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An overdenture may be defined as a removable prosthesis that covers the entire occlusal
surface of a root or implant. Such prosthesis has found ever-increasing applications in
prosthodontics, which may be a reflection on population trends and the demand for better
treatment. The concept of the overdenture covers a number of possible solutions for patients
with nearly all the teeth missing. Common to all is the combined periodontal and mucosal
support and the similarity of the external form to that of complete dentures.
Definition (according to Glossary of prosthodontics terms 1999)
A removable partial denture or complete denture that covers and rests on one or more
remaining natural teeth, the roots of natural teeth, and/or dental implants.
Synonyms
- Overdentures (English)
- Hybrid prosthesen (German)
- Overlay dentures.
- Telescopes dentures.
- Biologic dentures.
- Overlay prosthesis.
- Superimposed prosthesis.
History
The overdenture, a complete or partial denture prosthesis constructed over existing teeth or
root structure, is not a new concept in a technical approach to a prosthodontic problem.
Indeed, its use dates back over 100 years.
In 1856, Ledger had described a prosthesis resembling an overdenture. True, his
restorations were referred to as plates covering fangs
1888 Evans had described a method of using roots actually to retain restorations. In
1896 Essig had described a telescopic-like coping. At around the same time Peeso was
also making what appeared to be removable telescopic prosthesis.
1906WILLIAM HUNTER put forward his focal sepsis theory and this dealt a great
blow to the overdenture mode of treatment. The main point of contention was that
the exposed roots act as foci of infection.
1916PEESO was employing removable telescopic crowns. Later on, the bar type of
construction was developed.
MILLER (1958 ) published his classic article where the retention of previously
unusable teeth and their advantageous use in overdenture treatment was explained as a
basic tenet in management.
Prieskal(1968)described various commercially available overdenture attachments
Directional sensitivity
Dimensional discrimination'
Canine response
Requirements
1. Maintenance of health:
The health of the underlying tooth structure should be maintained, without which the
overdenture cannot sustain. Teeth used as abutments must be evaluated for their periodontal
conditions. An increased crown-to-root ratio, extensive bone loss, and mobility do not
necessarily negate the use of a tooth for an abutment. However without question the
periodontal condition must be treated first, with whatever means.
2. Reduction in crown-to-root ratio:
The reduction of crown has an immediately favorable effect on tooth mobility because of the
decrease in length of lever arm delivering the torque to the mobile tooth. In addition tooth
mobility has lessened under long-term overdenture use provided that the periodontal health
has been maintained.
3. Basal seat tissue:
The tissue covering the basal seat should be in good condition so that a well fitting base can
distribute the load over as wide an area as possible. Intimate tissue contact is also necessary
to prevent food and plaque accumulation under the base.
4. Simplicity of construction:
It should be simple to construct and maintain. In many areas due to the lack of available
space, sections of the overdenture base are quite thin. If metal reinforcement is not used,
fracture of the base and prosthetic teeth is common. The overdenture should be constructed in
such a way that its repair is relatively unremarkable.
5. Ease of manipulation:
The base should be easily manipulated by the patient. The use of a retaining device becomes
a struggle for the patient to insert and remove. This cause unwanted forces to seriously
damage the base or the abutment teeth. Therefore, proper consideration should be given in
selecting the course of treatment.
6. Other Requirements:
An overdenture which fulfills allof the above requirement should also fulfill those
requirements of any conventional denture. Therefore matters such as adequate tissue
coverage, underextension and overextension of bases, jaw records, harmonious occlusion and
esthetics cannot be compensated because an overdenture is being constructed.
Classification
A. According to the nature of support:
- Tooth supported.
- Implant Supported.
B. According to indication spectrum:
- Immediate overdentures.
- Transitional overdentures.
- Definitive overdentures.
C. According to the method of abutment preparation:
- Non-coping.
- Coping.
- Attachments.
IMMEDIATE OVER DENTURE:
This is of current research interest. It attempts to obviate some basic problem associated with
the more conventional over denture abutments. In these cases selected vital roots are
transacted and -reduced to 2mm below the crestal bone and then covered by a mucoperiosteal
flap.ADVANTAGES:
1. Preservation of alveolar bone:
Preserving the teeth retains not only the alveolar bone supporting the teeth but also the
alveolar bone adjacent to the teeth.
2. Preservation of proprioceptive response:
The preservation of periodontal membrane under the overdenture gives the patient a sense of
discrimination not possible with conventional dentures.
3. Support & Stability:
The natural tooth stops of an over denture provide for a static, stable base unparalleled by any
conventional denture. The overdenture literally does not move.
When compared with a conventional denture, we can see the rather obvious advantage of
function.
4. Retention:
Usually sufficient by merely over laying the teeth. However in some cases it may be desirable
to increase the retention. This can be done by either using attachments or by resilient liners.
5. A simple approach to the problem patient:
In the past, patients with congenital defects, such as cleft palate, partial anadontia,
microdontia, amelogenesis imperfecta, and so on, had a rather detailed lenghty and expensive
procedure. But with the advent of overdenture concept a reasonable relatively fast, and
inexpensive mode of treat became possible. They can be restored back to function esthetics
and comfort.
6. Periodontal maintenance:
Because the abutment teeth are easily accessible and because any form of splinting seldom is
involved the patient is able to take a vigorous home care to maintain periodontium in an
optimum state of health.
7. Patient acceptance:
Patients are most receptive and appreciative of this treatment because they experience a
striking improvement in function and esthetic while still maintaining some of their own teeth.
Hence the psycologic scarring some patients incur because of the loss of all their natural teeth
is decreased. Moreover in some cases were retentive attachments are given; extension of the
denture bases can be reduced.
8. Convertability:
The overdenture is designed so that if for some reason overlaid teeth must be extracted the
overdenture can readily be converted to accept the alteration. Even if all the teeth are lost the
overdenture, can be converted to a conventional complete denture.
9. Cost:
There is a large initial cost, mainly due to periodontal and endodontic treatment and
occasionally due to cast coping or due to retainer device. However, when weighing total
service involved, the ease of maintenance in years to come, the low percentage of remakes,
and the alternative treatment of extensive fixed and removable partial dentures, the cost of an
overdenture is very favorable.
Contraindications:
1. When a patient cannot economically afford or cannot or will not give the necessary time
for the procedures.
2. Poor candidates such as mentally or physically handicapped people for whom plaque
control and good oral hygiene are difficult.
3. Contra indications for periodontal and endodontic treatment.
Periodontal:
Class III mobility with no bone support and which cannot be corrected.
Soft tissues and osseous defects, which cannot be corrected.
Patient who will not keep the retained teeth free of plaque.
Failure to establish a sufficient zone of attached gingiva by mucogingival or
grafting procedure.
Excessive reduction of the adjacent residual alveolar ridge as a result of
elimination
of osseous defects and the establishment of normal architecture.
Endodontic:
Vertical fracture of roots
Mechanical perforation of the roots
Internal resorption that has perforated through the side of the root.
Broken instrument in the root canal
Horizontal fracture of the root below the bony crest.
4. More specific contraindications are the diagnostic findings such as:
Bony undercuts which results in over or undercontouring of the flanges.
Compensated occlusal curves
Probability of over bulked prosthesis.
Lack of vertical space.
All the above mentioned which causes an altogether compromise in esthetics,
comfort, stability etc.
DIAGNOSIS AND TREATMENT PLAN:
FUNDAMENTALS:
The foundation of every prosthetic plan is a comprehensive clinical and radiological
examination and diagnosis. For overdenture treatment, the health of the remaining teeth and
the periodontium must also be thoroughly evaluated, vitality testing performed and
radiographs scrutinized. The health history interview is of great importance frequently the
non-clinical factors are more decisive for the feasibility of overdentures than are the clinical
conditions.
-Panoramic radiographs provide an excellent over view for treatment planning,
however intra oral films of individual teeth are indispensable for evaluating
critical details.
o Examination charts are used to record all clinical findings. Such as:
o Tooth mobility
o Probing depths
o Width of attached gingiva
o Inflammatory condition of the marginal gingiva and plaque index as
parameters of the periodontal condition.
o Vitality of the teeth.
o Condition of the hard tissue.
PLANNING PROCESS:
When planning treatment for patients who will have very few teeth remaining after the
preprosthetic treatment phase, all conceivable courses of action must be considered. The
treatment plan is divided to three phases.
Phase I - Teeth that can be retained are identified, this goes hand in hand with indications.
Phase II - Determining the usefulness and/or necessity of retaining those teeth that can be
saved. Based on this results treatment options are worked out and discussed with patients.
Out of this emerge the provisional treatment plan and the necessary preliminary treatment
initiated.
Phase III - Determination of the definitive treatment plan in regard to number of abutments
and type of construction. This can be established only after the reevaluation of the provisional
plan and at the end of the preliminary treatment. The final decision on the details of
construction is not made until after the final try in of the trial denture.
A. Negative evaluation decision: No overdenture
B. Positive evaluation decision: Provisional treatment plan
C. Provisionally negative reevaluation Further preliminary decision: treatment.
D. Definitive negative re-evaluation
decision: Abandon overdenture treatment
E. Positive re-evaluation decision: Definitive treatment plan.
Evaluation criteria & Patient Selection:
I Clinical factors:
Perhaps the two most significant decisions in successful overdentures are selecting the proper
type of patient and establishing a careful mode of treatment that will satisfy both the patient
and dentist.
a. Possibility of fixed or removable partial dentures:
If the remaining natural teeth are capable of supporting a fixed or removable prosthesis, then
this form of treatment must be considered the primary plan of treatment. There are many
disadvantages of an overdenture that can be easily avoided if this type of treatment is
adopted.
b. Endodontic therapy:
It must be ruled out that successful endodontics can be performed because a tooth usually
must be treated endodonticaly. Ideally a patient with single rooted teeth is best candidate even
though multirooted teeth can be used. A two-or four weak interval before commencing any
further treatment on the tooth is good to rule our endodontic complications.
3 main advantages
The crown root ratio can be made more favourable.
Reduction of the clinical crown provides an interocclusal distance more favourable for the
placement of the artificial tooth in an esthetically acceptable position and in more favorable
relation to the opposing teeth.
For securing attachments.
Careful evaluation of the possibility of F.P.D or R.P.D must be done.
CONTRA INDICATIONS FOR ENDODONTIC TREATMENT
i. Vertical fracture of the root (or) roots.
ii. Mechanical perforation of the root canal.
iii. Internal resorption that has perforated through the side of the root.
iv. Broken instrument in the root canal.
v. Horizontal fracture of the root below the bony crest.
Vi. Posterior teeth that are tilted more than. 25 degrees..
c. Periodontal condition of the abutment teeth:
Periodontal evaluation is a critical stage in the construction of an overdenture. Optimum
periodontal health to ensure the longevity of teeth is required.
Inflammation, pocket formation, bony defects and a poor zone of attached gingiva must all be
eliminated before commencing treatment. An adequate amount of attached gingiva is need for
the abutments. If this is not present it should be rectified through periodontal surgery.
d. Caries:
The presence of high caries index and the creation of a situation that will easily promote a
caries environment are two of the most devastating sequelae to improper patient selection. If
abutment teeth are caries prone, we must think our selves whether it can be easily removed
and crown restored, and then to create a caries free environment. The restoration should be
properly prepared and polished moreover the patient must be instructed to strictly follow
meticulous home care along with regular visits.
e. Young patients:
Careful evaluation should be made in selection of young patients for overdentures.
Here their needs and failures can be much greater. Because of the length of time the
overdenture will be in service, failure of the denture is an eventuality that must be
anticipated. Proper tooth treatment and home care become more critical.
f. Location of abutment teeth:
Teeth are most useful in areas of maximum occlusal force and ridge resorption potential. The
anterior aspect of the residual ridge especially that of mandible, is very susceptible to change,
so canines and premolars or valuable teeth to preserve in this area. Upper anterior teeth that
oppose natural lower teeth prevent the destruction of the anterior maxillary ridge, when
utilized in maxillary overdenture. Mandibular canines are most often utilized because they
are usually the last teeth to be lost. If only a single tooth remains that should be remained if
possible. If canines and premolars are present it is better to retain canine and second
premolars because, it gives better support and favorable oral hygiene.
Two teeth in each quadrant presents an ideal situation in which stress is distributed
over a rectangular area.
The tripod is the next most favourable form for support and stabiliy
The use of two teeth in each arch or one arch has met with satisfactory results
g. Economics:
Finally the extend of treatment necessary to save an abutment tooth must be considered
taking in to account the expenditure of time and economic reality.
Therefore in the treatment plan, we should evaluate the situation, as it exists; teeth that
already have endodontics, teeth that could be reduced without endodontics, single rooted
rather than multirooted teeth, and the minimum number of teeth needed to achieve support
and bone preservation should be kept to hold the line on cost so that this form of treatment
can be viable.
II Non-clinical factors:
The results of the clinical evaluation must be considered along with the nonclinical factors in
order to form an overall judgment. Foremost among the non-clinical factors are the wishes,
expectations and demand of the patient. Against these must be weighed other factors, which
can be considered parameters of feasibility, such as: the patients attitude towards the
situations, financial resources, and information from health history.
They are:
1. Early conversion to a provisional overdenture:
The periodontium of the remaining teeth is often found to be injured by unsupported clasps,
lingual connectors and parts of the base of a partial denture. Very few of these denture
components can be modified so that they no longer traumatize the denture supporting tissue.
Root support of the modified prosthesis is accomplished at the same time, resulting in a
reduction of the forces born by the residual ridge.
Periodontal therapy and prophylaxis of the prospective abutments for the future overdenture
can be carried out at this point.
2. Modification of an existing removable partial denture:
One of the indications for the replacement of a partial denture with an overdenture is tissue
damage and related problems caused by wearing the partial denture. Overextension,
underextension and imprecise adaptation of existing denture bases produce load
concentrations on certain areas of the residual ridge and mucosa. This leads to recurring
points of pressure and friction, inflammatory hyperplasia, or generalized inflammation of
mucosa. It can also be caused by incorrect occlusion, or by the chemical toxins from
accumulations of plaque on the tissue side of the denture.
The oral mucosa can be conditioned by correcting the border extensions and temporarily
relining the dentures. Relining eliminates the mechanical and chemical irritants for a period
of time. Correction of occlusion can be made by making new jaw relations.
Abutment configuration:
The number and position of the teeth in the arch, influences the support and stability. Two
teeth in each quadrant probably present a situation in which stress is been distributed in a
rectangular area. The tripod is the next most favorable form of support and stability. The use
of two teeth in each arch or one tooth in one arch has met with satisfactory results when the
patient has been educated in what to expect from treatment.
Design options and Support possibilities:
There are various options available to the dentist for support and retention of overdenture. In
addition to the more complex and expensive designs, there are also simple designs that place
less financial burden on patients. The way in which the remaining teeth or roots are treated
and integrated in to the construction depends on the type of design selected. The root may
have only a denture-supporting function, or they may serve to provide both support and
retention for the overdenture.
Various techniques:
1. Simple tooth modification and reduction:
In this procedure remaining teeth are merely reshaped to eliminate undercuts and reduced in
vertical height, if necessary to create more inter ridge space for the overdenture. The
requirements for this modality is low caries index good oral hygiene sufficient vertical space
and the pulp must have receded sufficiently. After the final impression a master cast is
poured, surveyed for undercuts and a denture is constructed.
2. Tooth reduction and cast copings:
Minimal tooth reduction is done and a cast coping is placed, so as to prevent sensitivity and
caries. The requirements for this treatment are the same with simple modification and the
tooth must be periodontally stable. The coping is called thimble shaped coping or
telescope copings.
3. Non coping abutment:
Selected root abutments are reduced to a coronal height of 2 to 3 mm and then contoured to a
convex or dome shaped surface. Most teeth require endodontic therapy and in the final step
are prepared conservatively to receive an amalgam or composite type restoration. It is
indicated when there is normal coronal height to the teeth and normal interocclusal distance
with little or no loss of vertical dimension.
4. Abutment with copings:
Here a casting is placed on tooth instead of placing a simple amalgam restoration in the root
canal. The casting may be used because of fear of recurrent delay on the exposed dentin when
there is a history of carious involvement. If home care is not drastically improved, then the
placement of a cast coping does little to prevent carious lesions. Cast copings may be short or
long. Short cast copings are 2-3 mm long and normally require endodontic therapy because
the required coronal root reduction would expose the pulp. Retention is gained from short
posts that are placed within the root canal. The post is short because of the possibility of
removal of the casting, if caries could develop or if only support & stability is required from
abutments.
5. Abutment with attachment copings:
Usually requires endodontic therapy, and has long posts about 5-8mm long into the root
canal. This approach is reserved for the situation in which not only stability is desired but
also in which a significant improvement in retention is desired. The main requirement of this
is a drastic reduction in the crown-root ratio, sufficient vertical space & a good periodontal
support. Retentive attachments are soldered on to the copings after final try-in.
6. Submerged vital roots:
This additional abutment category is included because of the past research and interest.
Selected abutment roots are transected and reduced to 2mm below the crestal bone and then
covered by mucoperiosteal flap. This is done to prevent caries, gingivitis periodontitis etc.
The results are both discouraging and encouraging. The two major postoperative problems
are the development of dehiscence and pulpal pathosis. The use of submerged vital tooth is
not been successful and not recommended now.
Retentive mechanism:
Is by friction between male and female components. The retentive force of an anchoring
element should amount to at least 400g in order to ensure adequate retention. However it
must not exceed 1000g, because excessive tensile force on the abutment tooth may result in
damage to periodontium.
Two types:
-Rigid
-Non rigid
A. Rigid Attachments:
A retentive attachment is considered to be rigid if it grasps the abutment tooth bodily and
permits no movement between anchor and prosthesis except for rotation along its long axis.
Advantages:
- Reduction of the load on the edentulous ridge during function and parafunction.
- Minimum tipping of abutment teeth when subjected to lateral forces.
Disadvantages:
Applied forces and movements of the denture are transmitted almost entirely to the abutment
teeth.
B. Non-rigid attachments:
A retentive attachment is Considered to be non rigid when it permits rotational movements of
the denture around the anchor in one or more planes, or vertical bodily movements. The
greater the number of non-rigid attachments used in the same denture, the more limited will
be the movement of each.
Advantage:
- Reduced effect of tipping force on the abutment teeth (Principal of shortening)
Disadvantage:
- Greater stress on the tissues supporting the denture (Ridge resorption)
- Greater tipping of the teeth under lateral forces.
Selection of appropriate attachments:
In most cases the final selection of the appropriate attachment can be made only after the
denture has been tried in patients mouth. The amount of vertical and faciolingual space
available to house the retentive element after the teeth are set influences the selection of
retainers. However it is all upon operators choice to select the retentive device, which is
most suitable.
Rigid attachments should be used whenever possible because they place lower demands on
the edentulous ridge during function and parafunction and requires fewer repairs than nonrigid attachments.
Indications of non-rigid attachments:
1. When the geometric distribution of the remaining teeth is unfavorable for the stability of
the denture. This can give rise to unfavorable tipping and rocking movements, especially if
the soft tissue support is more resilient and/or less expanded than normal.
Unfavorable geometric distribution of the remaining teeth
2. When only a short dowel can be used to anchor the coping. If a rigid attachment were used
over a short dowel, uncontrolled movement of the denture might loosen the dowel from the
root.
The idea behind non rigid attachments is to lessen the torque the prosthesis exerts on the
periodontium of the abutment teeth by shortening the clinical crowns of the natural teeth
flush with the gingiva and providing a loose connection between the denture and the
remaining root. This is the principle of prophylactic shortening. The movable attachment
shortens the lever arm of the torque acting on the abutment tooth.
Attachments anchored directly in the root canal space without copings are well suited as
retainer for interim overdentures. These are cases in which the roots are too periodontally
weakened to justify the placement of expensive attachments, but can still be called upon to
serve as transitory denture retainers. Such limited duration treatment is also indicated for
elderly patients because they can be provided at less expense and facilitate the adaptation to
complete denture. One disadvantage is that the omission of protective coping increases the
risk of carious destruction and root fracture. There is a limited indication, for resilient eg:
where the remaining teeth are in a topographically unfavorable arrangement and the soft
tissues are highly compressible. In either of these situations the overdenture must be checked
frequently after placement so that any possible harmful movement of the denture can be
eliminated.
Single attachment versus bar attachment:
Whether the overdenture abutments are to be left separate or are to be connected by a bar
depends primarily on the number, distribution and periodontal condition of the remaining
roots. In many cases both type of retainers can be used with equal chances of success. This
preference depends upon the operator experience.
Indications for single attachments:
- Only one tooth remaining.
- Diagonal position of the abutment.
- Spans too long to be bridged by bars.
- In sufficient space above the residual ridge to accommodate the attachments. In such cases
placement of a bar often causes the anterior portion of the denture base to lie too far to the
lingual and encroach upon the tongue space.
Arches that are markedly V shaped or acute in front. Prefabricated bars, unlike individual
retainer, often restrict the tongue space enough in the labiolingual direction to cause
disturbances of speech and mastication. This is because bars must be straight, at least in the
portion where the clip attaches, and therefore cannot follow residual ridge closely enough.
One exception to this is a bar that is round in cross section and is grasped by short clips. This
can be made to conform to the arch form more precisely and thus restrict the tongue space to
a lesser extent.
The enlarged root canal is reamed with a standardized Rotex canal trimmer used in Thomas
finger wrench. The Dalbo-Rotex is screwed clockwise into the post space with the finger
wrench under moderate pressure. The screw cuts its own threads in to the canal walls. Then
the anchor is backed out of the canal. The post space is now coated with 2-inch phosphate
cement and the Dalbo-Rotex again screwed back. First it is turned anti clockwise until it falls
into the previously cut threads and then clockwise until completely seated. After the cement
has hardened the cavity above the base of the anchor is seated with glass ionomer cement or
amalgam. The female portion is incorporated directly in to the denture base with
autopolymerizing acrylic resin.
c. Tooth preparation for Dowel-copings:
A dowel coping that is to serve as a connection between abutment tooth and denture base
must fulfill a number of criteria that depends essentially on an adequate tooth preparation.
The preparation is therefore a very exacting task in which the periodontal, functional, esthetic
and technical implication must be considered.
According to current concepts tooth preparation that results in subgingival crown margins is
undesirable. Supra gingival preparations are also preferred for dowel copings, because they
cause less gingival irritation and leave easily cleansable margins.
Requirements for supragingival margins:
- The sound tooth structure available for preparation must extend atleast 1.5mm above the
gingiva.
- There must be little danger of rapid caries formation at the margins of the coping.
- Visible coping margins especially in the maxillary anterior region, must not present esthetic
problems. As s rule supragingival preparation margin can be made in lingual and proximal
surfaces.
Requirements for partially subgingival preparations:
- Esthetics demands a subgingival margin. The preparation finish line and the margin of the
coping may be placed 5mm subgingivaly if and only if the coping can be tapered to a fine
margin and be finished with at most care.
- Supragingival margins would not allow adequate space for concealed attachment.
- Caries activity is high.
Tooth preparation for dowel coping must shorten the root enough to create ample space for a
retentive element, but must at the same time leave enough tooth structure to provide sufficient
retention for the coping. Retention is achieved by means of a standardized prefabricated
dowel that precisely fits the walls of the enlarged root canals and by preparing the external
surface of the root approximately parallel with long axis dowel.
Steps:
- After the tooth has been shortened to about 2mm above the gingival margins the roots canal
is prepared with a standardized drill set to receive a root dowel, which is usually tapered. The
post space is refined with hand. The length and angulation of the inserted dowel can be
monitored radiographically.
- The external root surface is prepared nearly parallel to the axis of the dowel with a light
chamfer as finish line. The preparation is kept supra gingival wherever possible. In many case
the preparation will have to extend subgingivaly partly or even completely around the root.
- Shortening the preparation is now done to its final length, approximately 1-1.5mm above
the gingival margin.
- Facially shortening is accomplished through placement of round occlusal shoulder so that,
its outer edges about .25mm above the gingival margin.
- Occlusal box is prepared where the cross sectional dimension of the root allows it.
This serves to increase retention, enlarge the area were the coping is cast to the post and it
provides a certain amount of reserve space for the mounting element. The remaining root
walls must not be reduced to a thickness less than 1mm or the risk of root fracture would be
too great.
- A Bevel is placed between the box walls and occlusal surface.
d. Preparation for thimble shaped or telescope prosthesis:
Abutment for telescopic prosthesis will be covered by two layers of metal while facial
surfaces may require facings as well. All these require extensive preparation and planning, as
a poorly executed abutment preparation is one of the most common mistakes. The results of
such errors are thin inner copings that become perforated after a period of use, together with a
bulky and unsightly removable prosthesis.
Occlusal reduction of 2-3mm is the minimal requirement. Although height and size of the
inner coping must influence retention, the principal factor for retention appears to be its
taper, assuming that the outer casting is accurately adapted. If the convergence angle of the
axial walls is 6 degrees or less, a significant amount of retention can be provided.
Problems with tooth preparation and consequences:
The rules for preparing dowel coping cannot be followed consistently in all cases.
Often compromises must be made because of periodontal attachment loss and root caries.
These affect not only the abutment tooth itself but also the shape of the coping and denture
base.
a. Loss of attachment:
If there is loss of attachment on the facial surface but no root caries, the preparation margin
should be kept supragingival. By doing this the root coping can be given the optimal form for
function and periodontal health. If the denture base is kept away from the periodontium, the
bare root surface will be exposed even with the denture in place. If this causes any esthetic
problem, then base may be made to conceal the root surface. Because this design is
disadvantageous it should be used in areas with high priority on esthetics.
b. Root caries:
Caries that extends subgingivaly must be exposed through periodontal surgery to provide
access so that the cavity can be excavated down to sound dentin. When root caries is confined
to the facial surface, removal of caries and preparation for a root coping will result in a finish
line that are at different levels. This makes it difficult to achieve the described concavity on
the surface of the coping and a nearly right-angled transition from occlusal surface to the
axial surface. This results in fabrication of coping, which is too steep, and there will be
increased danger of fracture of the neck of the artificial tooth it will have to be thin and
narrow where it terminates the facial margin of the coping.
c. Caries at entrance of the root canal:
Preparation problems are also encountered when carious destruction is present at the entrance
of the root canal. This necessitates the enlargement of occlusal box or a dowel, which is too
large in relation to the diameter of the root to be used so that its sides will be in apposition
with sound dentin. This results in weakening of roots and formation of root cracks and related
bony pockets in that area. Usually the diagnosis of a cracked root is not made until the tooth
is extracted.
d. Mistakes made when preparing a tooth for dowel coping:
- Shortening the abutments below the level of the gingiva. The gingiva reacts to this with
hyperplastic proliferation.
- Making the outer axial walls overtapered or divergent from the long axis of the dowel. This
reduces retention, causing the coping to come loose from the root. It must be either
recemented repeatedly or remade, if there is still enough tooth structure remaining to allow
modification of the preparation.
Impression procedures:
A. Impressions of the abutment teeth:
Impressions of the prepared teeth are used to make dies on which patterns for dowel- copings
can be formed. NB (No special impression technique is required for teeth that will not be
fitted with dowel, or copings or those that receive directly mountable retentive elements. It is
only necessary that their form and position be reproduced on the working cast on which the
denture will be processed. For this they can simply be recorded in the overall impression of
the arch).
a. Single- tooth impression in a copper band:
It is one of the oldest techniques practiced. It can be performed with either a thermoplastic
material (Impression compound) or an elastomeric material. The copper band must be
trimmed to terminate at the preparation finish line where it must fit the tooth precisely. Use of
a thermoplastic impression material permits an immediate check of parallelism between the
external preparation and the root dowel. Any undercuts will cause the hardened impression
compound to break as it is removed from the tooth. When an elastic material is used the
preparation cannot be checked until it has been reproduced in the stone die.
are not parallel with one another. Dowels furnished with the retentive heads separate from the
impression less frequently, but when they separate, they can never be repositioned accurately.
The procedures are the same used for single tooth. Single tooth and multiple tooth
impressions can be poured in extra hard die stone, or they can be electroplated with silver or
copper and filled with acrylic resin to form dies. The die forms the basis for fabrication of the
dowel copings.
B. Combined full arch impression:
To fabricate an overdenture that will be supported by dowel-copings with retentive elements
requires a working cast that reproduces the edentulous ridge and the same time hold the
dowel-copings in their correct positions. The latter must be incorporated into definitive
working cast because the retentive elements are attached to them only after the denture has
been set up on the working cast and tried in the mouth.
a. Two stage technique:
In this two-stage procedure the impression of the edentulous jaw segments and the
incorporation of the root coping are done in separate steps. The coping is fabricated on the
die, cast in gold and fitted with an acrylic resin transfer device. The root copings are tried in
the mouth and any necessary corrections are made. Accurate seating of the copings is
evaluated using indicator paste.
First stage:
A custom tray is fabricated with the same extension as for complete denture. It is windowed
or fenestrated at the areas of abutments, so that it doesnt touch both the coping and transfer
device. A zinc oxide eugenol impression is made of the edentulous segment following the
criteria for a complete denture. The impression is evaluated and necessary corrections are
done.
Second stage:
The tray is reseated on the arch and a light body elastomer or impression plaster is admitted
through the windows under visual control. If the procedure is carried out correctly, a smooth
transition between the two impression components can be achieved. If the dowel copings
remain in the tooth it can be repositioned accurately.
b. One stage technique with dowel copings:
Edentulous segments and dowel-copings can also be included simultaneously in a singlestage full-arch impression. Elastomer is the only suitable material for these techniques. It
allows root copings to be accurately repositioned in the impression if they should remain on
the roots when the impression is removed. This sometimes occurs in cases with strongly
retentive preparations or divergent roots.
The custom tray used for a one-stage impression is not fenestrated over the abutments as in
the two-stage technique. Because it must fit over root copings and transfer devices mounted
there on with out touching them, it will be bulky. Under some circumstance, this can lead to
an undesirable lifting of the movable mucosa from the underlying bone as the impression is
made.
NB (The two stage combined impression is a more involved and time consuming procedure,
but it produces the best impression of the edentulous segments. The one stage technique is
somewhat less time consuming than the two-stage technique but the major disadvantage is
the errors cannot be corrected and it should be remade).
c. One stage technique with supporting elements:
- For designs that rest on abutment teeth without root copings, the full-arch impression is
made as soon as the abutments are prepared.
- When root copings without retentive elements have been used, the impression is made after
final cementation of the copings. There is no need to incorporate this type of root coping in to
the working cast because they will not be processed further.
The full arch impression is made in a custom tray which covers all the ridge except for any
under cut areas near the abutment teeth that could not be utilized for the future denture base.
Anyway the impression is made using a zinc oxide eugenol or elastomer impression
materials.
d. One stage technique for existing retentive element:
A single step full arch impression in zinc oxide-eugenol paste or elastomer can be used for
overdenture that will rest on pre-existing retentive elements. Transfer matrices are set in place
on the involved retentive elements and picked up in the impression. This makes it possible to
incorporate retentive element analogs in the working cast. In this situation also, a custom tray
is formed similar to those used for complete dentures. The tray must not touch the root
copings and the transfer matrices.
Areas of the ridge that are undercut relative to the path of insertion of the retentive elements
should not be included in the impression.
Jaw relation records:
Recording maxillomandibular relation for an overdenture is no different than for making a
complete denture. Registration of the occlusal vertical dimension is followed by the
determination of the horizontal relations through intraoral and extraoral registrations using a
central bearing pin.The shape of the base for the occlusion rim must correspond to that of the
future overdenture, ie; it should not cover the facial marginal gingiva in the abutment regions.
This improves the stability of the rim. In a few selected cases the rim can be temporarily
fixed to the abutments for greater stability. Such situations are:- When there are dowelcopings and retentive elements already present from previous treatment.- When directly
mountable retentive elements have been inserted prior to registering jaw relations. With an
overdenture, erroneous registration of the horizontal relations will have its first destructive
effect on the abutment teeth. The displacement of the dentures when they occlude will result
in shearing or lifting forces on the abutments if they are fitted with retentive attachments.
This frequently leads to increased tooth mobility and, in extreme cases, the loss of the
abutment teeth.
Tooth arrangement:
Tooth arrangement in overdentures should strictly follow the rules of arrangement in
complete dentures. The basic considerations in establishing the occlusion for conventional
complete dentures are:
- The occluding rows of artificial teeth will provide optimum chewing efficiency.
- Functional stability of the prosthesis.
- Comfort in chewing without exerting injurious forces on the denture-bearing tissues or
adversely affecting esthetics or phonetics.
The dentures, which tip, slide or generate heavy horizontal forces during function, will
accelerate resorption of the ridges. Therefore the occlusion must be designed to minimize the
tipping and sliding movements when chewing forces are applied. In case of an overdenture,
part of the force of mastication is transmitted to, or absorbed by the periodontium of the
abutment teeth in direct proportion to how rigidly and retentively the denture is attached to
the abutments. Forces that causes tipping or displacement of the denture will push and tug
against the abutment teeth of an overdenture that has retentive attachments. This type of force
places the most stress on the periodontium and can contribute to an increase in tooth mobility.
Therefore the same occlusal concept used for complete dentures must also be used for
overdentures in order to minimize the non-physiologic effects of occlusal forces, The greater
the quantitative and qualitative loss of periodontium has occurred the more closely must the
rules be followed. They are:
- Position of artificial teeth with in the envelopes of action of tongue, cheeks and lips.
- Harmony between cuspal inclines and movement of mandible.
- Multilocal autonomous stabilizing contacts.
Incorrect occlusal form may not itself damage the periodontium but a poor oral hygiene,
improperly formed root copings and denture base add to this. Because one cannot be sure that
the patient maintains oral hygiene, the occlusion must be designed according to the abovementioned criteria for the sake of avoiding the traumatic effects. Moreover an over denture
may have to be converted in to conventional complete denture when remaining teeth are lost.
The less the existing prosthesis has to be modified, the easier it will be for the patient to adapt
to the new edentulous condition. If the occlusal form already complies with the requirements
for a complete denture, the corresponding reflex pathways and denture stability will have
already been established.
Final try-in:
As with a complete denture, the try in of waxed up- overdenture allows for evaluation and
adjustment of all the prosthetic parameters before the denture is completed. In this regard, the
following points must be observed:
- Vertical dimension, position of the occlusal plane, and occlusal form should not be
compromised by the use of construction elements. The criteria for complete dentures have
priority.
- The trial denture base should conform as closely as possible to the shape of the final denture
base, even around the abutment teeth. Facings must be ground to fit precisely on roots or root
copings. Only in this way can extension, functional stability, and the relation of the future
denture base to the lips and cheeks be judged.
- The lingual or palatal form of the base must be firmly established, including the areas
adjacent to the abutment teeth. The functionally crucial tongue space must not be
compromised during the subsequent fabrication procedures.
Mounting of the attachments:
The final selection and mounting of retentive elements are made after the evaluation of trial
denture. Along with the other considerations in selecting the suitable elements, the amount of
space available for an attachment can now be reliably evaluated. Construction elements must
always take a subordinate role to the prosthetic conditions. Facial and lingual indices of the
final wax up of the overdenture are made with plaster or silicone putty. With the lid of an
index it is possible for the first time to accurately judge the amount of space available for an
attachment. Only now is the final decision made concerning which attachment to use. Using
mounting rods in a surveyor or, the selected attachment components are mounted as near the
centers of the root copings as possible. The axis of an attachment should line up with axis of
the root as far as possible. Final checkup with the index is made to see the ample space
available for female recipient. Single retainers are preferred over bar attachments and small,
slender retentive elements may be selected instead of larger ones if tongue space is not to be
reduced.
Dowel copings:
Requirements:
- Not impede plaque control.
- Not encourage the accumulation of plaque.
- Not mechanically irritate the gingival.
- Not interfere with proper shaping of super structure.
- Have the greatest possible retention to the tooth.
- Be solid.
To meet these requirements the copings margins, axial surfaces, occlusal surface
and internal surface must possess certain characteristics.
a. Occlusal surface:
- Concave and meeting the axial surface at nearly a right angle.
- Where the margins are sublingual, meeting the axial surfaces .25mm above the gingiva.
Objectives:
- Accurate fit of the artificial tooth and its cast backing against coping.
- Sufficient thickness of the artificial tooth at the facial shoulder to minimize the risk of
fracture.
- No direct contact between super structure and gingiva.
b. Axial surface:
Slightly divergent occlusally.
Objectives:
- Restoration of original root contours.
- Avoidance of overcontouring, which would promote the accumulation of plaque and make
cleaning more difficult.
c. Coping margin:
- Supra gingival wherever possible.
- 0.5mm subgingival where esthetics dictates.
- Fine extensions thinly worked.
Objectives:
- No promotion of plaque accumulation
- No mechanical irritation of the gingiva.
d. Internal surface:
- Negative reproduction of the prepared surface of the abutment tooth.
- Surfaces nearly parallel to the axis of the dowel and to each other, in conjunction with an
occlusal box.
Objectives:
- In some types of ridges eg club shaped the path of insertion of the retentive attachments
dictates the extensions. The base must end at survey line or else, it may lead to food
entrapment.
- For a maxillary denture the posterior extension should not extend till vibrating line if
retentive attachments used.
Cast reinforcing frameworks:
These presence of mechanical attachments and interruption of the denture flange near
abutments reduce the cross sectional area of the denture and increase the danger of fracture.
This weakness cannot be compensated by increasing the thickness of the base by acrylic.
Even by using prefabricated metal reinforces can cause thickness of the base resulting in
muscular interferences. Hence custom-made reinforcement should be given especially with
cobalt chromium alloys. They have best physical properties that ensure high deformation
resistance in thin section of 0.5-1mm.
a. Circumdentally open design:
It is possible to keep the denture base completely away from the abutments only if the body
of the denture is comprised entirely of reinforcing framework in the abutment region.
Advantages:
- The base cannot traumatize the gingiva around the abutments.
- It is possible to clean the abutments with out removing the denture.
- Psychologically, the minimal extension of the base with its fixed prosthesis like elegance is
an advantage.
Disadvantages:
- The fabrication is technically very complex.
- The risk of fracture is greater especially when adequate thickness is impossible because of
restricted space or when excessive loads are encountered such as during bruxism.
- The possibilities of modifying and adding are limited when the abutment teeth are lost.
Indications:
Abundant space over the abutment and a good prognosis for the remaining roots.
b. Facially and Proximally open design:
Overdentures that are open facially and proximally have enough rigidity only if they
incorporate custom cast reinforcing frameworks.
Advantages:
- Relatively less involved technical construction.
- Reduced risk of fracture.
- Ease of modification when abutment is lost.
- Seldom causes any problem with phonation.
Disadvantage:
- Increased difficulty in cleaning the abutment teeth and root copings, especially the proximal
and lingual surfaces.
- Greater extension of the denture base hence psychological discomfort.
- The exposed metal parts in the inner surface of the framework are difficult to reline.
Indications:
- Poor prognosis for the abutments
- Unfavorable spatial relations around the abutments.
- Speech problems, and extensive tissue loss in the anterior region that must be compensated
with the base.
Placement or insertion:
The following points must be checked prior to insertion:
Alignment of the denture base with root copings.
Small misalignments are caused due to the polymerization shrinkage between the root coping
and their contact surfaces, in the denture base. This leads to premature contact between the
base and coping and resultant rocking. The attachments will not fit together accurately. These
problems have to be relieved.
Occlusion:
The resulting changes in occlusion due to polymerization shrinkage should be corrected.
Border extensions:
The extension of the base as established at wax try in may change during finishing of the
denture, either inadvertently or for technical reasons, and must be evaluated during
placement. Checking of extensions carried out before any retentive elements are cemented.
After the above things are evaluated and correction are made dowel copings with retentive
elements may be permanently cement. The denture is inserted in mouth and checked for final
occlusal discrepancies. This should be corrected and the patient is thought to master the skill
of insertion and removal before leaving the clinic.
Maintenance and follow up care:
a. Oral hygiene instruction:
Motivating and instructing the patient in the care of the overdenture is of the at most
importance for its long-term success. Periodontal treatment and careful attention to the details
of design and construction are rational only if rapid periodontal or carious breakdown of the
abutment teeth can be decreased or preserved by proper oral hygiene.
- A normal toothbrush with moderately hard, rounded, synthetic bristles is used for
preliminary cleaning of the abutments.
- Toothbrush takes care of only the occlusal surface of the coping and the gingiva hence it
must be followed with a single fluted interdental brush to cleanse the axial surfaces of the
coping and the sulcus.
Unfortunately this is not always accomplished especially with older patients due to: - Oral hygiene is considered increasingly unimportant by many elderly people.
- Changing eating habits and reduced flow of saliva favors accumulation of plaque.
- Extreme difficulty in cleaning the construction element.
- Diminishing vision in increasing age.
- Longer time to function and decreased learning efficiency.
b. Care of the abutment teeth:
Accomplished by regular tooth brushing followed by interdental brushing of the abutment
teeth, both with and without root copings and the marginal gingiva. Dental floss is used only
to clean under interdental bars and between root copings that are soldered together.
If mechanical cleaning is impossible or inadequate, chemical aids can be used.
- Fluoride in gel form can be applied directly to the exposed roots or indirectly by placing, it
inside the denture over the abutments. It can also be used (.025%) as a daily rinse.
- Chlorhexidine used in a .1-.2 % solution as daily rinse or in a gel to be applied inside the
denture base or the female attachment.
The patient must be informed about the side effects associated with prolonged use, such as
changes in taste sensation, burning mouth, mucosal desquamation, and staining.
c. Care of the overdenture:
The overdenture is mechanically cleansed with an ordinary toothbrush or special denture
brush with toothpastes with low abrasives and non-alkaline soaps. Denture cleansers can be
used as an adjunct with this. (Peroxide based). To disinfect the denture from candidiasis it is
treated with .2% chlorhexidine solution or salicylate (.05%) for 10-15 minutes every day.
d. Recall visits and Examinations:
Patient recall for early detection of periodontal and carious lesions is extremely important for
overdenture patients. The first recall is scheduled for 3 months after placement of the
prosthesis. After that when oral hygiene is optimum, periodontal resistance is good and no
problems with prosthetic interactions, the interval can be as great as 12 months; in all other
cases, a recall every 6 months should be adequate.
The following points should be checked during recall visits and appropriate treatment should
be given together with oral hygiene instructions.
- Root caries detection through visual probing and radiographs.
- Periodontal conditions.
- Patients cleaning.
- Pocket depths.
- Tooth mobility.
- Width of attached gingiva.
- Degree of inflammation of marginal gingiva.
- Radiographic evaluation.
- Evaluation of occlusion.
- Evaluation of fit of the denture.
- Ridge resorption and associated rocking.
- Fractures of the overdenture base due to
- Casting defects.
- Inadequate thickness
- Excessive misdirected forces
- Damage to the attachments:
- Due to wear
- Contact with opposing teeth
Conversion of an overdenture to a complete denture:
Over denture, which has only the facial and proximal surfaces open, can easily be corrected
by relining with autopolymerizing resin either directly or indirectly. But the circumdental
design involves problems due to a great deal of exposed framework. A second stage
impression will be necessary if extensive denture base to be added facially and lingually. The
metal work in the former anterior abutment regions will not give necessary retention hence
retention loops should be made on to the framework for acrylic retention.
Implant overdentures:
Definition:
assessed. Bone mapping done to find out the mucosal thickness and contours of maxillary
bone.
2. Panoramic radiographs:
Are made to scout anatomical structures, possible pathological findings, and to access bone
density. Templates with metallic markers of known diameter may be used to measure the
alveolar bone hight on radiographs and to predetermine a favourable location of the implants
with respect to the topography of the residual ridge and anatomic landmarks such as
mandibular nerve or the maxillary sinus. Cephalometric tracing used for determining
faciolingual dimensions plus the lingual aspect of the residual mandibular bone and the shape
of the maxillary ridge. CT Scans are also used.
3. Examination of existing dentures:
To decide whether they are adequate for temporary use during the healing phase is important.
The transmucosal aspect of Bonefit- ITI implants during the healing phase may pose a
problem, because to prevent inadvertent loading in patients who are not willing to remain
without denture during healing period may not be controlled. New dentures should be made
prior to surgery. Old dentures are examined for esthetic merits plus the presence of loss of
vertical dimensions of occlusion.
4. The number of implants placed:
The number of implants placed for overdenture support differs in the mandible and the
maxilla and is influenced by residual jaw morphology. Maxillary overdenture requires the
placement of a minimum of three to four implants usually joined with connecting bars. Two
implants in selected cases can be placed but contraindicated in loose trabecular bone, and
curved shape of the ridge. The implant length should be minimum of 10mm or longer.
Several implants should be preferred when bone sites preclude placement of 10mm or longer
fixures. In maxillary ridge short bar segments connecting multiple 1mplant units are preferred
to follow the ridges without encroaching palatal space. Mandibular overdenture will have
adequate support by two implants. When the anterior ridge is straight or slightly curved, a bar
is used to connect which is parallel to the patients arbitrary hinge axis. The interimplant
distance should exceed 12 mm to provide sufficient space to accommodate retentive
components. When curvature of mandibular ridge is more, then placement of more than two
implants are recommended and then connected with bars there by converting it to entirely
implant supported. Patients with advanced mandibular ridge resorption will have to be given
shorter implants hence more than two implants have to be given for adequate support.
Surgical procedure and osseointegration:
The surgical protocol is well documented and aims at placing titanium tooth analogs into
predetermined host sites to fulfill prosthodontic design objectives. A surgical template is used
to ensure optimal alignment and location of the implants. The patient premedicated and
surgery carried out atraumatically. Postoperative care is composed of standard analgesia plus
use of ice packs and chlorhexidine mouthwash. After 7-10 days sutures removed depending
on the process of wound healing of the soft tissue. The denture is relined and given to patient.
Incase of single stage surgery, the area corresponding to the implant site is relieved in denture
and relined. The patient is motivated on oral hygiene both mechanical and chemical and the
relining is done at regular intervals. Healing phase is about 3-4 month, for mandibular
implants and 6 months for maxillary implants.
Denture design:
The design and fabrication of implant-supported overdentures follow the principles of
fabricating complete dentures. It should have well fitting base and properly extended flanges.
The denture base can be reduced slightly in its extensions when desired due to the immobility
of the denture or incase patient object prosthesis bulk.
Tooth Set up:
The rules should closely follow that of complete denture and not to interfere with protection
of implant from over loading.
Clinical and laboratory procedures:
The preliminary impression is made in stock trays and alginate. The custom acrylic tray
requires opening for accommodating transfer copings placed on implants. The final
impression is made and removed and laboratory implant analoges are connected to the
transfer copings. The master cast is poured with the analogues insitu. The subsequent steps
are similar to the conventional complete dentures. An exception is the inclusion of retentive
elements in the fitting surface of the prosthesis. The bar is cast soldered to the prosthetic
copings and tried in the mouth. The same orientation index is used to cast the metal
framework, necessary after final soldering of the bar. The female part of the bar clip should
never be soldered to the framework.
Guidelines for selecting retentive anchoring devices:
Consideration:
1. No of supporting implants and their distribution over the ridge.
2. Type and size of the single attachment or bars.
3. Length of the bar segments.
4. Number of female retainers.
5. Degree of atrophy of the residual ridge.
A resilient retention mechanism is widely recommended for anchorage of overdentures to
implants based on the assumption that this will protect implants from overload.
- Patients with frequent complaint of lack of retention when single attachment is used.
- Recommended for maxillary overdenture atrophic residual ridges in the mandible and
mandibles with more than two implants due of pronounce ridge curvature.
Maintenance care:
Although periimplant tissues do not appear to be as vulnerable to plaque byproducts as
periodontal tissues, nuisance variety responses may develop and should off course be
avoided. The objective of regular recalls for all overdenture patients is to maintain the health
of the oral tissues, particularly the periimplant tissues, and to check the denture with regards
to its fit, stability and occlusion. Growth of hyperplastic soft tissues around implants are
particularly underneath the bars has been recorded. It has to be corrected by vigorous
massage and surgical excision of the overgrowth. Rest all procedures are similar to those
mentioned in tooth supported over denture.
Discussion:
Teeth may be lost because of trauma, caries, periodontal disease, congenital defects and
iatrogenic treatment. Once the teeth are lost, the residual alveolar bone undergoes a period of
accelerated resorption there after. The concept of overdentures helped to retain some natural
teeth, which helped to bring down the rate of bone loss and increase the retention and
stability of the complete denture. This can also boost up the satisfaction of patient.
Overdentures are designed to distribute the masticatory load between the edentulous ridge
and the abutments. Tooth supported overdenture transfers occlusal forces to the alveolar bone
through the periodontal ligament of the retained roots. Proprioceptive feed back from the
periodontal ligament to the muscles of mastication may act to prevent occlusal over load and
there by prevent bone resorption because of the excessive forces. The relationship of
complete dentures to osseointegrated implants resembles the clinical situation of overdentures
retained by natural tooth roots and copings. Inspite of lack of a periodontal ligament,
periodontal receptors appear to be adequately compensated for in the resultant sensory, motor
feed back system via receptors in the oral mucosa, bone, temporomandibular joint, and
muscle spindles. It seems that the masticatory ability of implant-supported overdentures is
greater importance of oral function than the presence of a periodontal ligament itself. Patients
with implant report high functional satisfaction and subjective feeling of sense of having
natural teeth. Although tooth and implant abutment attachment mechanism differ, their
prosthetic role is identical. They provide enhanced prosthesis retention and stability and their
influence on adjacent bone levels appears to be smaller. Studies have shown that mandibular
overdentures retained by implants maintain bone height, in the area where it is located.
However resorption of the posterior residual ridge was increased when compared with similar
sites in patients treated with implant-supported prosthesis. It seems therefore prudent to
suggest that younger edentulous patients would benefit most from fixed prosthesis supported
by implants where as, overdentures should be recommended routinely for elderly edentulous
patients.
Comparative studies have been conducted taking into consideration the advantages and
disadvantages of tooth supported over dentures, conventional complete dentures and implant
supported over dentures.
- Pacer and Bowman (1975) compared occlusal force discrimination between complete
denture and overdenture wearers. They found that the overdenture patient posses more typical
sensory function i.e. closer to the natural teeth than a complete denture wearer
- Shannon and Crown 1975 have concluded through their investigation that frequent
application of low-concentration stannous fluoride to exposed dentin as a homecare
mouthwash.
- Crum and Rooney in a five-year study (1978) compared bone loss between patients with
conventional dentures and patients with overdentures. They found out that by retaining the
mandibular canines in the use of an overdenture, the resorption of the alveolar bone
surrounding these were reduced by 8 times. In addition the alveolar bone between the canines
and posterior to it were also preserved in both height and width.
- Toolson and smith (1978) in a 2 year longitudinal study has shown that fluoride therapy had
markedly reduced the caries incidence.
- Kroone et al 1979 found out that the temperatures in the gingival sulcus are significantly
higher under closed bases that cover the gingival margin than with open designs.
- Bissada et al found that this gingival reaction was always most severe where the denture
base covered the gingival margin and least severe in uncovered gingival margins. The
reactions were more pronounced under acrylic resin than under polished metal.
- Freidline and wear 1981 described a technique to block out a bony labial under at through
the use of free soft tissue palatal graft.
- Bolender smith and Toolson 1984 said that bare root surfaces should not be left opposing
natural teeth. They saw incidence of longitudinal root fracture is high.
- Morrow 1984 opposing hare surfaces should not be used on a long term basis because,
dentin to dentin contact can produce high rate of wear.
- Renner et al in 1984 conducted a four-year study and concluded that 50 percent of the roots
that were used as overdenture abutments remained immobile. Also 25 percent of the roots
that were mobile initially became immobile and 25 percent of the roots that were mobile
became less mobile.
- Kunder and Palla 1988 stated that circumdentally open design helps in cleansing of the
abutment, which is often having small copings.
- A study conducted by Timo et al described salivary fluoride levels after topical fluoride
application was found to significantly reduce caries susceptibility in overdenture abutments.
- A study conducted by Thayer and Caputo concluded that the best design for uniform
distribution of occlusal forces of remaining structures was the conventional amalgam plug
design, but this provided less effective retention and stability than other designs.
Conclusion:
The concept of the overdenture covers a number of possible solutions for patients with nearly
all the teeth missing. Common to all is the combined periodontal and mucosal support and the
similarity of the external form to that of complete dentures. The benefits of the
comprehensive preventive dentistry are becoming available to more people in many
countries. This raises, the question of whether, in the future, overdenture will still be part of
the armamentarium of reconstructive dentistry. At the present time, the answer is an
unequivocal Yes. Because of peoples changing attitudes toward their health, improved
therapeutic methods and increasing life expectancy, we can predict that more people will
require denture at an advancing stage of their life.
References:
Textbook references:
1. Zarb, Bolender, Carlsson. Bouchers prosthodontic treatment for edentulous
patients. 11th ed. Mosby- Year Book, Inc; 1997.
2. Sheldon Winkler. Essentials of complete denture prosthodontics. 2nd ed. Ishiyaku
Euro America, inc; 1996.
3. Arthur O. Rahn, Charles M. Heartwell, Jr. Textbook of complete dentures. 5th ed.
Lea & Febiger, 1993.
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