TOOTH SUPPORTED OVERDENTURE

TOOTH SUPPORTED OVERDENTURE

1. TOOTH SUPPORTED OVERDENTURE Dr. Shari.S.R 2 ND YR MDS GDC TVM

2. Introduction . Conventional dentures are commonly fabricated in dental practice. But in some situations, dentures other than conventional dentures can be used. Such types of dentures are called as unconventional dentures.

3. GPT-8 (2005) , Overdenture is defined as a removable partial denture or a complete denture that covers and rests on one or more remaining natural teeth, the roots of natural teeth, and/or dental implants DEFINITION

4. Tooth supported denture Overlay denture/ Onlay denture/ Inlay denture Telescopic denture Superimposed prosthesis Hybrid denture Biological denture Coping prosthesis TOOTH SUPPORTED OVER DENTURE SYNONYMS

5. Tooth supported overdenture Heartwell , A tooth supported overdenture is a dental prosthesis that replaces lost or missing natural dentition and associated structures of the maxilla and/or mandible and receives partial support and stability from one or more modified natural teeth

6. LEDGER (1856) prescribed a prosthesis resembling an over denture. His restorations were referred to as plates covering fangs (teeth) EVANS(1888) described a method for using roots to retain restorations after intentional devitalisation of the roots. ESSIG(1896) described a telescopic ‐ like coping

7. 1906–WILLIAM 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. 1916 ‐ PEESO was employing removable telescopic crowns . Later on, the bar type of construction was developed.

8. Occlusal forces are transmitted on oblique fibres and dissipated as tension resulting in osteoblastic respose Heartwell 4 th Ed page 503

9. 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 Preiskel HW. Prefabricated attachments for compete overlay dentures. Br Dent J 1967;123:161.

10. ADVANTAGES

11. Ridge preservation Proprioception Superior patients acceptance Open palate possible Definitive vertical stop for denture base Support, stability and retention are improved Less trauma to supporting tissues Fever post insertion problems than conventional complete denture Conversion to complete denture Increased biting force (Pacer FJ, Bowman DC. Occlusal force discrimination bydenture patients. J Prosthet Dent 1975;33:602–9) P s y ch ological Advantage

12. DISADVANTAGES

13. Caries susceptibility. Periodontal disease around abutments Bony undercuts. ( due to limited path of insertion) Encroachment of inter occlusal distance. Meticulous oral hygiene is required. Time consuming. Technique sensitive.

14. INDICATIONS

15. Patient with badly worn teeth. Pt. with few natural remaining teeth. Poor prognosis for routine complete denture. Congenital or acquired intra oral defects. Mandibular arch where loss of bone is more rapid Edentulous maxilla opposing intact mandibular dentition. Post traumatic or post surgical cases. Severe attrition and loss of vertical dimension. Young patient. Cleft palate causing large free way space. Hypodontia Tooth wear cases

16. CONTRAINDICATIONS

17. High caries index. Poor oral hygiene. Poor prognosis of abutment. Reduced inter-arch space. Undercuts. Sufficient attached gingiva not present. Where endo and perio treatment can not be performed satisfactorily. Grade III mobility

18. Classification

19. ACCORDING TO METHOD OF ABUTMENT PREPARATION (Heartwell)

20. O V E R D EN T U RE Tooth supported Implant supported Non Coping Coping Attachments Short Long Stud Bar M a gne ts

21. BASED ON TYPE OF OVER DENTURE (Brewer and Morrow) IMMEDIATE TRANSITIONAL / INTERUPT DENTURE REMOTE / P E R MA N E N T DENTURE

22. Immediate over denture It enhances patients ability and adaptability to wear dentures constructed for insertion immediately after the removal of natural teeth. With good oral hygiene and regular professional supervision an immediate overdenture may have a long life. .

23. Sometimes, it can be a prognostic aid before a more comprehensive overdenture procedure . If prognosis is poor and response to treatment is poor an immediate overdenture can be converted into a serviceable complete denture

24. Interim over denture Used for patients in transition or preparation phase until permanent overdenture constructed Patient old partial denture can be modified & used by extending the denture and add new artificial teeth using self cure acrylic resin

25. Advantages: Less expensive Smooth transition Minimal interference with function and appearance Disadvantages Border extension, esthetics, occlusion, support and stability of the R.P.D. often are inadequate, particularly after many years of use, making satisfactory conversion difficult. Weaker overdenture Therefore, the converted prosthesis is considered as interim or temporary overdenture, to be replaced by a definitive prosthesis.

26. Remote or Definitive over denture Conventional complete over denture constructed over one or more abutment teeth Could be made entirely of acrylic resin or in conjunction with metal bases - usually placed on well healed ridges -usually after a period of satisfactory experience with an interim overdenture

27. NON COPING ABUTMENTS Selected tooth abutments are reduced to a coronal height of 2 to 3 mm. and then contoured to a convex or dome shaped surface . Most teeth required endodontic therapy and in final step are prepared conservatively to receive an amalgam or composite type restoration.

28. Advantages Least expensive option More amenable to treatment, retreatment and modification in contingency situations

29. ABUTMENTS WITH COPINGS Coping is a cover for the exposed tooth surface Cast metal coping with a dome shaped surface and a chamber finish line at the gingival margin are fabricated and cemented. Short coping Medium coping Long coping

30. SHORT CAST COPINGS Short copings are 2-3 mm and normally require endodontic therapy because the required coronal root reduction would expose the pulp.

31. MEDIUM COPINGS

32. Long cast coping Long cast copings are normally 5-8 mm long, conservative reduction of coronal tooth structure is done. The end result is long ellipsoidal shaped coronal coping and a larger crown root ratio. Consequently, long cast coping require a greater level of osseous support.

33. ABUTMENT WITH ATTACHMENTS

34. Attachments are small precision devices. Objective is to improve retention of denture base. Most attachments are secured to abutment by a cast coping. Consists of two parts Male Female

35. Requirements for the Attachments Patients should have a low caries index . Perform proper home care Sound periodontal health Proper bone support

36. Rigid attachment Doesn’t allow movement of denture base Provide adequate retention May induce more torque on abutment Resilient attachment Allows some control of movements Induces less torque on abutments

37. 1. Stud attachment simplest of all attachments Consists of two parts The stud(male component) usually attached to metal coping cemented over prepared abutment Housing (female component) embedded in the fitting surface of over denture

38. Extra radicular stud attachment Male element projects from the root surface The stud is attached to the metal coping cemented over the prepared abutment, while the housing is embedded in the fitting surface of denture. Gerber Ceka Rotherman

39. Gerber anchor Readily replace able male or female attachments by unscrewing the worn unit.

40. Rothermann attachment Male part consists of groove Female part (housing) consists of C shaped ring which fits in deeper part of retaining groove

41. Ceka attachment Male part round with cementable titanium post Female part in titanium alloy with replaceable plastic part that is flexible and compressible (split vertically into four sections )

42. Other attachments of importance Ancrofix attachment Introfix attachment Schubiger attachment Quinlivan attachmentr

43. Intra radicular stud attachment The stud is attached to the fitting surface of the denture and the housing is incorporated in the abutment. Zest Anchor

44. Zest anchor system Female sleeve is cemented in post space made within the root Male portion consists of nylon

45. Advantage Disadvantage

46. The attachments should be aligned to each other Should be in line with the path of insertion of the denture. A divergence of 10 degree can be tolerated Significant divergence of roots or implants should be considered a contra indication for this approach.

47. One stud attachment on either side of the arch will suffice; the remaining roots can be covered by simple copings. Increasing the number of attachments does not necessarily increase retention; it may contribute to improved stability, but leads to a weaker structure. Two stud attachments on adjacent roots are unnecessary as it would complicate hygiene measures and also weaken the denture base

48. Bar attachments A bar contoured to connect abutment teeth together, run parallel & overlie residual ridge Preformed metal or plastic. The purpose of using bars are: Splinting of abutment teeth Retention and support of prosthetic appliance

49. Spreads loading Soldered to copings Increased torque Plaque control difficult Relining complicated

50. The bulk of bar and related structures raises several problems. Vertical and buccolingual space requirements limit their applications. Bar attachments also demand more oral hygiene maintenance from the patients.

51. Bar units Rigid type No movement between bar and sleeve Transmits occlusal stresses totally to abutments Thus Tooth born

52. Bar joints Resilient Allow some movement of rotational type between bar and sleeve. Utilize support both from residual ridge and abutment Thus tooth tissue born

53. Bar attachments of importance Haden bar Dolber bar Baker clip Ackerman clip and CM clip King connector

54. Magnetic attachment o Detachable keeper element Made of stainless steel that is fixed to abutment teeth by Cementing Screwing o Denture retention element Has paired, cylindrical Co- Sm magnets axially magnetized and arranged with their opposite poles adjacent

55. Small, strong mini magnets One of poles cemented in the prepared cavity in endodontically treated abutment and the other attached to denture base.

56. DIAGNOSIS, TREATMENT PLANNING AND CASE SELECTION

57. No Diagnosis No Treatment If you don’t know where you go, you never get lost

58. History Examination Articulated diagnostic casts Full mouth radiographs Overall patient concerns

59. PATIENT SELECTION

60. Possibility of fixed or removable partial dentures: If the remaining teeth are capable of supporting a fixed or removable prosthesis, then that should be the primary mode of treatment.

61. Patient age Extractions are to be avoided in a young patient as far as possible, so overdenture do play a major role in treating young patients with mutilated dentition.

62. Factors influencing selection of abutment teeth Periodontal status Mobility Location Endodontic considerations Cost

63. Periodontal & Mobility status Ideally tooth should present minimal mobility , have acceptable bone support and be responsive to periodontal therapy. Circumferential band of attached gingiva is an absolute necessity. Compromised teeth with good treatment prognosis are suitable candidates even when horizontal bone loss is present

64. Slight tooth mobility with horizontal bone loss is not contraindicated as decrease in C- R ratio required for abutment preparation improves mobility. Reduces the length of the lever arm Vertical bone loss particularly accompanied by Class II or III mobility excludes tooth selection.

65. Abutment location Ideal: Two teeth per quadrant (stress is distributed over a rectangular area) Tripod is next most favorable form for support and stability. Clinical experience recommends at least one tooth per quadrant.

66. Isolated teeth are preferred to several adjacent teeth as inter dental areas are difficult to clean and susceptible to gingivitis. Robert M. Morrow, Colonel , Ret. USAFDC, Virginia, 1970

67. Anterior mandibular ridge is most vulnerable to time dependent RRR Canines and premolars are regarded as best overdenture abutments

68. In maxilla central incisors are ideal as overdenture abutments( Protects pre maxilla) Canines are next (Longest Root) Lateral incisors(widely spaced, facilitating plaque control)

69. Endodontic Status Preserve teeth that are already endodontically treated. Usually anterior teeth are preferred as they are easier to prepare and economical too. Whenever pulpal recession to the extent of calcification has occurred , endodontic treatment usually can be avoided.

70. Ettinger in 1990 showed that the most common cause of abutment failure was vital teeth developing periapical lesions as a result of pulpal necrosis ( 53.8%).

71. A c co r ding t o Za r b 1 3 t h e d it i on After 5-6years, about 10% of abutment teeth supporting overdentures were lost Periodontal disease 70% Caries 25% Endo complications 5%

72. Patient is motivated to maintain adequate oral hygiene to prevent abutment loss. Patients must clean all exposed dentin and use 0.4% stannous fluoride daily . Thayer, H. H. Overdenture and the periodontium. DCNA 24:369-377, 1980.

73. PREPARATORY TREATMENT FOLLOWING SEQUENCE OFT TREATMENT CAN BE USED AS A GENERAL GUIDE BUT MAY NOT BE SPECIFICALLY APPLICABLE TO ALL PATIENTS: Construct an immediate treatment clasp less denture . It replaces missing and hopelessly involved teeth for esthetic reason and retain jaw relations. Remove hopeless teeth and insert the removable prosthesis. During the healing period, institute the periodontic and endodontic treatment.

74. TOOTH PREPARATION Remove sufficient tooth structure to provide favorable root crown ratio. Reduce the crown length up to 2 mm above the gingival crest or extend a chamber type margin slightly beneath free gingival margin. Taper the preparation in occlusogingival direction.

75. Consequently optimal abutment preparation is achieved that has following features: Simple Short Convex Dome shaped Chamfer finish line

76. The finished tooth with cast coping is male member of denture. The female member is part of denture base.

77. COPING FABRICATION Make an accurate impression of the abutment and pour a die. Carve the wax pattern. Cast the coping Cement the polished coping to the tooth. Instruct the pt. in home care of abutment tooth.

78. IMPRESSION FOR THE DENTURE Follows the same technique that is used in constructing a conventional complete denture. PRELIMINARY IMPRESSION BORDER MOLDING FINAL IMPRESSION

79. RECORD BASES AND OCCLUSAL RIMS RECORDING MAXILLO MANDIBULAR RELATIONS A face bow transfer is used to relate the maxillary cast to the articulator. Jaw relations and arrangement of teeth for phonetics are verified at the time of try in.

80. TOOTH SELECTION Artificial teeth placed over the abutment teeth should be acrylic resin. When teeth in opposing arch have Gold occlusal surfaces ---- occlusal surfaces of artificial teeth should be either gold or acrylic resin, preferably gold. Restored with porcelain --Porcelain artificial teeth are preferred. Natural teeth ---- Gold occlusals are preferred, otherwise acrylic

81. TRYING THE DENTURE Verify jaw relation records Make eccentric jaw relation records and adjust the articulator. Assure esthetic acceptability by the patient. Verify phonetic acceptability. LABORATORY PROCEDURES CONTOUR THE WAX FLASK THE DENTURE ELIMINATE THE WAX PRAPARE RESIN PACKING RELIEF FOR MARGINAL GINGIVA

82. DENTURE INSERTION Review instruction in denture use and care. Use pressure disclosing paste to locate contacts between female and male members. Evaluate the tissue side of denture base and borders for pressure areas and over extensions. Perfect the occlusion by remounting and selective grinding. Place pt. on recall system After insertion Final try in

83. SUBMERGED VITAL ROOTS Selected vital roots are selected and reduced to 2 mm. below the crestal bone and then covered by mucoperiosteal flap Still in experimental stage. The method is innovative attempt to obviate the basic problems like caries, gingivitis, periodontitis Major post operative problems are: development of dehiscences over retained roots and pulpal pathologies.

84. REVIEW OF LITERATURE Tooth supported overdenture retained with custom made attachments A case report.J Indian Prosthodont Soc Dec 2014 A novel method of fabricating a tooth supported overdenture retained with custom made ball attachments using orthodontic seperators . 2. Fabrication of custom overdenture attachments using indigeniously made parellometer .A technique-JIPS Vol 19 issue 1 jan -march 2019 This eliminates need for making full arch impression,surveying the attachments before casting.parallelism of castable attachment patterns become chairside procedure

85. CONCLUSION Over denture is an excellent viable treatment alternatives. Emphasis must be placed on proper patient selection , pt. motivation , basic prosthodontic principle & detail program of home care instruction & frequent recall. The overdenture is an out standing mode of treatment. Breakdown in tooth structure or a breakdown in their periodontal support immediately negates an overdenture concept.

86. RE F ER E NCES

87. Essentials of complete denture prosthodontics – Sheldon Winkler 2ndedition Prosthodontic treatment for edentulous patients –Zarb-Bolender 12thedition Complete denture prosthodontics –John J. Sharry Syllabus of complete dentures –Charles M. Heartwell & Arthur O. Rahn 4thedition Dental Implant Prosthetics –Carl E . Misch Articles from different journals mentioned earlier