PRESENTER HARISH.V.

S FINAL yr PG

CONTENTS

INTRODUCTION TERMINOLOGIES INDICATIONS FOR OVERDENTURE CONTRAINDICATIONS ADVANTAGES OF OVERDENTURE DISADVANTAGE CLASSIFICATION OF IMPLANT OVERDENTURE DIAGNOSIS IMPLANT SITE SELECTION IN MANDIBLE ATTACHMENTS IN OVERDENTURE PROSTHESIS MOVEMENT TREATMENT OPTIONS REFERENCES

INTRODUCTION

INTRODUCTION

David R. Burns, Mandibular Implant Overdenture Treatment: Consensus and Controversy; J Prosthod 2000;9:37-46.

TERMINOLOGIES
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; also called overlay denture, overlay prosthesis, superimposed prosthesis PATRIX - the extension of a dental attachment system that fits into the matrix MATRIX - the portion of an attachment system that receives the patrix ATTACHMENT
1: A mechanical device for the fixation, retention, and

stabilization of a prosthesis 2: A retainer consisting of a metal receptacle and a closely fitting part

INDICATIONS:
To reduces resorption of the ridge
Presence of tori which precludes conventional dentures Unfavourable muscle attachments Young edentulous patients

Patient desire for implant treatment.

Systemic health status, which permits a minor surgical procedures. Patient willingness and ability to maintain oral health status. Patients, who psychologically, cannot tolerate a full lower denture. Where extremely sharp mylohyoid ridges exist that cannot be easily and surgically corrected.

CONTRAINDICATIONS
Residual ridge dimensions do not accommodate

preferred implant dimensions. General health conditions preclude a minor surgical intervention. Immunosuppressive therapy, prolonged intake of antibiotics or corticosteroids, or brittle metabolic disease history. Communication with patient is not possible because of his or her compromised cognitive skills.

ADVANTAGES

Improved aesthetics and stability Provides stable occlusion Improves psychological acceptance towards the

treatment.

DISADVANTAGE
Long-term maintenance
Food impaction

CLASSIFICATION OF IMPLANT SUPPORTED PROSTHESIS

5 TYPES

1999

1989

CARL.E.MISCH

CLEPPER 4 TYPES

MISCHS CLASSIFICATION

FP-1

FP-2

FP-3

RP-4

RP-5

CLEPPERS CLASSIFICATION
Type I overdentures is a The Type II overdentures can

tissue-supported overdentures retaiined by freestanding implants.

be supported by a straight, round bar with clips in the overdentures. The straight, round bar provides an axis of rotation with the type II overdentures.

CLEPPERS CLASSIFICATION
The Type III overdentures

are supported by a bar with distal rotational attachments and a midline clip attachment.

The Type IV overdentures

are supported completely by the bar and implants.

DIAGNOSIS
George Bernard Shaw worst disease is the wrong

diagnosis Mandibule fixed or removable ? With overdenture, support is obatained from both implant and tissue depending on number of implants, Zitzmann and Marinello described a detail parameters that need to be evaluated bone quality & quantity, facial support, mucosa, aesthetic demands etc.

 Good facial support

Poor facial support -

Lip support
Short lip / high smile line

Long lip / decreased mobilty -

INTRAORAL EXAMINATION
Mucosa Bone Quality Quantity Muscle attachment Bony exostosis

BONE QUANTITY AND QUALITY

Tooth loss limited bone far from

original position biomechanical disadvantage. Visual examination with and without denture CT scan

LEKHOLM AND ZARB CLASSIFICATION

Shape five types A to E minimal resorption to severe Quality

LINKOW AND CHERCHEVE CLASSIFICATION OF BONE DENSITY

3 categories in 1970
Class I ideal bone consisting of evenly spaced

trabeculae with small cancellated spaces Class II bone has slighty larger cancellated spaces with less uniformity of trabecular pattern Class III Large marrow-filled spaces exist between bone trabeculae.

MISCH BONE DENSITY CLASSIFICATION:

AVAILABLE BONE
The available bone is classified into following

divisions: Division A Division B Division C Division D

DIVISION A BONE
Width 5mm
Height 12mm Length 7mm Implant angulation 30

degrees between occlusal plane and implant long axis Crown-height 15mm(high profile attachments like O-ring are contraindicated)

DIVISION B BONE
Width 2.5-5mm (B+ 4-5mm, B

w 2.5-4mm) Height 12mm(with augmentation can be converted to Div-A) Length 6mm Implant angulation 20 degrees(due to smaller dia implant) Crown-height 15mm (crestal bone might require osteoplasty to improve crown height)

DIVISION B
TREATMENT OPTION: Grafted ridge wil result in FP-1 or FP-3 prosthesis, whereas osteoplasty results in FP-2,FP-3 or RP4.

DIVISION C BONE
Width 0-2.5mm (C-w

bone) Height 12mm (C- h bone) Implant angulation 30 degree (C-a bone) Crown height 15mm

DIVISION C
TREATMENT OPTIONS: osteoplasty for C-w bone, Sub periosteal implants for (C-h and C-a bone) and Ramus blade implants/ transosteal implants for c-h completely edentulous mandible. RP-4 and RP-5 are ideal treatment options, FP2 or FP-3 incase of partially edentulous.

DIVISION D BONE
Severe atrophy
Flat Maxilla & Pencil thin

mandible 20mm crown height. The only treatment option for Division D is grafting.

MANDIBULAR IMPLANT SITE SELECTION

OVERDENTURE ATTACHMENTS
Intra coronal / Extra coronal attachments
Resilient / Non-Resilient attachments

INTRACORONAL ATTACHMENTS
Zest anchor locators
Ginta attachments

EXTRACORONAL ATTACHMENTS
Stud attachments
Bar attchments Auxillary attachments

STUD ATTACHMENTS
Gerber
Dalabona Ceka

Rotherman
Ancrofix

BAR ATTACHMENT
Hader bar
Dolder bar Andrew bar

PROSTHESIS MOVEMENT
PM-0 : The prosthesis does not move in

function PM-2 : A prosthesis with hinge movement, i.e in two direction facial & lingual. PM-3 : A prosthesis that moves in three planes, facial, lingual and apical. PM-4 : A prosthesis that moves in four directions. PM-6 : A prosthesis that moves in all directions.

OVERDENTURE TREATMENT OPTION

Five options
Implant retained to Implant supported To reduce risk of failures

OD-1:
cost is of primary concern if only retention of existing denture is poor. Bone volume should be abundant (Div A or B) Posterior ridge form should be an inverted U shape with high parallel walls Two independent implants are placed in B & D position with equal distance from the midline, at the same occlusal height O-ring attachment is used

OD-1

OD-1:
Advantage: Cost effective Existing denture can be rebased with the attachment components Hygiene maintenance is easy

OD-1
Disadvantages:
Poor implant support and stability compared to other

options ( rigid connections with bar). Jemt et al in 1996, demonstrated decrease in occlusal forces in splinted implants with bar attachment) No reduction in posterior bone loss due to placement of only two implants anteriorly. Frequent prosthetic maintenance like relining and change of attachments. If the positioning of independent implants are not proper ,complication of failure of implant or attachment is more likely.

OD-1:
Patient selection criteria: Cost is primary factor Good anatomic factors Patients needs and desire are less Additional implant placement in near future

OD-2:
Most commonly used option than OD-1
Two implants are placed in B and D position which

are splinted together with a metal superstructure without any distal cantilever. Dolder in 1961, presented that reduced loading forces are exerted on two anterior implants when splinted with bar compared with individual implants. Usually splinted implants are not advisable in A and E positions because as the distance increase, the flexibility of the metal bar increases.

OD-2

OD-2:
B&D Vs A&E:
Increased flexibility of superstructure (9 times more than

B&D positions) When attachments with retentive clips are used on a curved bar on A & E, the clips are placed in different planes and it prevents movements, which generates more lateral load on implants. Straight bars cannot be used to splint A & E because it will create excessive lingual projection. Bite force is higher than for B and D position, because of splinting the forces on posterior region is greater.

OD-2:
Patient selection criteria: Anatomical conditions are good to excellent Posterior ridge form is good providing good support and stability When retention is the only problem in old prosthesis

OD-3:
Three implants are placed in

A,C and E positions and are splinted with bar No distal cantilever is given This option reduces the flexure by 6 folds. Greater surface area of implant to bone allows better force distribution.

OD-3:
Advantage of A,C,E splint
Six times less bar flexure compared to A & E position Less screw loosening Less stress to each implant due to better stress

distribution over greater surface area Half the moment force compared to A & E positions A-P spread between the C-implant and A,E is more which provides greater biomechanical stability. Rotation of the prosthesis may be more limited compared to OD-1 and 2. When the patient has poor posterior ridge form Div (Ch), implants are given in B,C & D position splinted with bar. This option allows greater posterior movement of the prosthesis and reduces load on implants.

OD-3:
Patient selection criteria:
Usually the first option Patient needs and desires about retention is more Improved retention, support and stability Anatomic conditions are good Posterior ridge form is good moderate.

OD-3

OD-4
Here four implants are placed in A,B,D & E positions These implants usually provide sufficient support to include a

distal cantilever upto 10mm on each side if the stress factors are low. Additional implant support, biomechanical advantage and less undesirable forces. The distal cantilever magnifies the occlusal load which is proportional to its length The moment forces is resisted by the length of the bar anterior to the fulcrum.

OD-4:
According to the arch form the A-P spread changes, square

form limits the A-P spread and cannot tolerate a distal cantilever. In tapering arch form the A-P spread is usually 10mm and it can withstand 10mm distal cantilever, whereas ovoid is most common, which allows a A-P spread of 8mm hence cantilever may be upto 8mm distally.

OD-4
Other factor which influence the length of cantilever is that

as the occlusal forces increases the length of the cantilever decreases. Under ideal conditions with low occlusal stresses the cantilever may be extended upto 1.5 times the A-P spread for OD-4 overdentures.

OD-4:
Patient selection criteria: Moderate to poor posterior anatomy Lack of retention and stability Speech difficulty More demanding patient type.

OD-5:
This is a minimum treatment option for patient with

moderate to severe problems with traditional denture. In this option 5 implants are placed in A,B,C,D & E positions. The superstructure is cantilevered distally a maximum of 2.5 times the A-P spread. Last teeth does not extend beyond the bar/ molar region. Under ideal conditions RP-4 is the treatment option.

REFERENCES:
Carl.E.Misch, Dental Implant Prosthetics. Allen A.Brewer, Overdentures, 2nd edition. Treatment planning of the edentulous mandible,

W. Chee and S. Jivraj; British Dental Journal 2006; 201: 337-347 George A.Zarb, Implant supported prostheses for edentulous patients, Prosthodontic Treatment for Edentulous patients, 12th edition. Steven J. Sadowsky, Mandibular implant-retained overdentures: A literature review, J Prosthet Dent 2001;86:468-73 Alfred H.Greering, Complete and Overdenture Prosthetics,1993.

REFERENCES:
Harold.W.Prieskel, Overdentures made easy.
David R. Burns Mandibular Implant

Overdenture Treatment:Consensus and Controversy; J Prosthod 2000;9:37-46 Sarah Enright ,Treatment of edentulous patients using implant supported mandibular overdentures improves quality of life, TSMJ vol.8, 2007.