OVERDENTURES

CONTENTS

 INTRODUCTION
 CONCEPT AND RATIONALE
 REVIEW OF LITERATURE
 PROS AND CONS, INDICATIONS AND CONTRAINDICATIONS
 CLASSIFICATION, OF OVERDENTURES AND ABUTMENTS
 TREATMENT PLANNING
 CLASSIFICATION, OF ATTACHMENTS
 SPECIFIC CLINICAL PROCEDURES
 SOME POPULAR ATTACHMENT SYSTEMS
 SUMMARY AND CONCLUSION
 BIBLIOGRAPHY

The dental profession has expanded the preventive dentistry concepts into
prosthodontics to bring about the prescription called "The Over denture". It is
further buttressed by the fact that the alveolar bone with its overlying mucosa
was never intended to receive the full force of a complete denture. So then, what
is an overdenture.

 A complete or removable partial denture that covers and rests on one or

more remaining natural teeth or roots.
Or
 A prosthesis that covers and is partially supported by natural teeth, tooth
roots or dental implants.
Or
 A prosthesis covering the occlusal surfaces of the teeth.
Or
 The overlay of artificial teeth on the surface of natural teeth to
improve occlusion, arch form and/or esthetic-superimposed prosthesis
 SYNONYMS
1. Biologic denture
2. Hybrid denture

RATIONALE FOR THE OVER DENTURE CONCEPT

 Extraction of all natural dentition and replacement with a complete denture

is not the most desirable treatment. Preventive prosthodontics emphasizes the
importance of any procedure that can delay or eliminate prosthodontic problems.
The over denture is a logical method for the dentist to use in preventive
prosthodontics..

 The sequelae after the extraction of all the teeth make complete denture
progressively less effective. Among these sequel are
a. The 'loss of discrete tooth. proprioception
b. The progressive 'loss of alveolar bone
c. The transfer of all occlusal forces from the teeth to the oral mucosa.

 From physiologic view point the roots provide not only periodontal ligament
Support but also

 Directional sensitivity
 Tactile sensitivity to load
 Dimensional discrimination'
 Canine response
 Proprioception and salivary secretion
 Decreased perception in older individuals

GOAL OF THE RATIONALE

– Maintains teeth as part of the residual ridge

– Reduced rate of resorption
– Increase in manipulative skills of handling the dentures

REVIEW OF LITERATURE
GEORGE L . MARQUARD (1976):described a technique by using dolber bar
joint mandibular overdentures for non parallel abutment teeth.Two
techniques for attaching bar to the teeth with divergent root canals were
used:1.The schubiger screw system for those teeth with extremely divergent
canals.
2.The stutz pivots system for teeth with only slight diveregent root canals.
The use of bar joint offered periodontally involved teeth an improved crown –
root ratio and splinting of the teeth.As the bar was close to the bone, forces of
mastication exerted much less leverage to the teeth.finally the bar offered
 slight vertical and rotational movementof the denture as well as a stress
breaker action.

ROBERT C KAHN (1985):described a method to prepare immediate overdenture

teeth accurately.The technique was easy to accomplish,and less chair time. In this
technique the master cast with the prepared teeth was duplicated.It was then poured
in stone.Two layers of baseplate wax was adapted to the duplicated cast in the
shape of a record base.The wax template covered the residual ridge and domed
crowns of the prepared tooth.The template was then processed in the usual manner
with clear acrylic resin .Final tooth reduction and shaping was accomplished and
template was placed over the partially prepared abutment teeth in the mouth.High
points were checked and relieved.

ARTHUR NIMMO et al (1986) described a technique that would prevent fracture of

maxillary overdenture by using a custom metal insert in the anterior region of the
denture. Chrome cobalt castings were used for reinforcement of the denture base
and to provide minimum thickness with adequate strength. The casting extended
along the lingual surface of the anterior teeth. The patient is less likely to grind
through the denture base in Para functional activity.

TODD FRIDRICH et al (1998) described an index for the fabrication of a

mandibular implant supported overdenture bar. The index in a two piece mold
made from an addition silicone putty material. It is used to record and
maintain the relative position of the morphologic contours of the trial denture
on the master cast. The split mold design permits direct visualization of the
amount of space available for the design of the retentive bar from both facial
and lingual aspects.

HISTORY
The idea of leaving roots of natural teeth to support an overdenture is far from
new.
1856-Ledger described prosthesis resembling an overdenture and were referred
to as plates covering flanges.
1861-There was an increasing awareness of the value of such roots might play in
supporting denture .
1888-Evans described a method of using roots to retain restorations.

1896-Essing prescribed a telescope like coping.

Pesso was also making removable telescopic prosthesis at the same time.
The reasons for retaining the roots were not always specified but it is likely that
denture retention and stability must have been uppermost in clinicians minds.
Most of the retention systems were developed between the wars and after the
WW II provided support stability and retention
– INDICATIONS

It may be of partial or complete type

1. For patients who face the loss of the remaining natural adult dentition.
Therefore the younger the patient greater the indication.
2. Cases where the retention is difficult to Obtain.
– Xerostomia of sialorrhea
– Absence of alveolar residual ridge
– Loss of maxilla and partial loss of mandible
– Congenital deformity (eg : cleft palate)

3. For patients with a poor prognosis for complete denture.

– High. palatal vault and ridge slope
– Poorly defined sublingual fold space
– In Class III tongue position
– Knife edged ridge that will provide inadequate support.
4. When pronounced vertical over-lap of the anterior teeth is required to
produce good esthetic results.
5. Unilateral over denture can be given to provide a good function and esthetics
when a large amount of bone and soft tissue have been lost on one side of the
arch.

6. Patients with badly worn out teeth.

7. When complete denture will be opposed by retained mandibular anterior
teeth (combination syndrome).
8. Therapeutics in the form of in situ irradiation.(McDermott and Rosenberg
1983).

– CONTRA INDICATIONS

– Un co-operative and under motivated patients who insists on removal of his

remaining teeth. Any indication of patient who will not cooperate in oral hygiene
and regular office procedures, recall for adjustments which is required to maintain
the remaining teeth and the supporting tissue in a state of health.
– Psychologically some –patients cannot accept any type of removable denture.
– Mentally and physically handicapped patients for whom. plaque control
and good oral hygiene are difficult.
– When a patient cannot economically afford
 ADVANTAGES
– Preservation of alveolar bone
– Improved denture retention, stability and support
– Provides a vertical definite stop
– Psychological acreptanre hence better patient cooperation.
– Preservation of masticatory proprioception
– Fewer post insertion problems

– Convertibility
– Harmony of arch form
– Ideal occlusion
– Open palate possible
– Less trauma to supporting tooth
– Esthetics
– Ease in construction and maintanance
– Lower cost when compared to R.P.D.

DISADVANTAGES

– Over denture treatment is more expensive than conventional denture

because of periodontic and endodontic therapy and the subsequent restoration of
teeth with gold coping.

– Bulkier than F.P.D. (or) R.P.D.]

– If oral hygiene is not Maintained properly caries and periodontal disease

may still progress.

– Bony undercuts may cause either over contouring or under contouring of

the denture.
– Encroachment. of interocclusal distance.
– Esthics.
– In many cases, owing to lack of available space sections of the denture base
are quite thin. If metal reinforcement is not used fracture of the base and prosthetic
teeth is common
– TYPES OF OVER DENTURES

The type of over denture depends primarily on the status of the patient's
dentition at the start of treatment.

– IMMEDIATE OVER DENTURE:

– An immediate overdenture is constructed for insertion immediately after

removal of some natural teeth of which many hopeless abutment teeth. are treated
and the over denture is inserted as an immediate replacement. The immediate over
denture modified as required. It can be worn for several years under favourable
circumstances.

– TRANSITIONAL OVER DENTURE

– A transitional over denture is obtained by converting an existing removable

partial denture to over denture.

– REMOTE OVER DENTURE

– A remote over denture is an over denture other than transitional or
immediate. It is usually constructed for insertion at some time "remote" from the
removal of hopeless natural teeth.

– CLASSIFICATION
– HEARTWELL’S
Based on the method of abutment preparation

1. Non coping abutments with simple tooth modification with endodontic

treatment without endodontic treatment
2. Abutment with Coping
3. Abutment with Attachments
4. Submerged vital roots

NON COPING (AFTER ENDODONTIC TREATMENT)

Selected abutments are reduced to a coronal height of 2 mm to 3 mm and then
contoured to a convex or dome shaped surface. Most teeth require endodontic
therapy and the final step is prepared conservatively to receive an amalgam or
composite restoration

WITHOUT ENDODONTIC THERAPY :

 The remaining teeth are merely reshaped to eliminate undercuts and reduce the
vertical height if necessary to create more inter ridge space for the over
denture.

ABUTMENT WITH CAST COPING:

COPING:

Cast metal coping with a dome shaped surface and chamfer finish line at the
gingival margin are fabricated and cemented. These are 2 distinct types of
copings
– 1.Short
– 2.Long

– The short coping: These are 2-3 mm long and normally require endodontic
therapy since the required coronal tooth reduction would expose the pulp. Attached
to the coping is a post fitted to the canals.

– Long coping :These are normally 5 to 8 mm long. an attempt is made to

circumvent endodontic therapy by a conservative reduction with a ellipsoidal
shaped coronal coping and an increased crown root ratio

ABUTMENTS WITH ATTACHMENTS:

– Most attachments are secured to the abutment by cast coping. The objective
of any attachment is to improve retention of the denture base.
– Because of the factors like time, cost and risks the procedure should be
reserved for patient with a favourable prognosis. Here the low caries index, proper
home care, periodontal health and inter ridge distance are absolutely necessary.

SU'BMERGED VITAL ROOTS :

This is of current research interest. It attempts to obviate some basic problem

associated with the more conventional over denture abutments. In these cases
selected vital roots are transacted and -reduced to 2mm below the crestal bone
and then covered by a mucoperiosteal flap.

TREATMENT PLANNING:

This includes

– Periodontal considerations
– Endodontic treatment
– Caries Management
– Location and Distribution of forces
– Economics

PERIODONTAL CONSIDERATION

– Periodontal inflammation, Pocket formation, bony defects, and poor zone of

attached gingiva must all be eliminated before commencement of the treatment.. A
common periodontal requisite with over denture abutment teeth is that an adequate
zone of attached gingiva is mandatory. This can be accomplished through
periodontal surgery utilizing either a free gingival graft or apically repositoned
split thickness flap. This results in a band of attached gingiva adjacent to the
abutment tooth.

– ENDODONTIC CONSIDERATION

3 main advantages
– The crown root ratio can be made more favourable.
– Reduction of the clinical crown provides an interocclusal distance more
favourable for the placement of the artificial tooth in an esthetically acceptable
position and in more favorable relation to the opposing teeth.
– For securing attachments.

Careful evaluation of the possibility of F.P.D or R.P.D must be done.

– CONTRA INDICATIONS FOR ENDODONTIC TREATMENT

i. Vertical fracture of the root (or) roots.

ii. Mechanical perforation of the root canal.
iii. Internal resorption that has perforated through the side of the root.
iv. Broken instrument in the root canal.
v. Horizontal fracture of the root below the bony crest.
Vi. Posterior teeth that are tilted more than. 25 degrees..

– CARIES MANAGMENT :

– The presence of high caries index and the situation that will create a carious
environment are the devastating sequelae to improper over denture patient
selection.
 – Choice of abutment is a tooth that have a healthy clinical crown.
– Caries activity in a protected environment is undesirable
– Frequent recall check up and treatment of the abutment with periodic
fluoride application to insure against any further break down.

– LOCATION AND DISTRIBUTION OF ABUTMENT

 Preference for anterior over posterior teeth therefore the alveolar ridge
appears to be more vulnearable to reduction than the posterior alveolar ridge.
 Two teeth in each quadrant presents an ideal situation in which stress
is distributed over a rectangular area.
Eg : Cuspid 2nd premolar and/o-r second molar in each quadrant

 The tripod is the next most favourable form for support and stabiliy
 The use of two teeth in each arch or one arch has met with satisfactory
results.
Marrow recommends that it is better to use isolated teeth as abutments
rather than adjacent teeth because they return to a state of good health more
rapidly and are easier for patients to maintain hygiene.

OVERDENTURE ATTACHMENT CLASSIFICATION

According to shape, design and primary area of use,
CORONAL : a. Intra coronal b. Extra coronal
– i. Resilient
– ii. Non resilient
RADICULAR :
– a. Telescope stud attachments
– b. Bar attachments
– i. Joints ii. Units
ACCESSORY : AUXILLARY ATTACHMENTS
– a. Scre Units
– b.Pawl connectors
– c. Bolts

-d.Stabilizers/ Balancers MAGNETS:

-e. Interlocks Permanent magnet
-f. Pins/Screws Induced magnet
Open field
 EXTRACORONAL: INTRARADICULAR
– Gerber attachments Zest anchor
– Dalbo attachment
– Ceka attachment
– Schubiger attachment
– Quinliran attachment
– Rothermann attchment
– Infrofix attachment

– .A mounted diagnostic cast is an important aid to check the space available

before an attachment is selected.
– Most of the stud types can be considered to be snap fasteners. Stud devices
are simplest among all attachments. The male part of the unit consists of a stud
shaped projection soldered to the diaphragm 'of a dowel retained restoration. The
female part fits over the male unit and is embedded within the denture base of the
prosthesis. There are a few system which work in the reverse Eg. Zest Anchor. A
few studs are entirely rigid (Because the size makes it difficult to prevent a small
amount ol"movemert between the two components). In some springs are
specifically 'incorporated to allow a controlled degree of movement.

– Advantages
– Retention, stability and support
– A positive lock of certain units can maintain the border seal of the denture.
– The success of a prosthesis usually depends on careful treatment planning
and attention to the prosthodontic problems. The mechanical integrity of the
attachment is important but must take second place. The shape and size of the,
units is normally the over riding consideration although the auxillialy devices that
accompany the attachment must influence the choice.Correct vertical space
assessment must be taken care of. Extraradicular stud attachments are relatively
strong and can often provide more effective retention than their intra radcular
counter parts
– 20

– The number of stud attachment:.

– One stud attachment on each side of the arch will usually suffice other
remaining roots can be covered with simple copings. Increased number of
attachments in a denture does not produce a corresponding improvement in
retention.

 SINGLE ATTACHMENT
 – Only one remaining tooth
– Diagonal position of abutment teeth
– Span too long to be bridged by bars
– Arches that are markedly V shaped
– BAR CONNECTORS
– periodontally weak abutments where
splinting is desirable
Roots that will acco
modate only short do
– wels
– offer greater mechan
ical stability and mor
e wear resistance

– SPECIFIC CLINICAL PROCEDURES

– Preparation of the abutment teeth

– Treatment with a provisional overdenture
– Impression procedures
– Maxillomandibular relation records and tooth arrangements
– Final tryin
– Designing the base

TREATMENT WITH A PROVISIONAL OVERDENTURE:

– IMMEDIATE OVERDENTURE
– DIRECT CONVERSION TO PROVISIONAL OVERDENTURE
– INDIRECT CONVERSION TO PROVISIONAL OVERDENTURE

IMPRESSION PROCEDURES::

– IMPRESSION OF THE ABUTMENT TEETH

COMBIMED FULL ARCH IMPRESION:

 THE TWO STAGE TECHNIQUE
In the first step a ZOE paste impression is made of the edentulous segments exactly
as for a complete denture and a window is cut over each abutment tooth.
In the second step the dowel-coping is incorporated into the impression by fixing
them using plaster,acrylic resinor elastomeric impresion material

THE ONE STAGE TECHNIQUE

Edentulous segments and dowel copings can also be included simultaneously in a
single stage full arch impression using elastomer.

– MAXILLOMANDIBULAR RELATION RECORDS::

Basically it is no different than for making a complete denture.

TEETH ARRANGEMENT::
Overdentures being periodontally supported complete dentures, their occlusal form
therefore corresponds to that of complete denture.

FINAL TRYIN MOUNTING THE ATTACHMENTS

The final selection and mounting of retentive attachments does not take place until
the occlusal form and shape of the base have been finalized during the evaluation of the
trial denture.

– DESIGNING THE BASE

When an overdenture base must provide all the retention it is shaped like a
conventional complete denture
– In the presence of retentive elements however a circumdentally open design
with minimum flange extensions is realized.

POPULAR ATTACHMENT SYSTEMS

Dalbo stud Unit

– a. Ball and socket
– b. Rigid Dalbo
– Extremely popular of the design series neatness strength time tested.Features : 4
mm high with spherical shape male section easy to clean. The fingers of the socket are
surrounded by nylon rirgs. That simplifies adjustments. Retention can be increased by
altering free ends of lamellae.

Gerber Attachment :
That allows vertical movement. Rigid attachment (popular). Retention of both types
is obtained by a retaining spring in the female unit engaging a peripheral groove in the
male section. The spring clip may be removed for adjustment by unscrewing.
 Ceka System :
1. Rigid 2. Resilient-
Rigid and Resilient designs share a common base. But the ceka extracoronal units
are not identical. Therefore it is not possible to change resilient for rigid constructions
merely by changing, the Retention portions. The vertical travel allowed by the resilient
stud unit is 0.4 mm: The retention pin. or male section is screwed on to the base ring.

Schubiger :
Consists of a short screw block for bar fixation a larger one for fixed removable
bridge work and an individual cap core system.
– a Solder base common to the Gerber
– b Sleeve in ceramic metal
– c. A cap nut
– d. Overall height is 2.8 mm.

INTRARADICULAR STUD ATTACHMENTS::

The advantages of this system lies in cost and space requirements. They do not
require precious metal coping dowel nor special laboratory procedures. They are
relatively simple and quick.

Zestanchor system:
A nylon male element is incorporated in the denture base and projects down ward@
engagmg a recess in the root preparation. Further the loads are applied at a point that is
well apical to the gingival margin of the root. A variety of abutments may be employed
including hemi-sected molar roots. 2 sizes of zest anchor are available depending on the
root length and diameter.

Bar attachments:

The bar attachments help in splinting of the abutment teeth, retention and support of
the appliance. Bar attachments are classified into two types bar units and bar joints.
Bar unit has a rigid fixation where there is no movement between the bar and overlying
sleeve and can be classified as tooth born. Bar joints permits rotational movement
between sleeve and bar and derives more of residual ridge support.
Types of bar attachments are:
1. Hader bar
2. Dolder bar attachment
3.Bakres clips
4.Ackerrnan clips and
5. C.M.Clip.

MAGNETIC DENTURE RETENTION:

 – Are of two types:
– 1. Those depending on the mutual repulsion or like magnetic poles
(Eg.,Friedman magnetic stabilizers).
– Disadvantages
– i. Less retentive when most needed (when jaws are apart).
– ii. Continued depending resorbtion.
– 2. Those depending gn the mutual attraction unlike poles.
– Disadvantages
Continuous attracting forces could cause the embedded bar magnets to move
through the bone, erode the soft tissues ar-d become exfoliated.

SUBMERGED VITAL ROOTS:

This innovative method attempts to obviate some of the basic problems associated
with conventional over denture treatment like caries, gingivitis, periodontitis and need
for endodontic procedures. Here selected vital roots are transected and reduced to 2mm
below the crestal bone and then covered by a mucoperiosteal flap. Problems with this
technique include dehiscences,pulpal pathoses and lack of sensory discrimination.

SUMMARY AND CONCLUSION::

To summarize it would not be a repetition to say that overdenture is a
preventive dentistry concept which has been brought into prosthodontics and the
alveolar bone and the oral mucosa were never intended to receive the full force of
the complete denture. Even though the technique resembles that of complete
denture there are important differences. The prognosis of the restoration is likely
to be influenced by numerous factors like :
Selection of patient
Treatment planning
Preparation of mouth
Execution of prosthodontic work and maintanence

Finally it is reasonable to conclude that the retention of a part of the natural

dentition affords the overdenture patient a gain in neuromuscular performance
thereby giving him an edge over his edentulous counterpart.
 BIBLIOGRAPHY

-Sheldon Winkler-Essentials of complete denture prosthodontics, second edition

-Zarb-Bolender-Prosthodontic treatment for edentulous patients, twelfth edition
-Charles M. Heartwell Jr, Arthur O.Rahn- Syllabus of complete dentures, fourth
edition
-Alfred H.Geering, Martin Kundert and Charles C. Kelsey-Color atlas of dental
medicine Complete denture and overdenture Prosthetics
-

-George L. Marquardt, Dolder bar joint mandibular overdenture: A technique for

non parellel abutment teeth. J Prosthet Dent 1976;36:101-111
-Robert C. Kahn A method to prepare immediate overdenture teeth accurately. J
Prosthet Dent 1985;53:290
-Arthur Nimmo, Preventing fractures of maxillary overdentures. J Prosthet Dent
1986;55:773-775
-Todd Fridrich, Tooth position index for the fabriocation of a mandibular implant-
supported overdenture bar. J Prosthet Dent 1998;80:121-123