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allow room for the implants, together with were placed with a large thickness of
the housings for the retentive mucoperiosteum remaining, which
components. Even mildly divergent resulted in relatively tall transmucosal
implants will increase the incidence of elements. One consequence of this was
fracture and wear of the retentive an unfavourable suprastructure to
components (Figure 3). implant ratio, resulting in bone loss
The buccal–lingual positioning of the adjacent to the distal implants; another
implants is critical (Figure 4). Implants was that the tall transmucosal element led
placed away from the centre of the ridge to the development of a long epithelial
Figure 1. An example of divergent implants. may cause the overdenture to encroach junction which is poorly attached to the
into the tongue space or distend the titanium abutment. This may result in the
labial/buccal soft tissues. This may lead development of a pocket that is difficult
to ulceration or instability of the to clean (Figure 7 b and c); subsequently
prosthesis. Many of these positional soft tissue hyperplasia can develop.
complications can be avoided by the use When using an overdenture there is no
of a surgical stent (Figure 5) – a clear advantage in placing the implant well
acrylic denture, often manufactured by below the mucosal cuff, as the emergence
copying the original denture. The profile is of less importance in this
prosthetist can indicate to the surgeon situation.
optimal implant position and alignment
Figure 2. Split-bar as a solution to the divergent
implants shown in Figure 1. by preparing pilot holes in the stent. The
stent shown in Figure 5 is designed to RESTORATIVE PROBLEMS
give the surgeon some flexibility in
deciding the final implant position.
There is little doubt that the longer the Temporization Phase
implant the higher the chance of success. Tissue conditioners are often used to
Wider implants, which contact the outer reline the existing denture during the
and inner cortical bony plates, may also healing phase, but they require frequent
be advantageous. Short implants, which replacement and maintenance. The
are often used in the maxillary ridge placement of healing abutments at
because of poor bone volume, can lead to exposure necessitates further extensive
Figure 3. Damaged rubber ‘O’-rings, possibly as an imbalance in the implant abutment modification of the patient’s existing
a result of mildly divergent implants.
ratio (Figure 6). With the overdenture in denture. Such alterations may weaken the
place, the resulting torque can lead to denture, leading to fracture. It may be
high cantilevering forces. The use of necessary to consider the use of some
acceptable implant alignment. short implants has been associated with form of strengthener within the patient’s
When restoring implants placed in the an increased rate of bone loss and denture at this stage. If cobalt chromium
maxilla, the implants should be splinted eventual implant failure.12,13 has been used as the denture base
by means of a bar. This will ensure that Figure 7a demonstrates an atrophic material in the original denture,
occlusal loads are shared more mandible where three short implants have adjustments may be extremely difficult
favourably to the linked implants. To been placed to support a bar-retained and in some cases construction of a new
restore markedly divergent implants, overdenture. In this case the implants acrylic temporary denture may be
some systems may require the
connecting bar to be of a split design in
order to allow different paths of insertion.
This increases the complexity and cost of a b
the technical work and reduces the
number of implants that are splinted
together (Figure 2).
Malaligned implants can compromise
the oral hygiene, as access may be
difficult because of the close proximity of
the anchorage and abutment or conflict
with the lip or cheek or tongue. In
Figure 4. (a) Lingually placed implant causing trauma to the lingual frenal attachments. (b)
addition, the bulk of the final overdenture
Labially placed implants supporting magnets.
may have to be increased in order to
may also lead to a thin weak denture, of the necessity for regular reviews.14
which will be prone to fracture (Figure 8). There are three commonly used
Patients with a clenching or grinding techniques for retaining overdentures:
habit will rapidly wear down or fracture
acrylic teeth. The use of teeth with a hard bar and retentive clips;
wear resistance surface (for example magnets;
Ivoclar-Vivadent teeth; Ivoclar-Vivadent ball attachments with various retentive
UK Ltd, Leicester, UK) will reduce the elements housed in the denture.
incidence of this problem. Bruxists also
Figure 5. Clear copy of maxillary denture apply high non-axial loads to the implants The maintenance factors of each are
modified to form a maxillary stent. via the prosthesis and attachments. This discussed below.
may be especially important if the
implants are not splinted in the maxilla. Bar and Clip Design
Restoring one arch with an implant- Walmsley13 stated that the bar and clip
retained prosthesis, which generates design is relatively costly in clinical and
higher occlusal forces, can result in the technical time. The most common
patient becoming more aware of the prosthetic complication that can arise is
limitations of the opposing denture. This fracture of the clip or loss of retentive
now becomes a source of complaint, and capacity. This is one of the main reasons
relines and remakes may be necessary. for patient re-attendance. The clip may be
of metal or plastic. The metal clip is
usually more durable and easily adjusted
Maintenance to improve retention, but can be prone to
Figure 6. Failing maxillary implant, possibly due to
occlusal overload on short implants in vascular bone. There is already a large body of evidence fracture (Figure 9) and the bar can wear.
that overdentures require significant The use of plastic clips is
necessary: this requires pre-planning. postinsertion maintenance: during the advantageous as they are more easily
Patients undergoing more complex first year after insertion, a higher than replaced and usually less expensive than
surgery, such as ridge augmentation, expected number of review visits were metal. In addition, plastic clips may
before or at the time of implant placement, required to adjust attachments and ease produce less wear of the metal bar than
present particular difficulties during the dentures in a number of studies.1,7,14 metal clips.16 If the plastic clip becomes
temporization phase. Radical denture Workers have reported as many as 25% non-retentive it usually requires
adjustment followed by frequent relines of maxillary overdentures failing within replacement; the complexity of this
using tissue-conditioning materials may the first 3 years.15 This high maintenance procedure depends on the system in
be required. The patient must be warned should be explained to the patient at the question. With many systems, the clips
of the difficulties they are likely to start of treatment so that they are aware are retained by a metal plate secured in
experience through the initial healing
period.
a b
Impression Stage
It is important to realize that, although the
denture is implant-retained, standard
prosthetic principles apply. It is essential
to record an accurate mucocompressive
impression of the free-end saddle to
distribute the masticatory loads evenly
and reduce rocking around the
attachments. Greenstick low-fusing c
impression compound in a special tray Figure 7. (a) Radiographic appearance of
can be very useful in achieving this result failing Brånemark implants. (b)
when recording the working impression. Inflammation around failing implants. (c)
The transmucosal element with debris
clearly visible around the neck.
Occlusal Problems
Lack of interocclusal space restricts the
type of attachment that can be used. It
Int J Oral Maxillofac Implant 1999; 14: 646–653. of hydroxylapatite coated implant retained fixed
4. Zitzmann NU, Marinello CP. Implant-supported and removable mandibular prostheses over 4 to
removable overdentures in the edentulous 6 years. Clin Oral Implant Res 2001; 12: 159–166.
maxilla: Clinical and technical aspects. Int J 12. Engquist B, Bergendal T, Kallus T et al. A
Prosthodont 1999; 12: 385–390. retrospective multicenter evaluation of
5. Goodacre CJ, Kan JYK, Rungcharassaeng K. osseointegrated implants supporting
Clinical complications of osseointegrated overdentures. Int J Oral Maxillofac Implant 1988;
implants. J Prosthet Dent 1999; 81: 537–552. 3: 129–134.
6. Watson RM, Jemt T, Chai J et al. Prosthodontic 13. Walmsley AD, Frame JW. Implant supported
treatment, patient response, and the need for overdentures – the Birmingham experience. J
maintenance of complete implant-supported Dent 1997; 25: 43–47.
overdentures: an appraisal of 5 years of 14. Jemt T, Book K, Linden B, Urde G. Failures and
Figure 12. Replacement of small metal clip,
prospective study. Int J Prosthodont 1997; 10: complications in 92 consecutively inserted
which is easily damaged during normal function. 345–354. overdentures supported by Brånemark implants
7. Chan MFW-Y, Johnston C, Howell RA. in severely resorbed edentulous maxillae: A study
A retrospective study of the maintenance from prosthetic treatment to first annual check-
requirements associated with implant stabilised up. Int J Oral Maxillofac Implant 1992; 7: 162–167.
mandibular overdentures. Eur J Prosthodont 15. Hutton JE, Heath MR, Chai JY et al. Factors
ACKNOWLEDGEMENTS Restor Dent 1996; 4: 39–43. related to success and failure rates at 3-year
We are grateful for the support from the Department 8. Watson RM, Davis DM. Follow up and follow-up in a multicenter study of overdentures
of Medical and Dental Illustrations, Leeds Dental maintenance of implant supported prostheses: a supported by Brånemark implants. Int J Oral
Institute. comparison of 20 complete mandibular Maxillofac Implant 1995; 10: 33–42.
overdentures and 20 complete mandibular 16. Walton JN, Ruse ND. In vitro changes in clips and
fixed cantilever prostheses. Br Dent J 1996; 181: bars used to retain implant overdentures. J
321–327. Prosthet Dent 1995; 74: 482–486.
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1. Hemmings KW, Schmitt A, Zarb GA. Complications Adjustments and complications of mandibular DV. A 5-year prospective randomized clinical trial
and maintenance requirements for fixed overdentures retained by four implants. A on the influence of splinted and unsplinted oral
prostheses and overdentures in the edentulous comparison between superstructures with and implants retaining a mandibular overdenture:
mandible: A 5-year report. Int J Oral Maxillofac without cantilever extensions. Int J Prosthodont prosthetic aspects and patient satisfaction. J Oral
Implant 1994; 9: 191–196. 1998; 11: 307–311. Rehab 1999; 26: 195–202.
2. Davis DM. Implant supported overdentures – 10. Walton JN, MacEntee MI. A retrospective study 18. Naert I, Quirynen M, Hooghe M, Steenberghe D.
the Kings experience. J Dent 1997; 25: S33–S37. on the maintenance and repair of implant- A comparative prospective study of splinted and
3. Cooper LF, Scurria MS, Lang LA et al. Treatment supported prostheses. Int J Prosthodont 1993; 6: unsplinted Brånemark implants in mandibular
of edentulism using Astra Tech Implants and ball 451–455. overdenture therapy: A preliminary report. J
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Periodontics: Current Concepts and The Periodontium in Health and The chapter ‘Peri-implantitis’ covers,
Treatment Strategies. By P.N. Galgut, Disease Reasons for failure, Implant management
S.A. Dowsett and M.J. Kowolik. Martin Epidemiology in the Study of in practice (including monitoring and
Dunitz Ltd, London, 2000 (208pp., Periodontal Disease management), Instrumentation and
£49.95). ISBN 1-85317-981-7. The Microbiology of Periodontal management of the failing implant. As
Diseases more implants are being placed, it is
Periodontology is a fast moving subject The Host Response in Periodontal inevitable that we will all see more failed
and, although some of the basic Diseases cases in our routine practice, and
principles of treatment haven’t Systemic Influences and Periodontal information on how to manage such cases
changed, there is an ever increasing Health is obviously very helpful.
amount of new research, which has Gingival Disease and Hyperplasia The final chapter gives insights into
implications about how we treat our Early Onset Periodontal Disease where research might be leading in the
patients. Diagnosis and Treatment Planning in next few years, and includes sections on
It’s important that students, general the Periodontitis Patient Advances in diagnosis, Risk factors,
practitioners and specialists keep up- Mechanical Treatment of Periodontal Therapeutics and tissue repair.
to-date with current research, which Diseases In summary, this colour hardback
can be difficult with the ever increasing The Role of Surgery in Periodontal textbook is clearly written and well
number of research papers published. Treatment illustrated and offers anyone with an
So any textbook that offers a review of Chemotherapeutic Agents in the interest in this specialty a fascinating
the subject is welcomed. Management of Gingivitis and update, and I would thoroughly
This textbook gives an overview of Periodontal Diseases recommend it.
current research and its implications Restorative Considerations in the Mike Milward
from a clinical point of view. The book Periodontitis Patient Birmingham Dental School