Over Denture

A few well-placed implants can really improve the retention and stability of a removable denture. Many people find lower full dentures in particular, extremely difficult to manage but notice immediate improvement once they have some implant support. Placing the implants in the jaw bone is a relatively simple procedure and, once done, can be used to stabilise a denture, whether it be an existing one or a new one. Because the implants are usually at the front of the mouth, the denture still needs to be well shaped for maximum benefit.

A few well‐placed implants can really improve the retention and stability of a removable denture. Many people find lower full dentures in particular, extremely difficult to manage but notice immediate improvement once they have some implant support. Placing the implants in the jaw bone is a relatively simple procedure and, once done, can be used to stabilise a denture, whether it be an existing one or a new one. Because the implants are usually at the front of the mouth, the denture still needs to be well shaped for maximum benefit.




Overdenture

Lower arch attachments

Main Features

1. Removable overdenture

2. Stabilized on two implants and ball

3. Inexpensive

4. Removable, simple and convenient solution for immediate function

5. Good stabilisation (implant and ball‐abutment)

6. Applicable to existing denture



High patient acceptance potential‐highly supported by evidence based dentistry.

Robert resisted having implants for many years and when he finally decided to do it, his comment was “after all these years I can finally chew a steak!”



Note that the mouth is wide open without the tongue holding the denture in place.

The McGill Consensus Statement of 2002 states that a mandibular two‐implant overdenture should be the first choice standard of care for edentulous patients.

The McGill consensus statement on overdenture. (Quintessence Int. 2003;34(1):78‐9)

In 1997 the Faculty of Dental Surgery published guidelines on ‘Selecting appropriate patients to receive treatment with dental implants: priorities for the NHS’ (www.rcseng.ac.uk). This is an important document that explains the need for those patients struggling to function with a complete lower denture, the use of two dental implants in the lower canine regions (provided there is an adequate volume of bone of alveolar bone) is indicated. The McGill Consensus Statement of 2002 has been challenged by some clinicians who suggest that good lower denture is all the patient needs, however as a clinician, I am yet to see a patient who is happy with all the functions and comfort of a lower denture. However I have numerous patients who can testify improvement in comfort, function and confidence by 500% when implant retained overdenture is considered. I am sure you agree, otherwise you would not be reading this site!

Bar retained overdenture



Implant bar fixed to the four implants




Bar retained full lower denture intaglio surface


The lower overdenture fitted over the bar. This is a highly successful modality for all patients who find it difficult to cope with their full lower denture. However it is even more important for patients who have terminal lower dentition (few lower front remaining teeth) is to consider 2‐4 implants and overdenture correction. Once you reach the age of 50, it is difficult to adapt to removable dentures, let alone the full lower denture. This is irrespective of how good your dentist or prosthodontist is. It is all about you neuromuscular adaptation, which may be limited.

Note retracted tongue position providing no assistance to denture stability. This is because the implant bar retention is superb. Providing comfort, function and confidence.


Fixed bar‐retained overdenture, similar concept as a fixed hybrid bridgework, except the patient can remove and reinsert the overdenture. With removable options.



Patient was referred by his general dentist for options in using implant support‐retention on upper arch prosthesis (partial denture)as there is a presence of failed strategic abutment teeth that support and provide retention to chrome cobalt based partial upper denture.



Currently the patient was extremely comfortable with the removable upper denture: speech and aesthetics (level of tooth display, colour, and degree of gums showing) therefore, he requested to simply copy this denture shape outright.

We discussed at length all options: consideration initially of upper partial denture to be used in transition to full upper denture or no treatment at all. However patient has preferred implant supported upper overdenture or hybrid bridgework on the upper arch, depending on his speech pattern and general comfort. Both solutions (fixed bar on six implants supporting an upper removable‐foxed hybrid denture or fixed hybrid bridgework supported by six implants that cannot be removed by the patient) will provide optimal support.



Note the extent of tissue loss that requires reconstruction

The main deciding factor is speech and comfort. Patient is a professional puppeteer, therefore I feel, since speech comfort level lies with the current upper denture shape and outline, we may err towards fixed barremovable overdenture. However, with this concept, once the denture is “clicked” on to the bar, will give the same feeling of fixedness as fixed bridgework. Naturally the nylon retention units would require changing every 12 months, with minimal cost.

Note the residual ridge defects and the horizontal distance between upper edentulous ridge and lower teeth.

Unfortunately we need the initial support provided by the remaining upper teeth to the current denture. Loosing these teeth may affect the patient’s neuromuscular adaptation and coping mechanisms in adapting to new highly movable full upper denture: ultimately affecting his work. Therefore implant placement is advised ASAP as the upper teeth are about to fail. I was hoping that implants will integrate in 4‐6 months, just enough time, as the timing of losing the remaining upper teeth is limited.




X‐ray examination revealed that we have adequate bone to place at least six implants (fixed bar on six implants supporting an upper removable‐fixed hybrid denture or fixed hybrid bridgework supported by six implants).

In the maxilla (upper jaw) the research on bar‐overdenture is limited in the scientific literature. However since neuromuscular adaptation is the deciding factor for the patient’s work, fixed bar supported removable maxillary hybrid overdenture is planned. This will provide similar support, comfort and confidence as fixed hybrid implant supported overdenture.



The initial implant placement total of six implants placed, while maintaining the “failed” abutment teeth on upper right quadrant. This helps the patient to stabilize the denture for comfort, function, speech and aesthetics, while the implants are integrating with the bone.



Implants have healed and healing abutments as shown are connected to the implants(connecting the implants to the outside).


The implant bar is “bolted” to the implants. This is a highly rigid structure and configuration.




The implant bar in function for 3 years.


X‐Ray confirms stable bone levels. Patient maintains regular professional visits and home care.

3 years post op, stable bone levels are evident. Patient maintains an excellent level of oral hygiene.

The lower jaw implant therapy has been planned and will be treatment when our patient is ready.



The implant bar in function for 3 years.


Bar retained overdenture. Note yellow nylon clips and the channels in the intaglio surface of the overdenture that “grabs” the bar and fixes in place. However the patient can remove and reinsert the upper fixed/removable overdenture. This is exactly like a fixed bridge and replaces considerable missing hard & soft tissue.

This is no different from a fixed bridge and the palate is missing.



We have copied the patient’s existing upper partial denture in the final implant supported overdenture to enable the patient an easy transitional neuromuscular adaptation into the new fixed bar retained overdenture.



All above procedures( surgical implant placement and prosthetics) were performed by Dr Sarkis Nalbandian.

Below is a scholarly article presented for our readers showing that both maxillary fixed bridgework and baroverdenture both achieved high satisfactory result.

Treatment outcomes of fixed or removable implant‐supported prostheses in the edentulous maxilla. Part I: Patients’ assessments

Nicola U. Zitzmann Dr med dent, Carlo P. Marinello Dr med dent, MS

Statement of problem:

Distinct clinical parameters determine whether fixed or removable implant‐supported prostheses are indicated to restore the edentulous maxilla. However, there is a strong belief that fixed implant prostheses meet with greater patient acceptance and satisfaction, but this may differ from the patients’ perceptions, their psychological responses to treatment, and their assessments of the treatment outcome.

Purpose:

This prospective clinical study compared the treatment outcomes of fixed and removable implant‐supported restorations in the edentulous maxilla with the main emphasis on the patient’s point of view.

Material and methods:

Twenty patients who requested an implant‐supported superstructure to restore the edentulous maxilla were asked to complete a questionnaire measuring their satisfaction with the present situation and the psychological impact of their oral health status with their responses marked on a Visual Analog Scale (VAS). Ten patients were treated with a fixed, screw‐retained implant prosthesis (group 1), and 10 were treated with a removable, implant‐supported and bar‐retained overdenture (group 2). Six months after prosthetic rehabilitation, patients were again given the questionnaire to assess their psychological well‐being and satisfaction with the implant‐supported restoration.

Results:

Both prosthesis designs were associated with significant improvements in comfort and retention, function, aesthetics and appearance, taste, speech, and self‐esteem. No difference was found between the 2 groups with respect to how the patients assessed the implant therapy. However, the results indicated that patients in group 2 experienced greater differences between pre‐treatment and post‐treatment scores for the parameters aesthetics, taste, and speech. Treatment costs per unit were significantly higher in group 1 than in group 2.

Conclusion:

Patients in groups 1 and 2 were similarly satisfied with their implant‐supported prostheses in the edentulous maxilla with regard to their well‐being and the cost‐utility, irrespective of whether the restoration was fixed or removable. (J Prosthet Dent 2000; 83:424‐33.)

All above procedures were performed by Dr Sarkis Nalbandian.

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