Diagnosis and Treatment Plan in Over Denture
Diagnosis and Treatment Plan in Over Denture
Continuing Education
Disclaimers:
• P&G is providing these resource materials to dental professionals. We do not own this content nor are we responsible for any material herein.
• Participants must always be aware of the hazards of using limited knowledge in integrating new techniques or procedures into their practice.
Only sound evidence-based dentistry should be used in patient therapy.
Please note: This is Part I of a two-part series. Full Arch Implant Prostheses: Part II - Fabrication
Procedures will describe all the procedural steps for fabricating a predictable implant-supported
removable dental prosthesis and an all-on-4/all-on-5 implant-supported fixed prosthesis. Each of
the two courses can be taken independently and in any order.
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Course Contents • Learn to plan restoratively driven implants
• Overview and understand the small but important
• Learning Objectives differences in implant placement for
• Introduction removable and fixed prostheses.
• Mode of Retention of Removable Implant
Prosthesis Introduction
• Bar Attachments
• Individual Stud Attachments
• Selection of the Optimal Attachment Definition
System for Implant Overdentures Implant prosthesis is a prosthesis
• Mode of Retention of Fixed Implant supported and retained in part or whole by
Prosthesis dental implants.
• Diagnosis and Treatment Planning for
Implant Prostheses
• Summary Edentulism is considered a major health
• Course Test problem as it affects the overall well-being of
• References / Additional Resources an individual.1-3 Traditionally, complete dentures
• About the Author were the only treatment option available for
edentulous patients.4 The lack of prosthesis
Overview retention and stability coupled with poor
Implants have helped improve the denture masticatory efficiency led to dissatisfaction
bearing foundation and quality of life of among denture patients, forcing them to seek
edentulous patients. Treatment options alternative therapy.5,6 The advent of implants and
available for edentulous patients are complete implant prostheses have positively impacted the
dentures, implant-supported overdentures, quality of life of many edentulous patients.6-10
and implant-supported fixed restorations. This
course describes the factors governing the An implant-supported and/or retained prosthesis
choice of implant prostheses and attachments/ can be fixed or removable. However, most
abutments for both removable and fixed dentists and patients believe that the most
implant restorations. It also details the entire suitable restoration (that will eliminate all of
treatment planning sequence starting with the patient’s existing problems) is a “fixed”
the treatment prosthesis, progressing to implant prosthesis.11-13 The choice of the
CBCT assisted implant planning, and finally definitive prosthesis should not be based on the
placement of implants with 3D surgical guides. preference of the dentist or the patient, rather,
it should be determined by comprehensive
Learning Objectives diagnosis and treatment planning.13 The bone
Upon completion of this course, the dental quantity and quality, the number, location and
professional should be able to: distribution of implants, the available restorative
• Understand the indications, space, smile line, lip length, opposing arch,
contraindications, advantages and oral hygiene compliance, financial implications,
disadvantages of implant-supported fixed and the time required for fabrication and
and removable prostheses. maintenance of the prosthesis should be taken
• Choose optimal prostheses for the patient into consideration while choosing the type of
based on all relevant factors. implant prosthesis.11,12,14 Removable implant
• Choose the most appropriate attachment prosthesis can be indicated in most situations
system for the patient based on all the which may be inconducive to the fabrication of
relevant factors including restorative space. fixed implant prosthesis.13,15,16
• Understand the entire workflow beginning
with implant planning to implant placement Removable implant restorations (Implant
based on both the anatomic and prosthetic overdentures) may be either implant-retained
determinants using CBCT, implant planning and mucosa-supported or implant-retained
software, and 3D surgical guides. and implant-supported. When the prosthesis
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is retained by implants and supported by can also be interpreted as advantages of fixed
mucosal tissues, it is termed as an implant- implant prosthesis) they include the following:
retained and mucosa-supported prosthesis.
When the prosthesis is retained and supported 1. All removable restorations must be kept out
by implants, it is an implant-retained and of the mouth for 6 to 8 hours in a 24-hour
implant-supported prosthesis. Implant period which may be objectionable to some
overdentures have several advantages of the patients.27
compared to conventional complete dentures 2. Removable implant prostheses generally
and removable partial dentures, including require more restorative space than fixed
decreased bone resorption (in locations where implant restorations.28
implants are placed),17 reduced prosthesis
movement, improved mastication, nutrition,18,19 Note: Restorative space is the 3-dimensional
appearance20 (teeth placement can be dictated oral space available (specific to the arch
by esthetics), satisfaction21 and quality of under consideration) to receive the
life22 and maintenance of the occlusal vertical proposed prosthodontics restoration.29
dimension (OVD). When compared to fixed Vertical restorative space may be assessed
implant prostheses, implant overdentures have using measuring tools, such as a Boley
the following advantages: (These can be also be gauge and existing complete dentures,
interpreted as disadvantages of fixed implant wax rims (Figure 1A), or wax trial dentures.
prostheses.) The tips of the measuring caliper should
simultaneously contact the intaglio surface
1. Fewer implants needed: Fabrication of of the denture or record base and the
implant-supported overdentures generally deepest aspect of the overlying occlusal
requires a lesser number of implants surface or the wax rim.29 Vertical space may
compared to fixed implant prostheses. also be directly calculated using mounted
2. Improvement of esthetics: Patients with casts with adjusted wax rims (Figure 1B)
significant resorption of the labial aspect of or wax trial dentures.29 Also, computed
the anterior maxilla require lip support to tomography (CT) scans with computer-based
optimize the esthetics. The labial flange of planning can also be used to determine the
the overdenture can be contoured to provide available restorative space.
the desired lip support.20,23 Managing this
situation with a fixed implant prosthesis The minimum vertical space requirement of
would necessitate bone augmentation various implant prostheses are as follows:28-30
procedures or the development of non- • Fixed screw-retained (implant level)
cleansable contours in the fixed restoration. prosthesis (porcelain fused to metal/
3. Improvement in speech: The overdenture Zirconia): 4-5 millimeters;
surfaces can be appropriately contoured • Fixed screw-retained (abutment level)
and the prosthetic teeth can be optimally prosthesis (porcelain fused to metal/
positioned to permit an improvement in Zirconia): 7.5mm;
speech. Also, the problem of air leakage • Fixed cement-retained prosthesis
between the prosthesis and the ridges is (porcelain fused to metal/Zirconia):
minimized with an overdenture.20,24,25 7-8mm;
4. Easy to clean: The oral cavity, attachments • Fixed screw-retained complete denture
and the prosthesis are easy to clean because (acrylic and metal): 15mm;*
the prosthesis can be easily removed from • Overdenture supported by locator
the mouth.20,26 attachments: 8.5mm;
5. Cost-effective: Removable implant • Overdenture supported by bar attachment
restorations are less expensive to fabricate system:13-14mm
and repair than fixed implant restorations.
*All the different types of fixed implant
However, there are a few disadvantages prostheses require lesser vertical
associated with implant overdentures (which restorative space compared to the
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Figure 1A. Evaluation of restorative space using the Figure 1B. Evaluation of restorative space using wax
wax rim and Boley gauge. rims on mounted casts.
removable implant prostheses except the Hader Bar (keyhole shape).31 Bars may be
fixed screw-retained complete denture. casted, milled, or fabricated by CAD-CAM
3. There is a need for constant replacement (computer-aided designing/computer-aided
of the retentive elements of the stud manufacturing) technology.31 Fabrication of
attachments when used in situations where a prosthesis supported by a bar attachment
the implants are not placed parallel to each requires substantial planning and is technique
other.27 sensitive.28,31-35 Bars require more vertical
4. Since fewer implants are placed, the restorative space (minimum 13‑14mm)
osseous structures will continue to resorb in compared to individual stud attachments.36
locations where there are no implants.27 Patients with bar-supported prostheses
may develop mucosal hyperplasia beneath
All these factors should be taken into the bar and mucositis around the implants
consideration while choosing the type of when optimal oral hygiene is not maintained
implant prosthesis. (Figure 2B).31 Individual stud attachments are
preferred attachments (due to reduced tissue
Mode of Retention of Removable coverage) for patients with poor oral hygiene
Implant Prosthesis (Figure 3).37
Implant overdentures may be retained
using bar and clip attachment systems and/ Individual Stud Attachments
or individual, free-standing abutment-based With the advent of the locator attachment
attachments. Freestanding attachments include system, there has been a decrease in the use
balls, magnets, resilient stud attachments, such of magnets, ball attachments, and the ERA
as the Locator system (Zest Dental Solutions), attachment system. Features such as resiliency,
Locator R-Tx system (Zest Dental Solutions) self-alignment38-40 (making it easy for the patient
and ERA (Sterngold), and non-resilient stud to align and seat the prosthesis), dual retention
attachments such as Ankylos Syncone (Dentsply (internal and external),38-40 ease of replacement
International).31 of the nylon retentive inserts41,42 and
maintenance of oral hygiene,43 lowest vertical
Bar Attachments profile40 (3.17mm for external hexagon implant,
Bars are usually planned to accommodate 2.5mm for internal connection) (Figure 4), high
non-parallel implant trajectories.31 Bars success rate44 and superior clinical performance
provide excellent stabilization, retention, (compared to ball and bar attachments)40
and force distribution (due to splinting have made the locator attachments very
effect) (Figure 2A). There are various designs popular among the restorative dentists. The
of bars such as Ackermann Bar (spherical locator attachment system has become the
shape), Dolder Bar (ovoid or “U” shape), and attachment of choice when there is reduced
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Figure 2A. Hader Bar fabricated with ERA extensions Figure 2B. Mucosal hyperplasia and mucositis in a
to support an overdenture. bar-supported prosthesis due to poor oral hygiene.
Picture courtesy of Dr. Cagna
Figure 4. Comparison of vertical dimensions of the locator (left), mini ERA (center), and
the ERA (right) attachment system.
Picture courtesy of Dr. Cagna
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Figure 5. Locator R-Tx attachment system.
Picture courtesy of Dr. Massad
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6. Restorative space: Minimum restorative in case of complications. Screw loosening,
space required for implant-supported the requirement of sectioning and soldering
overdentures with locator attachments is procedures, increased costs, greater complexity
8.5mm vertically.29 Implant overdentures of components and laboratory procedures,
supported by bar attachments require a increased chairside time, and compromised
minimum of 12 to 14mm of vertical space.36 esthetics, occlusion and porcelain strength
7. Ease of fabrication/repair: Removable are the major disadvantages associated with
restorations supported by a bar are more screw-retained prostheses.58-61 It is also difficult
challenging to fabricate and repair than to place a screw-retained restoration in a
removable restorations supported with patient’s mouth with a limited oral opening as
individual stud attachments.31,33,35 it may be challenging to insert the screwdriver
8. Opposing arch: It is necessary to identify in the oral cavity.62
the opposing arch in the treatment
planning process. If a complete denture is Cement-retained implant prostheses (Figure 7)
planned for the maxillary arch; it would be offer superior stability,63 occlusion, esthetics,
advised to treatment plan the mandibular stronger implant prosthetic connection,
implant overdenture with individual and improved force transmission compared
stud attachments as opposed to a bar to screw-retained implant prostheses.58,59
attachment system to avoid excessive forces Extrusion of the excess cement into the peri-
on the maxillary denture.37 implant sulcus (which may be difficult to
9. Economics: The cost of fabrication of recognize and remove) is one of the major
the bar attachments in contrast to stud drawbacks of a cement-retained prosthesis.58,64
abutments will be much higher in most Several techniques have been reported that aid
instances.11,53 However, treatment options in preventing/decreasing the flow of cement
should never solely be based on finances. into the subgingival sulcus.64-67
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Figure 7. Cement-retained prosthesis.
Picture courtesy of Dr. Wicks
to 20 degrees. The F-Tx Denture Attachment Diagnosis and Treatment Planning for
Housings (DAHs) are picked up in the Implant Prostheses
prosthesis via a chairside pick-up procedure Treatment Prosthesis
similar to that used for the conventional Prior to planning implant restorations, it is
locator attachment system.68 critical to assess the medical and dental history
and ensure that there are no contraindications
Fixation by revolutionary “snap-in” feature; to the placement of dental implants. For any
angulation correction up to 20°from the implant restoration to be successful, it is critical
vertical; stress-free passive fit; decreased to plan and place implants accurately.69,70 Ideally
requirement of vertical restorative space a treatment prosthesis should be fabricated for
(9-12mm); improved esthetics; and higher every patient. This prosthesis helps the dentist
patient comfort and satisfaction are the listed gauge the restorative space (Figure 9), the
advantages of the F-Tx attachment system.68 lip support, phonetics, OVD, the relationship
The F-Tx attachment is contraindicated for between the edentulous ridge and the
single-tooth restorations, unilateral partial fixed intended position of the prosthetic teeth, the
implant prostheses, implants with divergence intended design of the definitive restoration,
greater than 20° or where a resilient esthetics and expectations of the patient. The
connection is required.68 restorative dentist should decide the type and
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Figure 9. Boley gauge used to evaluate the vertical restorative
space at the location of the right first premolar.
the design of the prosthesis before implant guide itself. Using the implant planning
placement. If the patient is satisfied with the software, the raw data is converted into
treatment prosthesis, it can be converted DICOM (Digital Imaging and Communications
into a radiographic guide (by adding fiduciary in Medicine) data and the data from the two
markers or painting radiopaque ink) (Figure 10) scans is combined into one to treatment
and used to plan implant positions and plan the implants in relation to the bone
angulations based on the intended position of and prosthesis. This has helped change the
the prosthetic teeth.70 osseous-driven approach to a combination of
osseous- and prosthetic-driven approach for
CBCT Assisted Implant Planning implant placement.70-73
It is beneficial to plan implants using the data
generated from 3-dimensional (3-D) Cone The planning and placement of the implants
beam computed tomography (CBCT) scans and should vary depending on the design of
guided implant planning software.70-72 Usually the prosthesis. For an implant-supported
two CBCT scans are made (Dual scan protocol). removable restoration, the long axis of the
The first scan is made of the patient with the implants should emerge from the lingual
radiographic guide placed in the oral cavity, aspect of the prosthetic teeth since it is the
and the other scan is made of the radiographic bulkiest part of the prosthesis. For a fixed
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implant restoration, the implants should
emerge (the long axis of the implant) through
the center of the prosthetic teeth. Implants
should be planned such that they are parallel
to each other and perpendicular to the occlusal
plane (Figure 11).
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Figure 14. Implants placed through the 3D
surgical guide.
Figure 13. 3D surgical guide.
procedures. Combining the CAD/CAM Note: The implant placement through the
technique, digital implant planning can be guide is exactly as planned in the software.
applied to clinical practice using 3-D surgical It is so accurate that a cast may be retro
guides.71-73 Once the plan has been approved engineered using the surgical guide and a
the CAD (computer-assisted design) files may transitional restoration can be fabricated on
be sent to the 3D surgical guide manufacturer the cast prior to the placement of implants. If
for the fabrication of the 3D surgical guide a transitional fixed restoration (pre-fabricated
(Figure 13). by the laboratory) is planned, the prosthesis
is adjusted, the temporary abutment cylinders
The surgical guide should be tried in the mouth are picked up clinically, the prosthesis is
and adjusted to ensure that it completely finished and polished, screws are tightened
seats in the mouth. The osteotomy, as well and screw access holes are plugged with Teflon
as implant placement, can be accomplished tape and sealed with composite resin.
through the 3D guide following the
manufacturers’ recommended protocol Summary
(Figure 14). The surgical guide directs the Comprehensive diagnosis and thorough
osteotomies and placement of implants in the treatment planning are prerequisites to
X, Y, and Z-axis. Following implant placement, achieving successful implant rehabilitation.
cover screws (requires second-stage surgery) Information gathered during diagnosis can
or healing abutments may be attached to the seamlessly influence surgical decision making,
implants. At this time, the treatment denture implant placement, choice of prosthesis and
may be adjusted as needed and then relined attachments, and the design of a definitive
with a soft lining material. prosthesis.
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Course Test Preview
To receive Continuing Education credit for this course, you must complete the online test. Please
go to: www.dentalcare.com/en-us/professional-education/ce-courses/ce612/test
1. Selection of the attachment system for implant overdentures should be based on all of
the following factors EXCEPT one. Which one is this exception?
A. Oral hygiene
B. Retrievability
C. Desire for cross arch stabilization
D. Trajectory and position of implants
2. All of the following are advantages of cement-retained fixed implant prosthesis EXCEPT
one. Which one is this exception?
A. Esthetics
B. Ease of repair
C. Stability
D. Occlusion
4. The F-Tx and the R-Tx locator attachment system can be used for retaining and
supporting implant overdentures. The technique of incorporating the locator F-Tx
denture attachment housing in a prosthesis is similar to that used for the conventional
locator.
A. Both the statements are true.
B. Both the statements are false.
C. The first statement is true. The second statement is false.
D. The first statement is false. The second statement is true.
6. If a complete denture is planned for the maxillary arch which of the following prosthesis
would be the optimal choice for the mandibular arch in a patient with Class III jaw
relationship?
A. Fixed cement retained all ceramic implant prosthesis
B. Fixed screw retained porcelain fused to metal implant prosthesis
C. Implant over denture supported with stud attachments
D. Implant overdenture supported by a bar
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8. Full arch implant supported fixed restorations may be retained by all of the following
EXCEPT one. Which one is this exception?
A. Cement
B. Locator F-Tx
C. Locator
D. Screw
10. Design of the prosthesis should be determined after the placement and healing of
implants. Removable implant prostheses generally require more restorative space than
fixed implant restorations.
A. Both the statements are true.
B. Both the statements are false.
C. The first statement is true. The second statement is false.
D. The first statement is false. The second statement is true.
11. Bars are usually planned to accommodate parallel implant trajectories. Bars provide
excellent stabilization, retention and force distribution.
A. Both the statements are true.
B. Both the statements are false.
C. The first statement is true. The second statement is false.
D. The first statement is false. The second statement is true.
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