iS CHAPTER 19 COMPLETE OVERDENTURES Introduction Tooth supprted overdentures Indications and contraindications Types Immediate overdenture Interim (temporary) overdenture Remote (Definitive) overdenture Attachment retained overdenture Abutments for tooth supported overdenture Submerged roots Dome-shaped abutments with an amalgam plug Dome shaped abutments with cast copings Abutments with telescopic crowns Abutments with slight reduction and cast coping Abutments with simple reduction Abutments with an added form of attachment Steps of construction Examination and diagnosis Abutment selection Abutment preparation Priliminary impressions Final impressions Jaw relation records Try in Denture insertion Advantages and disadvantages Implant supported overdenture Indications and contraindications Classification Mucosa supported overdenture Combined mucosa-implant supported overdenture Implant-supported overdenture Design principles of removable implant overdentures ‘Number of implants Individual versus connected implants Location of implants Alignment of implants Retentive mechanism Occlusion Advantages and disadvantages 257INTRODUCTION The extraction of the natural teeth is usually followed by continuous and progressive alveolar ridge resorption. This will result in poor bony denture foundation and accordingly inefficient denture function. Also, the extraction of teeth results in loss of the tooth periodontal recep- tors which are important for the feed back mechanism responsible for proper masticatory function and accurate jaw movements. The retention of few remaining teeth to support the denture will help in preserving the alveolar bone in addi- tion to the preservation of the periodon- tal receptors. Such a complete denture which is supported by some remaining teeth is termed an overdenture. Definition ‘An overdenture is a complete or partial denture constructed over existing teeth, roots or implants for providing ad- ditional support, stability and retention, Overdentures are also called over- lay denture, overlay prosthesis, super imposed prosthesis TOOTH SUPPORTED OVER- DENTURES Tooth-supported overdenture is preventive prosthetic appliance. It is indicated as an alternative line of treat- ment to complete dentures in patients having few remaining natural teeth. Indications Over-dentures are indicated in the fol- lowing cases: 1- Cases having few hopeless teeth which are unsuitable as abutments 258 for fixed bridges or removable par- tial dentures. 2- Patients having few remaining teeth with periodontal diseases. The re- duction of the coronal portion of the tooth achieves a decreased crown- root ratio. This was proved to de- crease hypermobility of tecth and makes them good abutments for supporting overdentures. However, extensive bone loss eliminates the possibility of using these teeth for abutment service. 3- Patients exhibiting flat ridges have very little support, retention and de- creased patient’s ability to manipu- late dentures. 4- Patients with abnormal jaw size or position as in class I or class III Angle’s classification. 5- Patients presenting with congenital defects as clef palate, microdontia, amelogenesis or dentinogenesis im- perfecta or partial anodontia 6- Patients presenting with acquired defects as those with large maxil- lary or mandibular bone defects ot those with traumatic loss of many natural tecth 7- Patients presenting with single den- tures opposing few natural weak tecth. The construction of overden- tureis analternative line of treatment to those patients to avoid problems resulting from single denture op- posing natural teeth and problems associated with complete dentures if extraction is proposed. Contraindications 1+ Patients who are mentally or physi- cally handicapped because of general lack of contro! and bad oral hygiene. 2- Patients who cannot be motivated to develop good oral hygiene.mplete overdentures 3- Inadequate intermaxillary space, 4- Teeth with grade III mobility or with insufficient zone of attached gingiva, Types There are many types and techniques that are followed in overdenture construc. tion, starting from simple to more compli- cated forms, These types are: 1- Immediate over-dentures, 2- Interim over-dentures, 3- Remote over-dentures, 4- Attachment retained overdenture, 1- Immediate overdentures Tooth-supported immediate over- dentures are constructed prior to the Preparation of abutment teeth and is ready for insertion after abutment Pprep- aration and reduction. Immediate over- dentures enhance the patient's ability and adaptability to wear dentures suc- cessfully. 2- Interim over-dentures Interim or transitional over-den- lures are used for patients in the transi- tion or preparation phase when mouth preparation is performed and until per- manent overdenture are constructed. The patient’s old removable partial denture can be modified and used as in- tern denture by extending the denture and adding new artificial tecth using self-cure acrylic resin. 3- Remote or definitive overden- tures Remote overdentures are perma- nent complete overdentures constructed over one or more abutment teeth. They could be made entirely of acrylic resin or in conjunction with metal bases to increase its rigidity and strength and to minimize their liability to fracture. 4- Attachment-Retained overden- tures Attachment retained over-dentures are overdentures constructed with an incorporated attachment or retentive de- vices to improve the mechanical qual- ity especially the retention of over-den- tures, Attachment-retained overdentures are comparatively more expensive and require more time for their construction than remote conventional over-den- lures. So they are indicated for patients with good oral hygiene and low caries index. The abutment teeth should have good periodontal condition and ad- equate bone support that enable them to tolerate extra stresses that may be added by the attachment, Types of attachments Various types of attachments are designed for retaining over-dentures, a Rigid attachment This type does not allow movement of the denture base hence provide ad- cquate retention. However, it may in- duce more torque on the abutments. b- Resilient attachements This type allows some control of movement. These attachments induce less torque on the abutments, however, they are more complex in design and fabrication. Overdenture attachments could be in the form of: L- Stud attachments 2. Bar attachments 3- Magnetic attachments 259Chapter 19 : Complete overientures as Fig. (19.2) 2- Dome-shaped abutments with an amalgam plug (Fig. 19.3) The abutments teeth reduced in height. To be 1-2 mm above the gin- gival margin. Decreasing the crown- root ratio in this manner reduces lateral forces and torque’acting on abutment teeth, This helps in the preservation of the periodontium of the abutment and prevents abutment mobility. Fig. (19.3) Endodontic treatment is thus nec- essary to allow for this reduction in height. The root canal is filled wit gutta-percha and the opening is sealed with an amalgam plug. The abutments are prepared and contoured to attain a dome-shape. They are used to support over-dentures in patients with low car- ies index and good oral hygiene to en- sure the long term of the uncovered and unprotected abutments. 3- Dome-shaped abutments with cast copings (Fig. 19.4) - Abuiments are endodontically treated. The root canal is filled with gutta percha and sealed with cement. - The abutment is reduced to a height of 1-2 mm above the gingival margin. Fig. (19.4): Section through a tooth a shallow dome form of casting cemental in Position, A, Casting, B, Gingival margin, C, Alveolai bone ~ A metal dome-shaped cast coping is constructed to cover the pre- pared abutment. The metal coping has a short post cemented into the Toot canal to retain the coping, into the abutment, these abutments are called short-coping abutments. 4- Abutments with telescopic crowns ~ The abutment teeth are either vital or endodontically treated according to the planned abutment height. ~ The abutments are contoured to attain a tapered configuration, - Tapered metal copings are construct- ed and cemented over the abutments teeth, to be paralled to each other. - The denture is constructed with metal crowns having veneered facings. These crowns are made to overlie and cover the coping cemented on the abutment teeth. This design provides adequate reten- tion with minimal distortion to the abut meats. The telescopic crowns allow slight movement between the dentuse and the abutment without deteriora’”ag retention or causing abnormal stresses on the abut- ment teeth. This movement is also neces- saty t0 dissipate occhusal forces 2615- Abutinents with slight tooth reduction and cast coping The abutments are minimally reduced inheight. Contoured to a tapered configu- ration without endodontic treatment. The prepared abutments are coy- ered with cast metal copings (crown) to protect them against caries and tooth Sensitivity. They are thus called long. coping abutments. This type of abutment modification is rarely followed because it requires an adequate inter-ridge space, 6 Abutments with simple reduc~ tion and slight modification The abutments are slightly reduced in vertical height (to create enough inter- ridge space for the overdenture), reshaped and contoured to eliminate undercuts, These types of abutment modifica. tion is rarely used. It is mainly used in cases with partial anodontia and in eas. ¢s exhibiting enough inter-tidge space. 7 Abutnents with an added form of attachment The abutment tooth is endodonti- cally treated, reduced in both height and contour and covered with a metal coping. The coping has a long post to help its retention and cemented into the root canal of the abutment, Attachments are added to the metal coping either by soldering or during formulation of the wax pattem. They are usually used when added overden- ture retention is required, Steps of construction of overdenture The following, steps are generally used but it may not be specifically ap- plicable in all situations 262 Chapter 19 : Complete overdentures 1- Examination and diagnosis This includes; 4- History and records. 4) Medical history Deblitating diseases which rule out essential clinical procedures ate con. traindications for overdentures 4) Dental history Patients with acceptable oral hygiene have better overdenture prognosis, ©) Pre treatment records Diagnostic cast is prepared and Mounted on an articulator to provide the availability of occlusal analysis, checking of the tooth position, jaw re. lationship, tuberosity impingement, available denture space, and tissue un. dercuts, B- Examination @ Visual and digital examination of the oral cavity, tongue and teeth should be made, b- Dental examination for carious le- sions, defective restorations, pre ence of adequate denture space and unhygienic removable prosthesis, ¢- Periodontal « pocket depth ‘amination. including nd grade of mobility. @ Radiographic examination: Com. plete or partial periapical radio- graphic survey are indicated to show the bone support of the aver Jenture abutment, the status of previous en. dodontic treatment and the Status of Periodontium as well as any other pathology in the jaws. The success of tooth supported overdentures mainly depends on theProper selection, design and prepara- tion of abutment teeth supporting the denture, 2- Abutment selection The proper selection of abutments supporting overdentures requires the evaluation of four important factors, these are : @) Periodontal condition The amount of alveolar bone sup- porting the abutment root is the prima- ry factor in the selection of abutments. Sufficient bone is required to support the tooth and prevent its mobility. Therefore abutments in good periodon- tal conditions, surrounded by at least six millimeters of bone and exhibiting minimal mobility (not more than grade II mobility) are preferably selected to support over-dentures. 4) Positional considerations It is preferable to select teeth lying in areas where occlusal forces have a destructive effect on the residual ridge, hence transferring the occlusal load to the abutments, An example for these cases is a maxillary ridge opposed by natural teeth. The retention of one or more maxillary teeth to be used as over- denture abutments (Fig. 19.5) could prevent many of the hazards resulting, ifa single maxillary complete denture was planned It is preferable to retain anterior teeth to be used as abutments because the anterior part of the ridge is usually more susceptible to resorption. The presence of abutment teeth was proved to decrease the rate of bone resorption thus preserving the bony ridge. Fig, (19.5) Canines ate usually preferred over other teeth as overdenture abutments, because canines have a central strategic position in the dental arch and their peri- odontal membrane contains many nerve receptors which are important for per- forming masticatory function, Canines are also single rooted teeth facilitating the required endodontic procedures, Separate rather than neighbouring tecth are usually preferred to facilitate oral hygience care necessary for the abutments and hence the success of the denture. ©) Number of abuments (Fig. 19-6) The more the number of teeth that are retained to be used as abutments to support overdentures, the better the support, stability and retention of the denture, The ideal ab achieved by retaining two teeth in each quadrant, je, four teeth in each arch. It is preferable to retain both canines and first molars to achieve an ideal distribu- tion of stresses on the residual ridge. Itis even probable to retain even two teeth, one in each quadrant. These are ei- ther bilateral canines or first nremolars. d) Endodontic factors Root canal treatment is usually nec essary before abutment preparation in 263Fig. (19.6) order to allow for proper reduction in the height and contour of the tooth. For this reason, the selection of single-root- ed teeth, with obliterated or recessed pulp is usually preferable. On the other hand, teeth with necrot- ic pulps or having periapical lesions may afford poor prognosis if not properly treated. Endodontic treatment may not be necessary if the root canal is complet ly calcified 264 Chapter 19 : Complete overdentures 3- Abutment preparation: Adequate abutment preparation is also necessary for the long term and success of overdentures. This comprises three steps a) Endodontic abutment prepara- tion Endodontic treatment is usually re- quired to allow for sufficient abutment reduction and contouring. Gutta percha is usually preferred as a filling material over silver points to allow for further reduction or modification of the abut- ments. b) Periodontal preparation of abutments Proper periodontal treatment is re- quired to achieve a strong, healthy abut- ment tooth able to support the denture and sustain the stresses falling on it. Supragingival scaling, subgingival scaling and root planning are required to remove any deposits on the abut- ment teeth. Proper treatment results in the resolution of ocdema and shrinkage of the gingival tissues in order to regain its normal color and contour. ‘The elimination of periodontal pockets is also carried out either by cu- rettage, gingivectomy or even by surgi- cal procedures. o) Abutment reduction and con- touring: Reduction in height ‘The abutment teeth are prepared by reducing the height of the crown and contouring the buccal, lingual and proximal surfaces aa Fig. (19.7) Abutment teeth are reduced in height to provide a favourable crown- root ratio. A shorter crown and long root helps in reducing forces falling on the abutments, reduces abutment torque, even teeth with hypermobility may gain stability after height reduc- tion, Reduction of the crown is also necessary for providing, space for the overdenture and artificial tecth. The teeth are reduced in height ei- ther by disking or by using a tapered fissure bur. According to the reduction in height abutments are classified into: 1- Submerged roots: The abutments are reduced to a level below the gingi- val margin. 2- Short abutments: the abutments are reduced toa height of:1-2 mm above the gingival margin (Fig. 19.7a). 3- Long abutments: The abutments are reduced to a height of 6-8 mm above the gingival margin. Tooth contouring (Fig. 19.7b & c) Careful contouring of the buc- cal, lingual and proximal surfaces of the abutment is required to achieve a dome-shaped configuration. This shape helps in reducing stresses falling on the abutments and provides maximum sup- port for the denture. The contouring is started proximally using a tapered fissure bur and proceed- ing labially and lingually to create a dome-shaped preparation. ‘The crest of the dome-shape should be preferably over the long axis of the tooth. Long abutments are usually con- toured to an-occlusally tapered form. A more tapered abutment usually pro- vides less overdenture retention. Sharp edges should be rounded and undercuts should be eliminated 4- Preliminary impressions Impressions are made using algi- nate impression material in suitable stock trays to obtain primary. casts Special trays are then constructed. 265ac RRR 5- Final impressions Final impressions are made using rubber base impression material and poured into stone, If it is planned to cover the abut- ment with copings, then the stone casts are sawed to obtain separate dies rep- resenting the prepared teeth. Wax pat- terns for the copings are made, carved to attain either a dome shape or tapered configuration, sproued, invested, burnt out and cast in metal. The copings are then cemented on the prepared abut- ments. Impressions are made using rubber base to obtain casts for the cop- ing-covered abutments, 6- Jaw relations records - Face-bow record is made to mount the upper cast. . - Centric relation record is then made to mount lower the cast. Eccentric records may be required if adjust- able articulator is used. ~ Arrangement of teeth is then carried out. 7- Try-in ~ The trial dentures should be carefully tried in the patients mouth, to en- sure proper fit, support and stability of the over-dentures, ~ The fitting surface of the trial dentures should be relieved over the abut- ment teeth to ensure proper denture seating ~ The vertical dimension should be ad- equately checked to avoid any prob- able increase in vertical dimension that may affect occlusion, esthetics and temporomandibular joint > Ocelussion of teeth should also be checked to eliminate aity probable occlusal error, 266 8- Denture insertion Steps for overdenture insertion are similar to complete denture insertion. However, the fitting surface of the den- ture overlying the abutments should be properly relieved to avoid pressure on the gingival margin ofthe abutments and to allow proper seating of the denture, Over relieving should be avoided as excessive space around the abut- ment teeth may cause proliferation of the gingival tissues, Post-insertion care: Patients should be motivated to share the responsibility of overdenture maintenance and success through: Following oral and denture hygiene instructions, Properly brushing uncovered abut- ments to avoid caries and periodontal disease. Frequent recall visits for post-in- sertion care and prophylactic care of abutments, Advantages of tooth supported overdenture 1- Preservation of the alveolar bone be- cause the remaining teeth through their periodontal attachment pro- vide tensile stimulation conductive to bone repair and maintenance. 2- Preservation of the proprioception that enable the mandible to distin. guish the position and movements and to detect the amount of load, thus control the biting pressure. 3- Denture support because the sup- port will be detived not only from the residual tidge but also from the remaining teethEe “Chapter 19: Complete overdentures 4- Better denture stability and reten- tion. 5- Better psychology of the patient be- cause he feels that has teeth and not completely edentulous. Disadvantages of tooth supported overdentures 1- Overdentures are susceptible to heavy occlusal loads which may cause denture base fracture. 2- The overdenture base is frequently thin in the abutment regions in- creasing the possibility of denture base fracture in these areas. 3- Inadequate reduction of abutment teeth may result in an overdenture with increased vertical dimension. 4- Caries may affect the abutment teeth due to bad oral hygiene resulting in abutment loss and necessating mod- ification of the denture. 5- Overdenture construction is time consuming and is considered an ex- pensive line of treatment compared to conventional complete dentures. 6- Attachment-retained over-dentures are expensive and require more time and laboratory procedures in their construction. They are also more difficult to repair. 7- Hyperplasia in the gingiva around abutment teeth may occur due to ex- cessive space in the denture fitting surface around the gingival margins of abutment teeth. IMPLANT SUPPORTED OVER- DENTURE (Fig. 19.8a & b) Most complaints about complete dentures results from patients, who have resorbed lower ridge with resulting poor retention and stability of the lower den- : Implants can be joined by nonflexible bars, which are used with re- silient bar attachments. These implant frameworks provide excellent retention for overdentures 19.8b): Implants can also be used as single units, with ball attachements to provide overdenture retention ture and accordingly excessive denture movement resulting in mucosal irrita- tion and ulceration, reduced mastica- tory efficiency and increased patient discomfort. The use of dental implant to support the lower denture in these cases will increase retention and stability of the removable prosthesis, | ients with high muscle attachment or sensitive mu- cosa, sharp mylohyoid ridge or superfi- jon of the mental foramen will us 267be satisfied with the implant supported over denture as it effectively increases the masticatory forces generated by the mandible, Indications : Theremovable implant overdenture may be the treatment of choice when: 1- Case of considerable resorption of the jaws allowing only few implants to be placed. 2- The excessive stresse from the op- posing jaw. 3- Case of unfavorable ridges rela- tions. 4- Financial limitations that may pre- vent the use of fixed implant pros- thesis. 5- It is practical form of treatment to fy denture wearers who desire additional stability for their pros- thesis. 6- It can be used as substitute for fail- ing fixed prosthesis. 7- Hemi-mandibulectomy patients and other maxillofacial patients may be restored with an implant-retained overdenture. 8 It may be applied in medically com- promised or elderly patients with the use of two implants because of the procedure is less traumatic. Contra-indications 1- Patients with knife edge ridge to avoid pressure on ive tissues and to prevent excessive bone re sorption. 2- Patients who cannot accept wearing removable dentures for psychologi- cal reasons. 268 Chapter 19 : Complete overdentures Classification Mucosa supported overdenture Mainly the mucosa supported over- denture is attached to two implants by means of resilient stud attachments al- lows a rotation and translation of the overdenture. Itis indicated for patients who have a retention problem and when new dentures without implants will not ad- equately solve the problem. It is also useful in geriatric or hand- icapped patients in whom oral hygiene practice may be compromised, because access permits easy cleaning of the su- perstructure. Combined mucosa-implant sup- ported overdenture ‘Two to four implants are positioned in the anterior region of the mandible and connected with a bar. Retentive clips or a retentive sleeve were constructed in such a way that permits rotation around the bar. It is indicated with severely re- sorbed mandible and only short im- plants can be placed. Implant-supported overdenture In this design four to six implants placed in the anterior region of the mandible that are rigidly connected by abar superstructure. The overdenture is attached to the bar by clips and is thus implant-supported. It is indicated for patients with sen- sitive mucosa easily irritated by the pressure of a denture, in patients with extreme gag reflex and when the op- posing arch has natural teeth for reason of stress distribution— Design principles of removable im- plant overdentures 4- Number of implants The number of implants used with removable overdenture had included one midline implant, two, three, four or more individual implants and also two, three or more implants connected by a bar. Ithas been proposed that maxillary overdentures be supported by at least 4 implants. While, in the mandible 2 im- plants are sufficient, This is because the success rate for dental implants in the anterior mandi. ble are very high, because of these suc. Cess rates, as well as lower costs, it is Common to treat edentulous patients with just 2 implants and ball anchors for retention of the overdenture instead the use of 4 implants and a bar. However, four implants might be beneficial for patients with sore, pain- ful mandibular ridges since more force would be supported by the implants and bar rather than the edentulous mucosa, 2- Individual versus connected (plinted) implants Tt was found that individual im. plants with ball/ O-ring attachments transferred less stress to the implants than the design that used 2 implants connected by a bar, There were no biologic differences between the two designs but greater prosthesis retention was attained when the implants were connected by a bar. For most patients, two individu. al implants with associated retentive mechanisms provide good patient satis- faction and the treatment is less costly than a bar overdenture For patients where retention is a primary requirement (as evidenced by active oral musculature and functional demanding eating expectation), the use of 3, 4 or more implants and intercon, necting bars with multiple retentive mechanisms is recommended, 3- Location of the implants; The implants should be located so they are contained within the normal form of the denture base, Their form and location should ide- ally not produce substantial changes in the dimensions of the denture base When the implants placed too far lingual or facial this will result in en. Targed denture base, which prolong the time taken by the patient to adapt {0 the new prosthesis, also efforts are commonly made to reduce the amount of resin base over contouring and this leaves only thin areas of resin over the retentive mechanisms, the thin resin is more liable to fracture, 4- Alignment of implants Implants that are parallel to each other or have their long axes nearly aligned with cach other facilitate the prosthodontic phase of treatment. When individual implants will be used with O-ring retention, malalign- ment can make prosthesis placement more difficult and the O-rings are pinched more often during placement and removal, producing O-ring wear and earlier loss of retention To facilitate axial loading of the implants, it has been recommended that implants be aligned so their axes are Perpendicular to the occlusal p 269Chapter 19 : Complete overdentures erly controlled; bone loss, fracture of the prosthesis, or failure of the implant may occur. It was emphasized the role of occlu- sion as a key factor in implant success, 1 was found that overloading was the main cause for bone loss around fixtures, Although removable implant over- enture is more stable and retentive, is capable of movement owing to com, Pressibility of the soft tissues and lack of rigidity in the attachment used, Thus the overdenture functions more closely like a conventional denture than a fixer prosthesis. The occlusion for the tissue-borne overdenture should include multiple bilateral even contacts in centric rela. tion and eccentrie positions for proper distribution of force. Bilateral balancing occlusion has been advised in removable implant ovetdenture to distribute the toad and stresses, While bilateral balancing occlusion is the most commonly accepted goal for an ideal removable implant overdenture ccclusion, many authors described the lingualized occlusion as an acceptable @cclusal scheme for removable implant overdenture, The lingualized occlusion schemeis based on the use of the maxillary cusps as the stamp cusp, which occludes with # shallow mandibular central fossa. At ho time is there contact of the maxil- lary buecal cusp ot mandibular lingual Cusp. The effect creates a mortar and Pestle styles of occlusion. This concept has the advantages of decreasing the unfavorable horizontal movement in mastication and elimination the Poten- tial for lateral interferences in excursive movement. But it is less natural in ap- Pearance, and there is possible reduc, tion in masticatory efficiency, Advantages of implant supported over denture 1+ Maintenance of residual ridge vol. tune because the implant placement Ray Teduce residual ridge resorp- tion or in some eases actually pre. mote osseous regeneration. 2 Improvement of facial and tip sup- Port which can be obtained from Ih. bial and buccal flanges of the over. denture, $-Improvement of phonetics and speech when they are impaired either by the Space between the alveolar ridge and the fixed-anchored bridge or due to extension of the lingual flange in case of conventional denture, 4 Improvement of chewing ellicieney by about 20% compared with that of conventional denture. 5- Allow more hygiene conditions and home maintenance than fixed pros- thesis, 6- Decrease the effect of nocturnal Parafunction because it can be re- moved at bed time, 7- The prosthesis is usually easier in Processing than a fixed restora. tions. 8- More satisfaction and patient prefer. enee, 9 Pewer implants are used than for fixed implant Supported prosthesis 80 less costs and less complex pro- cedures,Disadvantages of over denture 1- Its surgical procedure of osteotomy needs skill, care and training 2- It has the problems and complica- tions of a surgery as edema, pain or bleeding. plant supported 3- Not suitable for case of reduced in- terarch space. 4- Inspite of to good retention, it is still considered a removable prosthesis. 5- Wear of retentive components with the need for replacement. Most of these disadvantages not longer met with the introduction of the new concept of mini dental implants to Chapter 19 : Complete overdentures be used with removable implant over- denture. - According to the number of implants. used the overdenture will be either implant retained or implant support- ed if two implants are inserted the overdenture will be implant retained the support will be obtained from the ridge. - If four implants are inserted the over- denture will be implant retained and combined implant tissue supported. - If more than four implants are insert- ed the overdenture will be implant retained and totally implant sup- ported.