Copy of implant supported overdenturespp/ dentistry schools


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implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic

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Copy of implant supported overdenturespp/ dentistry schools

  1. 1. Implant supportedImplant supported overdenturesoverdentures INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. IntroductionIntroduction The dental profession and theThe dental profession and the public are more aware of thepublic are more aware of the problems associated with aproblems associated with a removable complete dentureremovable complete denture (mandibular). The insertion of(mandibular). The insertion of implants for retention stability &implants for retention stability & support of an overdenturesupport of an overdenture contributes a more favorablecontributes a more favorable environment for restoration.environment for restoration.
  3. 3. IntroductionIntroduction This is also an ideal treatment modality toThis is also an ideal treatment modality to begin a learning curve in implant dentistry.begin a learning curve in implant dentistry. There is more lenience in implantThere is more lenience in implant positioning or prosthesis fabrication with apositioning or prosthesis fabrication with a implant overdenture. Hence one of theimplant overdenture. Hence one of the most beneficial treatments rendered tomost beneficial treatments rendered to patient is also the best introduction for apatient is also the best introduction for a dentist into the discipline of implantdentist into the discipline of implant dentistry.dentistry.
  4. 4. TREATMENT CONSIDERATIONS On the basis of the available literature, the following clinical treatment concepts should be considered: 1. The mandibular overdenture retained by implants in the interforaminal region appears to maintainbone in the anterior mandible. 2. In younger patients or those edentulous for less than 10 years, a fixed implant denture may preserve posterior bone better than an implant overdenture in the mandible.
  5. 5. 3. Although reports are conflicting, patients with mandibular implant overdentures may experience a loss of fit of their antagonist denture. Occlusal schemes with no anterior contact in the centric relation position and minimal anterior contact in excursions may reduce the combination syndrome effect. Frequent recalls to assess.
  6. 6. 4. It appears that retention, stability, and chewing ability improve only slightly with an implant supported mandibular overdenture as compared with an implant-mucosa–supported overdenture. 5. Multiple implants can be recommended for the mandibular overdenture when sensitive jaw anatomy, increased occlusal forces, or high retention needs are present or when implant length is <8 mm or implant width is <3.5 mm.
  7. 7. 6. When 2 implants are used in the anterior mandible to retain an overdenture, solitary ball attachments appear to be less costly, less technique sensitive, and more accommodating of tapered arches. However, ball attachments seem to be less retentive than the bar
  8. 8. 7. The use of immediately loaded implants in the anterior mandible for the overde nture design is a promising treatment concept. 8. Overdentures retained by 2 implants in the anterior mandible appear to demonstrate a higher burden of maintenance during the first year than in subsequent years. Controversy persists as to whether the ball or bar design requires more maintenance.
  9. 9. 9. There appears to be no statistical difference when long- term maintenance is compared among mandibular implant overdentures retained by 2 implants in contrast to those retained by 3 or more implants.
  10. 10. 10. Mandibular implant overdentures appear to show higher patient satisfaction scores than complete dentures, even with patients who have undergone preprosthetic surgery. 11. Patients appear to be similarly satisfied with a fixed implant complete denture or a removable implant overdenture on the mandible. Patients who rate stability more important than hygiene tend to choose a fixed prosthesis.
  11. 11. 12. When the anchorage system or number of implants is varied, there may be no significant differences in satisfaction with moderately resorbed edentulous patients restored with mandibular implant overdentures.
  12. 12. Effect of aging poplationEffect of aging poplation The increase in life expectancy hasThe increase in life expectancy has drastically increased the population ofdrastically increased the population of elderly people . It is projected that in nextelderly people . It is projected that in next 50 years the 65 yr old individual50 years the 65 yr old individual population would be more than 20% of thepopulation would be more than 20% of the population.population. The age is the indicator of tooth lossThe age is the indicator of tooth loss
  13. 13. Anatomic consequences ofAnatomic consequences of edentulismedentulism  Decreased width & height of supporting boneDecreased width & height of supporting bone  Prominent mylohyoid & internal oblique ridgeProminent mylohyoid & internal oblique ridge  Progressive decrease in keratinised mucosaProgressive decrease in keratinised mucosa  Forward movement of prosthesis from anatomicForward movement of prosthesis from anatomic inclinationinclination  Thinning of mucosa,with sensitivity to abrasionThinning of mucosa,with sensitivity to abrasion  Loss of basal boneLoss of basal bone  Increase in size of tongueIncrease in size of tongue
  14. 14. Esthetic consequencesEsthetic consequences Prognathic appearancePrognathic appearance Decrease in horizontal labial angleDecrease in horizontal labial angle Thinning of lipsThinning of lips Deepening of nasolabial grooveDeepening of nasolabial groove Facial wrinkle increaseFacial wrinkle increase Decrease in facial heightDecrease in facial height Loss of muscle toneLoss of muscle tone Witch’s chin appearanceWitch’s chin appearance
  15. 15. Advantages of implant supportedAdvantages of implant supported overdenturesoverdentures Prevents bone lossPrevents bone loss Maintain facial estheticsMaintain facial esthetics Reduce or eliminate prosthesis movementReduce or eliminate prosthesis movement Eliminates soft tissue abrasionEliminates soft tissue abrasion Improve chewing efficiencyImprove chewing efficiency Increase occlusal forcesIncrease occlusal forces Improves prosthesis stability,retentionImproves prosthesis stability,retention Improved speechImproved speech
  16. 16. Reduce denture sizeReduce denture size Require fewer implants comparedRequire fewer implants compared to fixed prosthesisto fixed prosthesis Eliminates extensiveEliminates extensive surgeries,grafting etcsurgeries,grafting etc Requires less specific implantRequires less specific implant placementplacement Esthetics better than fixedEsthetics better than fixed prosthesisprosthesis
  17. 17. Better hygeineBetter hygeine Removable by patientRemovable by patient Repair easyRepair easy Require short appointments,Require short appointments, reduced laboratory fees, fewerreduced laboratory fees, fewer implantsimplants Overall cost reducedOverall cost
  18. 18. DisadvantagesDisadvantages Patients desire for fixed prosthesisPatients desire for fixed prosthesis Difficult to fabricate in reduced inter archDifficult to fabricate in reduced inter arch space situationsspace situations
  19. 19. Diagnosis and treatmentDiagnosis and treatment planningplanning
  20. 20. Medical evaluationMedical evaluation Thorough general medical evaluation isThorough general medical evaluation is absolute necessary before implantabsolute necessary before implant treatment.streatment.s Cvs, Cns, respiratory system,digestive ,Cvs, Cns, respiratory system,digestive , endocrine, hemopoietic,allergies, bones &endocrine, hemopoietic,allergies, bones & joints, neoplasm,joints, neoplasm, Pt with debilitating sysytemic disordersPt with debilitating sysytemic disorders are contraindicated.are contraindicated.
  21. 21. Diagnostic imaging and techniquesDiagnostic imaging and techniques Preprosthetic implant imaging-identifyPreprosthetic implant imaging-identify diseae,determine bone quality quantity,diseae,determine bone quality quantity, implant position and orientationimplant position and orientation Surgical and interventional implantSurgical and interventional implant imaging- to determine the position ofimaging- to determine the position of implant placed,graft siteimplant placed,graft site Post prosthetic imaging - to evaluate thePost prosthetic imaging - to evaluate the status of the implant , adjacent bonestatus of the implant , adjacent bone
  22. 22. Imaging modalitiesImaging modalities Periapical radiographyPeriapical radiography Panoromic radiographyPanoromic radiography Occlusal ‘’ ‘’Occlusal ‘’ ‘’ Cephalometric ‘’ ‘’Cephalometric ‘’ ‘’ TomograpyTomograpy ComputedComputed
  23. 23.
  24. 24. tt
  25. 25. Division of available boneDivision of available bone Available bone height , width,Available bone height , width, length, angulation, crown –length, angulation, crown – implant body ratioimplant body ratio A-A- abundant , >5mm width,abundant , >5mm width, 13mm ht, 7mm lt, <30 deg angle,13mm ht, 7mm lt, <30 deg angle, C/I = <1C/I = <1 Root form wide diameter implantRoot form wide diameter implant
  26. 26. BB 2.5-5 mm width, 1o-13 mm ht,2.5-5 mm width, 1o-13 mm ht, >12mm lt <20 angulation,>12mm lt <20 angulation, C/I = <1C/I = <1 Osteoplasty, augmentation,Osteoplasty, augmentation, narrow implant,narrow implant,
  27. 27. CC Unfavourable width, ht ,length,Unfavourable width, ht ,length, Osteoplasty, augmention, narrow implantOsteoplasty, augmention, narrow implant DD Severe atrophy , basal bone loss, flatSevere atrophy , basal bone loss, flat maxilla, pencil thin mandiblemaxilla, pencil thin mandible augmentationaugmentation
  28. 28.
  29. 29. Bone densityBone density A key determinant for success.A key determinant for success. Strength of bone = bone densityStrength of bone = bone density Bone contact amnt, modulus of elasticityBone contact amnt, modulus of elasticity and axial stress contours are affected byand axial stress contours are affected by bone density.bone density. Treatment plan , implant no & size , shoudTreatment plan , implant no & size , shoud be modified according to bone densitybe modified according to bone density
  30. 30.
  32. 32. Treatment sequenceTreatment sequence Initial appointmentInitial appointment Medical ,dental history, dental & x-rayMedical ,dental history, dental & x-ray evaluation, diagnostic casts , CT scan etcevaluation, diagnostic casts , CT scan etc Confirmation appointmentConfirmation appointment Diagnostic wax up, final Rx plan, consentDiagnostic wax up, final Rx plan, consent forms, picture of existing conditionforms, picture of existing condition Presurgical restorative appointmentPresurgical restorative appointment Caries removal, periodontal therapy, try in ofCaries removal, periodontal therapy, try in of transitmplational denture, surgical guidetransitmplational denture, surgical guide templatetemplate
  33. 33. Implant surgery- stage 1 implantImplant surgery- stage 1 implant placementplacement Healing phase-Healing phase- Stage 2- secondary permucosal extensionStage 2- secondary permucosal extension ,initial loading,initial loading
  34. 34. PROSTHODONTIC PHASEPROSTHODONTIC PHASE Initial abutment preperation andInitial abutment preperation and impressionimpression Try in dentureTry in denture Final denture deliveryFinal denture delivery MAINTENANCEMAINTENANCE Radiographs, examination, homeRadiographs, examination, home instructions, mediactions etcinstructions, mediactions etc
  35. 35. Classification of completeClassification of complete edentulous arches in implantedentulous arches in implant dentistrydentistry
  36. 36.
  37. 37. TypeType 11 In the Type I edentulous archIn the Type I edentulous arch the division of bone is similarthe division of bone is similar in all three anatomicin all three anatomic segments. Therefore foursegments. Therefore four different categories of Type Idifferent categories of Type I edentulous arches areedentulous arches are present.present.
  38. 38. Type I Division AType I Division A  The ridge hasThe ridge has abundant bone inabundant bone in all three sections.all three sections. The patient mayThe patient may use as many rootuse as many root forms as needed,forms as needed, and whereverand wherever desired, to supportdesired, to support the final prosthesis.the final prosthesis.
  39. 39. It is more unusual to haveIt is more unusual to have enough posterior height inenough posterior height in either the maxilla or mandibleeither the maxilla or mandible to permit osteoplasty toto permit osteoplasty to improve the division. Thereforeimprove the division. Therefore if posterior implants areif posterior implants are needed, narrow implants areneeded, narrow implants
  40. 40. Type I Division BType I Division B  The edentulous ridgeThe edentulous ridge has adequate bone inhas adequate bone in all 3 sections in whichall 3 sections in which to place narrowto place narrow diameter root formdiameter root form implants. It isimplants. It is common practice tocommon practice to change the anteriorchange the anterior section of bone bysection of bone by osteoplasty to a Div Aosteoplasty to a Div A and to place full-sizeand to place full-size root form implants inroot form implants
  41. 41. Type I Division C-wType I Division C-w  Type I Division C-wType I Division C-w edentulous archesedentulous arches have inadequatehave inadequate bone width forbone width for implantation. If theimplantation. If the patient desires anpatient desires an implant-supportedimplant-supported removable prosthesis,removable prosthesis, an osteoplasty mayan osteoplasty may convert the ridge toconvert the ridge to C-h. The treatmentC-h. The treatment plan then follows aplan then follows
  42. 42. Type 1 div C-hType 1 div C-h  requires anrequires an autogenous onlayautogenous onlay graft in the C-w archgraft in the C-w arch to restore the ridge toto restore the ridge to Division A. Type IDivision A. Type I Division C-hDivision C-h edentulous arches doedentulous arches do not present all thenot present all the essentialessential requirements forrequirements for predictable long-termpredictable long-term implant support forimplant support for fixed prostheses . Anfixed prostheses . An implant-supportedimplant-supported removable prosthesisremovable prosthesis is often indicated tois often indicated
  43. 43. Type I Division DType I Division D the mostthe most challenging tochallenging to traditional andtraditional and implant dentistry .implant dentistry . If implant fail? in aIf implant fail? in a Type I Division DType I Division D patient, pathologicpatient, pathologic fractures or almostfractures or almost unrestorableunrestorable
  44. 44.  Yet these are the patients whoYet these are the patients who need the most help for support ofneed the most help for support of their prosthesis. The benefitstheir prosthesis. The benefits versus risks must carefully beversus risks must carefully be weighed for each patient.weighed for each patient. Endosteal implants may beEndosteal implants may be placed in the anterior mandible.placed in the anterior mandible.
  45. 45. Type 2Type 2 In the Type 2 completely edentulousIn the Type 2 completely edentulous arch, the posterior sections of bonearch, the posterior sections of bone are similar but differ from the anteriorare similar but differ from the anterior segment. The most common archessegment. The most common arches in this category present less bone inin this category present less bone in the posterior regions, under thethe posterior regions, under the maxillary sinus, or over themaxillary sinus, or over the mandibular canal than in the anteriormandibular canal than in the anterior segment in front of these Structures.segment in front of these
  46. 46.  These types ofThese types of edentulous ridges areedentulous ridges are described in thedescribed in the completely edentulouscompletely edentulous classification with twoclassification with two Division letters followingDivision letters following Type 2, with the anteriorType 2, with the anterior segment being listed firstsegment being listed first because it oftenbecause it often determines the overalldetermines the overall treatment plan.treatment plan.
  47. 47.  Therefore a mTherefore a maandiblendible with Division Bwith Division B between foraminabetween foramina and Division c distaland Division c distal to the mandibularto the mandibular foramen is calledforamen is called Type 2 DivisionB,CType 2 DivisionB,C arch. The anteriorarch. The anterior region is often theregion is often the only segment used foronly segment used for implant support.implant support.
  48. 48.  The Type 2 DivisionThe Type 2 Division A, B arch hasA, B arch has posterior sections thatposterior sections that may be treated withmay be treated with narrow-diameternarrow-diameter implants, whereas theimplants, whereas the anterior section isanterior section is adequate for largeradequate for larger diameter root formdiameter root form implants to supportimplants to support the prosthesisthe prosthesis
  49. 49. Type 3 ArchType 3 Arch In this the posterior section ofIn this the posterior section of maxilla or mandible differ frommaxilla or mandible differ from each other . Less commoneach other . Less common condition. Found more frequentlycondition. Found more frequently in maxilla than mandiblein maxilla than mandible Anterior bone volume is firstAnterior bone volume is first listed then rt post followed by leftlisted then rt post followed by left posteriorposterior
  50. 50. Type 3 Div A,B,DType 3 Div A,B,D  Has abundantHas abundant anterior bone (A),anterior bone (A), moderate bone inmoderate bone in post rt (B), severepost rt (B), severe atrophy in the left postatrophy in the left post region (D)region (D)  Sinus graftingSinus grafting required in maxilla.required in maxilla.  In mand additionalIn mand additional implant in ant sectionimplant in ant section with cantilever .with cantilever .
  51. 51. Type 3 Div C,D,CType 3 Div C,D,C  Ant section C, severeAnt section C, severe atrophy on one sideatrophy on one side of postof post  In mand subperiostealIn mand subperiosteal implant indicated.implant indicated.  In maxilla sinus graftIn maxilla sinus graft & subnasal elevation& subnasal elevation indicatedindicated
  52. 52.
  53. 53.
  54. 54. OVERDENTUREOVERDENTURE TREATMENTTREATMENT OPTIONSOPTIONS There are 5 treatment optionsThere are 5 treatment options for mandibular overdenturefor mandibular overdenture patient. They range frompatient. They range from primarily soft tissue support andprimarily soft tissue support and implant retention to aimplant retention to a completely implant-supportedcompletely implant-supported prosthesis with rigid stability.prosthesis with rigid stability. The patient's complaints,The patient's complaints, anatomy, desires, and financialanatomy, desires, and financial commitment determine thecommitment determine the amount of implant supportamount of implant support required to predictably addressrequired to predictably address these conditions. The amount ofthese conditions. The amount of implant support designed in theimplant support designed in the restoration is related therestoration is related the number and position of thenumber and position of the implants .implants .
  55. 55.
  56. 56. OverdentureOverdenture OptionOption OneOne  The first treatment option for mandibular overdenturesThe first treatment option for mandibular overdentures (OD-I) is indicated primarily when cost is the most(OD-I) is indicated primarily when cost is the most significant patient factor. However, the patient's desiressignificant patient factor. However, the patient's desires must be minimal. The posterior ridge form should be anmust be minimal. The posterior ridge form should be an  inverted U shape, with high parallel walls for good-to-inverted U shape, with high parallel walls for good-to- excellent anatomic conditions for conventional dentureexcellent anatomic conditions for conventional denture retention, support, and stability'. The problem associatedretention, support, and stability'. The problem associated with the existing denture relates only to the amount ofwith the existing denture relates only to the amount of retention. Under these conditions, two implants may beretention. Under these conditions, two implants may be inserted in the B and D positions. The implants remaininserted in the B and D positions. The implants remain independent of each other and are not connected with aindependent of each other and are not connected with a superstructure. The most common type of attachmentsuperstructure. The most common type of attachment used in OD-I is an O-ring design.used in OD-I is an O-ring design.  It is a much better prosthetic option in OD-I to have theIt is a much better prosthetic option in OD-I to have the implants in the B and D positions rather than in the Aimplants in the B and D positions rather than in the A and E regions.and E regions.
  57. 57.
  58. 58.
  59. 59. OD 1OD 1  Advantage- economicAdvantage- economic  Existing prosthesis canExisting prosthesis can be rebasedbe rebased  In conditions of poor ridgeIn conditions of poor ridge & insuffecient space& insuffecient space  Dis adv-Dis adv-  Relatively poor implantRelatively poor implant support & stabilitysupport & stability  Cant prevent posteriorCant prevent posterior bone loss.bone loss.
  60. 60.
  61. 61. Option 2Option 2  Implants in B & DImplants in B & D position, joined rigidlyposition, joined rigidly by a a bar.  Used only when idealUsed only when ideal posterior ridge form isposterior ridge form is present.present.  More economicMore economic  Retention & minorRetention & minor stability is provided.stability is provided.
  62. 62.
  63. 63. O D 3-1O D 3-1  Implants in positionImplants in position A,C,E positions ,A,C,E positions , rigidly joined by a barrigidly joined by a bar if posterior ridge formif posterior ridge form is good.  This providesThis provides retention & moderateretention & moderate stabilitystability
  64. 64.
  65. 65.
  66. 66. O D 3-2O D 3-2  Implants in B,C ,DImplants in B,C ,D position & rigidlyposition & rigidly joined by bar whenjoined by bar when posterior ridge is poorposterior ridge is poor  Div C-h anterior boneDiv C-h anterior bone volume is presentedvolume is presented  Retention & minorRetention & minor stability present.stability present.
  67. 67. O D - 4O D - 4  Implants in A B D EImplants in A B D E positions rigidly joinedpositions rigidly joined by bar rigidly &by bar rigidly & cantilevered distallycantilevered distally about 10 mmabout 10 mm  Indicated whenIndicated when desires majordesires major retention, stabilityretention, stability
  68. 68.
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  73. 73. O D - 5O D - 5  Implants placed inImplants placed in A,B,C,D,E positionsA,B,C,D,E positions rigidly joined by a barrigidly joined by a bar cantilevered distallycantilevered distally about 15mmabout 15mm  Indicated when ptIndicated when pt demands highdemands high retention ,stability &retention ,stability & supportsupport
  74. 74.
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  76. 76.                                                                                                                                                                               
  77. 77. End of part 1End of part 1
  78. 78. .                                                                                                       To the left you can see a clinical picture of aTo the left you can see a clinical picture of a toothless lower jaw. Many patients are alltoothless lower jaw. Many patients are all too familiar with this type of situation. Thetoo familiar with this type of situation. The traditional method of replacing teeth in thistraditional method of replacing teeth in this scenario was to make a fullscenario was to make a full denturedenture, which, which usually never quite satisfies a patient who isusually never quite satisfies a patient who is used to having teeth. On a ridge like the oneused to having teeth. On a ridge like the one on the right, a patient would have a lot ofon the right, a patient would have a lot of trouble with actually retaining the denture,trouble with actually retaining the denture, let alone chew with it at a satisfactorilylet alone chew with it at a satisfactorily level.level.                                                                                                                                                                
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  110. 110. Prosthodontic phaseProsthodontic phase
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  118. 118. Thank you For more details please visit