implant supported complete denture/ cosmetic dentistry training

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

CONTENTS
1. INTRODUCTION
2. HISTORY AND EVOLUTION OF ORAL
IMPLANTOLOGY
3. TYPES OF IMPLANTS
4. MAXILLARY - COMPLETELY
EDENTULOUS RESTORATIVE OPTIONS

A) MAXILLARY FIXED DETACHABLE
PROSTHESIS
DEFINITION
ADVANTAGES
DISADVANTAGES
DESIGN CONSIDERATIONS
MAXILLO-MANDIBULAR RELATION
CLASS I
CLASS II
CLASS III

B) MAXILLARY OVERDENTURE
PROSTHESIS
DEFINITION
ADVANTAGES
DISADVANTAGES
DESIGN CONSIDERATIONS

5. MANDIBULAR - COMPLETELY
EDENTULOUS
A) FIXED DETACHABLE PROSTHESIS
ADVANTAGES
DISADVANTAGES
NUMBER OF IMPLANTS
IMPLANT PLACEMENT
CANTILEVER LENGTH
DESIGN

B) MANDIBULAR OVERDENTURE
REVIEW OF LITERATURE
ADVANTAGES

6. OCCLUSAL CONSIDERATIONS
7. CONCLUSION
8. BIBLIOGRAPHY

The use of osseointegrated implants in
edentulous patients was first developed Dr. Per-
Ingvar Brànemark and the type of restorative
treatment studied was by using the fully
jawbone anchored prosthesis. The term used by
Branemark and others is “Tissue-Integrated
Prostheses” (Brànemark et al.,1985).

“CONCEPT OF OSSEOINTEGRATION”
Dr. Per-Ingvar Branemark
Orthopaedic surgeon
Professor University of Goteburg, Sweden.
Threaded implant design made up of pure titanium.

After fixture placement, healing, and subsequent
prosthesis insertion, the bone level reaches a “steady
state” (Brànemark et al., 1985). This is a balance
between forces transmitted through the prosthesis and
fixtures, and bone remodeling capabilities. The
resorptive process can be controlled with proper fixture
placement to prevent rampant resorption while offering
the patient a high quality, functional prosthesis.

Many fabrication methods for fully bone anchored
prostheses are introduced (Loos, 1986; Lundqvist,
Carlsson, 1983; Parel et al., 1986; Rasmussen, 1987;
Siirila et al., 1988; Zarb et al., 1987; Zarb, Jansson,
1985; Zarb, Symington, 1983).
Treatment planning is essential for successful results
and is an integral part of good communication between
the surgeon and the prosthodontist or restorative
dentist.

In particular, treatment planning for the maxillary
arch is critical and requires good communication.
Since the fully bone anchored prosthesis may not
obturate the space between the prosthesis and
residual tissues, air flow pattern produced during
speech is unimpeded. This might present problems
for the patient if their occupation requires good
speaking abilities.

Also if there has been severe resorption in the
maxilla, esthetic results are difficult due to the added
amount of material needed to replace missing
anatomical structure. Lip support may be insufficient
in the area of space between the prosthesis and
tissues. When discussing treatment alternatives with a
patient, be certain to discuss advantages and
disadvantages of each option.

For the patient with high esthetic demands, consider
overdenture treatment for the maxilla (Parel, 1986).
However, many patients prefer bone anchored
prostheses to satisfy functional demands.

Any object or material, such as an alloplastic
substance or other tissue, which is partially
or completely inserted or grafted into the
body for therapeutic, diagnostic, prosthetic,
or experimental purposes
GPT 8

A prosthetic device made of alloplastic
material(s) implanted into the oral tissues
beneath the mucosal or/and/ periosteal layer,
and on/or within the bone to provide retention
and support for an fixed or removable dental
prosthesis.
A substance that is placed into or /and upon the
jaw bone to support a fixed or removable dental
prosthesis.
GPT 8

HISTORICAL REVIEWHISTORICAL REVIEW

HISTORY
AND
EVOLUTION OF
ORAL IMPLANTOLOGY
Dental implant history dates back thousands of years and
includes civilizations such as the ancient Chinese, who
4000 years ago inserted bamboo into the jaw bone for fixed
tooth replacements.

The Eygptians and, later, physicians from Europe used
ferrous and precious metals for implants over 2000
years ago, and the Incas used pieces of sea shell,
inserted into the jaw bones to replace missing teeth.
600A.D: First evidence of use of implants; in mayan
population, Pieces of shell to replicate 3 lower incisors.

In the 1700’s: John Hunter; Transplantation of incompletely
Developed tooth into the comb of a Rooster.
In the 1800’s: Transplantation fell into dispute because of
disease transmission & rejection.
1809: Maggiolo: Gold root into extraction socket to support
teeth.

1911: Greenfield; Iridioplatinum basket implant soldered with
24 karat gold solder.
1939: Strock; Vitallium screw implant.
Mid 1940’s: Foramiggini; Stainless steel spiral implant.

SUBPERIOSTEAL IMPLANT
Mid 1943: Dahl used first Superiosteal Implant; Bulky, flat, abutment
and screw.
Mid 1948: Goldberg and Gerskkoff; Extension of the framework to the
external oblique region.
Mid 1952: Lew: Direct impression technique; Fewer struts on crest of
ridge.
In 1950’s: Bodine; More secondary struts.
1959: Lew; Minimum bulk, simple tapered abutment as transmucosal
abutment.

Mid 1950’s: Lee; Endosseous implant with central post and
circumferential extension
Early 1960’s: Chercheve; Double-helical spiral implant (Co-Cr)
Early 1960’s: Scialom; Tripodial endosseous pin arrangement.
Early 1960’s: Orlay; Vitallium post-endodontic implants.

Early 1960’s: Linkow; Ventplant implants self-tapping endosseous
screw implants.
Early 1960’s: Linkow; Blade vent implants.
Mid 1960’s: Sandhaus; Crystalline bone screw (Aluminum oxide)
In 1970’s: Roberts and Roberts; Ramus frame implants.
1973: Grenoble; Vitreous carbon Implants
1978: Small; Mandibular Staple implant

1986: Tatum; Omni R-implant (Titanium alloy root from
implant)
1973: Weiss and Judy; Intramucosal inserts
Early 1980’s: Nichnick: Core Vent Implants;
a) Hollow Basket Implant
b) Screw Vent Implant
c) Hydroxyapatite Coated Implant
In 1980’s: Driskell; Stryker root form implants (Titanium alloy
& Hydroxyapatite coated).

Late 1970’s: Krisch: IMZ implant; Titanium plasma spray &
intramobile element.
Early 1980’s: Calcitek corporation; Synthetic poly crystalline
ceramic hydroxyapatite calcite implants.
1985: Straumann Company: ITI Implants; Plasma sprayed
cylinder & screw “one-stage operation”.

1700 – John hunter → “Transplantation”
Transmission of various diseases

1809-Maggiolo
Gold roots
1939-Strock
Vitallium screw

1943 - Dahl 1948 - Goldberg and Gershkoff
Subperiosteal implant

1960 – Linkow Blade vent implant

• Inflammatory reaction
• Gradual bone loss
• Fibrous encapsulation

Classification of Implants :
1) Sub - periosteal implant
2) Transosteal implant
3) Endosseous implant
4) Endodontic or Diodontic implant
5) Intramucosal implant

Classification :
Based on placement within the tissues
Sub - Periosteal Implants
Transosteal Implants
Endosteal Implants

Sub Periosteal Implant :
an implant that is placed beneath the
periosteum of the bone.
It receives it’s primary bone support by
resting on it.
This implant does not osseointegrate.

They may be fabricated by making a direct bone
impression. They may be used in any part of either
jaw, and will serve as abutments for a variety of
prosthetic configurations, although the overdenture is
the most widely used to complement the complete
subperiosteal implant.

Prosthetic options: overdentures, fixed bridges.
Suitable arch: Maxillary or mandibular, completely or
partially edentulous
Required bone:
5mm
or mandibular augmentation is required.

Extremely thin (pencil-like) mandibular and maxillae
may permit subperiosteal implants to settle through
them. Therefore, seek a moderate amount of vertical
bone height (at least 5mm), or make plans to augment
the inferior mandibular border or elevate the antral
floor on a preventive basis.

Use of subperiosteal implants, which generally
are quite reliable, when sufficient bone is
unavailable for the use of endosteal varieties.
However, when extreme mandibular atrophy
exists, mandibular augmentation further
improves the prognosis.
Subperiosteal implants are always custom
made.

Transosteal Implants : an dental implant that penetrates both
cortical plates and passes through the entire thickness of the
alveolar bone.

Transosteal implants are one-piece, transmandibular
complex implants or are available as individual
abutments.
One advantage of using the transosteal implant is
predictable longevity. Several designs are available:

Single component:
Multiple component, staple designs (several varieties)
Prosthetic options: the usual application for these
implants is to support an overdenture. Fixed bridges
are rarely made as alternative.
Suitable arch: Mandible, anterior region, completely
or partially edentulous (single component may be used
in the presence of adjacent teeth).

Required bone:
6-mm vertical bone height
5-mm bone width (labial to lingual)

Endosseous Implant : an implant that
is present within the bone , extends into
basal bone for support.
Types : Screw form
Cylinder form (Hollow,Solid)
Blade form

Endosseous implant
1) Blade form or Plate
form
2) Root form implants
Screw ( V-thread, Buttress
thread, Power or square
thread)
Cylinder ( Hollow or Solid ) Endosseous, root
form, screw type,
power thread
Endosseous, root form,
tapered, hollow,
cylindrical,

Root Form Implants:
Given sufficient width and height of the bone
available, root forms (submergible, two-stage and
single-stage, one-piece) are the first choice in selecting
an implant. The following types are available:
Press-fit (unthreaded but covered with a roughened
hydroxyapatite [HA] or titanium plasma spray coating
[TPS])
Self-tapping (threaded)
Pre-tapping (threaded)

Prosthetic options: Prostheses may be supported by
fixed, fixed-detachable, overdenture, and single tooth
purposes (antirotational design required).
Required bone:
8-mm vertical bone height
5.25-mm bone width (buccal to lingual)

Blade Implants:
Blade implants are available as submergible. two-stage
and single-stage, one-piece devices as follows:

Ramus Blade and Ramus Frame:
The ramus implant is a one-piece blade made for use
in the posterior mandible when insufficient bone exists
in the body of this jaw. The ramus frame is a three-
blade, one-piece device designed for relatively
atrophied mandibles for which the subperiosteal
implant, because of cost or operator preference, is not
desirable.

Prosthetic option: overdentures
Suitable arch: mandibular. completely edentulous
Required bone:
6-mm vertical bone height (symphysis, rami)
3-mm bone width (buccal to lingual)

Other Implants:
Endodontic Stabilizers:
Endodontic stabilizers are highly successful, tooth
root-lengthening implants. One reason for their
success is that they have no site of permucosal
penetration because they are placed into bone through
the apices of natural teeth.

This implant offers a one-stage treatment for the
stabilization of teeth that suffer from inadequate
crown-root ratios. Their percentage of success when
periodontal problems have been treated approaches
that of conventional endodontic therapy.
Prosthetic options: Crowns and fixed bridge
abutments

Suitable arch: Maxillary or mandibular; any tooth may
be treated.
Required bone: 8mm of lesion-free bone in direct
proximity to apex-within the long axis of the recipient
root canal.

Intramucosal Inserts:
Intramucosal inserts are buttonlike, nonimplanted
retention devices that can be used to stabilize full and
partial maxillary and mandibular removable denture
prostheses. Because of the simple and relatively
noninvasive nature of the procedure placement, they
are of particular value for patients who are poor
medical risks.

Prosthetic options: Removal denture, full or partial
Suitable arch: maxillary, completely or partially
edentulous; mandibular partial only.
Required bone: none; required mucosa, 2.2mm thick
(bone beneath thinner mucosa may be deepened in
nonantral area)

Bone Augmentation Materials, including Guide Tissue
Regeneration Membranes:
Use bone augmentation materials for ridge
maintenance after dental extractions, for ridge
augmentation, for periodontal and periimplant repair
and support, and for maxillofacial surgical onlay and
inlay purposes when bone replacement is required.

None but autogenous bone and possibly bone
morphogenic protein (BMP) is osteogenic.
Demineralized freeze-dried bone (DFDB) is said to be
osteoinductive.

Doped surfaces that contain various types of bone growth factors or
other bone-stimulating agents may prove advantageous in
compromised bone beds. However, at present clinical documentation
of the efficacy of such surfaces is lacking : BMP = Bone
morphogenetic protein.
Doped surfaces

Ceramic:
Resorbable, tricalcium phosphate (TCP)
Nonresorbable: hydroxyapatite
Porous particulate and block forms
Nonporous particulate and block forms
Block are available as particles held together in
resorbable collagen media, strung like beads with
polyglycolic acid suture or supported in a matrix of
calcium sulfate (plaster of Paris-Hapset)

Polymeric:
Hard tissue replacement (HTR) particulate and porous
block forms
Biologic:
Autogenous bone
Irradiated bone
DFDB (Decalcified Freeze Dried Bone)
Bovine (i.e., BioOss)
Membranes: Resorbable and Nonresorbable

MAXILLARY - COMPLETELY EDENTULOUS:
Goal:
Identify patient’s need for a removable or fixed
prosthesis. This is critical because a patient’s need will
dictate the design of the prosthesis and may affect the
number of implants placed. For instance if the patient's
chief complaint is dislike of the removable aspect of the
existing denture, then a fixed prosthesis must be
planned. This often includes more implants and careful
planning.

Restorative Options:
A) Maxilla fixed-detachable prosthesis:

Definition: “An implant-supported prosthesis that is
fixed and not removable by the patient. This prosthesis
is retrievable by the dentist by unscrewing the
retaining screws”

Advantages:
1. Predictability based on research
2. Fixedness
3. Retrievability
4. No palatal coverage
5. Usefulness for patients with significant maxillary
resorption.
6. The metallic components will not be as likely to
show with severe resorption, v hen combined with a
low smile line.

Disadvantages:
1. Maintenance is difficult owing to contours Created to
hide metal components.
2. Phonetic problems can result from air escape.
3. Esthetic problems are possible with short lip or high
smile line: the metal components may show.

4. Limitation on cantilever extension often make it
impossible to match occlusal planes and provide
adequate centric contacts with some skeletal
relations.
5. Profile cannot be altered with flange.
6. The potential site for implants is often only in the
anterior maxilla. If the implant end up in a straight
line, the cantilever is limited.

Design Considerations:
1. Number of implants:
At least four
Ideally six or more

MANDIBULAR - COMPLETELY EDENTULOUS:
Goal:
Determine whether the patient requires fixed or
removable prosthesis.

Presurgical needs:
1. Mounted diagnostic casts
2. Wax trial denture set-up
3. Surgical guide
4. Plan for prosthesis type and design, which will
determine implant placement.
5. Examination of smile line

If teeth are removed and implant placed soon, there is
little resorption of the vertical height of the mandible.
There is a potential for metal to show due to this lack
of resorption because the restoration and its
components will be more superior.

6. Radiographic needs
a. Panoramic radiograph: essential
All other radiographic aids utilized if additional
information necessary:
b. Occlusal
c. Periapical
d. Tomograms
e. Lateral cephalometric
f. Computerized axial tomograms

OCCLUSAL CONSIDERATIONS:
I. Completely Edentulous:
Maxilla: Complete denture, no implants
Mandible: complete denture, no implants
1. Nonbalanced occlusion
2. Balanced occlusion
a. Bilateral balanced-anatomic tooth
b. Lingualized occlusion
c. Monoplane-balanced

Mandible: overdenture, implants
a. Potential problem with unstable maxillary
complete denture
b. Bilateral balanced
c. Lingualized occlusion
d. Monoplane-balanced

Maxilla: Overdenture, implants
Mandible: overdenture, implants
a. Bilateral balanced
c. Monoplane-balanced

Mandible: Fixed detachable prosthesis, 4 to 6 implants
a. Potential problem with unstable maxillary complete
denture
b. Potential painful tissue under maxillary complete
denture
b. Lingualized

Maxilla: fixed detachable prosthesis, 4 to 6 implants
Mandible: fixed detachable prosthesis, 4 to 6 implants
1. Anterior group function
a. Simultaneous contact on anterior and posterior
teeth in centric - goal is force over the implants. This
is often difficult to achieve with a class II
malocclusion patient due to lack of anterior occlusion
contact.
b. Contact on multiple teeth and over multiple
implants in laterotrusion and protrusion.
c. No force or contact on cantilever laterotrusion and
protrusion.
d. Avoid all contact on one tooth or one implant.

II. Completely and Partially Edentulous:
Maxilla: complete denture, no implants
Mandible: dentulous with implant-supported partial
denture (teeth + implants)
1. The goal is balanced occlusion (in order to stabilize
the maxillary complete denture

2.This is difficult to accomplish with natural
teeth.

Maxilla: overdenture, implants
Mandible: dentulous with implant-supported
fixed partial denture (teeth + implants,)

1. If the overdenture is totally implant supported,
avoid contact in laterotrusion on teeth distal to last
implant. It is a cantilever and may place excessive
load on the implants.
2. If the overdenture is joint implant and mucosal
supported, the goal is bilateral balanced or
Lingualized occlusion. This is difficult with natural
teeth.

Maxilla: fixed detachable prosthesis, implants
Mandible: dentulous with implant-supported fixed
partial denture (teeth + implants)
1. In laterotrusion and protrusion, avoid contact on
cantilever.
2. In laterotrusion and protrusion, contact is on
multiple teeth over multiple implants.
Avoid placing all contact on one implant.

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For many years, traditional complete denture designs
have been modified to gain additional support and
stability from a few retained and suitably prepared
natural teeth.
Brànemark’s original prosthodontic protocol described
a screw-retained full-arch fixed prosthesis. This
clinical objective produced a prosthesis that was
literally attached to the arch, while remaining
electively removable.

The argument was made that, if the prosthesis were
inseparable from the patient, it would be perceived as
part of the patient and would therefore be the best
solution to the problem of unsatisfactory adaptation of
the complete denture experience. The biotechnological
achievement of osseointegration was justifiably
heralded as a major therapeutic breakthrough for
edentulous people.

Prosthodontists had previously developed an
ingenious repertoire of methods and techniques to
manage the edentulous condition.
Experience and observation had taught them that the
vast majority of their patients’ early years of denture
wearing were without major problems. With the use of
implants more stable and retentive dentures can be
given to the patient preserving the underlying alveolar
bone and increasing the proprioception.

1.Michael Norton: “Dental Implants. A Guide for the
General Practitioner”. 33-51.
2. Patrick J. Stevens, Edward J. Fredrickson, M.L.
Gress: “Implant Prosthodontics, Clinical Laboratory
Procedures” 2 Edn., 2000; 63-75
3. Sumiya Hobo, Eiji Ichida, Lily T. Garcia:
“Osseointegration and Occlusal Rehabilitation” 1989;
65-273, 153-161, 169-180, 197-230.
4. Carl E. Misch: “Contemporary Implant Dentistry”,
1999; 420.

5. Babbush CA: “Dental Implants: The Art and
Science “, Philadelphia, Pennsylvania, W.B.
Saunders Company, 1997.
7. Cranin AN: “Atlas of Oral Implantology” St
Louis, Missouri, Mosby, 1999.
12. Watzek G: “Endosseous Implants:
Scientific and Clinical Aspects”, Chicago,
Illinois, Quintessence Publishing 1996.

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