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Overdentures

OVERDENTURES According to the glossary of prosthodontics terms, an overdenture is defined as a removable partial or complete denture that covers and rests on one or more remaining natural teeth, the roots of natural teeth and/or dental implants; a prosthesis that covers and is partially supported by natural teeth, natural tooth roots, and /or dental implants. An overdenture has also been referred to as overlay denture, overlay prosthesis or superimposed prosthesis. The overdenture is not a new concept and its use dates back 100years. Today with the stress on preventive measures the use of overdentures has increased to the point where it is now a feasible alternative to most treatment plan outlines in the fabrication of prosthesis for patients with some remaining teeth. NEED FOR OVERDENTURE When patients present with badly broken down teeth, grossly involved periodontal condition, teeth were extracted that could have been retained under more favorable conditions. This led to the complete denture with all its pitfalls. The most common being progressive deterioration in the fit of the denture due to residual ridge resorption that progresses in some cases at a very alarming rate. The dental cripple thus presented with a denture that had no appreciable residual ridge and therefore very little support and retention. This is where overdentures can make a distinct difference. HISTORY The idea of leaving roots to support an overdenture is far from new. IN 1856 Ledger constructed plates that covered the teeth and he referred
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the teeth to as fangs. In 1888 Evans described a method of using roots to retain restorations. In 1896 Essig described the telescope like coping after intentional devitalisation of the roots. Subsequently William Hunter put forward his focal sepsis theory and this dealt a great blow to the overdenture mode of treatment. The main point of contention was that the exposed roots act as foci of infection. Fortunately continental Europe did not share the enthusiasm of Hunter and associates. Miller published his classic article in 1958 where the retention of previously unusable teeth and their advantageous use in overdenture treatment was explained as a basic tenet in management. Before going on to the advantages of overdenture therapy we shall discuss the goals. There are three obvious but rather important goals. 1. It maintains teeth as part of residual ridge. This gives the patient a denture that has far more support than any conventional prosthesis. 2. There is a decrease in the rate of bone resorption. If the teeth are preserved then alveolar bone resorption is naturally retarded. A study by Crum and Crooney compares bone loss between patients with conventional dentures and overlay dentures. They concluded that by preserving the mandibular canines, the resorption rate is reduced 8 times. 3. The third goal achieved is an increase in the manipulative skills in handling the denture. With the preservation of teeth, the periodontal membrane is preserved and this maintains the Proprioceptive impulses from the tooth. The patient although wearing a complete denture retains that important sensitive ability to be aware of occlusal
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contact. A study by Pacer and Bowman confirmed that an overdenture patient possessed more typical sensory function, closer to that of natural teeth. There are certain advantages of preserving roots like - Effects on the edentulous ridge. - Psychological benefits. - Improved tactile discrimination - Improved stability and retention of the denture. EFFECT ON THE EDENTULOUS RIDGE Bone is constantly remodeled. In 1967 Tallgren showed that over a 7 year period the reduction in height of the anterior ridge was 4 times greater than that of maxillary ridge. Lord and Teel stated that teeth too weak for normal partial dentures may be suitable for overdentures. Cutting down teeth to mucosal level has a dramatic effect on the crown root ratio and also favors plaque control. TACTILE DISCRIMINATION Effective mastication requires tactile discrimination. The feedback mechanism goes far beyond the periodontal membrane. Implants have no periodontal membrane but have very high masticatory efficiency. IMPROVED STABILITYAND RETENTION Vertical walls of the root provide additional stabilization. Greater the vertical space occupied greater the stabilization. The only deterrent is the amount of space available. ADVANTAGES OF AN OVERDENTURE
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Preservation of alveolar bone. Preservation of Proprioceptive response. Extra support and retention. The natural tooth stops provide for a static stable base. Retention is sufficient by overlaying the teeth but in some cases it is desirable to increase the retention. This is done with one of the many attachment devices available in the market. Patients with congenital defects such as cleft palate, partial anodontia, amelogenesis imperfecta etc can be treated. Patient acceptance, cost effectiveness and convertibility are excellent. DISADVANTAGES OF AN OVERDENTURE Caries susceptibility: this is one of the most pressing problem confronting overdentures. Meticulous home care, frequent recall and fluoride treatment has shown to decrease the incidence of caries. Bony undercuts: this can pose a problem as close adaptation of denture flange is not possible. Surgical intervention is not often possible because the bone involved is the supporting alveolar bone of the abutment. Friedline and Wical described a technique to block out a labial bony undercut using a soft tissue palatal graft. Poor esthetics: at times due to undercuts especially in the canine region one may have to excessively block out the region and this can lead to an overcontoured flange. If one prefers to underextend this area then peripheral seal may be compromised. To avoid this proper case selection is vital and also proper preparation of the underlying teeth. Encroachment of vertical space: some cases have very little vertical space available to accommodate even the prepared roots. Attachments occupy more space and so there is always a spectrum of
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cases where overdentures are not feasible. Periodontal breakdown of abutment teeth: periodontal problem may be principal cause of the patient needing overdenture therapy and so if one is not careful the preexisting disease may continue leading to eventual loss of the abutment. Proper oral hygiene maintenance is very important to prevent periodontal breakdown of teeth. Other disadvantages include increased cost of treatment, increased bulk of prosthesis and another point is that more load is applied compared to conventional dentures and at the same time the bases are thinner which can lead to frequent fractures of the denture base. In a 1 year study the failure due to fracture was found to be 25% which comes second to the periodontal failure and the fracture characteristically occurs through or immediately adjacent to the abutment teeth. This failure was shown to occur 6-8 weeks after insertion prior to relining. DIAGNOSIS, TREATMENT PLANNING AND CASE SELECTION One of the most valuable assets in treatment planning is the visualization of the end result before the treatment is actually begun. The cases are straightforward when the patient presents with 2-3 roots but the situation is quite demanding when there is an arcade of hopeless teeth. The option of the osseointegrated implant has broadened the horizon of overdenture therapy. Dubious roots can be replaced with an implant though at an additional cost. In general there are two groups of patients who benefit from overdenture therapy. These are, Group 1: these are patients with few remaining teeth that may be healthy or periodontally involved, coronally intact or else morphologically
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compromised.

Treatment

here

is

conceptually

and

technically

straightforward. Analysis of articulated diagnostic casts, full mouth radiographs and overall patient concerns will enable the dentist to determine potential abutment teeth, their restorative and endodontic requirements. Special consideration should be given to patients in whom the overdenture will oppose a natural or restored natural dentition. Group 2: this group comprises patients who are diagnosed with a mutilated or severely compromised dentition. Generally speaking the treatment decision is often defined by the complexity, expense and time. Selective extractions are carried out and keeping those roots or teeth with good alveolar support. These groups have been defined by Boucher. Typically an overdenture patient presents with multiple hopeless teeth and a long standing periodontal problem. Lesser number of patients present solely due to caries activity. More commonly its a combination of caries and periodontal problem. Some cases are those who have congenital or acquired defects as a result of disease or catastrophic face/jaw injuries. Some congenital defects that can present as overdenture cases are partial anodontia which in turn can occur in an isolated fashion or in conjunction with certain ectodermal dysplasias, certain syndromes affecting the branchial arches development which have dental manifestations too. The loss of teeth and the costly, time consuming restorative work is not in itself an indication for an overdenture. One must evaluate many factors like, Possibility of fixed or removable partial dentures: If the remaining teeth are capable of supporting a fixed or removable
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prosthesis, then that should be the primary mode of treatment. Patient age: Extractions are to be avoided in a young patient as far as possible, so overdentures do play a major role in treating young patients with mutilated dentition. Abutment selection: There are many factors to be considered in abutment selection like endodontic status, periodontal status, location of the abutments, and number of abutments. We shall discuss each in detail. ENDODONTIC STATUS A tooth must more often than not be treated endodontically to allow enough reduction of the crowns. Esthetics and vertical height requirements dictate sufficient abutment reduction. Ideally patients with single rooted teeth and a single canal are the best candidates although multirooted teeth can also be used. Following endodontics a 2-4 week interval is desired before commencing further treatment on the tooth to make sure there are no endodontic complications. Vital teeth and even those having abundant secondary dentine are not very desirable abutments. Ettinger in 1990 showed that the most common cause of abutment failure was vital teeth developing periapical lesions as a result of pulpal necrosis ( 53.8%). This may be due to the fact that secondary dentine does not form an absolute seal. Yearly radiographs are necessary if vital teeth are used as overdenture abutments. PERIODONTAL STATUS It is axiomatic that a tooth with hopeless periodontal prognosis not be selected as an overdenture abutment. At least 6mm of bone support is
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needed to retain a tooth as an overdenture abutment. Bone support is assessed in terms of vertical height though it is not very reliable. A common periodontal problem is lack of adequate attached gingiva. Attached gingiva thickness adds to the favorable prognosis of the tooth. Attached gingiva can also be created through periodontal surgery. Inflammation, pockets, bony defects, and a poor zone of attached gingiva must all be eliminated before commencing treatment. Toolson and Smith on basis of their study emphasized the importance of a good periodontal work up of the potential abutments followed by frequent recall and proper regimen of home care. Abutment location and number A general rule is that if the patient presents with more than 4 retainable teeth in an arch that are periodontally sound some other treatment modality should be considered first. Exceptions to this rule do occur based on individual cases and patient desires. When one goes for overdentures in both arches, the mandibular arch abutment strength should be equal or greater than the maxillary arch. The location of the remaining teeth is important in terms of support for the overdenture and preservation of the alveolar bone. Teeth are most useful in areas of maximum occlusal forces and ridge resorption potential. The anterior mandible is very susceptible to change, so canines and premolars are important teeth to preserve in this area. Preservation of upper anterior teeth is especially important if the denture opposes natural teeth in the anterior mandible. This prevents excessive bone loss from the anterior maxillary ridge. According to a study the canines are the most frequently used abutments, in 70% of cases. Four widely separated abutments provide ideal stability and retention.
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Another favorable arrangement is the use of maxillary canines and a central incisor. This arrangement provides an excellent tripod effect and is especially effective when opposing natural dentition. Space between abutments: Adjacent roots are better avoided due to many reasons. When interradicular space is restricted, removal of the weaker root is a good option. The reasons for not selecting adjacent roots are, They do not provide more support and stability than one abutment. Hygiene maintenance becomes a definite problem. The connectors have to be swept upward from the gingiva which can complicate lab procedures too. This tends to increase the bulk of the denture and also makes it difficult to position the teeth correctly. Connecting or splinting root surfaces has many advantages. The most important advantage being that the inclined loads are resolved to more axial loads. There is also a marked resistance to lateral, horizontal or rotational forces (Thayer and Caputo 1980). CLASSIFICATION OF OVERDENTURES Many authors have put forward differing classifications. A few are presented below. Morrow and Brewer classified overdentures into immediate, transitional and remote. Heartwell classified overdentures on basis of abutment preparation, as coping, noncoping and attachment overdentures. Yet another classification is put forward by Prieskel. He classified overdentures into
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- Transitional overdentures. - Training overdentures. - Immediate overdentures. - Definitive overdenture. According to Brewer and Morrow remote overdentures are those constructed for placement at some time remote usually a year or two from the removal of the last hopeless tooth. Most patients are given immediate or transitional overdentures prior to the remote one. According to Prieskel definitive prosthesis are usually constructed 6 months following extraction of last teeth and preparation of overdenture abutments. The ridges should be matured and gingival margins firmly established before treatment starts. PREPARATORY PHASE OF OVERDENTURE THERAPY Lack of planning can cause a great deal of frustration and embarrassment. This phase can also be called the transitional phase of overdenture therapy. Modern society makes it unacceptable to leave a patient without anterior teeth during the lengthy phase of denture treatment. - Hopeless posterior teeth should be extracted as soon as possible and preferably 6 weeks before prosthodontics treatment. - Occasionally a minor periodontal procedure might be postponed 5-6 weeks following overdenture delivery. Often it is advisable to maintain occluding hopeless premolars to serve as temporary maintainers of vertical dimension. These are removed when the prosthesis is delivered along with the anterior teeth. - Immediate overdentures usually require relining after 6-8 weeks. The
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patient can wear immediate overdentures from several months to years. After a year however a remote overdenture or a definitive prosthesis is recommended. - Reduction of tuberosity or frenectomy can be carried out at this stage. - Endodontic treatment should be carried out during the initial healing phase of posterior tooth sockets. The transitional phase is considerably simplified if the patient is already wearing a partial denture. Adding flanges to partial dentures or a complete palate to an upper partial denture is an effective and rapid way of producing a transitional prosthesis. Once the transitional phase of overdenture therapy is over, definitive treatment is contemplated. This is begun only after all the preparatory treatment is completed, the soft tissues should be stable, abutments prepared and modes of attachment devices to be used finalized. Before going on to this phase of treatment we shall see one other option in regards to the abutment. Submerged vital roots: This method is an innovative attempt to obviate some of the basic problems associate with overdenture abutments which include caries, periodontal problems and endodontic problems. The selected roots are transected and reduced to 2mm below the crestal bone and then covered with a mucoperiosteal flap. There are a lot of disadvantages to this technique. First of all retention is not increased appreciably and one also loses the stability provided by the vertical walls of the abutment. Another problem is the development of dehiscences over the roots and pulpal pathosis. Moreover attachment devices are specially indicated in cases where retention is difficult to obtain e.g.
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xerostomia or sialorrhea, absence of edentulous ridge in edentulous cases, loss of maxilla or partial loss of mandible and congenital deformities especially cleft palate. ABUTMENT PREPARATION The vertical space available is the main consideration in overdenture abutment preparation. It should be appreciated that any projection from the root surface is a corresponding depression in the denture base which can weaken it. There are three basic approaches to abutment preparation, 1. Preparation of root surface just above mucosal level: there are 2 variants of this approach, one is leaving a bare root face and the other is using a dome shaped coping. This approach occupies the least amount of space and also prevents thinning of denture base. The drawback is that it offers very little extra stability and retention. 2. Use of attachments: stability and retention is quite good when attachments are used. Space requirements are intermediate compared to the other two approaches. The problem lies in the fact that repair and rebasing become complicated procedures. 3. Thimble shaped coping: this usually forms the inner layer of a telescopic prosthesis. This approach occupies the maximum space buccolingually and vertically. Another way of describing abutment preparation is as follows, Simple tooth modification and reduction: remaining teeth are merely shaped to eliminate undercuts and reduced in vertical height to create more interridge distance. Oral hygiene must be optimal for this technique. The vital pulps of the teeth should have receded sufficiently for this technique. It is often used in partial anodontic cases and in
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cases where there is severe abrasion of teeth. Sufficient interocclusal distance is desired. One advantage is that there is very little abutment preparation and hence it is quite reversible. Tooth reduction and cast coping: a casting is sometimes used to counter sensitivity or as a means of caries control. The drawback is that the tooth may require endodontics later on and sufficient vertical height is required. Endodontic therapy and amalgam plug: after endodontic therapy the tooth is sectioned at the gingival margin or slightly above it(2-3mm) and an amalgam restoration is placed into the exposed root canal. The remaining dentine is smoothed and polished leaving a surface that will accumulate minimum plaque and can be easily cleaned. This approach is used in those cases where vertical space is limited and caries index is also quite low. Endodontic therapy and cast coping: the procedure and indications are the same as in the previous technique except that a casting is placed instead of an amalgam restoration. The casting is made to a shallow dome shape with the margins slightly supragingival. This approach is used in patients who are prone to caries, but if home care is not ideal caries can occur. The reason is that the margins are exposed and are difficult to finish properly. Endodontic therapy with cast coping utilizing some form of attachment This approach is reserved for those cases where not only stability but significant improvement in retention is also desired. Here low caries index, proper home care and periodontal health are absolute. The abutment teeth require adequate bone support because of the added stress that the attachment brings to the tooth. The attachment does
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not reduce the crown/root ratio as much as the other approaches. The casting therefore requires additional retention which is provided by lengthening the post into the canal or by adding pins to the casting. BARE ROOT FACE An irregularly shaped root surface should never be left behind. The canal opening is either obturated with glass ionomer or amalgam. As mentioned earlier this technique has a few advantages, - It is the simplest, cheapest and least space consuming option. - It is the ideal solution when immediate dentures are provided. - It is the best solution when questionable teeth have to be evaluated prior to definitive therapy. There are certain contraindications. It should not be used on a long term basis especially when it opposes natural teeth as it increases the incidence of vertical root fracture. It also should not oppose another bare root face as dentine to dentine contact produces a very high degree of wear. PRECIOUS METAL COPING Operator has considerable scope in designing contours and establishing them. Single unconnected copings are preferred and only in cases where mechanical requirements are of importance are connections preferred. This technique was developed by Lord and Teel in 1969. As mentioned earlier space requirements are small and strength is unaffected. The number and distribution of roots together with the adaptation of the denture base to root contributes to stability. Precious metal copings were once advocated for immediate insertion prosthesis but considering the rapid tissue changes that occur it is best to wait 3 months after extraction
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of other teeth before embarking on definitive prosthesis. Any projection above the level of mucosa can be accommodated only by hollowing out a corresponding volume from the impression surface of the denture. In most of the cases lack of vertical space necessitates the root surface to be cut down to just above gingival level. Plaque control requirements dictate that copings shouldnt be overcontoured or bulbous. A chamfer finish line is advocated around the preparation. Preparation for dome shaped casting: Dome shaped castings resist vertical loads well but they should resist lateral loads too. A relatively short dowel, 4-5mm will suffice. The minimum requirements are an antirotation slot, minimum gold thickness of 1.5mm over the occlusal surface without which there is a high chance of perforation. Preparation for attachments: The occlusal surface is similar to the dome shaped coping but the centre of occlusal surface is hollowed out to increase the strength of the dowel/diaphragm junction and also to reduce the space requirements of the attachment. The antirotation slot becomes more important and the length of the dowel into the canal needs to be longer, at least 10mm. Using reamers and waxing the dowel and coping directly have been used with good results for years. It requires extensive removal of dentine but is useful in canals that are irregularly or unusually shaped. The simplicity of the method is deceptive and is actually quite clinically demanding. Moreover mechanical properties of cast metal are inferior to those of wrought metals in prefabricated systems. Prefabricated systems or the so called matched reamer dowel systems are convenient to employ and more commonly used when canals are circular. Most of them are designed to be used with engine driven
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reamers. ATTACHMENTS These provide increased mechanical retention and stabilization. Selection of the type of attachment is based upon available buccolingual and interarch space, clinical experience, preferences and cost. Retention by means of using attachments is usually not required in maxillary overdentures as normal flange extensions are possible. Prefabricated attachments are versatile and provide considerable retention and stability. As mentioned earlier their space requirement falls between thimble shape copings and dome shaped coping. A variety of attachments are available ranging from the traditional mechanical units to magnetic retention systems. The ideal overdenture has inherent stability and retention; the additional retention systems serve mainly an auxiliary role. Unfortunately the ideal situation does not always apply. Anatomical considerations demand flange reduction, open palate etc. which place additional demands on retention. Retention systems supply this extra retention. The most important stabilizing component is the prosthesis itself. Retaining components have to be rigid otherwise they deform or break during function. All this becomes very critical when interocclusal space is limited. We shall discuss some of the commonly used attachment systems in the following section. Stud attachments: Stud devices are among the simplest of all attachments. They can provide additional stability, retention and support and at the same time the positive lock of certain units can maintain the border seal of the denture. Few stud attachments are entirely rigid, since their size makes it
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difficult to prevent a small amount of movement between two components. There are two types of stud attachments, - Extraradicular in which the male element projects from the root surface of the preparation or implant. - Intraradicular, in which the male element forms part of the denture base and engages a specially produced depression within the root contour of the implant. Selection of stud attachments: There are a wide variety of stud attachments in the market, but the mechanical ingenuity of the attachment occupies a secondary role compared to proper treatment planning and execution. Assessment of the vertical space is the most important step. Extraradicular attachments represent a large and versatile group. These are available in a variety of sizes and range from 0-rings to pillar shaped projections. It should be appreciated that these units must be surrounded by a reasonable thickness of acrylic resin. The lower the level of attachment, more buccolingual space is available for the denture teeth. Whenever vertical space is limited consideration should be given to a less space consuming attachment such as bar retainer. Intraradicular studs differ in the fact that alignment is determined by the roots and any divergence will lead to rapid wear of the male units although replacement is quite straightforward. Space requirements of intraradicular studs are similar to the smallest extraradicular studs. Another advantage is that no other casting is required and the female component can be simply placed into a receptacle on the root. The disadvantage is that the receptacle in the root is likely to require extensive finishing as it is unlikely to match the contours of the root and also requires extensive removal of dentine.
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Some of the commonly available stud systems are microfix, ceka revax extra and Intraradicular systems, Dalbo series, Gerber units, Zest anchor system etc. Alignment of stud attachments: The attachments should be aligned to each other; it should be in line with the path of insertion of the denture. The ball and socket type retainer is the most popular. A divergence of 10 degree can be tolerated. Significant divergence of roots or implants should be considered a contra indication for this approach. One stud attachment on either side of the arch will suffice; the remaining roots can be covered by simple copings. Increasing the number of attachments does not necessarily increase retention; it may contribute to improved stability, but leads to a weaker structure. Two stud attachments on adjacent roots are unnecessary as it would complicate hygiene measures and also weaken the denture base. However connecting the copings will enable them to withstand rotational loads and also resolve inclined forces in a more axial direction. BAR ATTACHMENTS: This is one of the more popular class of attachments. They have been well tried, tested and popular stabilizers and retainers for overdentures. The bulk of bar and related structures raises several problems. Vertical and buccolingual space requirements limit their applications. Bar attachments also demand more oral hygiene maintenance from the patients. Bar joints: Bar joints are divided into two types; single sleeve and multiple
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sleeve bar joints. Single sleeve bar joints are best represented by the Dolder bar joint. This bar is produced from wrought wire, pear shaped in cross section and running just in contact with the oral mucosa between the abutments. An open sided sleeve is built into the impression surface of the denture and engages the bar when the denture is inserted. A single sleeve bar cannot follow the curvature of the ridge and so used in square shaped arches. Multiple sleeve bar joints have short retaining clips or sleeves and this feature allows the bar to follow the curvature of the ridge. The versatility afforded by these bars are considerable and used extensively with implant supported overdentures. Sleeves can be placed at sites with the greatest amount of space. These were first introduced in 1913 by Gilmore. Ackermann and others have proposed modifications to the original design. In case of implants the length of the span must be taken into account and failure to achieve rigidity at the abutment connection site can lead to loosening of the implant. Most of the systems are similar except for differences in sleeve design and use of spacers. In the Ackermann system, the sleeves have retention tags which project in a buccolingual direction whereas the C.M. bar has sleeves with retention tags in its own long axis. The Hader bar has a very ingenious design. The sleeves are made of resin and these can be very easily replaced and also the sleeve rests directly on the bar without an intervening spacer unlike the other systems.

Magnetic retention systems: These have been in use for the last 60 years. Until 1970 the
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magnets used were made of a cobalt platinum alloy or Alnico, an alloy containing aluminum, cobalt and nickel. Both these alloys produced disk magnets that worked quite well in paired attraction for multi component maxillofacial prosthodontics. They demonstrated a high magnetic field strength but their intrinsic coercivity was low which meant that they couldnt be reduced to a size which could be used in overdentures. The introduction of rare earth alloys with a high magnetic field strength and high coercivity allowed production of magnets not much larger than stud retainers. Pioneering work was led by Gillings in the University of Sydney. He developed a split pole assembly using Cobalt samarium alloys. Another rare earth alloy which has potential is the Iron-Neodymium-Boron alloys. These alloys can produce smaller magnets with equal if not greater field strength. The earlier systems were open field in nature which meant that living tissues were exposed to magnetic fields. Gillings pioneered the closed field systems where magnets in the denture base abutted a keeper on the root face. This keeper is a ferromagnetic material like stainless steel or a high Platinum alloy. This ensured that the magnetic fields were restricted to the local area. Advantages with these systems are that path of insertion is not very important and so debilitated and arthritic patients can effectively use it. The lab procedures are far less demanding compared to the other attachment systems. The size reduction allowed sandwich designs to come up in which one magnet is placed between two ferromagnetic plates and this occupies far less space. Disadvantages: The magnetic alloys are susceptible to corrosion in the oral environment. The corrosion of the magnet leads to dramatic drop in
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retention. Various techniques of preventing this undesirable phenomenon were devised. One thing was that whatever protection was offered had to be in very thin layer so that magnetic field strength was unaffected and also the covering did not impinge on the space requirements. This continues to be a problem and is the area of considerable research. Various corrosion resistant sleeves of metals, polymers etc. have been developed which can slow down the corrosion. IMPLANT OVERDENTURES With the advent of dental implants, the benefits and advantages of using an overdenture has become a reality for edentulous patients. It is really useful in the mandibular arch as it helps preserve the residual ridge and also increase the retention and stability of the prosthesis. Studies have shown that chewing efficiency is improved significantly compared to conventional complete dentures and bone loss is also reported to be minimal. In 1989 Misch reported 5 prosthetic options in implant dentistry. The first three are fixed restorations and the last two are removable prosthesis. RP-4 is a removable prosthesis supported by implants alone. RP-5 is a removable prosthesis supported by both soft tissue and implant. So basically there are two types of implant overdentures depending on their mode of support. The implant retained and tissue borne type relies primarily on the residual ridge for support. Implant retained and implant borne dentures do not require peripheral seal but the periphery of the denture should rest on soft tissue to prevent food accumulation beneath the denture. The differences between attachment of tooth to the bone and
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implant to the bone explains the difference between conventional and implant overdentures. This difference influences the design of the support system. A variety of implant types have been used to support overdentures which include endosseous through transosseous and subperiosteal of which the root form or endosseous variety is the most popular. In cases of severely resorbed mandibles, endosseous implants can be place only after grafting is completed and a period of 6-9 months have elapsed after grafting. The alternative is to go for a subperiosteal or transosseous system. The choice of an implant overdenture depends on patient desires, availability and location as well as quantity of bone, opposing occlusion, amount of interarch space, manual dexterity of the patient and financial considerations. TISSUE BORNE OVERDENTURES Implants are generally placed in the anterior part of the mandibular or maxillary arch. Two implants are the minimum required for this type of prosthesis. These implants can be left individually or splinted together for better biomechanics. A bar and clip mechanism is the most commonly used attachment system because it also provides a stress breaking action when the posterior portion is loaded. For the bar and clip mechanism to be stress breaking in nature, the area of the bar to which the clip attaches should be in the symphysis region. It should also be in a straight line, be parallel to the hinge axis and perpendicular to the mid sagittal plane. This is often impossible when more than two implants are placed. A bar length of 12-15mm is desirable in mandibular tissue borne overdentures. In maxilla bar and clip attachments are usually not used. Patients with tapered mandibular arch are not good candidates for the 2 implant bar and clip system because tissue space is encroached upon. The type of
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attachment depends on the number and location of implants used. Splinting: It is controversial as to whether splinting is good in all cases. Some authors say that attachments placed directly over the implant bodies without splinting does not place detrimental forces on the implant. If the implants are short and placed in poor quality bone splinting helps. IMPLANT BORNE OVERDENTURES These dentures rely on the implants to bear the entire occlusal load. This prosthesis requires a minimum of 4implants in the mandible and 6-8 in the maxilla. It is very important to avoid cantilevers in the maxilla. The firmer the connection of the superstructure on the implants, more precise the tooth contacts can be in centric and eccentric movements because movement due to tissue resiliency ceases to be a factor. As mentioned earlier bars and clips are the most popular attachment devices. It is necessary to space the implants in order to ensure clips of adequate length (5-6mm). to provide a firm union of prosthesis to the superstructure, a variety of attachments have been developed like slant lock, latch types, milled bars and spark erosion attachments. Others like ERA, Swiss anchor, o-rings do not provide enough security and rigidity. Firmer the connection of superstructure to the prosthesis, more difficult it is for the patient to manage. Attachments Selection of a specific attachment for an implant overdenture depends on the following; - Type of overdenture fabricated. - Location of implants on the ridge. - The condition of the residual alveolar ridge.
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- Dexterity of the patient. - Psychosocial needs of the patient. - Relative need for stability and retention. - Length of implant used. As a general rule, more complicated and sophisticated the attachment, more difficult it is to repair and maintain. The occlusion for the tissue borne overdentures should include multiple, bilateral, even contacts in centric and eccentric positions. In an edentulous patient the arch with the implants becomes the dominant arch in terms of occlusion.

References Zarb G A, Bolender C L, Carlsson G E : Bouchers Prosthodontic treatment for edentulous patients 11th Ed, Mosby Inc 1997. Rahn A O, Heartwell C M: Textbook of complete dentures 5th Ed Sheldon Winkler: Essentials of complete denture prosthodontics 2nd Ed, Ishiyaku Euro America Inc 1996. Carl Misch: Contemporary Implant Dentistry 2nd Ed, Mosby Inc 1999. Engelmeir R L: Complete dentures, DCNA Vol 40 1996. Nelson S J, Nowlin T P: Occlusion DCNA Vol 39 1995

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