REVIEW ARTICLE

IMPLANT OVER DENTURES: A CONCISE REVIEW OF

THE FACTORS INFLUENCING THE CHOICE OF THE
ATTACHMENT SYSTEMS
Haroon Rashid1 BDS, MDSc
Ayesha Hanif 2 BDS
3
Fahim Vohra BDS, MFDS, M.Clin.Dent, MRDRCS
4
Zeeshan Sheikh BDS, MSc, PhD

ABSTRACT: Provision of implant over-dentures (IODs) has become a popular treatment modality for edentulous
patients. Oral rehabilitation carried out using dentures supported by endosseous implants greatly improves oral
function and majority of the problems associated with the dentures i.e. poor stability and retention may be solved.
Good success rates have been reported regardless of the attachment system used for the IODs however; the
maintenance and complications may be influenced by the use of different attachment systems and other factors. The
aim of the current paper is to briefly review the attachment systems used for IODs and the factors influencing their
selection. Chair-side pickup Impression technique for mandibular implant over-denture is also briefly described.
KEY WORDS: 1. Implant retained over dentures. 2. Implant retained prosthesis. 3. Implant attachment systems
4. Chair-side pickup impression
HOW TO CITE: Rashid H, Hanif A, Vohra F, Sheikh Z. Implant Over Dentures: A Concise Review of The Factors
Influencing The Choice of The Attachment Systems. J Pak Dent Assoc 2015; 24(2):63-69.

INTRODUCTION the resorption was progressive, irrevocable and

continuous4,5. The rate of resorption is the greatest in the

O
ver-dentures are defined as,"removable dental first six months after tooth extraction however; it slows
prosthesis that cover and rests on one or more down due to several biological and mechanical factors4.
remaining natural teeth, the roots of natural teeth, Overdenture abutments, whether a retained root or
and/or dental implants"1. It may also be termed as an an implant, have shown to preserve alveolar bone height7,8
overlay denture, overlay prosthesis, superimposed and stabilize dentures, particularly the mandibular ones9.
prosthesis, hybrid prosthesis, a crown and sleeve Retained roots are cost effective than implants, with no
prosthesis, superimposing denture and a biological requisite of an invasive therapy, and therefore should be
denture1. considered by general practitioners as a useful platform
The concept of retaining teeth/roots of the terminal for over dentures, particularly for older individuals10.
dentition for the provision of an overdenture dates back From physiological viewpoint, the roots provide not only
to more than 100 years2,3. It was first described in 1950's a periodontal ligament to support the teeth, but also
that the residual alveolar bone undergoes resorption which directional sensitivity, tactile sensitivity to load,
continues to progress after tooth extraction compromising dimensional discrimination,7,11,12 and gives an individual
support for a conventional dentures to be provided. The a sense of not being edentulous13. Dental implants provide
analysis of several longitudinal studies confirmed that adequate retention and stability for overlying prosthesis
however; the individual is deprived of tactile sensitivity14.
1. Assistant Professor, Department of Prosthodontics,Ziauddin College of Dentistry, Dental implant therapy is considered the treatment
Karachi, Pakistan.
2. Clinical Lecturer, Department of Prosthodontics, Ziauddin College of Dentistry,
of choice for edentulous patients10. IODs have gained
Karachi, Pakistan. worldwide acceptance and improve the quality of life for
3. Assistant Professor, Department of Prosthetic Dental Science, King Saud University,
Riyadh, Saudi Arabia. edentulous patients. IODs although retentive and
4. Post-doctoral Fellow, Faculty of Dentistry, University of Toronto, Ontario, Canada. stable,require good maintenance of the prosthesis and
Corresponding author: “Dr Haroon Rashid ” < [email protected] >
implant retentive components6. Continued research related

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 Rashid H / Hanif A / Vohra F / Sheikh Z The Factors Influencing The Choice of The Attachment Systems

to IODs has resulted in multiple options and combinations of individual, abutment-based attachments called stud
for IOD attachment systems with varying success. The attachments (ball, magnets, and resilient stud attachments
aim of the current paper is to briefly review the attachment such as Locators [Zest Anchors], ERA [Sterngold], and
systems used for IODs and the factors influencing their non resilient stud attachments such as Ankylos Syncone
selection. Chair-side pickup Impression technique for [DENTSPLY Implants])24,25,26,27,28. Fabrication of an IOD
mandibular implant over-denture is also briefly described. over these systems is costly; require clinical expertise
The treatment of the patient described in the current paper and signification chair-side time18.
was carried out at the department of prosthodontics,
college of dentistry,Ziauddin University, Karachi. FACTORS INFLUENCING SELECTION OF THE
ATTACHMENT SYSTEMS
OVERDENTURE ABUTMENTS
Selecting the most apposite system for an individual
In the early days, only bare teeth with questionable is dependent on a variety of factors29. These factors are
prognosis as a whole were used as abutments for over identified during the treatment and planning phase of the
dentures. Recently, the use of implant abutments for therapy. Following are the factors that influence the
overdenture use has increased. The use of sub-mucosal selection:
roots with magnets is also still in use 15,16. a) Implant site:
When using naturally retained bare teeth, it is aimed that The location of the placed implant in reference to the
canines and second premolars are preserved on both sides bone and the pontics will guide the selection of the type
of the arches. Teeth are prepared in a dome shape, of attachments. However; the selection should ideally be
2-3 mm above the gingival level, with the dome converging decided during the phase of treatment planning. For ample
occlusally. To cope up with certain disadvantages of bare retention, it is highly recommended that the implants are
teeth such as caries progression, attrition of the abutment placed as parallel as possible30,31,32. Where parallelism
teeth, metal copings (short and long) were used over the cannot be achieved, a bar designed is favored. Bar design
dome shaped prepared teeth. Sub-mucosal root retention is also preferred in cases where the unfavorable location
helps to reduce the possible oral hygiene obligations for of the anatomic structures such as, prominent mental
the patients but delays residual ridge resorption. Being foramen or the knife-edge ridge, precludes the ideal
submerged, they escape the sequelae of poor oral hygiene placement of the implants33,34,35,36.
by being isolated from the oral cavity. b) Cross arch stabilization:
With advancements in implant dentistry, implant Bars are indicated in patients with shallow vestibules
supported over-dentures are gaining wide popularity. and resorbed ridges. The bar helps to resist the lateral
Along with implant abutments, sub-mucosal vital tooth loading and provides stabilization37. The stability of the
retention and use of magnets are also commonly used. prosthesis is also improved and cantilever design may be
For many years, osseointegrated implant-supported over- provided with one to two teeth distal to the most posteriorly
dentures have been used in the rehabilitation of the placed implant38. The cases where denture stability is not
edentulous jaws particularly the lower ones, offering a concern and retention is the only requirement, individual
promising results 17,18,19. attachments should be used which offer promising results.
Literature states that the IODs should become the first c) Prosthesis extent:
choice of care for the edentate mandibles20,21. This is a When the patient demands the prosthesis to be of the
lucrative option but simultaneously, has been questioned minimal size, custom designed milled bars is the
for the fact that wide number of the edentate patients are attachment system of choice39. These types of restorations
poor and cannot afford the cost of implant require ideal implant placement. The size of the prosthesis
therapy 22,23. may be limited while keeping in mind the principles of
anterior-posterior spread and cross arch stabilization. This
ATTACHMENT SYSTEMS FOR IODs also minimizes the lateral loads on the implants 38 .
Fabricating a denture using the neutral zone technique
IODs come with a variety of attachment systems will also determine the horizontal space availability for
including the bar and clip attachment systems or a range the prosthesis39. Neutral zone is the area of the minimal

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 Rashid H / Hanif A / Vohra F / Sheikh Z The Factors Influencing The Choice of The Attachment Systems

conflict i.e. the potential denture space; "that space in the h) The Aesthetic Space:
edentulous mouth vacated by the natural dentition and This is defined as "the space between the ridge crest
dental supporting tissues and bound by the tongue and the corresponding lips at rest"29. Prosthesis supported
medially, and the lips and cheeks laterally" 40,41,42 . by the individual attachment systems will require less
d) Sore spots: aesthetic space compared o the bar counterparts. The
It is established that the patients who are prone to measurement of the aesthetic space helps the dentist in
soft-tissue sore spots, for instance xerostomic patients, determining the space allowed for a particular type of the
are reportedly more comfortable with a bar, since the attachment system of an over-denture.
denture can rest entirely on the bar without impingement i) Ease of Fabrication and Repair:
of the soft tissues43. With individual attachments, the Bar supported removable prosthesis require manual
denture is supported by the mucosa and the compressive dexterity for the fabrication and repair compared with
forces acting on the mucosa cause may cause soreness in the removable prosthesis supported by individual studs
patients who are prone to it44. 24,57,58,59,60
. Many a times, the attachment systems are
e) Patient's Oral Hygiene: chosen without the proper consideration given to the
Dentures retained over bars are capable of gathering aforementioned factors. This eventually leads to a failed
more debris and hence make such patients more prosthesis with patient dissatisfaction.
susceptible to mucosal inflammation and peri-implantitis j) Resilience Difference:
44,45,46,47,48,49,50,51
. Unless the patient commits to the Another factor documented that influences the
meticulous oral hygiene measures52, the bar attachments selection of the attachment system for implant-retained
should be denied in patients with poor oral hygiene. over-dentures, is the difference of resilience between the
f) Treatment Costs: implant and the oral mucosa 61,62 . Furthermore, this
Bar attachments are costly as compared to the stud difference should be considered while taking the
abutments in most of the scenarios35,53. Cost is one of the impression of the implant and tissue retained over-dentures.
major decisive factors in the selection of the attachment k) The Attachment System:
system. Patients may be upgraded to the bars and a new IODs supported with bars or balls offer good survival
over denture may be fabricated if the financial condition rates and patient's appreciation levels with a denture
of the patient has improved and other factors are retained with implants are better as compared to a
considered. Yet, in every case, the selective treatment conventional complete denture63. The use of magnets for
option must follow the appropriate guidelines maximizing retaining over-dentures is also described in the literature
the welfare of the patient and the options should never however; their success rates have been limited64. The
be merely dependent on patient's finances. limited success of magnets is mainly due to corrosion of
g) The Restorative Space: the magnets caused by saliva and partly because of less
Restorative space is the space which is available retentive forces achieved as compared to other attachment
for prosthesis restoration. In general, this space is systems. Bar and ball attachment systems offer better
bounded by the planned occlusal plane, the denture mechanical retention and have many differences
bearing tissues, facial tissues i.e. the lips, cheeks and between them. Table 1 outlines the differences between
the tongue54. When planning an implant overdenture, Table 1: Differences Between Ball and Bar Attachments
considerations should be given to the adequate space
available for the denture base, denture teeth, and the
attachment system of the implant. The freeway space,
phonetics and aesthetics must also be considered. The
minimum space requirement for implant supported
over-dentures with Locator attachment system is 8.5mm
of vertical space and 9 mm of horizontal space55. Ideally,
for maxillary implant over-dentures, 13-14mm of vertical
space is required for dentures which are supported by
bars and 10-12mm for the over-dentures supported with
individual attachments56.

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 Rashid H / Hanif A / Vohra F / Sheikh Z The Factors Influencing The Choice of The Attachment Systems

the attributes of bar and ball attachment systems 65,45,66,49,67. Figure 2: Intra-oral view showing the housings placed over
ball abutments
CHAIR SIDE "PICK-UP" IMPRESSION
TECHNIQUE FOR IODs

The selected attachment can be incorporated into the

denture either chair-side or in the laboratory. Chair-side
pick-up technique allows for passive in-vivo pick up of
the attachment, furthermore, attachments are picked-up
under mucosal compression allowing for even load
distribution during function68,69. The technique requires
manual dexterity but simultaneously provides the
incorporation of the attachments into a pre-fabricated
denture. Direct chair-side attachment incorporation also
avoids laboratory cost and a further denture delivery visit. Figure 3: Intra-oral view showing the spacer placed to avoid
Usually resilient, non-splinted, prefabricated attachments acrylic block-out
are utilized.
Abutments are selected with an appropriate gingival
height (Figure 1), which is obtained by measuring the
vertical distance from the implant collar to the highest
Figure 1: Intra-oral view showing ball abutments placed over
mandibular endosseous implants

Figure 4: Existing denture showing spaces created for

the housings

point of soft tissue circumferentially. Another important

factor for abutment selection is the available space in
occlusion in the denture. The suitable abutments are
torqued at 25Ncm and housings are placed over the over-
denture abutments after placing a spacer to avoid acrylic
block-out (Figure 2, Figure 3). The prefabricated complete
denture prosthesis is hollowed at the location of abutments
for the housing to be incorporated, (Figure 4) and is
checked intra-orally. The denture preparation results in
two open windows lingual to the mandibular anterior attachments or the housings. Auto-cure denture base
denture teeth. The abutment housings are placed on to acrylic resin is mixed and placed into the housing space
verify and check the full seating of the final prosthesis and the denture is seated in position. The patient is made
and ensure there is not interference either from the to bite in centric occlusion and the acrylic resin excess

JPDA Vol. 24 No. 02 Apr-June 2015 66

 Rashid H / Hanif A / Vohra F / Sheikh Z The Factors Influencing The Choice of The Attachment Systems

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