Implant supported overdenture

implant supported overdenture in brief

1. IMPLANT SUPPORTED OVERDENTURE Dr. JISSA SUNNY 3 rd YEAR P.G

2. CONTENTS Introduction Definitions Prosthetic Options Advantages Of OD Disadvantages Of OD Implant OD V/S Fixed Prosthesis Advantages Prosthesis Movement OD Attachments OD Treatment Options- Mandible/Maxilla All On 4 Implants Review Of Literature Conclusion References

3. INTRODUCTION The consequences of total tooth loss

4. Treatment with conventional complete denture is successful when residual alveolar ridges are favorable . But such treatment will not be successful when, Residual alveolar ridges are resorbed Movement of denture leads to discomfort, pain, poor function. The patients with poor neuromuscular control. These difficulties can be overcome by the use of osseointegrated implants to support, retain and stabilize dentures.

5. DEFINITION 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; a dental prosthesis that covers and is partially supported by natural teeth, natural tooth roots, and/or dental implants. An overdenture is defined as a removable prosthesis that covers the entire occlusal surface of a root or implant ( Harold W Preiskel )

6. PROSTHETIC OPTIONS

7. ADVANTAGES OF IMPLANT SUPPORTED PROSTHESIS Minimum/ prevents anterior bone loss Improved esthetics Improved stability Improved occlusion Decrease in soft tissue abrasions Improved chewing efficiency and force Improved retention Improved support Improved speech Reduced prosthesis size Improved maxillofacial prostheses

8. DISADVANTAGES OF IMPLANT SUPPORTED PROSTHESIS psychological Greater abutment crown height space is required. Long term maintenance Continued posterior bone loss Food impaction Movement (RP-5)

9. CLASSIFICATION OF PROSTHESIS MOVEMENT (Misch 1985) PM0 No movement of prosthesis, requires implant support similar to fixed prosthesis PM2 Prosthesis with hinge motion PM3 Prosthesis with hinge and apical motion PM4 Allows movement in four directions PM6 All ranges of prosthesis movement

10. OVERDENTURE OPTIONS

11. OVERDENTURE OPTION 1 Patient Selection Criteria Opposing a maxillary full denture • Anatomical conditions are good to excellent •  Posterior ridge form is an inverted U shape. •  Patient’s needs and desires are minimal •  Edentulous ridge, with a tapered dentate arch form •  Cost is the primary factor. •  Additional implants will be inserted within 3 years.

12. 2 implants – B and D positions The implants remain independent of each other and are not connected with a superstructure. The most common type of attachment used – O-ring or Locator design. The IOD must be RP-5 A E B D

13. The implants should be perpendicular to the occlusal plane. The hinge rotation should be at 90 degrees to the rotation path. The two independent implants should be positioned at the same occlusal height. The implants should be equal distance off the midline.

14. ADVANTAGES Reduced cost. Hygiene procedures also are facilitated DISADVANTAGES Relatively poor implant support and stability Future bone loss is not reduced Increase in prosthetic maintenance appointments Wear of attachments

15. OVERDENTURE OPTION 2 PATIENT SELECTION CRITERIA Opposing arch is a maxillary denture.  Anatomical conditions are good to excellent  Posterior ridge forms an inverted U shape.  Patient’s need and desires are minimal Patient can afford new prosthesis and connecting bar. Additional implants will not be inserted for more than 3 years. Low patient force factors (e.g., parafunction)

16. The implants are positioned in locations B and D But they are splinted together with a superstructure bar without any distal cantilever The ideal distance between the implants is in the 14 to 16mm range

17. Disadvantages of A and E Splinted Implants Implants are joined with anterior curved bar. Greater bar flexibility (nine times the B and D positions) Increased screw loosening Increased moment forces on anterior aspect of prosthesis Implants joined with straight bar are lingual to ridge. Difficulty with speech Anterior tipping of overdenture Five times greater bar flexure than B and D positions Bite force is higher than for B and D positions. Greater lateral load from prosthesis to implants.

18. OVERDENTURE OPTION 3 PATIENT SELECTION CRITERIA Opposing arch is a maxillary denture Anatomical conditions moderate to excellent Posterior ridge forms inverted U shape Patient’s needs and desires require improved retention, support, and stability Cost a moderate factor Patient may have moderate force factors

19. Three root form implants are placed in the A, C, and E positions A superstructure bar connects the implants but with no distal cantilever

20. Advantages of Splinted A, C, and E Implants Six 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 One implant failure still provides adequate abutment support

21. OVERDENTURE OPTION 4 Four implants are placed in the A, B, D, and E positions. Patient has opposing maxillary teeth or c–h anterior bone volume with CHS greater than 15 mm. Distal cantilever up to 10 mm on each side if the stress factors are low.

22. PATIENT SELECTION CRITERIA 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 Unfavourable anatomy for complete dentures Problems with function and stability Posterior sore spots Opposing natural teeth C–h bone volume Unfavourable force

23. OVERDENTURE OPTION 5 Five implants are inserted in the A, B, C, D, and E positions. The superstructure is usually cantilevered distally up to two times the A-P spread and averages 15 mm, which places it under the first molar area

24. 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 Moderate to poor posterior anatomy Lack of retention and stability Soft tissue abrasion Speech difficulties More demanding patient type PATIENT SELECTION CRITERIA

25. MAXILLARY OVERDENTURE Only two treatment options are available. Independent implants are not an option because bone quality and force direction are severely compromised. Cantilever bars are usually not recommended The crown height space: 15 mm-anterior space 12 mm- posterior space

26. ADVANTAGES OF RP4 MAX OD Ability to provide a flange for maxillary lip support The improved sulcular hygiene Reduced laboratory fee If the maxillary lip requires additional support, two options are available: A bone or soft tissue graft to the premaxilla is performed before or in conjunction with implant insertion or at uncovery for a fixed implant prosthesis. A maxillary IOD is fabricated with a labial flange on the prosthesis.

27. TREATMENT OPTIONS RP-5 prosthesis: four to six implants in three to five arch positions RP-4 prosthesis: six to 10 implants in all five arch positions

28. Posterior implants (premolar and molar) without implant support in the canine regions are sometimes connected with a full-arch bar for a maxillary overdenture

29. Placement of implants in each posterior quadrant (no canine position) with independent bar segments and an over- denture . The prosthesis rocks forward and up every time the patient bites into food or the mandible moves into excursions. Do not resist the lateral forces as well. Often the attachments repeatedly need replacement And all the implants on one side of the arch may fail

30. OPTION 1: MAXILLARY RP-5 IMPLANT OVERDENTURE Four to six implants supporting a RP-5 prosthesis, of which three are usually positioned in the premaxilla. Implants should be at least 9 mm in length and 3.5 mm in body diameter. Implant positions- bilateral canine regions and at least one central incisor position. Other secondary implants -first or second premolar region.

31. Six implants are often indicated for a RP-5 prosthesis when force factors are greater. The implants are always splinted together with a rigid bar. No distal cantilever, and the bar design should follow the dental arch form. The prosthesis should have at least two directions of movement. A Dolder clip or O-ring

32. The maxillary RP-5 IOD is designed exactly as a complete denture with fully extended palate and flanges. Advantages Retention and stability from the implants. Posterior support is obtained from the soft tissue. Maintenance of the premaxillary bone because of the implant stimulation.

33. OPTION 2: MAXILLARY RP-4 IMPLANT OD 6 to 10 implants, which is rigid during function. Bilateral canines and distal half of the first molar positions Additional posterior implants are located bilaterally in the pre- molar position, preferably the second premolar site. In addition, at least one anterior implant between the canines often is the anterior implant often may be placed in the incisive canal.

34. The six to 10 implants are splinted together around the arch with a rigid bar. Four or more attachments are usually positioned around the arch. Palatal coverage is maintained. Occlusal scheme – centric occlusion around the arch and only anterior contact during mandibular excursions

35. ALL ON 4 IMPLANTS (Paulo Malo) Allows the rehabilitation of edentulous jaws without bone graft in one surgical step through the placement of four implants, optimizing the available bone. The four implants are placed: two posteriorly tilted between 30° and 45° and two anteriorly axial, well anchorated achieving a primary stability of at least 30Ncm. Indicated with a minimum bone width of 5mm and minimum bone height of 10mm from canine to canine in maxilla and 8mm in mandible

36. Advantages No anatomical structures interference. Angled implant reduces cantilevering. Immediately provisional bridge can be fabricated Teeth in a day No ill fitting dentures any more Feel and function just like natural teeth

37. Disadvantages Free hand arbitrary surgical placement of implant is not always possible Length of cantilever in the prosthesis cannot be extended beyond the limit. It is very technique sensitive and requires elaborate pre-surgical preparation

38. ALL ON 6 DENTAL IMPLANTS The standard of care for full arch rehabilitation with dental implants when the quality and the quantity of the alveolar jaw bone is excellent. By placing 6 implants in each jaw, molar to molar rehabilitation is possible giving a minimum of 12 crowns.

39. TREFOIL - ALL ON 3 DENTAL IMPLANTS Complete lower jaw rehabilitation First pre-manufactured bar with a passive fit Nobel Biocare It enables unique fixation mechanism with self-adjusting joints. Definitive teeth on the day of surgery

40. ATTACHMENTS USED TO RETAIN OVERDENTURE ( Since 1960s) Pillars of implant supported OD. To enhance the retention, the stability and support of overdentures together with the implants, increases longevity. An overdenture attachment permits movement during function and removal from the mouth. The attachment should offer the possibility of controlling the degree of retention.

41. According to retentive means Frictional Mechanical combination Magnetic attachments Attachments based on resiliency Rigid non resilient attachment Restricted vertical resilient attachment Hinge resilient attachment Combination resilient attachment Rotary resilient attachment Universal resilient attachment

42. Stud attachments Resilient Non resilient Ball attachments O- ring, ERA system & Spheroflex Bars Dolder & Hader Locator attachment system Zaag attachment system OT equator Hybrid bar system

43. O - RING ATTACHMENT SYSTEM Elastomeric retentive attachments Doughnut shaped Consisting of a ball and a socket Has the ability to bend with resistance and return back to their original shape. O-ring abutments are available in different designs and sizes, with gingival cuffs of varying lengths. Placed slightly supragingival , with approximately 1 mm of the cuff protruding above the tissue.

44. Metal Encapsulator A metal or plastic encapsulator permits the easy replacement of the O-ring after wearing or damage. This eliminates the need for chairside cold curing of a new attachment in place. Virtually every O-ring encapsulator has an undercut region that houses the O-ring, called the internal cavity. The overall size of the encapsulator is larger than the O-ring

45. The O-ring post usually is made of machined titanium alloy. The post has a head, neck, and body. The head is wider than the neck and the O-ring is compressed over the head during insertion. Typically three sizes of O-rings are used in implant prostheses.

46. O-ring hardness is measured with a durometer. The resultant numerical rating of hardness ranges from 0 to 100 in a Shore A Scale. The softest O-rings are usually 30 to 40, and the hardest are 80 to 90. Color - most O-rings are black. O ring material - silicone, nitrile, fluorocarbon, and ethylene-propylene.

47. ADVANTAGES Simplicity in design Good retention Ease of use and maintenance Low cost Varying degrees of retention Possible elimination of a superstructure. FAILURE OF O-RINGS Due to the combined adverse effects of stress and environmental factors Incorrect o-ring size Unsatisfactory laboratory technique Damage during insertion Poor maintenance.

48. ERA SYSTEM Resilient precision OD attachment. Universal hinge with vertical movement 4 color codes Types (based on interocclusal distance) Standard Micro

49. SPHEROFLEX Self paralleling combination of titanium implant abutment and ball attachment Compatible with any implant system. Diameter of 2.5 mm Flexible to 7.5 in any direction. Designed to correct angulation problems up to 43 ° between two implant abutments .

50. LOCATOR ATTACHMENT Zest anchors, escondido , CA, USA) in 2001. Classified as universal hinge. Dual retention Advantages Can be used in cases of limited inter-arch space Can accommodate inter implant angulations up to 40°. Disadvantages They cannot be used in cases where rigid restoration is required Regular replacement of male nylon part due to constant wear and tear.

51. O T EQUATOR Rhein83 . The newest line of low profile castable and direct implant overdenture attachments. Low vertical profile - 2.1 mm and diameter of 4.4 mm Can be used when vertical space limitations are a consideration. Available in two versions, castable and prefabricated titanium abutments Compatible with any implant system Manufactured with cuff heights from .5 mm to 7 mm. Female caps are retained by means of a stainless steel housing ranging in four levels of retention

52. BAR AND CLIP TYPE ATTACHMENTS Bar joint (resilient) Single sleeve Multiple sleeves Bar unit (non-resilient). Provides good retention and stability. The ideal length of a single bar should be minimum of 20-22 mm to accommodate two clips. 

53. DISDVANTAGES Vertical dislodgement Fabrication is technique sensitive Higher cost Maintenance of hygiene is difficult Frequent loosening of retentive clips. 

54. HADER BAR AND CLIP Helmut Hader (1960s) Hader EDS system. Donnel , and Staubli in 1992 Three different retention strengths and a 20-degree clip rotation to improve flexibility. Round superior aspect and an apron toward the tissue below. The total height may be as low as 4 mm Hinge resilient attachment Provides mechanical snap retention.

55. DOLDER BAR They are classified as combination resilient attachments Due to its adjustability, it is easy to control the retention provided by the bar. It is best-indicated when patient has adequate inter-arch space, and minimum resiliency and maximum retention is required.

56. MAGNETIC ATTACHMENTS Made up of mainly aluminum -nickel-cobalt metals. Classified as universally resilient attachments ADVANTAGES Shorter so can be used in cases of reduced inter-arch space. They can be used in moderately nonparallel abutments. Laboratory procedures associated with castings are not necessary. They are more resilient and allow for free movement of the prosthesis.

57. DISADVANTAGES Streaking- MRI  Least retention  Heating during sterilization leads to decrease in retentive forces in long-term use.  Get corroded in saliva on long-term use

58. TELESCOPIC CROWNS Used to connect teeth to overdenture, but their use as implant supported overdenture is limited. They provide rigid attachment hence can be used for immediate loading. ADVANTAGES Excellent immobilization of the restoration Flexibility of design Easy maintenance of oral hygiene Can also be used on angulated abutments. DISADVANTAGE They require adequate inter-arch space

59. The SYNCONE SYSTEM is an innovative type of telescopic attachments which is mainly indicated in immediate loading cases The syncone system has prefabricated titanium abutments and corresponding gold retainers which come in 4-6° taper. The abutments can correct angulations by 15° and can rotate 360° for precise alignment. Provides excellent retention Retention improves over time due to the settling phenomena. 

60. A Functional Impression Technique For An Implant-supported Overdenture: A Clinical Report Uludag ̆ B1, Sahin V. J Oral Implantol . 2006;32(1):41-3. A 50-year-old woman - poor retention of her mandibular complete denture Initial clinical examination - the lack of retention of the mandibular denture due to the resorption of the alveolar ridges Treatment plan - placement of 2 implants in the interforaminal region to provide retention for the mandibular denture.

61. CIRCUMFERENTIAL BONE LOSS AROUND SPLINTED AND NON-SPLINTED IMMEDIATELY LOADED IMPLANTS RETAINING MANDIBULAR OVERDENTURES: A RANDOMIZED CONTROLLED CLINICAL TRIAL USING CONE BEAM COMPUTED TOMOGRAPHY Elsyad MA Khirallah AS. J Prosthest Dent 2016;116(5):741-8 1 04

62. No significant difference in the survival rate VBL and HBLo increased significantly at T3 compared with T1 for both groups. At T1 and T3, BA had more significant VBL than RA The B site recorded the highest VBL The M and D sites recorded the highest HBLo Conclusion :- Two non splinted immediately loaded implants retaining mandibular overdentures were associated with significantly higher vertical and horizontal circumferential bone loss than those associated with splinted implants after a follow-up of 3 years.

63. CONCLUSION Implant-supported overdenture proves to be a better treatment alternative to the conventional denture. Hence, this treatment modality should be practiced whenever indicated. It will preserve hard and soft tissues of the patient and give psychological relief to the patient.

64. REFERENCES Misch,_carl_e._ Dental_implant_prosthetics Prasad D K, Prasad D A, Buch M. Selection Of Attachment Systems In Fabricating An Implant Supported Overdenture. J Dent Implant 2014;4:176-81. Mukherjee S, Banerjee S, Chatterjeed , Deb S, Swamy Sn, Mukherjee A. All-on-four Concept In Dental Implants. Int J Oral Care Res 2018;6(2):s77-79 All On 4 The Basics. Anandh Et Al.Biomed . & Pharmacol . J., Vol. 8( spl . Edn .), 609-612 Circumferential Bone Loss Around Splinted And Non-splinted Immediately Loaded Implants Retaining Mandibular Overdentures: A Randomized Controlled Clinical Trial Using Cbct . Elsyad Ma Khirallah As. J Prosthest Dent 2016;116(5):741-8 104 A Functional Impression Technique For An Implant-supported Overdenture: A Clinical Report Uludag ̆ B1, Sahin V. J Oral Implantol . 2006;32(1):41-3.