IMPLANT OVER DENTURES: A CONCISE REVIEW OF THE … · 2018. 4. 30. · support for a conventional dentures to be provided. The ... mandibular implant over-denture is also briefly

INTRODUCTION

ver-dentures are defined as,"removable dentalprosthesis that cover and rests on one or moreremaining natural teeth, the roots of natural teeth,

and/or dental implants"1. It may also be termed as anoverlay denture, overlay prosthesis, superimposedprosthesis, hybrid prosthesis, a crown and sleeveprosthesis, superimposing denture and a biologicaldenture1.

The concept of retaining teeth/roots of the terminaldentition for the provision of an overdenture dates backto more than 100 years2,3. It was first described in 1950'sthat the residual alveolar bone undergoes resorption whichcontinues to progress after tooth extraction compromisingsupport for a conventional dentures to be provided. Theanalysis of several longitudinal studies confirmed that

the resorption was progressive, irrevocable andcontinuous4,5. The rate of resorption is the greatest in thefirst six months after tooth extraction however; it slowsdown due to several biological and mechanical factors4.

Overdenture abutments, whether a retained root oran implant, have shown to preserve alveolar bone height7,8

and stabilize dentures, particularly the mandibular ones9.Retained roots are cost effective than implants, with norequisite of an invasive therapy, and therefore should beconsidered by general practitioners as a useful platformfor over dentures, particularly for older individuals10.From physiological viewpoint, the roots provide not onlya periodontal ligament to support the teeth, but alsodirectional sensitivity, tactile sensitivity to load,dimensional discrimination,7,11,12 and gives an individuala sense of not being edentulous13. Dental implants provideadequate retention and stability for overlying prosthesishowever; the individual is deprived of tactile sensitivity14.

Dental implant therapy is considered the treatmentof choice for edentulous patients10. IODs have gainedworldwide acceptance and improve the quality of life foredentulous patients. IODs although retentive andstable,require good maintenance of the prosthesis andimplant retentive components6. Continued research related

JPDA Vol. 24 No. 02 Apr-June 201563

IMPLANT OVER DENTURES: A CONCISE REVIEW OFTHE FACTORS INFLUENCING THE CHOICE OF THEATTACHMENT SYSTEMS

ABSTRACT: Provision of implant over-dentures (IODs) has become a popular treatment modality for edentulouspatients. Oral rehabilitation carried out using dentures supported by endosseous implants greatly improves oralfunction and majority of the problems associated with the dentures i.e. poor stability and retention may be solved.Good success rates have been reported regardless of the attachment system used for the IODs however; themaintenance and complications may be influenced by the use of different attachment systems and other factors. Theaim of the current paper is to briefly review the attachment systems used for IODs and the factors influencing theirselection. Chair-side pickup Impression technique for mandibular implant over-denture is also briefly described.KEY WORDS: 1. Implant retained over dentures. 2. Implant retained prosthesis. 3. Implant attachment systems4. Chair-side pickup impressionHOW TO CITE: Rashid H, Hanif A, Vohra F, Sheikh Z. Implant Over Dentures: A Concise Review of The FactorsInfluencing The Choice of The Attachment Systems. J Pak Dent Assoc 2015; 24(2):63-69.

1. Assistant Professor, Department of Prosthodontics,Ziauddin College of Dentistry,Karachi, Pakistan.2. Clinical Lecturer, Department of Prosthodontics, Ziauddin College of Dentistry,Karachi, Pakistan.3. Assistant Professor, Department of Prosthetic Dental Science, King Saud University,Riyadh, Saudi Arabia.4. Post-doctoral Fellow, Faculty of Dentistry, University of Toronto, Ontario, Canada.Corresponding author: “Dr Haroon Rashid ” < [email protected] >

Haroon Rashid1 BDS, MDScAyesha Hanif 2 BDSFahim Vohra3 BDS, MFDS, M.Clin.Dent, MRDRCS

O

Zeeshan Sheikh4 BDS, MSc, PhD

REVIEW ARTICLE

JPDA Vol. 24 No. 02 Apr-June 2015 64

to IODs has resulted in multiple options and combinationsfor IOD attachment systems with varying success. Theaim of the current paper is to briefly review the attachmentsystems used for IODs and the factors influencing theirselection. Chair-side pickup Impression technique formandibular implant over-denture is also briefly described.The treatment of the patient described in the current paperwas carried out at the department of prosthodontics,college of dentistry,Ziauddin University, Karachi.

OVERDENTURE ABUTMENTS

In the early days, only bare teeth with questionableprognosis as a whole were used as abutments for overdentures. Recently, the use of implant abutments foroverdenture use has increased. The use of sub-mucosalroots with magnets is also still in use 15,16.When using naturally retained bare teeth, it is aimed thatcanines and second premolars are preserved on both sidesof the arches. Teeth are prepared in a dome shape,2-3 mm above the gingival level, with the dome convergingocclusally. To cope up with certain disadvantages of bareteeth such as caries progression, attrition of the abutmentteeth, metal copings (short and long) were used over thedome shaped prepared teeth. Sub-mucosal root retentionhelps to reduce the possible oral hygiene obligations forthe patients but delays residual ridge resorption. Beingsubmerged, they escape the sequelae of poor oral hygieneby being isolated from the oral cavity.

With advancements in implant dentistry, implantsupported over-dentures are gaining wide popularity.Along with implant abutments, sub-mucosal vital toothretention and use of magnets are also commonly used.For many years, osseointegrated implant-supported over-dentures have been used in the rehabilitation of theedentulous jaws particularly the lower ones, offeringpromising results 17,18,19.Literature states that the IODs should become the firstchoice of care for the edentate mandibles20,21. This is alucrative option but simultaneously, has been questionedfor the fact that wide number of the edentate patients arepoor and cannot afford the cost of implanttherapy 22,23.

ATTACHMENT SYSTEMS FOR IODs

IODs come with a variety of attachment systemsincluding the bar and clip attachment systems or a range

of individual, abutment-based attachments called studattachments (ball, magnets, and resilient stud attachmentssuch as Locators [Zest Anchors], ERA [Sterngold], andnon resilient stud attachments such as Ankylos Syncone[DENTSPLY Implants])24,25,26,27,28. Fabrication of an IODover these systems is costly; require clinical expertiseand signification chair-side time18.

FACTORS INFLUENCING SELECTION OF THEATTACHMENT SYSTEMS

Selecting the most apposite system for an individualis dependent on a variety of factors29. These factors areidentified during the treatment and planning phase of thetherapy. Following are the factors that influence theselection:a) Implant site:

The location of the placed implant in reference to thebone and the pontics will guide the selection of the typeof attachments. However; the selection should ideally bedecided during the phase of treatment planning. For ampleretention, it is highly recommended that the implants areplaced as parallel as possible30,31,32. Where parallelismcannot be achieved, a bar designed is favored. Bar designis also preferred in cases where the unfavorable locationof the anatomic structures such as, prominent mentalforamen or the knife-edge ridge, precludes the idealplacement of the implants33,34,35,36.b) Cross arch stabilization:

Bars are indicated in patients with shallow vestibulesand resorbed ridges. The bar helps to resist the lateralloading and provides stabilization37. The stability of theprosthesis is also improved and cantilever design may beprovided with one to two teeth distal to the most posteriorlyplaced implant38. The cases where denture stability is nota concern and retention is the only requirement, individualattachments should be used which offer promising results.c) Prosthesis extent:When the patient demands the prosthesis to be of theminimal size, custom designed milled bars is theattachment system of choice39. These types of restorationsrequire ideal implant placement. The size of the prosthesismay be limited while keeping in mind the principles ofanterior-posterior spread and cross arch stabilization. Thisalso minimizes the lateral loads on the implants38.Fabricating a denture using the neutral zone techniquewill also determine the horizontal space availability forthe prosthesis39. Neutral zone is the area of the minimal

The Factors Influencing The Choice of The Attachment SystemsRashid H / Hanif A / Vohra F / Sheikh Z


conflict i.e. the potential denture space; "that space in theedentulous mouth vacated by the natural dentition anddental supporting tissues and bound by the tonguemedially, and the lips and cheeks laterally"40,41,42 .d) Sore spots:

It is established that the patients who are prone tosoft-tissue sore spots, for instance xerostomic patients,are reportedly more comfortable with a bar, since thedenture can rest entirely on the bar without impingementof the soft tissues43. With individual attachments, thedenture is supported by the mucosa and the compressiveforces acting on the mucosa cause may cause soreness inpatients who are prone to it44.e) Patient's Oral Hygiene:

Dentures retained over bars are capable of gatheringmore debris and hence make such patients moresusceptible to mucosal inflammation and peri-implantitis44,45,46,47,48,49,50,51. Unless the patient commits to themeticulous oral hygiene measures52, the bar attachmentsshould be denied in patients with poor oral hygiene.f) Treatment Costs:

Bar attachments are costly as compared to the studabutments in most of the scenarios35,53. Cost is one of themajor decisive factors in the selection of the attachmentsystem. Patients may be upgraded to the bars and a newover denture may be fabricated if the financial conditionof the patient has improved and other factors areconsidered. Yet, in every case, the selective treatmentoption must follow the appropriate guidelines maximizingthe welfare of the patient and the options should neverbe merely dependent on patient 's f inances.g) The Restorative Space:

Restorative space is the space which is availablefor prosthesis restoration. In general, this space isbounded by the planned occlusal plane, the denturebearing tissues, facial tissues i.e. the lips, cheeks andthe tongue54. When planning an implant overdenture,considerations should be given to the adequate spaceavailable for the denture base, denture teeth, and theattachment system of the implant. The freeway space,phonetics and aesthetics must also be considered. Theminimum space requirement for implant supportedover-dentures with Locator attachment system is 8.5mmof vertical space and 9 mm of horizontal space55. Ideally,for maxillary implant over-dentures, 13-14mm of verticalspace is required for dentures which are supported bybars and 10-12mm for the over-dentures supported withindividual attachments56.

h) The Aesthetic Space:This is defined as "the space between the ridge crest

and the corresponding lips at rest"29. Prosthesis supportedby the individual attachment systems will require lessaesthetic space compared o the bar counterparts. Themeasurement of the aesthetic space helps the dentist indetermining the space allowed for a particular type of theattachment system of an over-denture.i) Ease of Fabrication and Repair:

Bar supported removable prosthesis require manualdexterity for the fabrication and repair compared withthe removable prosthesis supported by individual studs24,57,58,59,60. Many a times, the attachment systems arechosen without the proper consideration given to theaforementioned factors. This eventually leads to a failedprosthesis with patient dissatisfaction.j) Resilience Difference:

Another factor documented that influences theselection of the attachment system for implant-retainedover-dentures, is the difference of resilience between theimplant and the oral mucosa61,62. Furthermore, thisdifference should be considered while taking theimpression of the implant and tissue retained over-dentures.k) The Attachment System:IODs supported with bars or balls offer good survivalrates and patient's appreciation levels with a dentureretained with implants are better as compared to aconventional complete denture63. The use of magnets forretaining over-dentures is also described in the literaturehowever; their success rates have been limited64. Thelimited success of magnets is mainly due to corrosion ofthe magnets caused by saliva and partly because of lessretentive forces achieved as compared to other attachmentsystems. Bar and ball attachment systems offer bettermechanical retention and have many differencesbetween them. Table 1 outlines the differences between


Table 1: Differences Between Ball and Bar Attachments


the attributes of bar and ball attachment systems 65,45,66,49,67.

CHAIR SIDE "PICK-UP" IMPRESSIONTECHNIQUE FOR IODs

The selected attachment can be incorporated into thedenture either chair-side or in the laboratory. Chair-sidepick-up technique allows for passive in-vivo pick up ofthe attachment, furthermore, attachments are picked-upunder mucosal compression allowing for even loaddistribution during function68,69. The technique requiresmanual dexterity but simultaneously provides theincorporation of the attachments into a pre-fabricateddenture. Direct chair-side attachment incorporation alsoavoids laboratory cost and a further denture delivery visit.Usually resilient, non-splinted, prefabricated attachmentsare utilized.Abutments are selected with an appropriate gingivalheight (Figure 1), which is obtained by measuring thevertical distance from the implant collar to the highest

point of soft tissue circumferentially. Another importantfactor for abutment selection is the available space inocclusion in the denture. The suitable abutments aretorqued at 25Ncm and housings are placed over the over-denture abutments after placing a spacer to avoid acrylicblock-out (Figure 2, Figure 3). The prefabricated completedenture prosthesis is hollowed at the location of abutmentsfor the housing to be incorporated, (Figure 4) and ischecked intra-orally. The denture preparation results intwo open windows lingual to the mandibular anteriordenture teeth. The abutment housings are placed on toverify and check the full seating of the final prosthesisand ensure there is not interference either from the

attachments or the housings. Auto-cure denture baseacrylic resin is mixed and placed into the housing spaceand the denture is seated in position. The patient is madeto bite in centric occlusion and the acrylic resin excess


Figure 1: Intra-oral view showing ball abutments placed overmandibular endosseous implants

Figure 2: Intra-oral view showing the housings placed overball abutments

Figure 3: Intra-oral view showing the spacer placed to avoidacrylic block-out

Figure 4: Existing denture showing spaces created forthe housings


on the polished surface of the denture is cleared. Oncomplete setting of acrylic resin, the prosthesis is removedand any defect in the reline/pick up, is filled extra-orallyusing the auto cure acrylic (Figure 5). The prosthesisafter the final finishing and polishing is ready to bedelivered(Figure 6).

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Figure 6: : Intra-oral view of the delivered over dentureprosthesis


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IMPLANT OVER DENTURES: A CONCISE REVIEW OF THE … · 2018. 4. 30. · support for a conventional dentures to be provided. The ... mandibular implant over-denture is also briefly