IMPLANT

SUPPORTED
OVERDENTURE & ITS
ATTACHMENTS
Presented By –
Dr. SOLANKI BHAVINI
PGT
CONTENTS
 Introduction
 Indication & contraindication
 Advantages of implant supported prosthesis
 Implant overdenture advantages versus fixed prosthesis
 Conventional dentures v/s implant overdentures
 Natural tooth overdentures v/s implant overdentures
 Disadvantages of overdenture
 Classification of prosthesis movement
 Maxillary and mandibular overdenture treatment options
 Occlusion
 Conclusion
 References
 INTRODUCTION

According to GPT 9:-

 Overdenture : Any removable dental prosthesis that
covers and rests on one or more remaining natural teeth,
the roots of natural teeth, and/or dental implants.

 Synonyms – OVERLAY DENTURE, OVERLAY

PROSTHESIS
INDICATIONS

1. Severe morphologic compromise of denture supporting areas that significantly

undermine denture retention.
2. Poor oral muscular coordination
3. Low tolerance of mucosal tissues
4. Parafunctional habits leading to recurrent soreness and instability of prosthesis.
5. Unrealistic expectations
6. Active or hyperactive gag reflexes.
7. Patient with abnormal jaw size and position where orthognathic surgery is
contraindicated.
8. Cleft palate cases & congential anomaly cases like microdontia, AI, DI and partial
anodontia.
9. Patients with worn out dentition.
CONTRAINDICATION

1. Poor oral hygiene.

2. Inadequate interarch distance to accept the denture and abutments.
3. Abutments exhibiting mobility.
4. Heavy smoking habits
5. Recent myocardial infarction
6. Generalized secondary osteoporosis
7. Radiotherapy in progress
8. Severe hormone deficiency
ADVANTAGES OF IMPLANT OVERDENTURES

 Prevents anterior bone loss

 Improves aesthetic and speech
 Improves prosthesis retention & stability - reduces or eliminates prosthesis
movement)
 Improves prosthesis support
 Improves chewing efficiency & biting force.
 In case abutments fails – relined & use as a conventional denture
IMPLANT OVERDENTURE V/S FIXED
PROSTHESIS
 Fewer implants (RP – 5)
 Less bone graft required.
 Less specific implant placement

 Improved esthetics
 Labial flange – soft tissue drape replaced by acrylic

 Soft tissue considerations

 Improved peri-implant probing (follow-up)
 Improved Hygiene
 Reduced stress
 Nocturnal parafunction (remove prosthesis at night)
 Stress-relief attachment

 Lower cost and laboratory cost (RP – 5)

 Fewer implants (RP – 5)
 Less bone grafting (RP – 5)
 Easy repair
 Laboratory cost decrease (RP – 5)

 Transitional device until fixed restoration guidelines are complete

 CONVENTIONAL DENTURES V/S IMPLANT
OVERDENTURES
Patient satisfaction increased when mandibular
implant overdentures were used instead of
conventional complete dentures (Burns,
1995;Boerrigter, 1995).
Implant overdentures generally offer the
advantages of improved comfort, support,
retention, and stability.
Annual bone resorption is more pronounced in
patients who wear conventional complete dentures
than implant overdentures (Jacobs, 1993).
NATURAL TOOTH OVERDENTURES V/S IMPLANT
OVERDENTURES

Overdentures supported by implants have a higher probability

of success than mandibular overdentures supported by the
roots of natural teeth (Mericske-Stern, 1994).
OVERDENTURE DISADVANTAGES
 Greater abutment CHS required (12 mm)

 Long-term maintenance
• Attachments (change)
• Relines (RP – 5)
• New prosthesis every 7 years

 Continued posterior bone loss

 Food impaction - against implants, bars, attachments

 High incidence of caries and periodontal breakdown around the abutments.

 The lack of sufficient inter-arch space makes an overdenture system more difficult to fabricate and more
prone to component fatigue and fracture.
 Psychological (need for non-removable teeth)
CLASSIFICATION OF PROSTHESIS MOVEMENT

 PM 0 : No movement of prosthesis, requires implant support similar to fixed

prosthesis
 PM 2: Prosthesis with hinge motion (2 planes)
 PM 3: Prosthesis with hinge and apical motion
 PM 4: Allows movement in four directions
 PM 6: All ranges of prosthesis movement
OVERDENTURE TREATMENT
OPTIONS
PROSTHETIC OPTIONS 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.
REMOVABLE PROSTHESES
 There are two types of removable prostheses, depending on the No. of implant support.
 REMOVABLE PROSTHESES-4 (RP-4)

 Completely supported by the implants

 The restoration is rigid when inserted

 Overdenture attachments usually connect the removable bar or

superstructure that splints the implant abutments.

 5 implants in mandible & 6-8 implants in the maxilla

 Denture teeth and the acrylic bulk are required for the restoration.

 Requires a more lingual and apical implant placement in comparison with

FP-1 and FP-2 prosthesis.
 REMOVABLE PROSTHESES-5 (RP-5)

 A removable prosthesis combining implant and soft tissue

support.
 2 anterior implants , independent of or splinted in the canine

region.
 Primary advantage is the reduced cost.
 MANDIBULAR IMPLANT SITE SELECTION
28
 OVERDENTURE OPTIONS 1 - PATIENT SELECTION CRITERIA

 Cost is the primary factor and minimal patients desires.

 Anatomical conditions – bone volume are good to
excellent (division A or B) in both anterior and posterior
regions.
 Posterior ridge form is an inverted U shape with high
parallel walls – for good to excellent stability & support for
conventional denture.
 Hygiene is improved.
Implant position : B & D – To limit the
 Type of prosthetic movements seen – ONLY 6 forward rocking of the restoration during
function.
 WHY NOT A AND E POSITION???

 Independent implants in A & E position

 More posterior to the anterior fulcrum line of the

anterior teeth
 Greater amplitude of unfavorable rocking of the
restoration and place greater leverage forces against the
implants.
 When using B, D position

 The anterior movement is reduced -- act as splint during anterior biting forces – decrease
stress on each implant

 Eliminates the unfavorable rocking leverages that exist when the replacement denture teeth
are anterior to fulcrum line

 Position closer to canine position -- much better suited for force distribution
IDEALLY, 2 IMPLANTS SHOULD BE

 Parallel to each other = not parallel---

 The prosthesis will wear one attachment faster because of greater

displacement during insertion and removal than other.
 When the implants are not parallel, the first attachment to engage wears
less and the second attachment rubs along the side of the male and
increases the wear rate
 If severe angulation difference --- the prosthesis may not engage one
attachment at all.
 Same height= Not ---

 Prosthesis will disengage from the lower implant during function and rotate primarily
on the higher implant ---- accelerate the wear of O ring on the lower implant
 Increased risk of complication may occur including abutment screw loosening, crestal
bone loss and implant failure – Higher implant receives majority of occlusal loads.
 Equal distance off the midline = not---
 Implant more distal = primary rotation point or fulcrum
when the patient occludes posteriorly and anterior implant
become fulcrum upon incising
 more distal implant will receive a greater occlusal load.

 Perpendicular to occlusal plane-----

 To allow the posterior region of overdenture to rock
downward and load the soft tissue over the buccal shelves
for support.
 If severe angulation difference --- the prosthesis may not
engage one attachment at all.
 THE ULTIMATE GOAL IN THE TREATMENT PLAN

 Is to convert OD-1 patients to a RP-4 or fixed prosthesis with more implant support and
stability before the loss of the posterior bone in the mandible occurs behind the foraminae.

 As soon as the patient can afford two more implants, the implants should be placed in the A and
E position, and all four ABDE implants should be connected with a bar that may be cantilevered
to the posterior and help reduce the posterior bone loss.
 If an additional implant may be inserted (after the initial two), it may be positioned in the C
position,
 Or if bone height and width distal to one mental foramen are adequate, the additional implant
may be positioned in one of the first molar regions.
 OVERDENTURE OPTION 2

 Implant position : B & D – they

are splinted together with a
superstructure bar without
any distal cantilever
 Type of prosthetic movements
seen – PM 3 or PM 6
PATIENT SELECTION CRITERIA – OD 2
 Anatomical conditions are good to excellent
 Posterior ridge forms is an inverted U shape.
 Patient’s needs and desires are minimal, primarily related
to lack of prosthesis retention.
 Patient can afford new prosthesis and a connecting bar.
 Low patient force factors (e.g., parafunction)
 The mandibular residual ridge form is square to ovoid,
and the dentate arch form is square to ovoid.
 Ideal distance between implants : 14 to 16 mm

 If placed closer than B &D : Reduced prosthesis

stability during function, whether they are connected or
independent units.

 If distal cantilever: Prosthetic Movement will reduced

and too much force on bar and implants will increase the
complications.
 2 SPLINTED IMPLANTS SHOULD NOT BE INSERTED IN
THE
A AND E POSITIONS
 The implants in this position are placed just anterior to the
mental foraminae and most often in the first premolar
positions. Because the bar is under the anterior teeth but
anterior to the implants, a greater moment of force also is
created
 Results in a curved arch form anterior to the implant sites.
 Increased length and even greater flexibility of the
superstructure.
 Greater moment of force created
 DISADVANTAGES OF A AND E SPLINTED IMPLANTS
( 1ST PREMOLAR TO 1ST PREMOLAR)
 Implants joined with straight bar are lingual to ridge.
 Difficulty with speech
 Anterior tipping of overdenture
 5 times greater bar flexure than B and D positions
 Implants are joined with anterior curved bar.
 Greater bar flexibility
 Increased screw loosening
 Increased moment forces on anterior aspect of prosthesis
 Attachment of curved bar may prevent prosthesis movement
 Bite force is higher than for B and D positions.
 Greater lateral load from prosthesis to implants than B and D positions
 If the surgeon inadvertently inserts the implants in A and E positions then 2
options exists.

1. To place atleast 1 additional implant, usually in the C position.

2. To leave the implants independently with O-rings.
 OVERDENTURE OPTION 3

 3 root form implants are placed in A, C and E position.

 A superstructure bar connects the implants but with no
distal cantilever.

 The additional implant – 6 fold reduction in superstructure

flexure and limits the connecting bar complications

 Screw loosening also occurs less frequently because 3 coping

screws retain the superstructure rather than 2.

 The risk of abutment loosening is reduced because force

Type of prosthetic movement seen – PM-2
factors to each unit are decreased.
to PM-6
 PATIENT SELECTION CRITERIA – OD 3

 Patient’s needs and desires require improved retention,

support and stability
 Anatomical conditions are good to excellent
 Posterior ridge form is an inverted U shape
 Cost is the moderate factor
 Rotation of the prosthesis is more limited compared

with OD-1 and OD-2.

 The IOD 3 usually does not use a Hader clip for

the attachment.

 Because the two clips do not rotate in the same

plane, the prosthesis is usually too rigid

 ADVANTAGES OF SPLINTED A, C & E IMPLANTS

 6 times less bar flexure compared with A and E positions

 Less screw loosening

 Less metal flexure
 Three implant abutments

 Less stress to each implant compared with A and E implants

 Greater surface area
 More implants
 Greater anteroposterior distance

 One-half moment force compared with A and E implants

 Less prosthesis movement

 If one implant failure occur, still provides adequate abutment support
 OVERDENTURE OPTION 4

 Four implants are placed in the A, B, D, and E positions.

 Distal cantilever up to 10 mm on each side if the stress

factors are low.

 Indicated when desires major retention, stability

 Type of prosthetic movement seen – PM-2 to PM-6

 PATIENT SELECTION CRITERIA OD-4
 Moderate to severe problems with traditional dentures

 Needs or desires are demanding

 Need to decrease bulk of prosthesis

 Inability to wear traditional prostheses.

 Desire to abate posterior bone loss

 Unfavorable anatomy for complete dentures

 Problems with function and stability

 Posterior sore spots

 Unfavourable force factors (parafunction, age, size six, crown height space
>15 mm)
 DISTAL CANTILEVER UP TO 10 MM ON EACH SIDE

The cantilevered superstructure is a feature of the

four or more implant treatment option for 3 reasons:

1. Increase in implant support compared with OD-1 to OD-3.

2. Biomechanical position of the splinted implants is improved in
an ovoid or tapering arch form compared with OD-1 or OD-2.
3. Additional retention provided by the fourth implant for the
superstructure bar, which limits the risk of screw loosening
and other related complications of cantilevered restorations
 Implant position is the primary local determinant – when considering a distal cantilever.

 Distal implant act as fulcrum. Therefore, the amount of the occlusal force is magnified by

the length of the cantilever, which acts as a lever.

 This moment force is resisted by the length of the bar anterior to the fulcrum.

 Therefore, if the two anterior implants (B and D) are 5 mm from the fulcrum (distal implants

A and E), the effect of the posterior cantilever is reduced.

 As a general rule, the posterior cantilever from
anterior implants may be equal to the A-P distance
when other stress factors are low to moderate.

 Square arch forms: limit the A-P spread between

implants and may not be able to counter the effect of
a distal cantilever. Therefore, rarely are distal
cantilevers designed for square arch.

 Ovoid and Taper arch forms: A-P spread between

implants in the A, E and D, B positions is greater
and permits a longer distal cantilever.
 Amount of distal cantilever is related primarily to the force factors

and to the arch form (A-P spread)

 Low-force conditions : the cantilever may be up to 1.5 times the A-P spread.

 Moderate force factor : cantilever should be reduced to one times the A-P spread.

 When stress factors such as occluding forces are greater, the cantilever is decreased.
Eg. When the crown height is doubled, the moment forces are doubled.
 OVERDENTURE OPTION 5

 Five implants are inserted in the A, B, C, D and E positions.

 Superstructure is usually cantilevered distally up to two times

the A-P spread

 Cantilever of two times this distance is indicated when force

factors are not excessive

Square : 5 mm

Ovoid arch : 5 to 8 mm

Tapered arch : > 8 mm

The mandibular arch form may be square,
tapering or ovoid.

1. Square arch forms limit the A-P spread between

implants and may not be able to counter the effect of a
distal cantilever. Therefore rarely are distal cantilevers
designed for square arch forms.

2. Ovoid arch, which is most common. The A-P 6-8 mm.

Hence the cantilever may be up to 8 mm long distally
from the A and E implants.
3. Tapering arch form, the A-P spread is greater
than 8 mm and therefore permits a longer distal
cantilever.
 This A-P spread is often 10 mm and therefore often
permits a cantilever up to 10 mm from the A and E
positions.
PATIENT SELECTION CRITERIA : OD-5
 Problems with function and stability

 Moderate to poor posterior anatomy

 Lack of retention and stability

 Soft tissue abrasion

 More demanding patient type

 Need to decrease bulk of prosthesis

 Inability to wear traditional prostheses

 Desire to abate posterior bone loss

 Anterior maxilla:

Narrow ridges bone augmentation / small diameter implants,

Their use results in increased stress concentration in the implants.

Resorption pattern - palatally and superiorly

Carl E. Misch - Dental Implant Prosthetics - 2nd Edition (2015)

 PREMAXILLA - COMPROMISED BIOMECHANICAL CONDITIONS

1. Narrow ridge is common in anterior maxilla and

often uses narrow implants. Ridges reduced in height
use shorter implants

2. Esthetics require facial cantilevers

 Use of facial cantilevers results in increased moment
loads at the implant crest and often leads to localized
crestal remodeling bone loss and soft tissue recession.
 Farther forward the maxillary anterior crowns
positioned – greater the moment force of leverage over
bone–implant interface, abutment screws, and
prosthetic components.
Carl E. Misch - Dental Implant Prosthetics - 2nd Edition (2015)
3. Oblique centric contacts against a thinner cortical plate

 The arc of closure of the mandible is anterior to the maxillary

residual ridge and is usually at an angle of 15 degrees or
more.
 An angled load to an implant crown increases the force by
25.9% when it is 15 degrees off axis.
 Oblique centric contacts result in potentially harmful, off-
axis load components.
 The force is also directed against the thinner facial bone.
4. Increased moment loads with lateral
forces during mandibular excursions

 All mandibular excursions place lateral

forces on the maxillary anterior teeth, with
resulting increased stress on the implant
system, including the prosthesis.
 These lateral loads in excursion further
increase the moment loads applied to the
implant system
5. Direction of force in excursion is outward

 A mandibular arch receives a load from the outside of the arch toward the center.

 A maxillary arch receives a force from within the arch to the outside of the structure,

especially in mandibular excursions.

 An arch is not as effective to resist this type of force.

7. The trabecular bone of the maxilla is usually fine and is less dense than the
anterior region of the mandible. The trabecular bone of D3, often found in the
maxilla, is 45% to 65% weaker than the trabecular bone of D2, usually found
in the anterior mandible. Reduced trabecular bone density of the maxilla
results in compromised bone strength and a weaker implant–bone interface.

8. Absence of thick cortical plate at the crest of the premaxilla results in loss of
high-strength implant support and less resistance to angled loads.

9. Crown height space often greater than ideal and is a force magnifier to any
angled or cantilevered force.

10. Maxillary arch opposing teeth or implant restoration in the mandible

 SEQUENCE OF TREATMENT:

MAXILLARY LABIAL LIP POSITION:

 The maxillary anterior region with multiple adjacent teeth missing

often is restored with an overdenture or a fixed restoration that
replaces teeth and the soft tissue drape (FP-3 prosthesis).

 Whether a denture, an overdenture, or a fixed prosthesis is being

fabricated, a full-arch or anterior edentulous maxillary reconstruction
begins with the determination of the facial position of the
maxillary incisal edge.
 The position of the maxillary lip also may be

determined by the position of the lower lip and chin

with the face at the proper vertical dimension.

 A horizontal line, represented by the Frankfort plane,

with the patient’s head in a vertical position.

 And a vertical perpendicular line drawn from the

Frankfort plane to the lower lip should have the

maxillary lip anterior to this landmark 1 to 2 mm
and the chin 2 mm posterior to this line
 The labial position of the lip in relationship to the premaxillary

bone is the primary criterion to determine whether a fixed

restoration, a bone graft and fixed restoration, or a maxillary
overdenture is indicated.

 When the labial position of the wax rim is forward of the

residual ridge more than 5 mm, a bone graft before implants or

a hydroxyapatite graft on the labial plate is required to support
the lip for a fixed restoration or a maxillary overdenture with a
labial flange is considered
 KEY IMPLANT POSITIONS:

 Important parameter in treatment planning is to provide adequate

biomechanical position and surface area of support for the load
transmitted to the prosthesis.

Guideline 1: No posterior cantilever

Guideline 2: No three adjacent pontics
Guideline 3: The canine sites
Guideline 4: The first molar sites
Guideline 5: Five sided arch

Carl E. Misch - Dental Implant Prosthetics - 2nd Edition (2015)

GUIDELINE 1: NO POSTERIOR CANTILEVER

 The premaxillary teeth may be cantilevered

forward from the implants for esthetics and
phonetics.
 Hence, it is more important to place posterior
implants connected to anterior implants to
increase the anterior-posterior (A-P) distance
and counter this affect.
 There should be little to no posterior cantilever
in a complete edentulous maxilla
GUIDELINE 2: NO POSTERIOR THREE ADJACENT PONTICS

 When the posterior teeth are included in a prosthesis,

there should not be three (or more) adjacent pontics.
 Under those conditions, the adjacent abutments are
bearing five or more adjacent teeth, the amount of
the force is greater in the posterior regions, and the
metal of the restoration flexes 27 times more than a
one pontic prosthesis.
 In addition, the bone density to support the implants
is often less in the posterior maxilla, hence the
strength of the bone is reduced.
 This further increases the overload risk to the
implants.
 GUIDELINE 3: THE CANINE SITES

 Fixed prosthesis replacing a canine tooth- at greatest

risk
 Lateral incisor – weakest anterior tooth
 First premolar – weakest posterior tooth
 Greater forces in the canine region
 As Fixed prothesis C/I= when a canine and two or more
adjacent teeth are missing
 GUIDELINE 4: THE FIRST MOLAR SITES

 Important abutment position – bite forces upto 200 lb

 The first molar natural tooth surface area is more than two times greater than the
premolars.
 Bone density insufficient than the premolar region so larger diameter implants or
more implants are suggested, not a cantilevered force applied in the molar regions.
 GUIDELINE 5: FIVE-SIDED ARCH

Dental arch is divided into five different

components related to their direction of
movement

 Atleast one implant in each section

 When three or more component splinted together –
different force of direction blended together and has less
movement and resist lateral forces
 The more sections of the arch splinted together, the
greater the A-P distance and the more resistant to any
lateral force or cantilever.
PRE MAXILLA ARCH FORM:

 Arch form of maxilla influences fixed treatment plan of edentulous pre

maxilla.

 Number and position of implants are related to the dental arch form not
on existing edentulous arch form.

Carl E. Misch - Dental Implant Prosthetics - 2nd Edition (2015)

DENTAL ARCH FORM:
SQUARE ARCH FORM –

• Lateral and central incisors are not cantilevered very

much facially from canine position.

• Mandibular excursions and occlusal force exert –

less stress on the canine implants.

• When the force factors are low, implants in canine

position to sufficient to replace 6 anterior teeth
OVOID ARCH FORM –

• Atleast three implants in the premaxilla

• Two – canine ; one – central incisor

• Central incisor implant position increases the A-P

distance from canine – improves biomechanical
support to the prosthesis.
TAPERED ARCH FORM –

• 4 implants – B/L canine and central incisor position

• This position are preferred when force factors are

greater like crown height, parafunction &
masticatory muscular dynamics

• Anteriot teeth creates significant facial cantilever

from canine position , with increased force in
centric occlusion & during mandibular excursions.
 COMPLETELY EDENTULOUS MAXILLA-
TREATMENT PLAN

• Low implant survival – as compared to mandibular prosthesis

• Biomechanical disadvantages – poor bone quality & force

direction

• Need for grafting

• CHS is important for maxillary overdentures and more often a
lack of space may compromise tooth position compared with
the mandibular situation. As it required and least 12 mm of
posterior CHS is required and 15 mm of anterior space because
the central incisor tooth is greater in height

Carl E. Misch - Dental Implant Prosthetics - 2nd Edition (2015)

RP 5 IMPLANT OVERDENTURE
• Complete denture with fully extended plates and flanges
• Anterior implants act as a fulcrum
• Four to six implants - Three in the premaxilla
• Key Implant positon - B/L Canine, atleast One Central incisor ,
2nd position- 1st or 2nd Premolar

Advanatges:
• Maintenance of the anterior bone
• Less expensive treatment option than a RP-4 or FP

NOTE - When an implant cannot be placed in at least one central incisor

position, the incisive foramen may be considered for implant insertion.
• Alternative - use of bilateral lateral incisor implants. In this option, because
of the reduced A-P spread, two implants are planned in the anterior region.
• Implants prevent continued bone resorption of pre maxilla
• Implant should be splinted with a rigid bar. The bar is not cantilevered distally and should
follow the dentate arch form slightly lingual to the maxillary anterior teeth.
• The prosthesis should have at least two directions of movement.
• Hence, when a Hader clip is used, it is placed in the center of the arch and perpendicular to the
midline. The restoration should be allowed to move slightly in the incisal region during
function to rotate toward the posterior soft tissue around a fulcrum located in the canine or
premolar position. The benefits are retention, stability and support is obtained from the soft
tissue.

NOTE -Implant no. and location are more important than implant size, but the implants should
be at least 9 mm in length and 3.5 mm in body diameter.
RP 4 IMPLANT OVERDENTURE
 Minimum 7 -10 implants - Rigid during function.

 2 key implant positions - B/L Canines and distal half of the first
molar positions
 When force factors are greater, the next most important sites are
the 2nd molar sites (bilaterally) to increase the A-P spread and
improve the biomechanics of the system. The tenth implant would
be placed in the premaxilla for a tapered arch form.`

 Treatment planning and cost are similar to fixed prosthesis – need

for bone augmentation, greater number of implants

 Advantages : Maintains greater bone volume.

Provides confidence and security to the patients. 9 implants – excessive CHS space
& greater force factors
 The implants are splinted together with a rigid bar.
 Four or more attachments are positioned around the
arch.
 This provides a retentive, stable prosthesis. Usually,
palatal coverage is maintained.
OCCLUSION
 Occlusion scheme for the RP-5 IOD is bilateral balance occlusion
 Occlusal scheme for the RP-4 IOD is posterior disclusion and anterior
guidance when opposing a RP-4 or fixed dentition in the mandible.

Carl E. Misch - Dental Implant Prosthetics - 2nd Edition (2015)

 Patient-reported outcome measures and clinical assessment of implant-
supported overdentures and fixed prostheses in mandibular edentulous
patients: A systematic review and meta-analysis

 Fixed prostheses showed significantly higher quality of life when compared with overdentures
regarding functional limitation (P<.001), physical disability (P=.001) and physical pain
(P=.003).
 Fixed prostheses also improved satisfaction, when compared with overdentures for comfort
(P=.02), ease of chewing (P<.001), retention (P<.001), and stability (P<.001).
 Only ease of cleaning presented greater satisfaction for the overdenture group.

Borges, G. A., Barbin, T., Dini, C., Maia, L. C., Magno, M. B., Barão, V. A. R., & Mesquita, M. F. (2022). Patient-reported outcome
measures and clinical assessment of implant-supported overdentures and fixed prostheses in mandibular edentulous patients: a systematic
review and meta-analysis. The Journal of Prosthetic Dentistry, 127(4), 565-577.
 Comparison of 4 implant retained overdenture & implant
supported fixed prosthesis using the all on 4 concept in the
maxilla in terms of patient satisfaction, quality of life and
marginal bone loss – a 2 year retrospective study

 Both the prosthesis present similar marginal bone loss and quality of life scores after 2 years
of function.
 However patients found overdentures easier to clean but more painful in comparison with
fixed prosthesis.

Mumcu, E., Dayan, S. C., Genceli, E., & Geckili, O. (2020). Comparison of four-implant-retained overdentures and implant-supported
fixed prostheses using the All-on-4 concept in the maxilla in terms of patient satisfaction, quality of life, and marginal bone loss: a 2-
year retrospective study. Quintessence international (Berlin, Germany : 1985), 51(5), 388–396. https://doi.org/10.3290/j.qi.a44368
 Maxillary implant overdentures: current controversies

• Implant survival-

 In the maxilla, factors of key importance include the degree of jaw atrophy, bone quality,
potential implant locations, aesthetics, function and phonetics.
 implant survival rates have been reported as low as 71% at five years.
 Goodacre et al. reported that maxillary implant overdentures were associated with the
highest incidence of implant loss when compared with all other types of implant
prostheses
 The survival rate of implants supporting maxillary overdentures is less than implants
supporting mandibular overdentures

Dudley, J. (2013). Maxillary implant overdentures: current controversies. Australian dental journal, 58(4), 420-423.
MANDIBULAR OVERDENTURE

 McGill Statement - suggested a two implant supported mandibular overdenture should become
the ‘first choice of treatment for the edentulous mandible’

 Having more than two implants did not lead to a more satisfied individual in terms of denture
and social function.
 Number of implants—
 Some sources have recommended a minimum of four implants to support maxillary
overdentures.
 In systematic review, Slot et al. reported that maxillary overdentures supported by six
connected implants resulted in the greatest implant and overdenture success, followed by four
connected implants.
• Attachment selection-
Factors such as rotational movement, desired retention, opposing dentition, space required
within the prosthesis and ease of maintenance should be considered while choosing.

• Patient satisfaction-
In patients with good bony support and those who are satisfied with their maxillary complete
dentures, it has been shown that no significant improvements in masticatory ability, stability,
retention, function and speech result from subsequent treatment with maxillary implant
overdentures.

• Maintenance-
Un-splinted implant attachment systems may offer greater ease for maintenance or repair than
splinted attachment systems
 Protocols for the Maxillary Implant Overdenture: A Systematic
Review.
• An implant overdenture offers a stabilized removable solution for the edentulous maxilla, which
provides increased patient satisfaction and quality of life improvement.
• A palate less design supported by four to six implants with a wide anteroposterior span has been
successfully applied in some investigations.
• A higher failure rate was experienced with machined implants, particularly with short implants
(length < 10 mm).
• Although both splinted and solitary anchorage systems are advocated, maintenance is higher for
solitary attachments and inflammation is increased beneath the bars.
• Long-term maintenance care is essential for all designs.

Sadowsky, S. J., & Zitzmann, N. U. (2016). Protocols for the Maxillary Implant Overdenture: A Systematic Review.
International Journal of Oral & Maxillofacial Implants, 31.
 To splint or not to splint oral implants in the implant ‐supported
overdenture therapy? A systematic literature review

 There is no difference in implant survival rates between splinted and un-splinted design.
 Un-splinted design needs more prosthetic maintenance and the bar-clip implant-supported
overdenture has been shown to be a more successful prosthesis.
 The peri-implant outcome does not significantly differ between splinted and un-splinted
implants retaining an implant-supported overdenture.
 The attachment mechanism did not have a notable effect on general patient satisfaction, the
satisfaction for the bar-clip group was significantly higher.

Stoumpis, C., & Kohal, R. J. (2011). To splint or not to splint oral implants in the implant ‐supported overdenture
therapy? A systematic literature review. Journal of oral rehabilitation, 38(11), 857-869.
OVERDENTURE
ATTACHMENTS
 Attachment Used in Tooth/Implant supported
Overdentures

Magnets
Stud Attachment

Bar Attchment

Intra-radicular – E.g.
1. Ceka Attachment
2. Zest Attachment
Extra-radicular – E.g.
1. O ring Attachment
2. Microflex

Principles and practice of implant dentistry; Charles Weiss,1 st edition.

Wismeijer et al. (1999) and Epstein et had described the absolute retentive
capacity of overdenture attachments.
Based on retention, the attachments can be classified into

1. Frictional,
2. Mechanical,
3. Frictional-Mechanical
4. Magnetic Attachments.
 BASED ON RESILIENCY

• Rigid Non- Resilient Attachments: ex: Screw retained hybrid overdenture.

• Restricted Vertical Resilient Attachments: prosthesis can move up and

down with no lateral, tipping or rotary movement.

• Hinge Resilient Attachments: resists lateral tipping, rotational and

skidding forces. Ex: Hader bar or any other kind of round bar can provide
hinge resiliency.

1. Sali, G., Aby Mathew, T., Joseph, S., Thomas, A. S., Abraham, M. A., & Rajesh, P. ATTACHMENT SYSTEMS IN
OVERDENTURE THERAPY: A REVIEW.
2. Clinical and laboratory manual of implant overdenture , Hamid R Shafie
• Combination Resilient Attachments: Allow unrestricted vertical
and hinge movements.Ex: Dalbo attachment.

• Rotary Resilient Attachments: prosthesis can provide vertical

hinge and rotary movements. Ex. Ceka attachment, ASC- 52

• Universal Resilient Attachments: provide vertical, hinge,

translation and rotation movements. Ex: Stud attachment, Magnetic
attachments.
 THE STUD ATTACHMENTS ARE CLASSIFIED
ACCORDING TO FUNCTION

Resilient attachments Non-resilient

 permit some tissue ward vertical and  It does not permit any movement of the
rotational movements, thus protecting the over denture during function and
underlying abutments or implants against
overload.
 Commonly employed when the
interocclusal space was limited.
 It usually require a large space and might
cause posterior mandibular resorption with
the vertical movement of the denture.

Prieskel HW. Overdenture made easy A guide to implant and root supported prosthesis, 1996, Quintessence Books
 STUD ATTACHMENTS ARE DIVIDED INTO TWO GROUPS:

EXTRARADICULAR INTRARADICULAR

 The male element forms part of the

 The male element projects from denture base and engages a specially
the root surface of the preparation produced depression within the root
or implant contour or implant
 Eg., ORS – OD , Microflex  Eg. Ceka attachment, Zest attachment
 O-RING OR BALL ATTACHMENT

 Doughnut shaped, synthetic gasket

 It is consists of a titanium male unit and an
easily replaceable rubber ring female unit that
is retained in a metal retainer ring or metal
encapsulator.
 It transfers the amount of stress to the
abutments and provides an excellent shock
resorbing effect during the function.
 Ability to bend with resistance and return to their
approximate original shape
 Retentive capacity of O-ring was affected by
implant inclinations.
ADVANTAGES:
• Ease of changing attachment
• Wide range of movement
• Low cost
• Different degrees of retention
• Possible elimination of time and cost of
superstructure
 DALBO STUD ATTACHMENT

 It can be rigid, resilient and stress broken, the resilient

being the most commonly used.
 The Dalbo-System uses a principle, which reduces the
effects of wear and tear to a minimum in comparison with
other systems .
 Every female part(nylon ring) has flexible precious metal
lamellae that prevent the build-up of abrasive plaque and
toothpaste.
 When fitting the denture, the flexible lamellae opens and
slides smoothly over the spherical male part without
damaging it.

Prieskel HW. Overdenture made easy A guide to implant and root supported prosthesis, 1996, Quintessence Books
 DALBO STUD ATTACHMENT
 They allow vertical and rotational movement of the female
component around a sphere shaped male component.

Rigid unit

Nylon ring – protects the lamella

Ball and socket unit
 Retention – altering the positions of free
ends of the lamella (Vertical and rotational movement)
 ZEST ANCHOR ATTACHMENT

 Derives retention from within root and

female component is cemented to place.

Advantages :
 Reduce vertical space requirement –
leverage force on abutment is also less
 Loads are transferred more apically.

 Parallelism may not be necessary

because of the flexibility of nylon male
component.
 CEKA ATTACHMENT

• Male portion affixed to the tooth and has a

rounded head at the top and split vertically
into four sections
• The four part are capable of being compressed
and are flexible.
 LOCATOR ATTACHMENT
 Self-aligning feature and has dual retention
(inner and outer).

 Rounded edges of the abutment help to guide the

nylon male within the denture into place (self-
aligning feature).

 Locator attachments come in different colors

(white, pink, and blue) and each has different
retentive value.

 Additional features are the extended range

attachments, which can be used to correct implant
angulation up to 20 they are offered in green,
which has standard retention & red which has
extra-light retention.

Ahmed, Y. A., & Kaddah, A. F. (2016). Attachments used with implant supported over denture. Adv Dent Oral Health, 1(2), 45-48.
ADVANTAGES DISADVANTAGE

• Reduced height (2.5) of this • Periodic repair

attachment – use in a limited • Higher maintenance
interocclusal space
• when retrofitting an existing old
denture.
• For patient with reduced manual
dexterity – Parkinson’s disease.
• Excellent retention & stability
 GERBER ANCHOR

 Largest stud unit

 It allows vertical movement and a rigid
attachment that does not allow The Gerber unit
movement of base.
 Retention is given by the spring clip in
the female housing engaging a groove
in the male section.
 It is easily replaceable.
 ROTHERMAN ECCENTRIC ATTACHMENT

 Button shaped attachment

 Patrix – eccentric cylinder with undercut or groove
 Matrix – Clip or clasp arm
 Activation : Bendingthe clasp arm towards center
Other important attachments-

Ancrofix attachment

Introfix attachment

Schubiger attachment

Quinlivan attachment
 BAR
ATTACHMENTS
 It consists metallic bar that splints two or more implants or
natural teeth spanning the edentulous ridge between them and
a sleeve (suprastructure) incorporated in the overdenture
which clips over the original bar to retain the denture.

 The bar attachments could be prefabricated or custom

made.
 Prefabricated bars are either round, ovoid, or rectangular (U-
shaped). Round bars offer more denture rotation than
rectangular bars, so produce less torque on implants

 Preformed metal or plastic retention clips. Round/ ‘U’

Oval/egg
circular shaped
shaped /
shaped parallel
sided bars

Prieskel HW. Overdenture made easy A guide to implant and root supported prosthesis, 1996, Quintessence Books
Attachments used with implant supported overdenture
2 BASIC TYPES BASED ON THE SHAPE AND THE ACTION PERFORMED:

BAR UNIT BAR JOINT

 Provide rigid fixation of the - Permit some degree of rotation or resilient
overdenture allowing no movement between the two components.
movement between the - Having sleeve joint allowing vertical and
sleeve and the bar rotational movements

Single sleeve - Run Multiple sleeves - Can

straight without allowing
the anteroposterior
curvature of the arch, so
it is used in square
arches.
follow the curvature of the
arch. It also enables the use
of more than one clip.
 DOLDER BAR

• Single open sided sleeve bar joint

• 2 sizes --with heights of 3.5mm x 1.6mm and 3.0 mm x
2.2 mm.
• Wrought wire, Egg shaped bar or pear shaped in
cross section
• It is best-indicated when patient has adequate inter-
arch space and minimum resiliency and maximum
retention is required

• Spacer – degree of movement

 MOVEMENTS SEEN IN DOLDER BAR

1. Prieskel HW. Overdenture made easy A guide to implant and root supported prosthesis, 1996, Quintessence Books
2. Harold Prieskel. Overdentures made easy
 • Roots or implants lie in a curved arch, the space for
the denture base will be restricted lingual to the bar
and the denture may break unless a metal lingual
plate is employed .

• In some circumstances, Two connecting elements can

be used to join the roots to a straight bar, but only the
straight bar can be used for retention - BUCKET
HANDLE EFFECT

Prieskel HW. Overdenture made easy A guide to implant and root supported prosthesis, 1996, Quintessence Books
 • Multiple sleeve bar joint-.
Relatively short, allows the bar
to follow the curvature of the
ridge and adapt to its vertical
contours.

The use of cantilevered

The connection between the
extensions requires at least
abutments must be rigid
four implant abutments.

Prieskel HW. Overdenture made easy A guide to implant and root supported prosthesis, 1996, Quintessence Books
 HADER BAR

 Semi-precision bar attachment that provides hinge movement.

 Function -based on the mechanical snap retention concept.
 Hader bar system consist of preformed plastic bars and plastic/
metal clips
 Bar is available as prefabricated plastic patterns that are adapted
on the master cast and then casted.
 Three color-coded clips/riders are available with three retentive
strengths. In order from the least to most retentive, they are white,
yellow, and red.
 It is more economic and easily available as compare with other bar
attachments.
 ADVANTAGES : DISADVANTAGES :

1. Rigidly splint the teeth 1. Bulk of bar

2. Provides good retention, stability and support 2. Plaque accumulation
3. Provides cross arch stabilization 3. Soldering procedure
4. Positioned close to the alveolar bone (exhibit 4. Manual dexterity
less leverage)
5. Less leverage forces on roots –close to
supporting bone
6. More apical transmission of forces to roots
 MAGNET ATTACHMENTS

 It is a popular method of attaching the removable prosthesis to

either retained roots or osseointegrate implants.
 The magnet is usually cylindrical or dome-shaped attached to the
fitting surface of the acrylic resin base of the overdenture.
 The magnet system used for overdenture retention incorporates the
magnet into the overdenture which is a neodymium-iron-boron
alloy or a cobalt-samarium alloy. Magnet attachment. The keeper is normally
fastened to the implant and the magnet will
 The ferromagnetic keeper casted to a metal coping cemented to be incorporated in the denture. (a) Magnet,
root surface or screwed over the implant fixture. (b) keeper, (c) implant, (d) teeth, (e) acrylic
flange, (f) alveolar bone.

Ahmed, Y. A., & Kaddah, A. F. (2016). Attachments used with implant supported over denture. Adv Dent Oral Health,
1(2), 45-48.
ADVANTAGES DISADVANTAGES

 Simplicity and low cost  Attachment needs to be removed before

taking MRI because it causes streaking
 Used in cases of reduced inter-arch space.
 They have least retention
 Automatic reseating after denture
displacement  Heating during sterilization leads to
decrease in retentive forces in long-term
 Freedom of lateral denture movement
use.
 Low potential for trauma to the retained
roots
 Self-adjustment
 Inherent stress breaking and no need of
adjustments
 TELESCOPIC ATTACHMENT
 Telescopic crowns are also known as a double crown, crown and
sleeve coping.
 These crowns consist of an inner or primary telescopic coping,
permanently cemented to an abutment, and a congruent detachable
outer or secondary telescopic crown, rigidly connected to a
detachable prosthesis.
 ADVANTAGES
1. Retainers provide excellent retention resulting from frictional fit .
2. Provide better force distribution due to the circumferential
relation of the outer crown to the abutment.
3. Ease of removability.

Ahmed, Y. A., & Kaddah, A. F. (2016). Attachments used with implant supported over denture. Adv Dent Oral
Health, 1(2), 45-48.
 RECENT ADVANCES - POST-CORE PEEK WITH PVS
ATTACHMENTS
 Li et al. evaluated the retention of PEEK post-core restoration with
polyvinylsiloxane (PVS) attachment systems and their cyclic
dislodgement test showed an inverse linear relationship between cyclic
times and retention force.
 The PVS’s retention was enhanced with an increase in Shore hardness,
thus showing a favorable retention force.
 Therefore, post-core PEEK with PVS attachments may comprise an
excellent alternative attachment system in dentistry.

Mirchandani, B., Zhou, T., Heboyan, A., Yodmongkol, S., & Buranawat, B. (2021). Biomechanical aspects of
various attachments for implant overdentures: A review. Polymers, 13(19), 3248.
 The effects of two attachment types on the stresses introduced to the
mandibular residual ridge: A 3D finite element analysis.

 Compared 2 types of attachments (bar and ball systems) on the basis of the stresses

introduced to the mandibular posterior residual ridge by an overdenture retained

by two implants.

 RESULTS: bar-retained overdenture introduced higher stresses to the posterior

mandibular residual ridge compared to the ball-retained overdenture (0.4 MPa and
0.1 MPa, respectively)

Dashti, M. H., Atashrazm, P., Emadi, M. I., Mishaeel, S., & Banava, S. (2013). The effects of two attachment types on the stresses
introduced to the mandibular residual ridge: a 3D finite element analysis. Quintessence International.
A comparison of 3 different attachment systems for mandibular
two-implant overdentures: 1-year report

 Comparison of the Locator with two traditional designs (a rotational gold matrix and a rubber
O-ring type) in clinical 1-year use was conducted.

 CONCLUSIONS: Prosthodontic maintenance was restricted to loss of retention for all

systems. Within the observation period of this study, the self-aligning attachment system
showed a higher rate of maintenance than the ball attachments.

Kleis, W. K., Kämmerer, P. W., Hartmann, S., Al‐Nawas, B., & Wagner, W. (2010). A comparison of three different
attachment systems for mandibular two ‐implant overdentures: One ‐year report. Clinical implant dentistry and related
research, 12(3), 209-218.
 Complications associated with the ball, bar and locator
attachments for implant-supported overdentures

 Prosthetic complications including fractured overdentures, replacements of O-ring attachment

and retention clips, implant failures, hygiene problems, mucosal enlargements, attachment
fractures, retention loss and dislodgement of the attachments were recorded and evaluated.

 CONCLUSION - locator system showed superior clinical results than the ball and the bar
attachments with regard to the rate of prosthodontic complications and the maintenance of the
oral function.

Cakarer, S., Can, T., Yaltirik, M., & Keskin, C. (2011). Complications associated with the ball, bar and
Locator attachments for implant-supported overdentures.
CONCLUSION
 Mandibular and maxillary IODs borrow several principles from tooth-supported
overdentures.
 The retention and stability achievable with the implant overdenture may far exceed that
obtained with successful conventional denture treatment.
 The number, location, superstructure design, and prosthetic range of motion can be
predetermined and based on a patient’s expressed needs and desires and anatomical
conditions.
 The advantages of IODs relate to the ability to place rigid, healthy abutments in the
positions of choice.
 The selection of attachment system depend on, amount of retention needed, available
inter arch space, manual dexterities of the patient, skills of the dentist and finally the
cost.
REFERENCES
1. Carl E. Misch - Dental Implant Prosthetics - 2nd Edition (2015)
2. Prieskel HW. Overdenture made easy A guide to implant and root supported prosthesis, 1996, Quintessence Books
3. Harold Prieskel. Overdentures made easy
4. Clinical and laboratory manual of implant overdenture , Hamid R Shafie
5. Borges, G. A., Barbin, T., Dini, C., Maia, L. C., Magno, M. B., Barão, V. A. R., & Mesquita, M. F. (2022). Patient-reported
outcome measures and clinical assessment of implant-supported overdentures and fixed prostheses in mandibular edentulous
patients: a systematic review and meta-analysis. The Journal of Prosthetic Dentistry, 127(4), 565-577.
6. Mumcu, E., Dayan, S. C., Genceli, E., & Geckili, O. (2020). Comparison of four-implant-retained overdentures and implant-
supported fixed prostheses using the All-on-4 concept in the maxilla in terms of patient satisfaction, quality of life, and
marginal bone loss: a 2-year retrospective study. Quintessence international (Berlin, Germany : 1985), 51(5), 388–396.
https://doi.org/10.3290/j.qi.a44368
7. Dudley, J. (2013). Maxillary implant overdentures: current controversies. Australian dental journal, 58(4), 420-423.
8. Sadowsky, S. J., & Zitzmann, N. U. (2016). Protocols for the Maxillary Implant Overdenture: A Systematic Review.
International Journal of Oral & Maxillofacial Implants, 31.
9. Sali, G., Aby Mathew, T., Joseph, S., Thomas, A. S., Abraham, M. A., & Rajesh, P. ATTACHMENT SYSTEMS IN
OVERDENTURE THERAPY: A REVIEW.
REFERENCES
8. Ahmed, Y. A., & Kaddah, A. F. (2016). Attachments used with implant supported over denture. Adv Dent Oral Health, 1(2),
45-48.
9. Stoumpis, C., & Kohal, R. J. (2011). To splint or not to splint oral implants in the implant ‐supported overdenture therapy? A
systematic literature review. Journal of oral rehabilitation, 38(11), 857-869.
10. Mirchandani, B., Zhou, T., Heboyan, A., Yodmongkol, S., & Buranawat, B. (2021). Biomechanical aspects of various
attachments for implant overdentures: A review. Polymers, 13(19), 3248.
11. Dashti, M. H., Atashrazm, P., Emadi, M. I., Mishaeel, S., & Banava, S. (2013). The effects of two attachment types on the
stresses introduced to the mandibular residual ridge: a 3D finite element analysis. Quintessence International, 44(8).
12. Cordaro, L., di Torresanto, V. M., Petricevic, N., Jornet, P. R., & Torsello, F. (2013). Single unit attachments improve peri ‐
implant soft tissue conditions in mandibular overdentures supported by four implants. Clinical oral implants research, 24(5),
536-542.
13. Koike, T., Ueda, T., Noda, S., Ogami, K., Patil, P. G., & Sakurai, K. (2013). Development of new attachment system with soft
lining material for implant-retained complete denture. Int J Prosthodont Restor Dent, 3(1), 21-4.
14. Wendler, F., Diehl, L., Shayanfard, P., & Karl, M. (2023). Implant-Supported Overdentures: Current Status and Preclinical
Testing of a Novel Attachment System. Journal of Clinical Medicine, 12(3), 1012.
15. Kleis, W. K., Kämmerer, P. W., Hartmann, S., Al‐Nawas, B., & Wagner, W. (2010). A comparison of three different attachment
systems for mandibular two‐implant overdentures: One ‐year report. Clinical implant dentistry and related research, 12(3),
209-218.
16. Cakarer, S., Can, T., Yaltirik, M., & Keskin, C. (2011). Complications associated with the ball, bar and Locator attachments
 THAN
K YOU
THANKYOU