OVERDENTURES : OUTLINE OF PRESENTATION: 1. DEFINITION. 2. RATIONALE. 3. TOOTH SUPPORTED OVER DENTURE. 4. INDICATIONS. 5. CONTRAINDICATIONS. 6. ADVANTAGES. 7. DISADVANTAGES. 8. CLASSIFICATION. 9.

TREATMENT PLANNING. 10. PROCEDURE. 11. IMPLANT SUPPORTED OVER DENTURE. 12. SUMMARY.

OVERDENTURE : Removable partial or complete dental prosthesis resting on one or more natural teeth, roots, & / or dental implants by completely enclosing them underneath its fitting surface. SYNONYMS : Tooth supported, Telescopic, Hybrid, Inlay / Onlay / Overlay Dentures, Superimposed Prosthesis. May be Constructed of : - Acrylic resin or in combination with Gold, ChromeCobalt, Ti-vaAl Alloys Frameworks.

RATIONALE FOR MAKING OVERDENTURES : The roots of the tooth offers the best available support for occlusal forces . Accelerated rate of bone resorption is prevented. It maintainsthe teeth as a part of the residual ridge. (so, denture has far more support than any other conventional appliance.) It increases patients manipulative skillsin handling the denture. (Periodontal membrane is also preserved along with the preserved teeth. Thus proprioceptive impulses, part of myofacial complex is retained). Patient feels not being edentulous.

INDICATIONS FOR OVERDENTURES :

1.Patient with badly worn teeth. 2.Patients with few natural teeth remaining. 3.When prognosis is poor for conventional CD. 4.Congenital or acquired intra oral defects. 5.Abnormalities in jaw size & position. 6.Mandibular arch with more rapid loss of RRR. 7.Edentulous maxilla opposed by natural dentition. 8.Post traumatic or post surgical cases. 9.Severe attrition & loss of vertical dimension. 10.Young patients. 11.Cleft palate causing large free way space. 12.Attachment may be indicated in patients suffering from xerostomia or sialorrhoea (Palateless / Flangeless Denture). 25.Patients with exagerated gag reflex. 14. Patients suffering from hypodontia.
1.

Badly Worn Teeth

Few Remaining Natural Teeth

Badly Worn Teeth

Congenital Anomalies

CONTRAINDICATIONS :

1.High caries index. 2.Poor oral hygiene. 3.Poor prognosis of abutment. 4.Reduced inter-arch space. 5.Undercut Ridges. 6.Insufficient attached gingiva. 7.Where endo and perio treatment can not be performed satisfactorily.

ADVANTAGES :
1.Preservation of alveolar bone. 2. Proprio-ception & perception maintenance. i.e. preservation of sensory input from perioreceptors. Relieves deep or traumatic bite. Improve masticatory efficiency in : a. Cases where lower molars occlude palatally making chewing difficult. b. Cases where lateral movements of mandible are limited due to locking of mandible in centric occlusion.

3.Cosmetic results are excellent. 4. 5.

6.Relieve TMJ trauma & Arthroses b/c of regression of condyles.

7.

ADVANTAGES .( CONTD ):
7.

Stability enhanced due to elimination of anterior, posterior & lateral slippage & sliding of denture.

8 . Denture is well retained & sometimes added with precision attachment retentive devices or attachment like: Dolder bar attachment & other attachment. 9. 11 . Support : - natural tooth stop of an overdenture provide for static stable base unparallel by any conventional denture. 10.A simple approach to avoid future problems of patient having denture difficulties. 11.Periodontal maintenance. 12. 13. 14. Patients acceptance of prostheses is enhanced. Harmony of arch form restored. Easy Acceptability & Convertibility to Conventional CDs.

DISADVANTAGES : 1.Caries susceptibility increased. 2.Bony undercuts. (limited POI). 3.Over contoured prosthesis. 4.Under contoured prosthesis. 5.Encroachment of inter occlusal distance. 6.Esthetics / Bulky prosthesis. 7.Periodontal breakdown of abutment teeth. 8.May cause attrition of teeth. 9.Meticulous oral hygiene is required. 10.Time consuming. 11.Require special material & attachment material.

CLASSIFICATION :
ACCORDING TO METHOD OF ABUTMENT PREPARATION : (Along with contemporary clinical terminology) 1. ABUTMENTS WITHOUT COPING: - without endodontic treatment. - with endodontic treatment. 2.ABUTMENTS WITH COPING: - without endodontic treatment. BASED ON TYPE OF OVER DENTURE : - with endodontic IMMEDIATE OD. TRANSITIONAL / INTERUPT OD. treatment. REMOTE / PERMANENT OD. 3. ATTACHMENTS RETAINED OVERDENTURES:
IMPLANT RETAINED OD.

ABUTMENTS WITHOUT COPING :

Selected tooth abutments are reduced to a coronal height of 2 to 3 mm. Contoured to a convex or dome shaped surface. Most teeth require endodontic therapy. In final step such teeth are prepared conservatively to receive an amalgam or composite restoration.

A Case for Non - Coping Abutment Overdenture ( Before Treatment ).

ABUTMENTS WITH COPINGS

Abutment tooth prepared to Receive a: Cast metal coping with a dome shaped surface. Abutment has chamfer finish line at the gingival margin. Coping may be SHORT or LONG. Coping fabricated and cemented over the prepared abutment in mouth. Short copings are 2 - 3 mm and normally require endodontic therapy b / c : - the required coronal root reduction would expose the pulp . Attached to cast coping is a post fitted to the canal . Root canals should be obdurated with soft gutta - purcha rather LONG CAST COPINGS (Crown Coping): than with metal points . Normally 5-8 mm long. Conservative reduction of coronal tooth structure is done. The end result is long ellipsoidal shaped coronal coping. Prepared abutment has larger crown root ratio. Long cast coping require a greater level of osseous support.

SHORT CAST COPINGS (Root Coping)

ABUTMENTS WITH PRECISION ATTACHMENTS :

Most attachments are secured to abutment by a cast coping. Objective: To improve fixation / or retention of OD. - Drastic reduction in crown root ratio results (Favourable). - Where indicated periodontal and endodontic therapy is required.

Teeth prepared to receive Coping Attachment

Splinted Cast Metal Coping With Bar Attachment

Metal Coping With Bar Attachment fitted over prepared abutments

the

TOOTH PREPARATION TO ENHANCE RETENTION :

Prepared abutments with some clinical crown will give: - positive retention when a bar is attached to their copings Cemented on them. Bar also has a splinting effect.

PRECISION ATTECHMENTS ( PAs ):

The B and D anchor. Gerber attachment. The CEKA anchor. Stud attachment. Dalbo attachment. Zest anchor. Rotherman attachment. Introfix attachment. Schubiger attachment. Quinlivan attachment. Magnets : Rare-Earth Cobalt-samarium Miniature Magnets. Bar Attachment : Baker clip Ackerman clip & CM clip Dolder bar / Hader Bar

SUBMERGED ROOTS AS OVERDENTURE ABUTMENTS :

Submerged root as overdenture abutment is still in experimental stage therefore can not be recommended. An innovative attempt to obviate the basic problems like: - caries, gingivitis, periodontitis. - need for endodontic therapy associated with conventional OD abutments. Vital roots are selected. Reduced to 2 mm below the crestal bone. Covered by muco-periosteal flap. Major post operative problems are: - development of dehiscences over retained roots. - pulpal pathologies.

Submerged root copings

Root copings placed on Teeth

Denture prepared and placed

TREATMENT PLANNING FOR OVERDENTURES :

SELECTION OF TEETH AS ABUTMENT FOR ODs :
Ideally tooth should present minimal mobility. Should have acceptable bone support. Be amenable to periodontal therapy. Isolated teeth are proffered to several adjacent teeth. Two teeth in each quadrant present an ideal situation in which: - stress is distributed over a rectangular area. Tripod is the next most favorable form for support and stability. Canine-longest root-more Proprioception. Molars-multirooted teeth are to be preserved. Preserve teeth that are already endodontically treated. Choose teeth that are surrounded by healthy peridontium.

PREPARATORY TREATMENT:
SEQUENCE OF TREATMENT (AS A GENERAL GUIDE): Construct an immediate treatment clasp-less denture. Make a cast from an irreversible hydrocolloid impression. RPD replaces missing and hopelessly involved teeth. Esthetic restored Jaw Relations Retained. Remove hopeless teeth and insert the removable prosthesis. 1. During the healing period, institute the: - periodontic and endodontic treatment.

TOOTH PREPARATION FOR MINIMAL RETENTION:

Remove sufficient tooth structure to: - Provide favorable root-crown ratio: - Allow insertion of OD in an acceptable esthetic position. - Maintain favorable occlusal relation with teeth of opposing arch. Reduce the crown length up to 2 mm above the gingival crest. or A chamber type margin slightly beneath FGM. Incorporate Occlusal Convergence. The finished tooth with cast coping is: - male member of denture. The female member is part of: - denture base.
Tooth preparation done and Special tray prepared impression.

for

CAST COPING FABRICATION :

If making a coping type PA. Make an impression of the abutment after its preparation. Pour a die. Carve the wax pattern. Place occlusal surface concavity in the pattern using a wax-up. Cast the coping in Type-III Aualloy. Cement the polished coping. Advise patient for home-care of abutments.

Short coping cemented onto prepared Tooth to receive Overdenture

PROCEDURES FOR MAKING OVERDENTURES : STEP 1 : IMPRESSIONS :

Same technique is used as when making a conventional CD: -Preliminary Impression. -Final Impression.

STEP 2 : RECORD BASES & OCCLUSAL RIMS : The only difference in the making of record bases for tooth supported overdenture & conventional denture is incorporation of metal bearing in record base .

RECORDING MMRs / TOOTH SET-UP & TRIAL:

Record Vertical & Retruded Contact Position. A face bow transfer register is used to relate the maxillary cast to the articulator. Jaw relations and arrangement of teeth for Esthetics & phonetics are verified at the time of try in.

TOOTH SELECTION :

Consider using acrylic resin denture teeth or their occlusal surfaces in Type-III Au-Alloy: 1. When natural teeth are in the opposing arch. 2. When teeth in the opposing arch have been restored with Gold occlusal surfaces. Gold Occlusal surfaces preferred. Use porcelain teeth in OD if opposing arch has been restored in porcelain.

TEETH SET - UP :

To set acrylic resin tooth over abutment requires : 1.Removing the acrylic resin record base to expose abutment. 2.Retrieving the metal bearing from record base and repositioning it in concavity by sealing the bearing to abutment tooth, at the margins with sticky wax. 3.Hollowing the acrylic resin tooth with an acrylic bur until it is properly positioned and the occlusion is adjusted. 4.Sealing the bearing to acrylic resin tooth with sticky wax. 5.Arranging the remainder of tooth in maximum occlusion 6.Contouring the wax-up denture for try-in appointment.

TRY - IN THE WAXED - UP OD : Verify jaw relations. Make eccentric jaw relation records. Adjust the articulator. Assure esthetic acceptability by the patient. Verify phonetic acceptability.
LABORATORY PROCEDURES: - CONTOUR THE WAX. - FLASK THE DENTURE. - DE-WAXING / ELIMINATE THE WAX. - PRAPARE RESIN MIX FOR PACKING. - PROCESS / CURE OVERDENTURE.

INSERTING / FITTING OVERDENTURE :

Review instruction in denture use and care. Use pressure disclosing paste to locate: - Contacts between female and male members. Evaluate the tissue side of denture base and borders for: - Pressure areas and over extensions. Perfect the occlusion by remounting and selective grinding. Give instruction for Oral & Denture Hygiene. Regular use of fluoride tooth-paste /varnish on abutments. Place patient on recall system (every 4 months ).

FINAL TRY - IN

AFTER INSERTION

IMPLANT - SUPPORTED OVERDENTURES : INDICATIONS :

Patients desire for implant treatment. Systemic health status permitting minor surgical procedure. Sufficient bone quantity to accommodate prescribed implant dimentions. Patient willing and able to maintain oral hygiene & health.

CONTRAINDICATIONS :

Residual ridge dimentions do not accommodate preffered implant dimentions. Communication with patient is not possible. Patient has history of substance abuse. General health conditions preclude a minor surgical intervention. Local anaesthesia with vasoconstricter is contraindicated. Immunosuppresive therapy, prolonged intake of antibiotics or corticosteroids, or meabolic disease history.

TREATMENT PLANNING : OBJECTIVES :

To determine the optimum location & number of implants in the context of the morphological aspect of the residual ridge. To design a favorable distribution for occlusal stresses on the implant and prosthesis bearing tissues. To avoid discrepancies among the design of the denture, the implant location, & the dentures retentive devices. To ensure an optimal esthetic result and hygiene protocol.

STEP BY STEP PROCEDURE :

Preliminary impression with irreversible hydrocolloid for custom tray fabrication (laboratory custom tray with openings over implants location). Abutment component selected ( may include additional prosthetic copings). Mounting of copings. Full arch or two- stage impression with custom tray (laboratory master cast with implant analogues, wax occlusal rims). Jaw relation records. Tooth selection (laboratory mounting the cast on the articulator , preliminary tooth set up). Verification of occlusion records. Esthetic & functional assessment of tooth set up with the patient. Indexing of setups to allow for optimal bar design (corrections as determined in try-in appointment; (bar fabrication). Contd

Complete try-in, obtain consent of the patient. Try-in for bar assembly: - Laboratory final corrections. - Preparation for processing the denture. - Assembly of clip / bar components. Processing the denture. Occlusal equilibration on articulator to rectify processing errors. Delivery of the dentures to the patient. Instruction about handling of the dentures. Cleaning instructions for implants, retention devices & dentures.

SUMMARY :

Overdenture is an excellent viable treatment alternatives. Emphasis must be placed on: Patient Selection. Patient Motivation. Following Basic Prosthodontic Principles. Detail Program of Home-care Instruction. Frequent Recall / Review Visits.

Overdenture is an outstanding mode of treatment. The teeth that are used for the maintenance of health must be properly looked after. A breakdown in the Coronal Structure or breakdown in the Periodontal Support of abutments immediately negates the very concept of overdenture therapy. IT IS IMPORTANT TO CONTROL : - FACTORS THAT JEOPARADIZE THE SUCCESS .