Presented by: Dr. Glareh Eblaghian Supervised by: Dr. Mansour Rismanchian and Dr.

saied Nosouhian Dental of Implantology Dental Implants Research Center Isfahan university of medical science

 Over the last 15 years, many of completely edentulus mandibular arches have been treated with implant overdentures Many of these patients choose to have a removable prosthesis because

of financial consideretions
Advantages of maxillary supported removable prosthesis is: upper lip support for aesthetic and daily maintanance

Labial flange of mandibular overdenture rarely is requred for aesthetic

For hybrid fix restoration and fully implant supported overdenture (RP4): labratoary and component cost is simillar Chair time required is similar

But

because dentures and partial dentures typically cost several times less than fixed restorations, the doctor often chareges half the fee for an implant denture

2. Removable implant overdentures require greater and exhibit 3. overdenture often traps food below its maintenance flanges 1.Mandibular Feeling and acting simillar to natural teeth more complications than fixed restorations the daily care for the bar implant overdenture isimplant similar supported to that for restoration fixed 4.Important role for presence of complete Problem of restoration IODs in review of litrature Goodacare: mandibular ( regeneration because ridge lap pontics are not required) is the maintenance and ofby posterior bone in mandible Retention and adjestement problem(30%) Clip or attachment fracture(17%) Fracture of prosthesis (12%) Reline(19%)

 the amount of force transmitted to an implant fixed prosthesis is similar to RP4 (then the number of implants to support either prosthesis should be simillar) For noctural parafunctional overload, patient is willing to remove the maxillary denture at night For patient with natural teeth or implants in the maxillary, more implants usually are indicated for mandibular fix prosthesis

Force factores: parafunction, crown height, masticatory dynamics, bone density of implant region

increased force factores contribute to

Uncemented restorations, screw loosening, component fracture, crestal bone loss

Fixed prosthesis may required an improved biomechanical position

 five different movement have been postulated (medial convergence is most common):
Mandible between mental foraminae is stable Distal to the foraminae , mandible exhibits movement toward the midline on opening ( because of attachment of internal ptrygoid) distortion of the mandible occurs early in the opening cycle maximum changes occure with as little as 28% opening (12mm) Flexture also occure during protrusive movement Amount of movement depends on density and volume of bone and location of the site

Mandibular body flexture to midline:

1500 micron in ramus to ramus 800 micron in first molar to first molar

 In animal study: mandible twisted on working side and bent on balancing side in the parasagital plan during power stroke
in human study Using strain gauges on screws attached to cortical bone

Using implant supported prosthesis

the torsion during parafunction is caused by contraction of masseter muscle attachments Posterior bone gain in edentulous patients restored with cantilevered prosthesis may be consequence of mandibular flexture and torsion

Because bite force may increase 300% with an implant prosthesis

compared with denture increase size stimulate posterior mandibular body to

 most common position of mental foramen is between the first and second premolar mandibular dynamic should be consider in splinting

teeth distal to the bilateral premolar The more distal the rigid splint from one side to other , the greater the risk thet mandiblular dynamics may influence the prognosis

The body of mandible flexes more when the size of bone decreases (C-h or D A)

Difference in movement between an implant and tooth: natural tooth 28 micron movement apically 56-108 micron movement laterally

rigid implant

5 micron movement apically 10-80 micron movement lateraly

Mandibular flexture and torsion may be more than 10-20 times

Flexture and torsion of mandibular body are more critical

In the past , 4 implant in the mandible is thwarted by the prosthesis but this introduces lateral stress to the implants

Molar implants, screws and bone have increase risk because of mandibular flexture and torsion

Consequence of cross arch connection of posterior mandibular implants loss of implant fixation material fracture (implant or prosthesis) unretained restorations

Just Implants placed in front of foraminae and splinted together, or

implants in one posterior quadrant joined to antrior implants have not shown these complication

discomfort upon opening

 Therfore all edentulous mandibular patients should be given the

option of having fixed prosthesis

There are five treatment option used to restore a complete

edentulous mandible with fixed prosthesis or RP4 overdenture

The mandible does not flex or exhibit significant torsion between mental

foraminae, so anterior implants may be splinted together

Branemark approach: placement of 4 or 6 anterior root form implant between the mental foraminae and distal cantilever off each side to replace the posterior teeth

Result:

80% to 90% implant survival for 5 to 12 years after first year

84% success rate for 18 to 23 years

The anterior arch form + foraminae position , affects the position of the distal most implants

The anterior arch form (square, oval, tapered) is related to the anterior most implant position

 The greater the A-P spread, the further the distal cantilever may be extended The most common number of implants used today in the Branemark option is five This number allows as great an A-P spred as six implants with greater interimplant distance

If bone loss occurs on one implant, the loss whould not automatically affect the adjacent implant sites

Genaral rule: for five anterior implants

in the anterior mandible between the foraminae the cantilever should not exceed 2.5 times the A-P spread

o If the stress factors are high ( parafunction , crown height, masticatory musculature dynamics, opposing arch) , cantilevering may be contraindicated Length of the posterior cantilever depends on the specific force factors of the patients

oThe area over which the forces are applied from the prosthesis to the implant can be modified through the number, size, and design of the implants oA cantilever rarely is indicated on three implants, even with a simillar spread as five implants o Narrow implants are not designed to support cantilevers A-P

 treatment option 1 depends greatly on patient force factors, arch form, number, size and design of implants

The safest action: reserve this option for patients with low
force factors such as older female, wearing upper denture, abundant
anterior bone, crown height to 15mm , tapered or ovoid mandibular arches

A slight variation of the Branemark protocol to place additional implants above the mental

foraminae

A slight variation of the Branemark protocol Bone strain model is of to place additional flexture torsion implantsand above the mental foraminae

in university of
Advantages :

Alabama

1. number of implants may be increased to as many as seven 2. AP spread for implant placement is greatly increased, even when the total implant number is 5

3.The length of the cantilever is reduced dramatically because the distalmost

implant is placed one tooth more distal

 A prerequisite available bone in height and width over the foraminae (because foraminae usually is located 12mm above the inferior border of the mandible) the most distal implant bears the greatest load when loads are placed on the cantilever A minimum recommended implant height of 9mm and a greater diammeter of an enhanced surface area recommended

Key implant positions: second premolars, canines, centeral

incisor or midline position

One posterior segment connected to anterior segment

Misch has evaluated full-arch fixed prostheses on implants with one posterior segment connected to the anterior region over the last decade another treatment option to support a fixed mandibular prosthese consist of additional implants in the first molar or second premolar, connected to 4 or 5 implant between the mental foraminae

The key implant position are: first molar (on one side), bilateral premolar, bilateral canine The secondary impalnt position are: second premolar on the same side as the molar implant, central incisor (midline) One pice casting can be fabricated and one cantilever to the opposite side of the molar implant would replace those posterior teeth When one or two implants are placed distal to the foraminae on one side and joined to anterior implants, a considrable biomechanical advantage is gained

option 3 is a better option than anterior implants with bilateral cantilevers The A-P spread is 1.5 to 2 times greater , because on one side the distal aspect of the last implant now corresponds to the distal aspect of the first molar

When force factors are greater , 6 or 7 implant may be used five implant between foraminae and one or two implant distal on one side
this option requires available bone in at least one posterior region

Bilateral implant that they are not splinted together

This option is selected :

1. When force factors are great or the bone density is poor 2. When the body of mandible is division C-h and subperiosteal or disc like implants are used for posterior

Key implant positions: first molars, first premolars, canines Secondary implant positions: second premolars and/or incisor

 al l implants in the anterior and one posterior side are splinted together for a 9-unit fixed prostheses The other posterior segment is restored independently

Most often three implant are used for smaller segment to compensate for force factores and the alignment of the implants almost in a straight line

advantages:
1. Elimination of cantilever 2. risk of uncemented restorations and occlusal overload are reduced 3. prostheses has two segments rather than one

4. Weaker cements can be used 5. If the prostheses requires repair , the affected segment may be removed easily Disadvantages need for abundant bone in both posterior region additional cost

The restoration should

exhibit posterior disclusion in excursions to limit lateral loads, especially to the prostheses supported by fewer implants

Three independent prostheses

Key implant positions: 1. Two first molars, two first premolars, two canines posterior restoration extend from first molar to first premolar and anterior restoration replaces the six anterior Treatment option 4 is better 2. Two first molars , second premolars, first premolars, and both canines

Treatment option 5 is better

 posterior restorations are two independent implant prostheses unit and anterior prosthesis extend from first premolar to first premolar

Advantages :
Smaller segments for individual restorations Most flexibility and torsion of the mandible in greater body movement (in parafunction and decrease in size of the body)

choice option when force factors are sever

Disadvantages:
Greater number of implants required Available bone needs are greatest in this option Most common scenario for option 5 is when the posterior mandible is C-H bone volume and a circumferential subperiosteal or disc-design Implant is used as the second premolar and first molar