the capped abutments to record centric relation, vertical dimension, and

esthetic contours. Mount it using a face bow transfer. Remove the caps from

the abutments. Select teeth of an appropriate shade and mold. Place the

verification jig on the abutments, and tighten a screw at one end.

On satisfactory seating of the copings, transfer them to a working

cast, set appropriate teeth on the record base and schedule a try-in. After

verification of vertical dimension, tooth shade, tooth shape and the overall

esthetic appearance of the overdenture, place a cast metal frame into it. The

space accommodation for the abutment and bar creates weak points in the

denture that may cause wear or fractures. Make the cast metal frame of a

nonprecious metal; it serves most successfully if it accommodates the

implant abutments, attachments and bar. Make the cast metal frame when

the record base is prepared. If selection of the metal frame after the tryin

phase is done, reset the teeth on the casting and try in the denture before

processing.

50
 Position the bar on the abutments with an index of the waxed-up

denture in position. In this manner the bar and attachments may be

positioned relative to the tooth and flange positions. Ideally place the bar

just lingual to the cingulum areas of the anterior teeth. This permits

maximum vertical space. The positioning of the attachments depends on

their design, how they function and how the denture uses them. If using two

implants with a harder bar for attachments, make sure the bar is

perpendicular to the posterior alveolar ridges. Use a single clip as the

attachment to the bar.

If ERA attachments are used, place them distal to the most posterior

abutment on either side of the bar.

Try in the bar and denture wax-up along with the casting. Reconfirm

the denture esthetics, centric relation, and vertical dimension. Fit the bar by

removing the protective caps from the abutments and tightening a screw on

the side with the most distal abutment.

When using submergible implants, impression techniques may vary.

An open tray or closed tray technique may be used.

Closed Tray Technique:-

The closed tray technique requires a custom impression tray. Make an

alginate impression with the healing collars in position. After pouring, the

implant locations are evident on the cast. Block out each healing collar on

51
the cast with a tube of hard wax 5 mm in diameter and 15 mm in height.

Aluminium shells or annealed copper bands function well as matrices. Use

petroleum jelly to lubricate the tubes and mold a self-curing resin tray over

them. The wax spacer provides the tray sufficient relief to permit room for

impression posts that must be placed into the tissue epithelial attachment

(TEA).

Remove the intraoral healing collars (no local anesthesia is needed)

and replace them with TEAs. Insert an impression post of coping into the

threaded receptacle of each TEA.

Make the final impression using a rigid elastic polyether impression

material (Impregum) to ensure that the impression posts or copings remain

firmly placed in their correct positions. Examine each impression post for

the presence of a thin slot or a small depression on its head (used for

screwing them into place). Block out this slot or depression with wax before

making the impression because recording it interferes with the accurate

reseating of the posts or copings into the impression. After removing the

impression, unscrew the posts or copings from their TEAs and attach them

to the implant analogs supplied by the manufacturer. Place these combined

units into the impression, box and pour them in a hard dental stone like

Velmix. The laboratory uses the resulting cast to complete construction of

the prosthesis. If subgingival margins are required, soft tissue models are

52
required. Insert a soft tissue material, such as GI mesh around each abutment

analog in the final impression before pouring with stone.

Open Tray Technique:

This impression technique uses square impression posts around which

elastomeric materials lock, making it impossible to remove the impression

before backing off the retaining screws. To allow this maneuver, these

systems require a specially constructed impression tray that must be

supplied with a window on its occlusal surface. To fabricate such a tray,

make a study model with the TEAs in position in the implants. Erect a

chimney of wax 15 mm in height to surround them. Next, soften and press

one layer of pink base-plate wax over the abutments and adjacent edentulous

ridges to serve as relief for the fabrication of a tray. Place resin over the wax

in all areas except over the chimney. After curing and trimming the tray,

access to the TEAs is available from above. Attach the square impression

posts to the TEAs using specially supplied long screws. Tie dental floss in

figure-8 patterns joining the impression posts, and paint Duralay or GC

pattern resin incrementally over the floss, thus forming a solid matrix.

Ensure that the custom tray, when tried in, is not encumbered by the splinted

complex. Place a piece of softened base-plate wax over the open window

and press until the heads of the impression posts make indentations into it.

Remove the tray and seal the wax roof to the housing using sticky wax. The

indentations in the wax made by the impression posts are excised through its

53
full thickness. Replace the tray, and ensure that the top of the screwed

impression posts can be seen through the holes just made.

Make the final impression using a standard elastomeric technique.

Express impression material from a syringe around all of the TEAs before

seating the tray, which is filled with the same material. The tray, if seated

accurately, demonstrates impression material extruding through the holes

just cut in the wax. After setting, excise the extruded impression material

with a scalpel using a No.11 BP blade, revealing each of the long screw

heads. Back out these screws, allowing removal of the impression. Retain

the square posts in the impression. Attach the appropriate implant analogs,

and pour the model in die-stone material.20

54
 ATTACHMENTS
Overdenture retention components:16
Overdenture restorations

Bar-retained Abutment-retained

Conical abutment Direct abutment Supra-snap abutment

non-hexed

STUD Attachments:19

Stud attachments being relatively small they can provide additional

stability, retention and support, while the positive lock of certain units can

55
maintain the border seal of the denture. The female portion of the

attachment (matrix) in the prosthesis should be designed to wear and be

replaced, while the male portion (patrix) connects to super-structure or

implant.

Classification of Attachment (Most Popular):

1. Coronal
-
Intracoronal
-
Extracoronal

2. Radicular
-
Telescope stud (pressure buttons)
-
Bar attachments

3. Accessory – Auxillary attachments e.g., screws, bolts.

Abutments for Overdentures:13

These abutments are used only in case of soft-tissue bone, non-bar

supported overdenture maintained directly by a minimal number of (two or

three) implants used in the mandible. These may apply to bar overdenture as

well, if the attachments are soldered to or cast as part of the bar’s (i.e., ERA

or O-ring components incorporated into mesostructure bars).

Sheroflex ball abutments made by Preat key into metal-based females

processed into overdentures. These abutments are made available for use

with natural teeth in the form of endodontic posts.

56
 These abutments are typically available from implant manufacturers

and most often consist of a male component, which is screwed directly into

the implant head and a female component, which is processed into the

denture. New entries into the field include the life care-O-ring, Della Bona,

and three sized snap abutment products. Paragon’s one stage implant also

offers a ball screw for overdenture retention. Exceptions to the conventional

design are the Zest/ZAAG and ERA systems, which use male components in

the denture, while the abutment serves as the female. The male pivot up to

10 degrees and may be changed in less than 1 minute. These abutments are

available in either one or two piece configurations, are angled at 15 and 25

degrees. When necessary come in various lengths (3.0; 4.0; .0 mm),

allowing supragingival abutment placement. Attachment of the devices is

facilitated by use of simple armamentaria. When considering the use of

these anterior-based systems, ensure that the attachments will allow

rotations of the denture posteriorly to avoid overloading the implants.

The choice of two or four implants with retentive anchors in the

maxillae is mostly based on financial and anatomic factors. However, four

implants are preferred for obvious biomechanical reasons.14

57
Various Attachments:19

Advantage
Magnets -Easy to use
-Easy to repair
-No stress relief
Ceka; Octa-Link -Easy to use
-Easy to repair
-Good retention
-Stress breaking
ERA -Adjustable retention
-Easy to replace
-Modest in cost
Zest, O-rings -Inexpensive
-Good retention
-Stress breaking
-Easy to use (O-rings)
Hader, Dolder -Stress breaking
-Easy to maintain
-Easy to repair and replace
Pinlock, low -Easy to maintain
-Easy to use
Shortcomings
-Questionable retention
-Poor lateral stability
-Corrosive
-Loosen or unthread
expensive
-Expensive
-Requires frequent
maintenance
-Loosen or unthread
-Need frequent replacement
-Abutment must be parallel
-Less rigid than metal to
metal
-Wear more quickly than
metal
Expensive
Expensive

Bar Attachments:

Mesostructure bars act as a connector between the implant complex

(infrastructure) and the superstructure.

Mesostructure may be designed in many forms – continuous bars or

non-continuous bilateral bars, with a broad variety of shapes to permit the

use of internal clips, O-rings or withdrawable pins (i.e., low attachment).

58
Continuous Bars:-

Comes in different shapes. They can be round, ovoid, rectangular or

square.

The amount of implant support, the location in the arch of that

support, and type of retentive devices that are chosen determine bar shape.

Superstructure may be:-

1) Simply the rest on the bar (“sloppy fit”, which require occasional

acrylic relining).

2) Be attached to the bar or locked under it by the use of a variety of

unique attachments, either custom made or manufactured.

3) Be secured by supplementary attachments incorporated into or onto

the bar (such as O-rings, ERA and zest attachments).

4) Be used in conjunction with a fixed-detachable or cementable

superstructure, that was made because of faulty implant angulation. In

such situations the double-bar technique may be employed. In this a

mesostructure bar of optimal shape and diameter should be cast and

then screwed or cemented to the malaligned implant abutments or

directly into the implants themselves.

Non-continuous bar:-

A mandibular subperiosteal implant with a continuous bar may have

caused pain to the patient on opening the mouth. In such instances, cut the

59
anterior component, thus creating bilateral bars, or when implants are placed

in the canine areas only an anterior bar is needed.

Examples of different bars are – Doldar bar, Hader bar; Andrews bar, Ceka,

Octalink, M.F. Channel, Ackermann bar, customized bar.

In vitro and in vivo studies by Menicucci et al. compared the stresses

on the bone surrounding 2 implants with either a bar-clip or ball attachments

for overdentures. They found greater stresses on the peri-implant bone with

a bar-clip attachment.20

Keith F. Thomas in 1995 published the use of freestanding, magnetic

retention expanded into a wider range of applications because of the

improved corrosion resistance and strength of the new generation magnets.

The main advantages of magnets overbar retentions are (1) improved

abutment hygiene because of greater access; (2) easier placement of the

prosthesis by patient; (3) magnets that provide a stress break up element to

lateral forces, placing less direct stress on the implant and elimination of the

requirement for parallel alignments.21

60
 MAINTENANCE PHASE

The consensus of many studies is that maintenance requirements were

greatest during the first year of service and related to alteration of contour

and repair of the matrix or patrix. 23 Controversy persists as to whether the

bar or ball design requires more maintenance. Wear or fracture of the ball

attachment head seems less frequent than that of gold alloy bars. In a 5-year

multicenter study, replacement of O-rings was reported in 50% of patients,

usually within the first year. Clip adjustments and fractures occurred in as

many as 62% and 33% of patients, respectively. The shorter the bar

segment, the greater the chance of clip loosening in the acrylic resin.24

Quick tips for implant hygiene maintenance:25

 Metal scalers should be avoided. Use nylon, plastic, carbon, or resin

scalers designed specifically for cleaning around implant.

 Recall should be minimally every 3 months for the first 2 years.

Depending on the situation, recalls may be alternated between

practices.

 Ultrasonic and sonic scalers should be avoided.

 A rubber cap with tooth paste, fine polishing paste, implant polishing

paste, or tinoxide is recommended.

 A prophy jet should be avoided.

61
  Periodontal probing should be performed for baseline data and when

inflammation and other pathologic symptoms arise.

 Mobility should be checked at every visit if possible.

 Occlusion should be evaluated to detect and correct possible traumatic

or abnormal occlusal contacts of relationships.

 Plaque, calculus, and bleeding indices should be assessed at every

visit.

 Oral hygiene instructions should be assessed and reinforced or

corrected at every hygiene maintenance appointment.

 Radiographs should be taken using the paralleling technique to avoid

image distortion.

Plaque Control:25

Proper hygiene is critical since poor hygiene has been related to

marginal bone loss. Plaque control should begin immediately after the

second stage surgery and the patient should understand the importance and

necessity of this aspect of treatment. Hygiene maintenance is tedious and

requires considerable effort, especially when a patient has a fully bone

anchored prosthesis. After abutment connection to the fixture, a sulcus is

formed between the abutment and mucosa. Good plaque control is important

in preventing soft tissue complications such as gingivitis. The challenge also

involves decisions on the various hygiene implements available. Each

62
patient may not need every gadget but rather the devices are selected to meet

that particular patient’s needs. We should help evaluate and select devices

which best suit the individual’s needs. Toothbrushes are available in a

variety of sizes, shapes, and textures. A soft bristle toothbrush is an effective

aid for cleaning easily accessible areas of the abutment and /or prosthesis.

Purchase a precurved brush or modify an existing brush. Apply a heat

source to the neck of the toothbrush until the plastic is pliable. The tufted

portion is bent at an acute angle to the handle. This curvature may help gain

access to the often difficult lingual surface. The bristles of a toothbrush can

be trimmed to create a shorter length head with fewer rows of bristles. In

conjunction with the bent angle, the brush may be useful for a prosthesis

with a large surface area to clean. An end-tufted toothbrush can also be

used. This type of toothbrush provides fewer bristles on a short head. As

manufactured, the toothbrush may be ideal for easy access to smaller areas

and to lingual areas.

Dental floss is an important hygiene aid and is available in many

textures as well as flavors. A different type of floss is available with a

combination of textures within one individual strand, called Super Floss

(Oral B, Atlanta, Georgia).

The latter is a rotary instrument with various brush tips for easily

accessible areas. Both instruments can benefit patients with less manual

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dexterity or for patients desiring additional hygiene aids. A 2x2 gauze or

nylon mesh can also be used as a hygiene aid (Balshi, 1986). The gauze is

cut into usable lengths and can be passed through an interproximal areas

such as from the facial to lingual. The gauze is used in a back-and-forth

motion, “shoe-shine” motion, and used to clean the prosthesis gingival

surface as well as the adjacent abutment surfaces. Abutment hygiene

maintenance for overdentures may differ according to the attachment design.

If the abutments are freestanding using magnetic attachments, the procedure

required can be limited to use of a soft-bristled toothbrush. Each abutment

and all surfaces are easily accessible since the prosthesis is removable. The

prophy II can be a good alternative or adjunct to a toothbrush for a patient

using an overdenture. A chlorhexidine solution can be prescribed as a rinse

but it has possible side effects that should be noted before routine use. The

adverse effects include possible staining of teeth and/or prosthesis,

possibility of increased calculus formation, and possible change in taste

perception. Other rinses include salt water and mouthwashes that help

reduce plaque accumulation such as Viadent (Vipoint, Inc., Fort Collins,

Colardo). The main objective when using any mechanical device or special

rinse is maintenance of a clean, plaque-free exposed abutment surface.

If hygiene maintenance is poor, “permanent” closure of the prosthesis

channels is not advised. Review hygiene procedures with the patient and

reinforce the protocol as necessary. The patient should be placed on a three

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month recall schedule for evaluation and further instruction until the level of

care is satisfactory. The prosthesis can be removed and cleaned using an

ultrasonic cleaner and when replaced intraorally, the channels are sealed

temporarily. Some patients have a natural tendency for calculus

accumulation and these patients require the use of additional devices. At

recall appointments, the abutments can be cleaned using a very soft prophy

cap and chalk to remove tenacious material. Prophy paste and similar

substances should be avoided since their abrasives damage the titanium

surfaces. Plastic instruments such as the Wiz-Stick (Wiz-Stik, Plantation,

Florida) or a double-ended plastic instrument (Noblepharma) may help in

calculus removal, since the plastic is smooth and does not scratch the

titanium surface. The patient should be taught to use this if calculus

accumulation is a persistent problem. If the patient is maintaining a

satisfactory level of care, the prosthesis, either the fully bone anchored

prosthesis or the partially edentulous fixed partial denture, can be

“permanently” sealed. The patient should be on a six-month hygiene recall

schedule as a minimum standard. At annual appointments, the permanent

seal is removed and the prosthesis is cleaned using an ultrasonic cleaner.

Place the gold screws in the identical positions when the prosthesis is

replaced and secured.

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Roles in Implant Maintenance:

Patient Role:

1. Plaque control of 85%+.

2. Use of interdental (ID) brushes, hand and motorized (Proxa-Brush,

Oral-B Brush, Rota-Dent, Sonic).

3. Dip brush in chlorhexidine, 0.12% (Peridex, Periogard).

4. Use of flosses, yarns, tapes, dipped in chlorhexidine (Super-Floss,

Perio-Floss, G-Floss) accomplished at night before retiring.

5. If patient has tooth-colored materials, composites, and so on, use a

cotton swab dipped in chlorhexidine.

Hygienist Role:

1. Check plaque control effectiveness (85%)

2. Check for inflammatory changes

3. If pathology is present, probe gently with plastic probe (Sensor).

4. Scale supragingivally only (or slightly subgingivally) with Impla-

Care, Implant Prophy+, or Steri-Oss Graphite Scaler.

5. Check for problems such as loose suprastructure, broken screw, sore

spots, and so on.

6. No need to probe if no pathology is present.

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Clinical Role:

1. Check patient every 3 to 4 months

2. Check for 85% plaque control effectiveness

3. Expose radiographs every 12 to 18 months if no pathology is present,

and as needed if pathology is present.

4. If suprastructure is retrievable, remove and clean in ultrasonic every

18 to 24 months (remove and clean abutment also).

5. If implant needs repair, degranulate, detoxify, and graft with guided

bone regeneration (GBR) if necessary.

6. Wait 10 to 12 weeks before placing back in full function. Check to see

if the implant needs to be repaired. Document all procedures and

data.1

Recall:1

The patient should be recalled two weeks after temporary sealing

procedures are done. At this time, check the prosthesis adaptation and

evaluate any problems that may be due to gold screw loosening. After that

recall appointment, allow approximately four weeks before the next recall

appointment. This time lapse allows the patient time to function and adapt to

a new hygiene regimen. Evaluate the level of maintenance and further

review are done at this time. The recall schedule is at 1 month, 3 months, 6

months, and 12 months after prosthesis delivery. After the first year, recall

annually then a minimum recall schedule is at 3,5,7 and 12 years, to monitor

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prosthesis integrity, plaque control, and radiographic analyses monitoring

bone levels. The following should be included at the recall appointments:

i) Oral examination: Question any abnormality, discomfort, masticatory

problem, and prosthetic functional problems. Within the 18 month

period after the first surgery, the bone is still healing so any abnormal

habits such as bruxism, should be checked and monitored. If a problem

exists, immediate management should be done.

ii) Intraoral Examination: Check the hygiene maintenance condition,

abnormal pocket formation, gingival bleeding, and peri-implant tissue

condition. Carefully evaluate each individual since conventional soft

tissue indices may not be reliable in the implant situation. Check the

occlusion and reinforce plaque control procedures.

iii) Radiographic Examination: Check the bone density at the fixture sites

and monitor marginal bone loss. With a good parallel radiograph, the

marginal bone loss is measured using the fixture threads as a reference;

the threads are machined at 0.5mm intervals. As described, the marginal

bone loss can range from 1.0 to 1.5mm vertically in the first year. Also

check the fit between abutment and fixture and check for fixture

fractures. After the first year, estimated bone loss per year is less than

0.05-0.1 mm and offers a predictable long term prognosis. Radiographs

are made at the time of abutment connection and prosthesis insertion;

follow-up radiographs are made at 1,3,5,7,10,15 and 20 year recall.

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After the 20 year recall, the radiographs are made every five years. This

schedule is not limited such that if any problem exists, a radiograph can

be made to help evaluate the situation.

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 CONCLUSION

There are treatment alternatives that aid in increasing retention and

stability when conventional denture therapy is inadequate. These include

surgery to augment the alveolar ridge or increase vestibular depth, dental

implants to provide anchorage for an all implant-supported prosthesis, or

mucosa- and implant-supported overdentures.

Compared to all other disciplines, implant dentistry has enjoyed far

more innovation and progressive development in recent years.26

The implant overdenture is an especially attractive treatment because

of its relative simplicity, minimal invasiveness, and economy. Existing

complete dentures can be converted for many patients and maintain facial

support with the denture flange when moderate to extreme alveolar ridge

resorption is present. The implant overdenture is supported by both implant

and mucosa and therefore fewer implants are necessary than for the

prosthesis supported only by implant.

The overdenture usually consists of two or more implants placed

within alveolar bone on opposite side of the arch. Connected to the implants

is an attachment device that has a corresponding coupling unit processed to

the tissue surface of the complete denture. When the attachment components

are appropriately connected, the complete denture is held in position on the

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mucosa and both mucosa and implants provide support, retention and

stability. The overdenture is easily removed for hygiene. When the treatment

involves independent implant maintenance access for oral hygiene is

favorable because of easy access around the abutments.

Overdentures have been shown to improve the quality of life for

edentulous patients and to contribute significantly to the patient’s

psychological well-being. Patients reported increased satisfaction with the

implant-retained overdenture rather than conventional complete dentures. In

a randomized clinical trial comparing the efficacy of these overdentures and

conventional dentures in diabetic patients, patients reported that the

overdentures provided better masticatory function than conventional

complete dentures, and there was improved general satisfaction.

One can postulate that, even with otherwise successful conventional

complete denture treatment, it may be possible with the implant-retained

overdenture to take this treatment to a higher clinical standard of success.

The retention and stability achievable with the implant overdenture may far

exceed that otherwise obtained with successful conventional treatment.

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