Misch 23

CHAPTER 23
The Edentulous Mandible: Treatment

Plans for Implant Overdentures
Carl E. Misch
The complete edentulous population comprises more than 10% a patient with dentures may improve 300% with an
of the adult population and is directly related to the age of the implant-supported prosthesis.44,45 A study of chewing efficiency
patient. By the age of 70 years old, almost 45% of the popula- compared wearers of complete dentures with wearers of implant-
tion has no teeth in either arch. The vast majority of these supported overdentures. The complete denture group needed
patients are treated with complete dentures. Yet the dental pro- 1.5 to 3.6 times the number of chewing strokes compared with
fession and the public are more aware of the problems associ- the overdenture group.38 The chewing efficiency with an IOD is
ated with a complete mandibular denture than any other dental improved by 20% compared with a traditional complete
prosthesis. denture.6,7,46,47
The placement of implants enhances the support, retention, Mericke-Stern48 and Mericke-Stern et al.49 also compared
and stability of an overdenture. As a result, edentulous patients mastication between root overdentures and IODs. Whereas the
are very willing to accept a treatment plan for a mandibular former was more discriminative, the latter developed slightly
implant overdenture (IOD). There is greater flexibility in harder chewing strokes and tended to masticate more vertically.
implant position or prosthesis fabrication with a mandibular Jemt et al.50 showed a decrease in occlusal force when the bar
IOD; as a result, it is also an ideal treatment modality to begin connecting implants was removed, which they attributed to the
an early learning curve in implant surgery and prosthetics. loss of support, stability, and retention. As a result of improved
Therefore, one of the most beneficial treatments rendered to mastication, patients with IODs can chew significantly better
patients is also one of the best introductions for a dentist into than with their complete dentures6 (Figure 23-1).
the discipline of implant dentistry. The contraction of the mentalis, buccinator, or mylohyoid
An increased awareness from the profession and patients has muscles may lift a traditional denture off the soft tissue. As a
now rendered the mandibular IOD the treatment of choice in consequence, the teeth may touch during speech and elicit click-
the edentulous patient regardless of most clinical situations, ing noises. The retentive IOD remains in place during mandibu-
bone densities, and patients’ desires to restore an ever-growing lar movement. The tongue and perioral musculature may
number of patients.1–38 As a consequence, mandibular overden- resume a more normal position because they are not required
tures have become the minimum standard of care for most to limit mandibular denture movement.
completely edentulous mandibles. The IOD may reduce the amount of soft tissue coverage and
extension of the prosthesis. This is especially important for new
Advantages of Mandibular Implant Overdentures denture wearers, patients with tori or exostoses, and patients
with low gagging thresholds. Also, the existence of a labial
The patient gains several advantages with an implant-supported
overdenture prosthesis.7,8,11 (Box 23-1). The complete mandibu-
lar denture often moves during mandibular jaw movements BOX 23-1 Mandibular Implant Overdenture
during function and speech. A mandibular denture may move
Advantages
10 mm during function. Under these conditions, specific occlu-
sal contacts and the control of masticatory forces are nearly • Prevents anterior bone loss
impossible. An IOD provides improved retention and stability • Improved esthetics
of the prosthesis, and the patient is able consistently to repro- • Improved stability (reduces or eliminates prosthesis
duce a determined centric occlusion.39 movement)
Bone loss after complete edentulism, especially in the man- • Improved occlusion (reproducible centric relation
dible, has been observed for years in the literature.39–41 Soft tissue occlusion)
abrasions and accelerated bone loss are more symptomatic of • Decrease in soft tissue abrasions
horizontal movement of the prosthesis under lateral forces. An • Improved chewing efficiency and force
implant-supported overdenture may limit lateral movements • Increased occlusal efficiency
and direct more longitudinal forces. The anterior implants stim- • Improved prosthesis retention
ulate the bone and maintain the anterior bone volume.40–44 The • Improved prosthesis support
attachment of the mentalis muscle and others are maintained as • Improved speech
a result and therefore improve facial esthetics. • Reduced prosthesis size (reduces flanges)
Higher bite forces have been documented for mandibular • Improved maxillofacial prostheses
overdentures on implants. The maximum occlusal force of
573
574 Dental Implant Prosthetics
100 P .05 P .01 P .01 P .05 P .05 P .05 P .05 portion of the occlusal load. Regions of inadequate bone for
90 implant placement therefore may be eliminated from the treat-
80 ment plan rather than necessitating bone grafts or placing
VAS scores (mm)
70
implants with poorer prognosis. As a result of less bone grafting
60
50 and number of implants, the cost to treat the patients is dra-
40 matically reduced.
30 When cost is a factor, a two-implant-retained IOD may
20 improve the patient’s condition at a lower overall treatment cost
10 than a fixed implant–supported prosthesis.52 A survey by Carls-
0 son et al. in 10 countries indicated a wide range of treatment
General Carrot Cheese Lettuce
chewing Apple Sausage Bread options.53 The proportion of IOD selection versus fixed implant
ability dentures was highest in the Netherlands (93%) and lowest in
Sweden and Greece (12%). Cost was cited as the top determin-
CD group IOD group ing factor in the choice.
The esthetics for many edentulous patients with moderate to
FIGURE 23-1. In a study by Awad et al.,6 implant overdenture advanced bone loss are improved with an overdenture com-
(IOD) patients were able to chew different types of food significantly pared with a fixed restoration. Soft tissue support for facial
better than patients with complete dentures (CDs). (Data from Awad appearance often is required for an implant patient because of
MA, Lund JP, Dufresne E, et al: Comparing the efficacy of mandibular advanced bone loss, especially in the maxilla. Interdental
implant-retained overdentures and conventional dentures among papilla and tooth size are easier to reproduce or control with
middle-aged edentulous patients: satisfaction and functional assess- an overdenture. Denture teeth easily reproduce contours and
ment, Int J Prosthodont 16:117-122, 2003.). esthetics compared with time-consuming and technician-
sensitive porcelain metal fixed restorations. The labial flange
BOX 23-2 Implant Overdenture Advantages may be designed for optimal appearance, not daily hygiene. In
addition, abutments do not require a specific mesiodistal place-
versus Fixed Prosthesis
ment for an esthetic result because the prosthesis completely
• Fewer implants (RP-5) covers the implant abutments.
• Less bone grafting required before treatment Hygiene conditions and home and professional care are
• Less specific implant placement improved with an overdenture compared with a fixed prosthe-
• Improved esthetics sis. Periimplant probing is easier around a bar than a fixed
• Denture teeth prosthesis because the crown contour often prevents straight-
• Labial flange line access along the abutment to the crest of the bone. The
• Soft tissue drape replaced by acrylic overdenture may be extended over the abutments to prevent
• Soft tissue considerations food entrapment during function in the maxilla.
• Improved periimplant probing (follow-up) An overdenture may be removed at bedtime to reduce the
• Hygiene noxious effect of nocturnal parafunction, which increases
• Reduced stress stresses on the implant support system. In addition, a fixed
• Nocturnal parafunction (remove prosthesis at night) prosthesis is not desired as often for a long-term denture wearer.
• Stress relief attachment Long-term denture patients do not appear to have a psychologic
• Lower cost and laboratory cost (RP-5) problem associated with a removable restoration versus a fixed
• Fewer implants (RP-5) prosthesis.54–62
• Less bone grafting (RP-5) In a randomized clinical report, Awad et al.6 compared sat-
• Easy repair isfaction and function in complete denture patients versus
• Laboratory cost decrease (RP-5) patients with two implant-supported mandibular overdentures.
• Transitional device is less demanding than a fixed There were significantly higher satisfaction, comfort, and stabil-
restoration ity in the IOD group (Figure 23-2). A similar study in a senior
population yielded similar results.7 Thomason et al., in the
United Kingdom, also reported a 36% higher satisfaction for
flange in a conventional denture may result in exaggerated facial implant IOD patients than complete denture wearers in the
contours for a patient with recent extractions. Implant-supported criteria of comfort, stability, and chewing.8
prostheses do not require labial extensions or extended soft The overdenture prosthesis is usually easier to repair than a
tissue coverage. fixed restoration. Reduced laboratory fees and fewer implants
Soft and hard tissue defects from tumor excision or trauma allow the restoration of patients at reduced costs compared with
do not permit the successful rehabilitation of patients with tra- a fixed prosthesis.
ditional denture support. Hemimandibulectomy patients and In conclusion, the primary indications for a mandibular IOD
other maxillofacial patients also may be restored more favorably relate to problems found with lower dentures such as lack of
with an IOD compared with traditional procedures.51 retention or stability, decrease in function, difficulties in speech,
An IOD also provides some practical advantages over an tissue sensitivity, and soft tissue abrasions. If an edentulous
implant-supported complete fixed partial denture (Box 23-2). patient is willing to remain with a removable prosthesis, an
Fewer implants may be required when a RP-5 restoration is overdenture is often the treatment of choice. In addition, if cost
fabricated because soft tissue areas may provide additional is a problem for a patient who desires a fixed restoration, the
support. The overdenture may provide stress relief between the overdenture may serve as a transitional device until additional
superstructure and prosthesis, and the soft tissue may share a implants may be inserted and restored.
Chapter 23 The Edentulous Mandible: Treatment Plans for Implant Overdentures 575
Conventional
denture group Overdenture group
Variable Mean (SD) Mean (SD)
General satisfaction 63.7 (34.7) 89.2 (21.8)*
Comfort 63.6 (36.8) 88.9 (21.4)†
Esthetics 88.9 (17.8) 90.6 (14.9)
Ability to speak 85.2 (20.9) 91.7 (11.8)
Stability 64.5 (36.4) 90.6 (19.8)†
Ability to clean 89.9 (17.8) 91.1 (18.3)
*Significant between-group difference; t tests. P .001.

†Significant between-group difference; t tests. P .05.
FIGURE 23-2. In a study by Awad et al.,6 the patients with

implant overdentures scored significantly higher for general satisfac-
tion, comfort, and stability compared to the conventional complete
denture patients. SD, Standard deviation. (Data from Awad MA, Lund FIGURE 23-3. Long-term complete edentulism can result in
JP, Dufresne E et al: Comparing the efficacy of mandibular implant- severe bone atrophy. This cephalometric radiograph demonstrates
retained overdentures and conventional dentures among middle- that the body of the mandible is less 5 mm high and the superior
aged edentulous patients: satisfaction and functional assessment, Int genial tubercle is 10 mm above the crest of the ridge.
J Prosthodont 16:117-122, 2003.)
Philosophy for Implants in the

Edentulous Mandible
From a bone volume conservation standpoint in the jaws, com-
plete edentulous patients should be treated with enough
implants to completely support a prosthesis whether the patient
is partially or completely edentulous. The continued bone loss
after tooth loss and associated compromises in esthetics, func-
tion, and health make all edentulous patients implant candi-
dates. These issues are addressed in Chapter 1. The average
denture patient does not see a dentist regularly. In fact, more
than 10 years usually separates dental appointments of edentu-
lous patients. As a consequence, patients are unaware of the
insidious loss of bone in the edentulous jaw.
During the long hiatus between dental visits after dentures
FIGURE 23-4. The majority of mandibular overdentures per-
are used to replace the dentition, the amount of resorption from
formed by dentists are with two implants regardless of factors such
initial denture delivery to the next professional interaction
as the remaining bone, the opposing arch, and patient complaints.
already has caused the destruction of the original alveolar
Although this treatment is an improvement compared with a denture,
process. The bone loss that occurs during the first year after
the posterior bone loss continues, and the anterior implants may
tooth loss is 10 times greater than in following years. In the case
experience greater problems than when additional implants are
of multiple extractions, this often means a 4-mm vertical bone
used.
loss within the first 6 months. This bone loss continues over the
next 25 years, with the mandible experiencing a fourfold greater
vertical bone loss than the maxilla 35(Figure 23-3). As the bony existing bone volume and improve prosthesis function, mastica-
ridge resorbs in height, the muscle attachments become level tory muscle activity, esthetics, and psychologic health.
with the edentulous ridge.39,40 The more often a patient wears a The majority of mandibular overdentures used by the profes-
denture, the greater the bone loss, yet 80% of denture patients sion are supported by two implants anterior to the foraminae
wear their dentures day and night. To the contrary, the anterior and soft tissue support in the posterior regions (Figure 23-4).
bone under an overdenture may resorb as little as 0.6 mm verti- Yet posterior bone loss occurs four times faster than anterior
cally over 5 years, and long-term resorption may remain at less bone loss. In a completely edentulous patient, the eventual
than 0.05 mm per year.4,35,43 paresthesia and mandibular body fractures are primarily from
Therefore, the profession should treat bone loss after tooth posterior bone loss (Figure 23-5). The anterior implants allow
extraction in a similar fashion as bone loss from periodontal improved anterior bone maintenance, and the prosthesis ben-
disease. Rather than waiting until the bone is resorbed or the efits from improved function, retention, and stability. However,
patient complains of problems with the prostheses, the dental the lack of posterior support in two- and three-implant over-
professional should educate the patient about the bone loss dentures allows continued posterior bone loss. A primary
process after tooth loss. In addition, the patient should be made concern for RP-5 overdentures (soft tissue support in the pos-
aware the bone loss process can be arrested by a dental implant. terior regions) compared with RP-4 or fixed restorations (resto-
Therefore, most completely edentulous patients should be rations completely supported, retained, and stabilized) is the
informed of the necessity of dental implants to maintain continued bone loss in the posterior regions. The posterior
bone resorbs faster than the anterior bone, and implant pros- (fixed prosthesis) restoration. In addition, reports indicate that
theses with posterior soft tissue support may accelerate poste- RP-5 mandibular IODs may cause a combination-like syn-
rior bone resorption two to three times faster than in a complete drome, with increased looseness, subjective loss of fit, and
denture wearer.41–43 Therefore, the short-term benefit of midline fracture of the upper denture.64–68 Although not yet
decreased cost for RP-5 overdentures may be offset by the accel- established as a cause-and-effect situation, the condition may
erated bone loss that is a primary consideration, especially in be reduced with a proper occlusal scheme.66
younger edentulous patients. Financial considerations have been identified as the reason
Patients wearing fixed implant–supported prostheses show for the selection of a limited treatment, which may consist of
little to no bone loss and usual occurrences of bone apposi- two or three implants to support the overdenture.14,25,34 These
tion.44,63 For example, studies by Wright et al.31 and Reddy RP-5 restorations may be used as transitional devices until the
et al.40 found prostheses completely supported by implants in patient can afford to upgrade the restoration. When a partially
the edentulous mandible actually may increase the posterior edentulous patient cannot afford to replace four missing first
bone volume (even though posterior implants are not inserted) molars, the dentist often will replace one molar at a time over
(Figure 23-6). Therefore, the next progression in the implant many years. Likewise, the dental implant team can insert one
philosophy is to convert all mandibular implant and soft or two additional implants every few years until finally a com-
tissue–supported restorations to a completely implant- plete implant–supported prosthesis is delivered.
supported prosthesis. As a result, complete implant–supported The ultimate goal of bone maintenance with a complete
restorations should be the restoration of choice. implant–supported prosthesis may be designed in the begin-
As a consequence of continued posterior bone loss with a ning of treatment even though it may take many years to com-
two- or three-implant overdenture, the recommendation is to plete. The advantage of developing a treatment plan for
consider a RP-5 prosthesis as an interim device designed to long-term health, rather than short-term gain, is beneficial to
enhance the retention of the prosthesis. These restorations the patient. As such, if finances are not an issue, the dentist
should not be considered an end result for all patients. Instead, should design a prosthesis that is completely supported,
a regular evaluation of patients’ performance paired with patient retained, and stabilized by implants. If cost is a factor, a transi-
education should enable the transformation to a RP-4 or FP-3 tional implant-retained restoration with fewer implants greatly
improves the performance of a mandibular denture. Then the
dentist may establish a strategy for the next one or two steps to
obtain the final complete implant–supported restoration.
Disadvantages of Implant Overdentures

The primary disadvantage of a mandibular overdenture is
related to the patient’s desire, primarily when he or she does
not want to be able to remove the prosthesis. A fixed prosthesis
often is perceived as an actual body part of the patient, and if
a patient’s primary request is not to remove the prosthesis, an
implant-supported overdenture would not satisfy the psycho-
logical need of the patient.
The mandible bone may also be a disadvantage for an IOD.
The mandibular overdenture treatment plan requires more than
12 mm of space between crestal bone and the occlusal plane
(Figure 23-7). When sufficient crown height space (CHS) is
FIGURE 23-5. A panoramic radiograph of a patient treated with lacking, the prosthesis is more prone to component fatigue and
anterior implants and mandibular overdenture 30 years before. The fracture and has more complications than porcelain-to-metal
posterior bone has continued to be lost and has partial paresthesia. fixed prostheses. The 12-mm minimum CHS provides adequate
The maxillary bone has also completely atrophied during this time. bulk of acrylic to resist fracture; space to set denture teeth
FIGURE 23-6. Wright et al.31 and Reddy et al.40

found full arch implant–supported prostheses may
prevent posterior bone loss and even may cause some
gain in bone volume even though implants are not
inserted in the posterior regions. This 25-year-old fixed
implant prosthesis have maintained anterior and poste-
rior bone in the mandible.
Hader clip O-ring
Tooth > 8 mm
Bar + Hader clip = 3 mm Bar + O-ring = 5 mm
Soft tissue to
bar = 1 mm Bone crest to
soft tissue = 3 mm
FIGURE 23-7. The mandibular overdenture requires at least 12 mm between the soft tissue and the
occlusal plane to provide sufficient space (15 mm from bone level to occlusal plane) for the bar, attachments,
and teeth.
FIGURE 23-8. A panoramic radiograph of a patient

with abundant mandibular bone and an implant over-
denture. The prosthesis fractured several times each
year because there was inadequate bulk of acrylic for
the restoration.
without modification; and room for attachments, bars, soft Quirynen et al. of 210 computer tomogram images, 28% of the
tissue, and hygiene. In the mandible, the soft tissue is often 1 anterior mandibles were lingually tilted −67.6 degrees ± 5.5
to 3 mm thick above the bone, so the occlusal plane to soft degrees.7 The mandibles with less than −60 degree tilt represent
tissue should be at least 10 mm in height. An osteoplasty to about 5% of the cases.
increase CHS before implant placement is often indicated, Although the initial cost of treatment may be less for an
especially when abundant bone height and width are present IOD, overdenture wearers often incur greater long-term expenses
(Figure 23-8). Otherwise, a fixed porcelain–metal restoration than those with fixed restorations. Attachments (such as O-rings
should be considered. or clips) regularly wear and must be replaced. Replacements
Another complication related to the available bone is incli- appear more frequent during the first year but remain a neces-
nation or angulation of the mandible, especially when the sary maintenance step.18,21,35,69–76 In a study by Bilhan et al. on
alveolar process has resorbed. The division C–a anterior man- 59 patients, two thirds of IOD patients had prosthetic-related
dible is angled more than 30 degrees. If the surgeon is unaware complications the first year.77 For example, relines were neces-
of this angulation, the implants may perforate the lingual plate sary in 16%, loss of retention in 10.2%, fracture of the IOD in
and irritate the tissues of the floor of the mouth (Figure 23-9). 8.5%, pressure spots in 8.5%, dislodged attachment in 6.8%,
If the surgeon places the implants within the bone, they may and screw loosening in 3.4%.
enter the crest of the ridge at the floor of the mouth and make Denture teeth wear faster on an IOD than with a traditional
it almost impossible to restore (Figure 23-10). In a study by denture because bite force and masticatory dynamics are
FIGURE 23-9. An occlusal film of a C–a mandible and five implants perforating the lingual plate of
bone. The floor of the mouth would swell up and remain irritated.
BOX 23-3 Overdenture Disadvantages
• Psychological (need for nonremovable teeth)

• Greater abutment crown height space required
• More long-term maintenance required
• Attachments (change)
• Relines (RP-5)
• New prosthesis every 7 years
• Continued posterior bone loss
• Food impaction
• Movement (RP-5)
In 1986, a multicenter study reported on 1739 implants

placed in the mandibular symphysis of 484 patients.2 The
FIGURE 23-10. Four anterior implants in a C–a mandible. The implants were loaded immediately and restored with bars and
implants enter in the floor of the mouth, cause constant irritation, IOD with clips as retention. The overall implant success rate was
and are difficult to restore. 94%. Engquist et al.3 reported a 6% to 7% implant failure for
mandibular implant–supported overdentures in 1988. Jemt
improved. A new overdenture often is required at 5- to 7-year et al.4 reported on a 5-year prospective, multicenter study on 30
increments because of denture tooth wear and changes in the maxillae (117 Brånemark implants) and 103 mandibles with
soft tissue support. Therefore, patient education of the long- 393 implants. Survival rates in the mandible were 94.5% for
term maintenance requirement should be outlined at the onset implants and 100% for prostheses.4 Attard and Zarb followed
of implant therapy.57 IOD wearers for 20 years with a success rate of 84% and 87%
A side effect of a mandibular IOD is food impaction. The for prosthesis and implants, respectively.35
flanges of the prosthesis do not extend to the floor of the mouth More recent studies demonstrate even greater implant success
in the rest position (to eliminate sore spots caused by elevation rates when used to support a mandibular overdenture. A review
of the floor of the mouth during swallowing). However, during of implant literature by Goodacre et al. in 2003 found man-
eating, food particles migrate and become impacted under the dibular implant overdentures have higher implant survival rates
prosthesis during swallowing. A similar condition is found with compared with any other type of implant prosthesis.78 Wismei-
a traditional denture. However, because a lower denture “floats” jer et al.5 reported on 64 patients with 218 titanium plasma-
during function, the food more readily goes under and then sprayed implants with a 97% survival with overdentures in a
through, but the IOD traps the food debris against the implants, 6.5-year evaluation. Naert et al.15 found 100% implant success
bars, and attachments (Box 23-3). at 5 years for mandibular overdentures with different anchorage
systems. In Belgium, Naert at al. reported on 207 consecutively
Review of the Literature treated patients with 449 Brånemark implants and Dolder-bar
mandibular overdentures. In this report, the cumulative implant
The concept of mandibular implant–supported overdentures failure rate was only 3% at the 10-year benchmark.9,10 Similarly,
has been used for many years. Successful reports were published Hutton et al.12 reported 97% survival rates for mandibular
originally with mandibular subperiostal implants or with overdentures.
immediately loaded and stabilized root form implants in the Misch13 reported less than 1% implant failure and no pros-
anterior mandible more than 4 decades ago.1,2 thesis failure over a 7-year period with 147 mandibular
overdentures (IOD) when using the organized treatment The overdenture options err on the side of safety to reduce
options and prosthetic guidelines presented in this chapter. the risk of failure and complications of bone loss and super-
Kline et al. reported on 266 mandibular implant–supported structure loosening. The initial treatment options are presented
overdentures for 51 patients, with an implant survival rate of for completely edentulous patients with division A (abundant)
99.6% and a prosthesis survival rate of 100%.79 Mericke-Stern or B (sufficient) anterior bone treated with division A anterior
et al. reported 95% implant survival with two implant overden- root form implants of 4 mm or greater diameter. Modifications
tures in the mandible. In a 10-year study of IODs in Israel, with related to posterior ridge support and arch form also are dis-
285 implants and 69 implant overdentures, Schwartz-Arad et al. cussed. Following these standardized conditions, anterior bone
reported implant survival was 96.1% with higher success rates volume conditions of moderate atrophy (division C minus
in the mandible.42 height [C–h]) are presented.
In conclusion, many reports have been published over the
past 2 decades that conclude that mandibular implant– Overdenture Movement
supported overdentures represent a predictable option for
denture wearers. To develop a treatment plan for a mandibular IOD, the final
prosthesis should be determined related to the necessary reten-
Overdenture Treatment Options tion, support, and stability required for the restoration. Reten-
tion of the restoration is related to vertical force necessary to
Traditional overdentures must rely on the remaining teeth to dislodge the prosthesis. Support is related to the amount of
support the prosthesis. The location of these natural abutments
is highly variable, and they often comprise past bone loss associ-
ated with periodontal disease. For a mandibular implant–
supported overdenture, the implants may be placed in planned,
specific sites, and their number may be determined by the
restoring doctor and patient. In addition, the overdenture
implant abutments are healthy and rigid and provide an excel-
lent support system. As a result, the related benefits and risks of
each treatment option may be predetermined.
In 1985, the author presented five organized treatment RP-5
RP-4
options for implant-supported mandibular overdentures RP-4
in completely edentulous patients.13,80,81 The treatment RP-5
options range from primarily soft tissue support and implant
retention (RP-5) to a completely implant-supported prosthesis
(RP-4) with rigid stability (Table 23-1). The prostheses are
supported by two to five anterior implants for these options.
The four RP-5 options have a range of retention, support, and FIGURE 23-11. Five prosthetic options are designed for the
stability. The RP-4 restoration has a rigid cantileverd bar that mandibular overdentures. Four options are RP-5 (posterior soft tissue
completely supports, stabilizes, and retains the restoration support) and one option is RP-4 (prosthesis completely supported by
(Figure 23-11). implants and connective bar).
TABLE 23-1
Mandibular Overdenture Treatment Options
Option Description Removable Prosthesis Type 5
OD-1 Implants in the B and D positions independent of Ideal denture
each other Ideal anterior and posterior ridge form
Cost is a major factor
Retention only PM-6
OD-2 Implants in the B and D positions rigidly joined by a Ideal posterior ridge form
bar Ideal denture
Cost is a major factor
Retention and minor stability
PM-3 to PM-6
OD-3A Implants in the A, C, and E positions rigidly joined by a Ideal posterior ridge form
bar if posterior ridge form is good Ideal denture
Retention and moderate stability PM-2 to PM-6 (two-legged chair)
OD-4 Implants in A, B, D, and E positions rigidly joined by a Patient desires greater retention, major stability, and support
bar cantilevered distally about 10 mm PM-2 to PM-6 (three-legged chair)
OD-5 Implants in the A, B, C, D, and E positions rigidly joined Patient has high demands or desires
by a bar cantilevered distally about 15 mm Retention, stability, and support PM-0 (four-legged chair)
OD, Overdenture option; PM, prosthesis movement class.
From Misch CE: Misch Implant Institute manual, Dearborn, MI, 1984, Misch International Implant Institute.
vertical movement of the prosthesis toward the tissue. Stability

of a prosthesis is evaluated with horizontal or cantilevered
forces applied to the restoration. The amount of retention is
related to the number and type of overdenture attachments. The
stability of the IOD is more related to implant (and bar) posi-
tion, and support is primarily related to implant number (and
bar design in the posterior region). The patient’s complaints,
anatomy, desires, and financial commitment determine the
amount of implant support, retention, and stability required to
predictably address these conditions. Because different ana-
tomic conditions and patient force factors influence these
factors for an IOD, not all prostheses should be treated in the
same manner. In other words, a two-implant overdenture
should not be the only treatment plan offered to a patient. One
should emphasize that most mandibular overdentures should
be designed to eventually result in a RP-4 prosthesis, as previ- FIGURE 23-12. Prosthesis movement for overdentures is often
ously discussed. different than “attachment” movement categories. In this RP-4 over-
The most common complications found with mandibular denture bar, O-rings (a class 6 attachment movement), and Hader clip
implant overdentures are related to prosthetics and an under- (a class 2 attachment movement) support a rigid overdenture. The
standing of retention, support, and stability of the prosthesis. prosthesis movement is PM-0.
For example, when a fixed restoration is fabricated on implants,
it is rigid, and cantilevers or offset loads are clearly identified.
Rarely will a practitioner place a full-arch fixed restoration on
three implants, especially with excessive cantilevers because of an apical and hinge motion is PM-3. A PM-4 allows movement
implant positioning. However, three anterior implants with a in four directions, and a PM-6 has ranges of PM in all
connecting bar may support a completely fixed overdenture, directions.
solely because of attachment design or placement. The restoring
doctor thinks the three-implant overdenture has less implant Prosthesis Movement
support but does not realize that an overdenture that does not The dentist determines the amount of PM the patient desires or
move during function is actually a fixed restoration. Therefore, the anatomy may tolerate. If the prosthesis is rigid when in place
an overdenture with no prosthesis movement (PM) should be but can be removed, the PM is labeled PM-0 regardless of the
supported by the same number, position, and design of implants attachments used. For example, O-rings may provide motion in
as a fixed restoration. six different directions. But if four O-rings are placed along a
Many precision attachments with varying ranges of motion complete arch bar and the prosthesis rests on the bar, the situ-
are used in implant overdentures. The motion may occur in zero ation may result in a PM-0 restoration. A hingelike PM permits
(rigid) to six directions or planes: occlusal, gingival, facial, movement in two planes (PM-2) and most often uses a hinge-
lingual, mesial, and distal. A type 2 attachment moves in two like attachment. For example, the Dolder bar and clip without
planes and a type 4 attachment in four planes. An IOD may a spacer or Hader bar and clip are the most commonly used
also have a range of movement during function. It should be hingelike attachments. A Dolder bar is egg shaped in cross-
understood that the resulting overdenture movement during section, and a Hader bar is round. A clip attachment may rotate
function may be completely different from the one provided by directly on the Dolder bar. A Hader bar is more flexible because
independent attachments and may vary from zero to six direc- round bars flex to the power of 4 related to the distance and
tions depending on the position and number of attachments, other bar shapes flex to the power of 3. As a result, an apron
even when using the same attachment type. For example, an often is added to the tissue side of the Hader bar to limit metal
“O” ring attachment may allow six directions of movement. flexure, which might contribute to unretained abutments or bar
However, when four “O” rings are placed on a bar, the prosthe- fracture. A cross-section of the Hader bar and clip system reveals
sis movement (PM) during function or parafunction may have that the apron, by which the system gains strength compared
no directions of movements (Figure 23-12). Therefore, attach- with a round bar design, also limits the amplitude of rotation
ment and PM are independent from each other and should be of the clip (and prosthesis) around the fulcrum to 20 degrees,
evaluated as such. An important item for the IOD treatment thus transforming the prosthesis and bar into a more rigid
plan is to consider how much PM the patient can adapt to or assembly (Figure 23-13). Therefore, the Hader bar and clip
tolerate on the final restoration. system may be used for a PM-2 when posterior ridge shapes are
favorable and soft tissue is firm enough to limit prosthesis
Classification of Prosthesis Movement rotation.
The classification system proposed by the author in 1985 evalu- It should be noted that for these systems to function effi-
ates the directions of movement of the implant-supported pros- ciently, the hinge attachment needs to be perpendicular to the
thesis, not the overall range of motion for the individual axis of prosthesis rotation, so the PM also will be in two planes
attachment; therefore, the amount of PM is the primary concern. (i.e., PM-2). If the Hader or Dolder bar is at an angle or parallel
An overdenture is by definition removable, but in function or to the direction of desired rotation, the prosthesis is more rigid
parafunction, the prosthesis may not move. If the prosthesis and may resemble a PM-0 system (Figure 23-14). As a conse-
does not have movement during function, it is designated PM-0 quence, the implant system may be overloaded and cause com-
and requires implant support similar to a fixed prosthesis. A plications such as screw loosening, crestal bone loss, and even
prosthesis with a hinge motion is PM-2, and a prosthesis with implant failure. A Hader bar-clip system is an ideal low-profile
A
?
B C D E
FIGURE 23-15. The anterior mandible is divided into five equal

columns of bone between the mental foramens: A, B, C, D, and E.
overdenture restoration usually do not extend beyond the first

molar. This helps prevent a hidden cantilever, which may extend
beyond this position.
Mandibular Implant Site Selection

FIGURE 23-13. An implant overdenture with a Hader clip may
rotate 20 degrees around a bar when the bar is perpendicular to the Anterior retention and stability for an overdenture prosthesis
midline of the mandible. offer several advantages. Overdentures with posterior move-
ment gain better acceptance than removable restorations with
anterior movement. The anterior denture teeth are most often
anterior to the edentulous ridge. As a result, horizontal or verti-
cal forces to the anterior teeth cause the prosthesis to rock down
in the front (and up in the back). The range of movement is
often excessive because there is no bone under the anterior
teeth. In the posterior regions, the posterior denture teeth may
be positioned over the bone (of the ridge or buccal shelf of
bone), which is often parallel to the occlusal plane. As such,
when posterior vertical bite forces are applied, the posterior PM
is limited to the movement of the tissue.
An axiom in removable partial denture (RPD) design for a
class IV Kennedy-Applegate partial edentulous arch (posterior
teeth and anterior missing teeth across the midline) is to gain
rigid prosthetic support in the anterior region. When the pros-
thesis has poor anterior and good posterior stability, it rocks
back and forth during function. This rocking action applies
FIGURE 23-14. Hader bar clip is a class 2 attachment system. torque to the abutments and increases stresses on the overden-
However, when the clips are placed parallel or at an angle to the ture components and bone–implant interface. Therefore,
desired prosthesis movement (PM), the prosthesis is rigid. In this case, whereas anterior forces to the IOD should be resisted by
two implants are not enough to support a PM-0. Screw loosening, implants or bars, posterior forces may be directed on a soft
bone loss, and implant failure resulted. tissue area, such as the mandibular buccal shelf.
The greatest available height of bone in an edentulous man-
dible is located in the anterior mandible between the mental
attachment for a RP-4 prosthesis with PM-0. Usually, these clips foraminae. This region also usually presents optimal density
are placed on the bar in different planes around the arch. of bone for implant support. Therefore, the implant overden-
ture treatment options presented are designed for anterior
The Hidden Cantilever implant placement between the mental foramina because the
The hidden cantilever is the portion of the prosthesis that prostheses’ movement will be more limited and the available
extends beyond the last implant or connecting bar. If the pros- bone volume and density are more favorable than when
thesis does not rotate at the end of the implant or bar to load implants are inserted more posterior.
the soft tissue, a hidden cantilever exists. For example, if a can- The available bone in the anterior mandible (between the
tilevered bar extends to the first molar but forces on the second mental foramen) is divided into five equal columns of bone
molar of the restoration do not result in movement of the res- serving as potential implant sites, labeled A, B, C, D, and E,
toration down in the back and up in the front, the cantilever starting from the patient’s right side80,81 (Figure 23-15). Regard-
really is extended to the second molar position. Therefore, the less of the treatment option being executed, all five implant sites
cantilever length is measured to the point of PM, not to the end are mapped at the time of treatment planning and surgery.
of the bar and attachment system. The teeth on the final There are four reasons for this treatment approach:
1. The patient always has the option to obtain additional In overdentures supported by natural teeth, the dentist is
implants and prosthesis support and stability in the future forced to choose the best remaining teeth to support the
if all five sites were not initially used for implant support. restoration. These remaining teeth have a wide range of clini-
For example, a patient may receive adequate retention, sta- cal conditions and locations. As a consequence, each tooth-
bility, and support for an implant overdenture with four supported overdenture is slightly different in regard to
implants. However, if the patient desires a fixed prosthesis retention, stability, and support. In implant dentistry, healthy
in the future, these four implants may fall short of the new predictable abutments in preselected locations and the range
prosthetic requirements. If the implant surgeon did not plan in the number of implant permit the restoring dentist to
an additional implant site at the initial surgery but instead obtain more similar clinical results for each treatment option
placed the four implants an equal distance apart, the addi- selected. Hence, a more predictable predetermined treatment
tional space may not be available without removing one of may be planned for each patient, depending on psychologic
the preexisting implants. need, anatomic conditions, and financial restraints.
2. A patient may desire a completely implant-supported resto-
ration (e.g., RP-4 or fixed prosthesis) but cannot afford the Overdenture Option 1
treatment all at once. Three implants in the A, C, and E posi- The first treatment option for mandibular overdentures (OD-1)
tions and an IOD may be provided now, two implants may is indicated primarily when cost is the most significant patient
be added in the B and D locations later, and a completely factor. However, it is important to note that the patient’s desires
implant-supported overdenture or fixed restoration may should also be minimal, and the bone volume in both the
then be fabricated (Figure 23-16). anterior and posterior regions should be abundant (division A
3. If an implant complication occurs, the preselected option or B). The posterior ridge form should be an inverted U shape,
sites permit repeatable, corrective procedures. For example, with high parallel walls for good to excellent anatomical condi-
if implants were placed in the A, B, D, and E positions and tions for conventional denture support and stability (Box 23-4).
an implant fails to achieve rigid fixation, the failed implant The problem associated with the existing denture relates primar-
may be removed and an additional implant placed in the C ily to the amount of retention. In addition, the opposing arch
position at the same time. This saves an additional surgery should be restored with a traditional complete denture.
and eliminates the time required for bone grafting Under these more ideal intraoral conditions, two implants
and healing before another implant could be reinserted may be inserted in the B and D positions (Figure 23-18). The
(Figure 23-17). implants remain independent of each other and are not con-
4. The fourth reason the five implant sites are repeated for each nected with a superstructure. The overdenture attachment
treatment option is for the experience of the restoring dentist. improves retention. The most common type of attachment used
FIGURE 23-16. A, This patient wore a three-

implant overdenture for several years. She then decided
to improve the overdenture support, stability, and
retention. The implant sites B and D could be added A
later because all five implant sites were initially planned.
B, A hybrid fixed prosthesis was fabricated after the two
additional implants were placed (same patient as in A).
B
FIGURE 23-17. A, A panoramic radiograph of

implants in the A, B, D, E position. B, A postoperative
panoramic radiograph of the removal of implant B and
insertion of implant C (and uncover of A, D, E). C, An
option OD-4 with a RP-5 prosthesis was fabricated.
BOX 23-4 Patient Selection Criteria: OD-1
• Opposing a maxillary full denture

• Anatomical conditions are good to excellent (division A or
B anterior and posterior bone.
• Posterior ridge form is an inverted U shape.
• Patient’s needs and desires are minimal, primarily related to
lack of prosthesis retention.
• Edentulous ridge, not square with a tapered dentate arch
form
• Cost is the primary factor.
• Additional implants will be inserted within 3 years.
B D
FIGURE 23-18. Overdenture option 1 consists of two indepen-
dent implants. These are best placed in the B and D positions to limit
the forward rocking of the restoration during function.
in OD-1 is an O-ring or Locator design. The stability of the It should be noted that the edentulous ridge may be square,
restoration is improved in the anterior section by the implants ovoid, or tapering. The dentate arch form is also divided into
and the posterior regions from the ridge form. The support of square, ovoid, and tapering categories and may be different than
the restoration is provided primarily from the buccal shelf in the ridge form. When a tapered dentate arch form is supported
the posterior and the ridge in the anterior similar to a tradi- by two independent implants in a square residual ridge form,
tional denture. The IOD must be RP-5, which means it must be the anterior teeth are cantilevered anteriorly from the implant
able to rotate and load the posterior soft tissue regions of the retentive system. More implants are required in this dentate–
mandible (Figure 23-19). The implant support mechanism is ridge form combination to help stabilize the prosthesis.
poor because stress relief of the attachment is permitted in any The prosthesis may act as a splint for the two B and D
plane. In other words, the stability and support of the prosthesis implants during anterior biting forces, thereby decreasing some
are gained primarily from the anatomy of the mandible and of the stress to each implant. However, most situations do not
prosthesis design, which is similar to a complete denture. allow the prosthesis to act as a true splint because a stress relief
Positioning of the implants in the B and D position is a attachment permits movement in any plane. As a result, only
much better prosthetic option in OD-1 than positioning in the one implant is loaded at a time in most situations, and the
A and E regions (Figure 23-20). Kennedy-Applegate class 1 restoration is more unstable than when a bar connects the
patients (with bilateral distal extensions) and anterior missing implants.
teeth often are restored with a fixed prosthesis anteriorly and a The patient’s primary advantage with treatment option OD-1
class 1 RPD. This eliminates the unfavorable rocking leverages is reduced cost. The two implants are usually the fewest implant
that exist when replacement denture teeth are anterior to the number, and no connecting bar reduces the prosthetic appoint-
fulcrum line.85 Independent implants in the A and E positions ments and the laboratory costs. The existing prior denture may
are implant locations in the first premolar region, which is more even be adapted with an intraoral rebase and pickup procedure
posterior to the anterior fulcrum line of the anterior teeth around the implants and attachments. This further reduces the
and allows a greater amplitude of rocking of the restoration fee. In addition, on occasion, the connecting bar may not be
(Figure 23-21). When using B and D implants (which is similar passive, and additional complications may ensue. Because this
to the natural canine positions), the anterior movement of the option does not have a connecting bar, there may be fewer bar-
prosthesis is reduced. related complications. In addition, hygiene procedures also are
facilitated with independent implants.
The disadvantages of the OD-1 prosthesis relate to its rela-
tively poor implant support and stability compared with any of
the other options (which have connecting bars and more
implants) because of the independent nature of the B and D
implants. Jemt et al.4 demonstrated a decrease in occlusal force
when the bar connecting implants was removed from implant
overdenture patients. In addition, future bone loss in the eden-
tulous regions of the mandible is not reduced significantly
because only two anterior implants are inserted.
The other disadvantages of OD-1 restorations relate to an
increase in prosthetic maintenance appointments. For the res-
toration to be inserted and function ideally, the two implants
should be parallel to each other perpendicular to the occlusal
FIGURE 23-19. A RP-5 prosthesis must rotate during function on plane at the same horizontal height (parallel to the occlusal
the anterior implants, so the prosthesis may load the soft tissues of plane) and equal distance off the midline. If one implant is not
the posterior mandible. parallel to the other, the prosthesis will wear one attachment
E
A
FIGURE 23-20. Independent implants in the A and E positions FIGURE 23-21. Independent implants in the A and E position
allow a greater rocking of the restoration and place greater leverage are distal to the incisal edge of the anterior teeth. As a result, anterior
forces against the implants. tipping of the implant overdenture during excising food is common.
faster because of the greater displacement during insertion including abutment screw loosening, marginal bone loss
and removal than the other. If the angulation difference is around the implant, and implant failure.
severe, the prosthesis may not engage one attachment at all The implants should be equal distance off the midline. If
(Figure 23-22). one implant is more distal (farther from the midline), it will
The implants should be perpendicular to the occlusal plane serve as the primary rotation point or fulcrum when the patient
because the goal is to allow the posterior regions of the over- occludes in the posterior segments. As such, the more medial
denture to rock downward and load the soft tissue over the implant attachment will wear faster, and the more distal implant
mandibular buccal shelves for support. The hinge rotation will receive a greater occlusal load. When the patient bites in
should be at 90 degrees to the rotation path; otherwise, one side the anterior region, the more anterior implant acts as the
is loaded different than the other. In addition, because only two fulcrum, and the posterior attachment more rapidly wears.
implants sustain the occlusal load during function or parafunc- As a consequence of additional maintenance risks, indepen-
tion, minimization of the forces to the implant components dent implants should be used less frequently than implants
and crestal bone by placing them in the long axis of the implant joined together with a bar. Attachments in a connection bar may
body and perpendicular to the occlusal plane is ideal. be placed by the laboratory in similar horizontal, vertical, and
The two independent implants should be positioned at the axial planes much easier than the surgeon placing the implants.
same occlusal height parallel to the occlusal plane. If one It is emphasized the available mandibular bone should be
implant is higher than the other, the prosthesis will disengage division A or B, and the opposing arch for an OD-1 mandibular
from the lower implant during function and rotate primarily on treatment option should be a traditional complete denture
the higher implant (Figure 23-23). This situation will accelerate (Figure 23-24).The bite forces are reduced when the patient is
the wear of the O-ring or attachment on the lower implant. In completely edentulous before treatment. The maxillary denture
addition, because the higher implant receives the majority of has some movement during function and acts as a stress reliever.
the occlusal load, an increased risk of complications may occur, The instability of the maxillary denture and mandibular OD-1
A B
FIGURE 23-22. A, When one implant is placed more anterior than the other (as shown), the more distal
implant is the fulcrum when chewing in the posterior region and the more anterior implant is the fulcrum
for movement when the patient incises food. This causes instability, wearing of the attachments, and loosen-
ing of the O-rings from the implant bodies. B, When two independent implants are not parallel to each
other, equal distance from the midline and at the same occlusal height, the attachments will rapidly wear
and need to be replaced more often.
FIGURE 23-23. Two independent implants should

be at the same height, equal distance off the midline,
and parallel to each other. When the implants are posi-
tioned as in this radiograph, one implant (not two)
becomes the dominant fulcrum and increases the risk
of overload complications. This is especially important
when force factors are higher than usual. The patient’s
occlusal plane also should be modified to allow a bilat-
eral balanced occlusion on a RP-5 overdenture.
FIGURE 23-24. A, A panoramic radiograph of two A

independent implants in a division D mandible. B, One
implant failed, and the mandible fractured through the
failed implant site.
FIGURE 23-25. A two-mandibular implant over-

denture should oppose a complete denture. Otherwise,
instability and sore spots are common related to the
implant overdenture.
overdenture is shared. The support requirements of the poste- A, B, D, E, and molar position, the connected implants and
rior regions of the mandible are reduced when opposing a cantilevered bar will result in a RP-4 or fixed restoration and
complete denture (Figure 23-25). will help maintain posterior bone. The bar may be cantilevered
The OD-1 is used as a treatment option when patients under- to provide posterior support because of the greatly improved
stand that a connecting bar and additional implants are benefi- anteroposterior distance (A-P spread) between splinted implants
cial but financial constraints require a transition period of a few and the increase in implant number (Figure 23-26).
years before placing additional implants. The ultimate goal in
the treatment plan is to convert OD-1 patients to a RP-4 or fixed Overdenture Option 2
prosthesis with more implant support and stability before the The second treatment option for a mandibular overdenture
loss of the posterior bone in the mandible occurs behind the (OD-2) is selected as the initial option more often than OD-1.
foraminae. As soon as the patient can afford two more implants, The anatomic needs and patient desires are similar to the first
the implants should be placed in the A and E position, and all option, OD-1 (Box 23-5). The implants are also positioned
four ABDE implants should be connected with a bar that may in locations B and D, but in this option, they are splinted
be cantilevered to the posterior and help reduce the posterior together with a superstructure bar without any distal cantilever
bone loss. If an additional implant may be inserted (after the (Figure 23-27). Reduced loading forces are exerted on two ante-
initial two), it may be positioned in the C position, or if bone rior implants when splinted with a bar compared with indi-
height and width distal to one mental foramen are adequate, vidual implants.82–85 The bar is designed to position the
the additional implant may be positioned in one of the first attachments an equal distance off the midline parallel to each
molar regions. With implants in the A, B, C, D, E position or other at the same occlusal height and in a similar angulation to
A FIGURE 23-26. A, A panoramic radiograph of a

patient that had two implant overdentures opposing a
fixed prosthesis. One implant failed. B, Additional
implants were eventually inserted and a fixed prosthesis
fabricated.
anterior curve of the arch anterior to the first premolars results

in an improved lingual contour of the restoration. However, the
• Opposing arch is a maxillary denture. curve corresponds to an increased length and even greater flex-
• Anatomical conditions are good to excellent (division A or ibility of the superstructure. Because the bar is under the ante-
B bone in anterior and posterior regions). rior teeth but anterior to the implants, a greater moment of
• Posterior ridge forms an inverted U shape. force also is created.
• Patient’s need and desires are minimal, primarily related to Bars that course in a tangential direction do not permit
lack of retention. friction-free rotation of the prosthesis around the fulcrum.
• Patient can afford new prosthesis and connecting bar. Excess torsional loading is exerted on the implants and bar
• Additional implants will not be inserted for more than 3 resulting in screw loosening or crestal bone loss. The distance
years. between A and E implants represents approximately a span of
• Low patient force factors (e.g., parafunction) six teeth. The superstructure flexibility is related to the length.
As a result, five times more flexure is observed than if the
implants were in the B and D locations.85 The increase in the
connecting bar flexibility may result in loosening of the coping
provide added retention.28 (Figures 23-28 and 23-29). The ideal screws. If one screw becomes loose, the other implant supports
distance between the implants is in the 14- to 16-mm range or a cantilever of seven teeth. After this occurs, the remaining
B and D positions. However, it should be noted that implants attached implant receives a dramatic increase in moment of
placed closer than the B, D position will result in reduced pros- forces from the long lever arm of the superstructure. As a con-
thesis stability during function whether they are connected or sequence, bone loss and implant failure risk are increased. This
independent units. The connecting bar should not be cantile- increase in force may result in bone loss, mobility of the
vered to the distal from the two implants (Figures 23-30 and implant, and possible fracture of an implant component85
23-31). (Figure 23-33).
The two splinted implants should not be inserted in the A Joining A and E implants in the sagittal position with a
and E positions (Figure 23-32). There are many reasons why straight line of the superstructure also causes a problem. If the
two implants placed in the A and E positions should not be bar is straight and not bent to follow the arch, it occupies a
splinted together. The implants in this position are placed just lingual position relative to the arch. The lingual flange of the
anterior to the mental foraminae and therefore most often in denture then extends as much as 10 mm more lingually and
the first premolar positions. This results in a curved arch form 7 mm more vertically to accommodate the attachment, which
anterior to the implant sites. The superstructure that follows the is connected over the superstructure. Because the teeth are most
A
A B D
B
FIGURE 23-29. A, When O-rings are used for OD-2, the attach-
B B D ments are placed parallel to each other and at the some occlusal
FIGURE 23-27. Treatment option 2 has implants in the B and D height. B, The O-ring attachments are also positioned equal distance
positions, and a bar joins the implants. The bar should not be canti- off the midline.
levered off the distal side of the implants. The prosthesis movement
will be reduced, and too much force on the bar and implants will
increase complications. Attachments such as an O-ring (A) or a Hader
clip (B), which allow movement of the prosthesis, can be added to
the bar. The attachments are placed at the same height at equal
distances off the midline and parallel to each other.
B D
FIGURE 23-28. The implants in B and D are connected with a FIGURE 23-30. The connecting bar between implants B and D
bar. O-rings are often used for the implant overdenture. should not be cantilevered to the distal.
A B
FIGURE 23-31. A, Implants in the B and D position and a connecting bar, which is cantilevered to the
distal. B, The Hader clips in the prosthesis do not allow prosthesis movement. Hence, this is a PM-0 implant
overdenture and will cause repeated biomechanical complications.
BOX 23-6 Disadvantages of A and E Splinted

Implants (First Premolar to First Premolar)
• Implants joined with straight bar are lingual to ridge.
• Difficulty with speech
• Anterior tipping of overdenture
• Five times greater bar flexure than B and D positions
• Implants are joined with anterior curved bar.
• Greater bar flexibility (nine times the B and D positions)
E
• Increased screw loosening
A
• Increased moment forces on anterior aspect of
prosthesis
• Attachment of curved bar may prevent prosthesis
movement
FIGURE 23-32. Implants in positions A and E should not be • Bite force is higher than for B and D positions.
splinted together. • Greater lateral load from prosthesis to implants than B and
D positions
often set anterior to the crest of the ridge (anterior to the super-
structure bar), rotation and tipping of the restoration are more positions increase lateral movement of the prosthesis, which is
prevalent. The moment of force on a straight bar connecting a patient disadvantage, but the positioning also decreases the
implants in the A and E positions is twice that for implants in lateral forces on the implant system (e.g., coping screws, abut-
the B and D locations.85 ment screws) (Box 23-6).
The prosthesis attachment system to the superstructure also It should be noted that the A and E positions most often
may be compromised if Hader and Dolder clips are used for correspond to the first premolar sites. A bar connecting two first
retention. The connecting bar and clips should be perpendicular premolars is too long for an overdenture and will result in many
to the path of rotation. A curved bar often places the clips closer complications (Figure 23-34). Likewise, splinted implants in
to the implants and prevents rotation of the prosthesis. If the the A and E positions may also have biomechanical complica-
prosthesis rests against the sides of the curved bar, the PM may tions. As a result of these many disadvantages, the placement of
even be reduced to PM-0. This places a much greater vertical only two implants in the A and E positions is strongly discour-
and lateral load on the implant system. aged whether the implants are independent or splinted together.
Implants splinted in the A and E positions have greater If the surgeon inadvertently inserts the implants in the A and
potential load per surface area compared with implants in the E positions, two options exist. The first is to place at least one
B and D regions because the bite force increases toward the additional implant, usually in the C position. The second is to
posterior aspects of the mouth. As a result, a greater vertical load leave the implants independent with O-ring attachments. With
is also present, with increased stresses when implants are placed the second option, the anatomical ridge form should be good
in the A and E positions compared with the B and D positions. to excellent, and the overdenture should have excellent support
This is most important to consider when the patient has para- and retention independent of the implants. The two implants
functional forces such as bruxism or clenching. should not be splinted because they are too far apart. The length
The splinted A and E positions give more lateral stability to of the edentulous span, the position of the connecting bar, the
the prosthesis than the B and D positions. However, only two flexure of the metal span, and the additional forces on the
implants resist this lateral load. In contrast, the B and D implant system create considerable risk for prosthetic
FIGURE 23-33. Implants in the A, E position were

splinted together with a bar. The prosthesis screw
became loose on the A implant, which resulted in a
long cantilever on the E implant, which then failed.
• Opposing arch is a maxillary denture

• Anatomical conditions moderate to excellent
• Posterior ridge forms inverted U shape
• Patient’s needs and desires require improved retention,
support, and stability
• Cost a moderate factor
• Patient may have moderate force factors (e.g.,
parafunction)
natural teeth. The increase in crown height and the poorer pos-
FIGURE 23-34. This patient had an overdenture constructed on terior ridge form or the increase in bite forces and rigid oppos-
the two first premolar teeth. The bar became uncemented in the ing arch place additional stresses on the implant system and
patient’s right side and then acted as a cantilever on the patient’s left increase complications. Additional implants should be used to
premolar. This situation is similar to implant positions A and E because decrease the implant system and prosthetic risks.
the mental foramina are most often between the premolars or distal Some additional disadvantages of OD-2 treatments com-
to the second premolar. pared with OD-1 are possible tissue hyperplasia under the bar,
more difficult hygiene under the bar (compared with option 1),
complications in this treatment option. In other words, the B and a more expensive initial treatment option compared with
and D implant positions are closer to the canine positions and option 1 (because a bar and retentive elements are included).
are much better suited for force and prosthetic guidelines for
either OD-1 or OD-2 treatment options. Overdenture Option 3
Patient selection criteria for OD-2 treatments include the The third treatment option may be used when the opposing
following: arch is a denture and the patient has moderate to low anatomic
1. The patient’s opposing arch is a complete denture. needs. Three root form implants are placed in the A, C, and E
2. Anatomical conditions for a traditional denture are good to positions for the third overdenture treatment option (OD-3)
excellent. (Box 23-7). A superstructure bar connects the implants but with
3. The posterior ridge form is an inverted U shape and provides no distal cantilever (Figure 23-35). In addition, the opposing
good to excellent support and lateral stability. arch should be a denture to limit the amount of bite force. It
4. The patient’s complaints are minimal and relate primarily to should be noted that when the posterior ridge form is poor
retention. (C–h or D), the OD-3 is the lowest treatment option suggested.
5. The patient requires a new prosthesis and is willing to invest The A-C-E implant and bar position is much more stable than
slightly more time and expense than the patient with the the B-D position for the prosthesis. There are many advantages
OD-1 option. of splinting A, C, and E implants compared with implants in
6. The mandibular residual arch is square or ovoid and the the B and D positions (Box 23-8).
dentate arch form is ovoid or tapering, but only two implants The additional implant provides a sixfold reduction in super-
are used for support. structure flexure and limits the connecting bar complications
7. When the patient is unable to insert additional implants previously discussed compared with implants in the A and E
within a short time frame (within 3 years), OD-2 is safer positions.83 Screw loosening also occurs less frequently because
than an OD-1 independent implant approach. three coping screws retain the superstructure rather than two.
The risk of abutment or coping screw loosening is reduced
Disadvantages further because force factors to each unit are decreased.
Two-implant overdentures are not indicated in C–h or D bone Implant reaction forces are reduced with a third implant as
and are not indicated when opposing anterior or posterior compared with two implants. The greater surface area of
implant-to-bone contact allows better distribution of forces. The implants splinted in the A, C, and E positions usually
Three permucosal sites distribute stresses more efficiently and do not form a straight line. The C implant is most often anterior
minimize marginal bone loss around the implants. The reduc- to the more distal A and E implants (in the premolar regions)
tion in the maximum moment of force is twofold with a three- and ideally directly under the cingulum position of the anterior
implant system compared with two implants in the A and E incisor denture teeth (Figure 23-36). The restoration benefits
regions.85 Hence, this treatment option is better than OD-1 or from direct occlusal load to the implant support in the anterior
OD-2 when the patient has moderate parafunction. arch, which reduces tipping and improves stability. As a
BOX 23-8 Advantages of Splinted A, C,

and E Implants
• Six times less bar flexure compared with A and E positions
• Less screw loosening
• Less metal flexure
• Three implant abutments
• Less stress to each implant compared with A and E implants
• Greater surface area
A E • More implants
• Greater anteroposterior distance
• One-half moment force compared with A and E implants
• Less prosthesis movement
• One implant failure still provides adequate abutment
C support
FIGURE 23-35. Overdenture option 3 corresponds to implants
in the A, C, and E positions connected with a bar. The attachments
should be positioned to allow movement of the distal section of the
prosthesis.
A B
C
FIGURE 23-36. A, A mandible with division A bone and overdenture option 3, with implants in the A,
C, and E positions. B, The attachments are more distal than the OD-2 and are still equal distance off the
midline, parallel, and at the same height. C, The C implant is more anterior than the A and E implants, so
anteroposterior stability is improved.
consequence, when more than two implants are in the anterior In the future, when the patient can afford additional implants
mandible, a tripod support system may be established. to those in the A, C, and E positions, the next implant place-
To determine the amount of benefit of an A-P distance, ment is in the B and D positions when the posterior bone is
the distal of the most posterior implants on each side are inadequate for implants (C–h). When posterior bone permits,
connected with a straight line. The distance from this line to the the two new implants are positioned with one in a molar region
perpendicular position of the center implant is called the A-P and the other inserted in the contralateral B or D position. A
spread.85–87 The greater this dimension, the more biomechani- new overdenture bar and prosthesis then permits a RP-4 (or
cally stable the implants are when splinted together. The greater fixed) restoration.
the A-P spread of the A, C, and E implants, the greater the bio-
mechanical advantage of the bar to reduce stress on the implants. Overdenture Option 4
In addition to reduced stresses on the implant system, the In the fourth mandibular overdenture option (OD-4), four
lateral stability of the overdenture system is also improved implants are placed in the A, B, D, and E positions. This is often
because the implants are in the A and E position and the attach- the minimum number of implants when the patient has oppos-
ments are more distal than OD-2. As a result, rotation of the ing maxillary teeth or C–h anterior bone volume with CHS
prosthesis is more limited compared with OD-1 and OD-2. greater than 15 mm. These implants usually provide sufficient
Therefore, the third implant for OD-3 is a considerable advan- support to include a distal cantilever up to 10 mm on each side
tage for a mandibular edentulous patient. The IOD option 3 if the stress factors are low (i.e., parafunction, CHS, masticatory
usually does not use a Hader clip for the attachment. Because dynamics, and opposing dentition) (Figure 23-38).
the two clips do not rotate in the same plane, the prosthesis is The cantilevered superstructure is a feature of the four or
usually too rigid (Figure 23-37). more implant treatment options in a completely edentulous
The OD-3 treatment option is usually the first option pre- arch for three reasons: The first relates to the increase in implant
sented to a patient with minimal complaints who is concerned support compared with OD-1 to OD-3. The second is that the
primarily with retention and anterior stability of the IOD when biomechanical position of the splinted implants is improved in
cost is a moderate factor. The posterior ridge form should be an ovoid or tapering arch form compared with OD-1 or OD-2.
evaluated because it determines the posterior lingual flange The third is related to the additional retention provided by the
extension of the denture, which limits lateral movement of the fourth implant for the superstructure bar, which limits the risk
restoration in this treatment option.81 of prosthetic screw loosening and other related complications
of cantilevered restorations.
In considering a distal cantilever for a mandibular overden-
ture bar, the implant position is the primary local determinant.
A E
A E
A
C
A B D
B
FIGURE 23-38. A, In overdenture option 4, four implants are
placed in the A, B, D, and E positions. The implants provide sufficient
B support for a distal cantilever up to 10 mm. B, A panoramic radio-
graph of a mandibular overdenture option 4. In this option, implants
FIGURE 23-37. A, An implant overdenture option 3 rarely uses in the A, B, D, and E positions are connected with a cantilevered bar
a Hader clip for the attachment system. B, The Hader clips rotate in (up to 10 mm). The stress-breaking attachments are designed to
different planes and make the prosthesis too rigid for three implants. allow some movement of the prosthesis during function.
Cantilevers may be compared with a class 1 lever in mechanics. form, the A-P spread between implants in the A, E and D, B
The distal most implant on each side acts as a fulcrum when positions is greater and therefore permits a longer distal canti-
occlusal forces are applied to the distal cantilever. Therefore, the lever. This A-P spread is usually 8 to 10 mm in these arch forms
amount of the occlusal force is magnified by the length of the and therefore often permits a cantilever up to 10 mm from the
cantilever, which acts as a lever. For example, a 25-lb load to a A and E positions (Figure 23-40).
10-mm cantilever results in a 250-lb moment force. It may be emphasized that the A-P spread is only one factor
This moment force is resisted by the length of the bar ante- to determine the length of the cantilever. When stress factors
rior to the fulcrum. Therefore, if the two anterior implants (B such as occluding forces are greater, the cantilever is decreased.
and D) are 5 mm from the fulcrum (distal implants A and E), Parafunction, opposing arch, masticatory dynamics, and CHS
the effect of the posterior cantilever is reduced. If the implants affect the amount of force on the cantilever. For example, when
are 5 mm apart, the mechanical advantage of the lever is the the crown height is doubled, the moment forces are doubled.
100-mm cantilever divided by the 5-mm A-P spread, which Therefore, under ideal, low-force conditions (crown height less
equals 2. Rather than a 250-lb moment force on the distal than 15 mm, no parafunction, older female patient, opposing
implant, because it is splinted, a 25-lb distal force is magnified a maxillary denture), the cantilever may be up to 1.5 times the
to 50 lb to the anterior implant and 75 lb (50 + 25 = 75) to the A-P spread for OD-4 overdentures. When the force factors are
distal (fulcrum) implant. As a general rule, the posterior canti- moderate, the cantilever should be reduced to one times the A-P
lever from anterior implants may be equal to the A-P distance spread. The amount of distal cantilever is related primarily to
when other stress factors are low to moderate. the force factors and to the arch form, which corresponds to the
The mandibular arch form may be square, tapering, or ovoid. A-P spread.
Square arch forms limit the A-P spread between implants and The patient’s indications for the OD-4 treatment option as a
may not be able to counter the effect of a distal cantilever. minimum requirement include moderate to poor posterior
Therefore, rarely are distal cantilevers designed for square arch anatomy that causes a lack of retention and stability of the IOD,
forms (Figure 23-39). In a mandibular ovoid to tapering arch history of recurrent soft tissue abrasions, or difficulty with
speech. Remember that the edentulous posterior mandible
resorbs four times faster than the anterior mandible. In the C–h
posterior mandible, the external oblique and mylohyoid ridges
are high (in relation to the residual ridge) and often correspond
to the crest of the residual ridge. The muscle attachments there-
fore are at or near the crest of the posterior ridge. Other condi-
tions that indicate an OD-4 as a minimum treatment option is
when the patient’s complaints and desires are more demanding
than for the previous treatment options (Box 23-9).
The OD-4 prosthesis is indicated to obtain greater stability
and a more limited range of prosthesis motion. The overdenture
attachments often are placed in the distal cantilevers with an
O-ring attachment in the midline. The prosthesis is still RP-5
but with the least soft tissue support of all RP-5 designs. The
anterior attachment must allow vertical movement for the distal
aspect of the prosthesis to rotate toward the tissue. Clips, which
permit rotation, are difficult to use on cantilevered superstruc-
FIGURE 23-39. These four implants were placed in a square tures. To allow movement, the clip must be placed perpendicu-
ridge form and have no anteroposterior dimension. Therefore, no lar to the path of rotation, not along the cantilevered bar, where
cantilever should be extended from the implants. its only function then is retention (and limits rotation).
A B
FIGURE 23-40. A, These four anterior implants (A, B, D, E) are in an ovoid arch form. B, The four anterior
implants are splinted together with a cantilevered bar approximately 8 to 10 mm. The prosthesis type is
RP-5 because the molar region is supported by the soft tissue.
The patient benefits from the four-implant option because and should have a minimum cantilever even with five implants
of greater occlusal load support, lateral prosthesis stability, and joined together. An ovoid arch has an A-P spread from 5 to
improved retention. The prosthesis loads the soft tissue over the 8 mm and a tapered arch form more than 8 mm. In these situ-
buccal shelf and the first and second molars and retromolar pad ations, a cantilever of two times this distance is indicated when
regions. Therefore, the amount of occlusal force on the implant force factors are not excessive (Figure 23-43). If any major stress
system is reduced (compared with a fixed restriction or RP-4 factors (e.g., parafunction) are not favorable, the cantilever
prosthesis) because the bar does not extend to the molar posi- should be reduced. Stresses are magnified in direct proportion
tion, where the forces are greater. to the length of cantilever and should be planned carefully
The OD-4 treatment option is the lowest treatment rendered based on the patient force factors and the existing
when the patient has maxillary teeth. The greater vertical and anatomy.87–94
horizontal forces to the mandibular IOD require anterior dis- The fifth mandibular overdenture option (OD-5) is designed
clusion in excursions to decrease the bite force. As such, more for two types of patients. Most important, this is a minimum
anterior implants are required under these conditions. treatment option for patients with moderate to severe problems
The next treatment plan option for the patient with a moder- related to a traditional mandibular denture. The needs and
ate financial budget is to add an additional implant in the future desires of the patient are often most demanding and may
in one of the first molar positions (preferred) or the C position. include limiting the bulk or amount of the prosthesis, major
Both of these options increase the A-P spread to fabricate a RP-4 concerns regarding function (mastication and speech) or stabil-
prosthesis with an enhanced implant system support. The goal ity, posterior sore spots, or the inability to wear a mandibular
is to convert all patients eventually to a RP-4 or fixed restora- denture (Box 23-10).
tion, to prevent posterior bone loss and its associated disadvan- The second patient condition that determines this option is
tages (including esthetics of the posterior facial regions). for the treatment of continued bone loss in the posterior man-
dible. If no prosthetic load is on the posterior bone, the resorp-
Overdenture Option 5 tion process is delayed considerably and often reversed. Even
In the OD-5 treatment, five implants are inserted in the A, B, C, when no posterior implants are inserted, the cantilevered bar
D, and E positions. The superstructure is usually cantilevered
distally up to two times the A-P spread (if almost all of the stress
factors are low) and averages 15 mm, which places it under the
first molar area (Figures 23-41 and 23-42). The amount of the
distal bar cantilever is related (in part) to the A-P distance. A
square ridge form usually has an A-P spread of less than 5 mm
Hader clip
O-ring
• Moderate to severe problems with traditional dentures

• Needs or desires are demanding
• Need to decrease bulk of prosthesis
• Inability to wear traditional prostheses E
• Desire to abate posterior bone loss A
• Unfavorable anatomy for complete dentures
• Problems with function and stability B D
• Posterior sore spots C
• Opposing natural teeth
• C–h bone volume
FIGURE 23-41. In the overdenture option 5, implants are placed
in the A, B, C, D, and E positions. A bar splints the implants together
• Unfavorable force factors (parafunction, age, size six, crown
and is distally cantilevered. The length of the cantilever depends on
height space >15 mm)
the anteroposterior distance and the force factors.
FIGURE 23-42. A panoramic radiograph of an

option 5 overdenture bar and five implants in the ante-
rior mandible.
Cantilever
A-P
A E
B D
A C
Cantilever
FIGURE 23-43. Arch shape affects the
anteroposterior (A-P) distance. A, The square arch
form is less than 5 mm. B, The ovoid arch form
often has an A-P distance of 5 to 8 mm. C, A
A-P tapered arch form has the greatest A-P distance,
larger than 8 mm.
A E
B D
B C
Cantilever
A-P
A E
B D
C C
and overdenture avoid load to the posterior residual ridge and restoration, the arch form is square for a RP-5 prosthesis, or the
often halt its resorption process. Recent evidence shows that maxillary arch has natural teeth (especially in a young patient
completely implant-supported prostheses often increase the or male patient).
amount of posterior bone height even when no posterior The patient force factors are as important as the A-P spread.
implants are inserted.44,63 However, it should be noted that a In a study in which the failure criterion was the failure of the
better option to prevent this posterior bone loss and increase screw joint with arrangements of three, four, five, and six
the A-P spread is the insertion of one or more posterior implants implants with a similar A-P spread submitted to forces from 143
before the bone atrophy has occurred. The OD-5 treatment to 400 N, the greater transmitted forces to the prosthetic con-
option is also indicated when the patient desires a RP-4 or fixed nection always exceeded the yield strength of the system. This
study emphasizes the fact that the amount and duration of prosthesis support and range of motion should be part of the
occlusal load is even more important than the A-P spread to be initial diagnosis. The treatment options initially proposed are
considered for cantilever length determination.88 designed for completely edentulous patients with division A or
B anterior bone in desire of an overdenture. These options are
Challenging Force Factors: Patient and modified when the CHS is great (as when the anterior bone is
Anatomic Factors division C–h) and eliminated for division D. The increase in
crown–implant ratio and decrease in implant surface area
The five treatment options proposed for mandibular implant– mandate modification of these initial options. In addition,
supported overdentures provide an organized approach to when the patient force factors are greater than usual (parafunc-
solving a patient’s complaints or anatomical limitations. The tion, masticatory dynamics, opposing arch is natural dentition)
or the arch form is square (reduced A-P spread), these treatment
options must be modified.
For example, under these adverse conditions, one more
implant is added to each option, and OD-1 is eliminated com-
• Moderate to severe problems with traditional dentures pletely. Therefore, OD-2 has three implants (A, C, and E posi-
• Needs or desires are demanding tions), OD-3 has four implants (A, B, D, and E regions), OD-4
• Need to decrease bulk of prosthesis has five implants (A, B, C, D, and E areas), and OD-5 has six
• Inability to wear traditional prostheses implants, with one positioned behind one of the mental foram-
• Desire to abate posterior bone loss ina (when possible) (Figure 23-44). If six implants cannot be
• Unfavorable anatomy for complete dentures placed because of inadequate posterior bone, the cantilever
• Problems with function and stability length is reduced, and a RP-5 restoration is fabricated.
• Posterior sore spots
• Moderate to poor posterior anatomy Discussion
• Lack of retention and stability
• Soft tissue abrasion The doctor and staff can explain to the patient the amount of
• Speech difficulties support each treatment option can provide by comparing them
• More demanding patient type with the support system of a chair. Treatment option OD-1 is
similar to a one-legged chair. A one-legged chair can support
A B
C D
FIGURE 23-44. A, Six implants were placed in this edentulous mandible. B, The implants are splinted
together, and the bar is cantilevered to the molar region. C, The implant overdenture (IOD) option is a RP-4
prosthesis. D, The maxillary and mandibular IOD in place.
your weight but provides very little stability. Treatment options 4. Jemt T, Chai J, Harnett J: A 5-year prospective multicenter
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CHAPTER 23

The Edentulous Mandible: Treatment

*Significant between-group difference; t tests. P  .001.

FIGURE 23-2. In a study by Awad et al.,6 the patients with

Philosophy for Implants in the

Disadvantages of Implant Overdentures

FIGURE 23-6. Wright et al.31 and Reddy et al.40

Hader clip O-ring

Bar + Hader clip = 3 mm Bar + O-ring = 5 mm

FIGURE 23-8. A panoramic radiograph of a patient

BOX 23-3 Overdenture Disadvantages

• Psychological (need for nonremovable teeth)

In 1986, a multicenter study reported on 1739 implants

vertical movement of the prosthesis toward the tissue. Stability

FIGURE 23-15. The anterior mandible is divided into five equal

overdenture restoration usually do not extend beyond the first

Mandibular Implant Site Selection

FIGURE 23-16. A, This patient wore a three-

FIGURE 23-17. A, A panoramic radiograph of

BOX 23-4 Patient Selection Criteria: OD-1

• Opposing a maxillary full denture

FIGURE 23-23. Two independent implants should

FIGURE 23-24. A, A panoramic radiograph of two A

FIGURE 23-25. A two-mandibular implant over-

A FIGURE 23-26. A, A panoramic radiograph of a

anterior curve of the arch anterior to the first premolars results

BOX 23-6 Disadvantages of A and E Splinted

FIGURE 23-33. Implants in the A, E position were

BOX 23-7 Patient Selection Criteria: OD-3

• Opposing arch is a maxillary denture

BOX 23-8 Advantages of Splinted A, C,

• Moderate to severe problems with traditional dentures

FIGURE 23-42. A panoramic radiograph of an

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*Significant between-group difference; t tests. P .001.

FIGURE 23-2. In a study by Awad et al.,6 the patients with

FIGURE 23-6. Wright et al.31 and Reddy et al.40