S T H O D O N T I C S P R O S T H O D O NPTR I O C S

Implant Complications and Failures: The Complete Overdenture

C.J.WATSON, D.TINSLEY AND S. SHARMA
Abstract: The implant-retained overdenture has been advocated as an effective
method of restoring the edentulous patient with an appliance that offers significant benefits over conventional prosthetics. However, the success and survival of such appliances have been shown to vary considerably, depending on which jaw is treated: implants supporting overdentures in the maxilla have a significantly higher failure rate. The restoration also requires considerable maintenance, which is both time consuming and costly. The purpose of this paper is to look at common restorative complications and maintenance problems following the placement of dental implants to support an overdenture. A number of implant systems have been reviewed and the results of the authors clinical experiences with referred and their own cases are reported. Dent Update 2001; 28: 234-240

Clinical Relevance: Implant-retained overdentures require all the prosthetic skills of conventional treatment combined with a clear appreciation for the need for careful long-term maintenance. Planning the implant position is essential. Using attachments that are easy to replace can simplify maintenance and reduce ongoing costs.

of the implant-retained overdenture is relatively straightforward, as the techniques used are similar to those for conventional overdentures using natural teeth. However, it has to be appreciated that the costs of long-term maintenance of these restorations can be high710 in both time and money and this should be explained to the patient before treatment is undertaken. The overdenture needs to be carefully reviewed as potential resorption of the alveolar bone in the saddle areas means that frequent relines or replacement of the denture may be necessary.10,11 The purpose of this paper is to discuss the common problems encountered with implant- retained overdentures in a review and referral clinic at the Leeds Dental Institute.

mplant-retained overdentures make an attractive alternative to conventional complete dentures. Patients find their prosthesis more stable and retentive and have improved oral function. The treatment has a high success rate with minimal reported morbidity. The long-term reliability of implant-retained overdentures is well documented, particularly when they are placed in the mandible.13 The provision of these restorations is thought to be one of the more economical forms of implant treatment,3 and hence more

C.J.Watson, BDS, FDS RCS, PhD, Senior Lecturer/ Honorary Consultant in Restorative Dentistry, D. Tinsley, BDS, MDSc, MFDS RCS, Lecturer in Restorative Dentistry, and S. Sharma, BDS, FDS RCS, Staff Grade in Restorative Dentistry, Leeds Dental Institute, Leeds.

affordable to patients. The surgery is relatively simple because fewer implants are generally required to support an overdenture, as the occlusal load generated is shared between the alveolar ridge and the implants. For the patient with extensive bone resorption, an overdenture with its associated flanges can provide excellent soft-tissue support, particularly in the upper arch.4 Positioning of the implants is also less critical than may be required with fixed bridgework, giving the surgeon a greater degree of freedom in selecting sites with optimal bone quality and quantity. It must be noted, however, that success rates in the maxillary arch can be as low as 78.7%.5 This may be related to the placement of short implants in highly vascular, low-density, poor-volume bone.6 For the prosthodontist, construction

PLACEMENT AND POSITIONAL PROBLEMS

The ideal placement of implants can be compromised by a lack of alveolar bone width or height, due to alveolar bone resorption following the loss of natural teeth. This can result in non-optimal positioning with the implants being divergent, or positioned outside of the arch (Figure 1). Certain implant systems dictate that the anchorage abutment is placed before recording the impression. In these circumstances recording an accurate working impression of grossly divergent implants may prove to be difficult if there are significant undercuts present. This can restrict the choice of retention systems that can be used; for example, ball or O-ring attachments would not be recommended as they require
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Figure 1. An example of divergent implants.

Figure 2. Split-bar as a solution to the divergent implants shown in Figure 1.

Figure 3. Damaged rubber O-rings, possibly as a result of mildly divergent implants.

acceptable implant alignment. When restoring implants placed in the maxilla, the implants should be splinted by means of a bar. This will ensure that occlusal loads are shared more favourably to the linked implants. To restore markedly divergent implants, some systems may require the connecting bar to be of a split design in order to allow different paths of insertion. This increases the complexity and cost of the technical work and reduces the number of implants that are splinted together (Figure 2). Malaligned implants can compromise the oral hygiene, as access may be difficult because of the close proximity of the anchorage and abutment or conflict with the lip or cheek or tongue. In addition, the bulk of the final overdenture may have to be increased in order to
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allow room for the implants, together with the housings for the retentive components. Even mildly divergent implants will increase the incidence of fracture and wear of the retentive components (Figure 3). The buccallingual positioning of the implants is critical (Figure 4). Implants placed away from the centre of the ridge may cause the overdenture to encroach into the tongue space or distend the labial/buccal soft tissues. This may lead to ulceration or instability of the prosthesis. Many of these positional complications can be avoided by the use of a surgical stent (Figure 5) a clear acrylic denture, often manufactured by copying the original denture. The prosthetist can indicate to the surgeon optimal implant position and alignment by preparing pilot holes in the stent. The stent shown in Figure 5 is designed to give the surgeon some flexibility in deciding the final implant position. There is little doubt that the longer the implant the higher the chance of success. Wider implants, which contact the outer and inner cortical bony plates, may also be advantageous. Short implants, which are often used in the maxillary ridge because of poor bone volume, can lead to an imbalance in the implant abutment ratio (Figure 6). With the overdenture in place, the resulting torque can lead to high cantilevering forces. The use of short implants has been associated with an increased rate of bone loss and eventual implant failure.12,13 Figure 7a demonstrates an atrophic mandible where three short implants have been placed to support a bar-retained overdenture. In this case the implants

were placed with a large thickness of mucoperiosteum remaining, which resulted in relatively tall transmucosal elements. One consequence of this was an unfavourable suprastructure to implant ratio, resulting in bone loss adjacent to the distal implants; another was that the tall transmucosal element led to the development of a long epithelial junction which is poorly attached to the titanium abutment. This may result in the development of a pocket that is difficult to clean (Figure 7 b and c); subsequently soft tissue hyperplasia can develop. When using an overdenture there is no advantage in placing the implant well below the mucosal cuff, as the emergence profile is of less importance in this situation.

RESTORATIVE PROBLEMS Temporization Phase

Tissue conditioners are often used to reline the existing denture during the healing phase, but they require frequent replacement and maintenance. The placement of healing abutments at exposure necessitates further extensive modification of the patients existing denture. Such alterations may weaken the denture, leading to fracture. It may be necessary to consider the use of some form of strengthener within the patients denture at this stage. If cobalt chromium has been used as the denture base material in the original denture, adjustments may be extremely difficult and in some cases construction of a new acrylic temporary denture may be

Figure 4. (a) Lingually placed implant causing trauma to the lingual frenal attachments. (b) Labially placed implants supporting magnets.

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Figure 5. Clear copy of maxillary denture modified to form a maxillary stent.

may also lead to a thin weak denture, which will be prone to fracture (Figure 8). Patients with a clenching or grinding habit will rapidly wear down or fracture acrylic teeth. The use of teeth with a hard wear resistance surface (for example Ivoclar-Vivadent teeth; Ivoclar-Vivadent UK Ltd, Leicester, UK) will reduce the incidence of this problem. Bruxists also apply high non-axial loads to the implants via the prosthesis and attachments. This may be especially important if the implants are not splinted in the maxilla. Restoring one arch with an implantretained prosthesis, which generates higher occlusal forces, can result in the patient becoming more aware of the limitations of the opposing denture. This now becomes a source of complaint, and relines and remakes may be necessary.

of the necessity for regular reviews.14 There are three commonly used techniques for retaining overdentures: bar and retentive clips; magnets; ball attachments with various retentive elements housed in the denture. The maintenance factors of each are discussed below. Bar and Clip Design Walmsley13 stated that the bar and clip design is relatively costly in clinical and technical time. The most common prosthetic complication that can arise is fracture of the clip or loss of retentive capacity. This is one of the main reasons for patient re-attendance. The clip may be of metal or plastic. The metal clip is usually more durable and easily adjusted to improve retention, but can be prone to fracture (Figure 9) and the bar can wear. The use of plastic clips is advantageous as they are more easily replaced and usually less expensive than metal. In addition, plastic clips may produce less wear of the metal bar than metal clips.16 If the plastic clip becomes non-retentive it usually requires replacement; the complexity of this procedure depends on the system in question. With many systems, the clips are retained by a metal plate secured in

Figure 6. Failing maxillary implant, possibly due to occlusal overload on short implants in vascular bone.

Maintenance
There is already a large body of evidence that overdentures require significant postinsertion maintenance: during the first year after insertion, a higher than expected number of review visits were required to adjust attachments and ease dentures in a number of studies.1,7,14 Workers have reported as many as 25% of maxillary overdentures failing within the first 3 years.15 This high maintenance should be explained to the patient at the start of treatment so that they are aware

necessary: this requires pre-planning. Patients undergoing more complex surgery, such as ridge augmentation, before or at the time of implant placement, present particular difficulties during the temporization phase. Radical denture adjustment followed by frequent relines using tissue-conditioning materials may be required. The patient must be warned of the difficulties they are likely to experience through the initial healing period.

Impression Stage
It is important to realize that, although the denture is implant-retained, standard prosthetic principles apply. It is essential to record an accurate mucocompressive impression of the free-end saddle to distribute the masticatory loads evenly and reduce rocking around the attachments. Greenstick low-fusing impression compound in a special tray can be very useful in achieving this result when recording the working impression.

c Figure 7. (a) Radiographic appearance of failing Brnemark implants. (b) Inflammation around failing implants. (c) The transmucosal element with debris clearly visible around the neck.

Occlusal Problems
Lack of interocclusal space restricts the type of attachment that can be used. It
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Figure 8. Fracture of an overdenture due to thin acrylic over attachment housing.

Figure 9. Fractured gold clip.

could be helpful when inter-ridge space is limited. They are economical, easy to clean and replacement costs are low. Patients with dexterity problems find removal of magnet-retained dentures easier. However, there have been reports of corrosion and wear of magnets,13,17 and a high incidence of loosening of the keeper. Components can fracture (Figure 11) and the magnets may lose their ability to aid retention with time.17 Patients may complain of a clicking when chewing due to metal-on-metal contact when the denture moves during function. The denture may be prone to rock as it moves over the magnetic keeper. Over a longer period of time it has been found that magnets need replacement because of wear or perforation through the titanium cover box.18 Ball Attachments with Various Retentive Elements The use of free-standing implants to retain the overdenture has a number of advantages: the implant and attachments take up less room within the denture; the implant abutments are easier to clean by the patient; the prosthetic treatment is easier and more economical; routine maintenance, such as relines, is easier to manage. However, in general, the attachments tend to lose retention over time (Figure 12) due to wear and fracture of components. In our experience, the simple rubber O-ring system has proved reliable. It is easy to replace the O-ring and maintain the overdenture. Regardless of the retentive element used, it is important that overdentures are carefully reviewed and the fit over the free-end saddle assessed. Bone resorption in the saddle area will result in movement of the denture. Untreated, a pronounced rock may develop, which will result in significant rotational forces being applied to the retaining implant. This may result in failed attachments or cervical bone loss around the implants. Regular relines of the saddle areas can

help to reduce this complication.

SUMMARY
Implant-supported overdentures provide an economic and reliable means of restoring an edentulous ridge. The prosthesis offers support to the facial muscles and can aid aesthetics in patients with a high smile line. It also offers greater latitude in implant position and angulation than a fixed prosthesis. However, provision is not without complications and, as with all restorative treatments, case selection and careful treatment planning is the key. Practitioners must be aware that this treatment is associated with a higher implant failure rate especially in the atrophic maxilla, which has low-density bone. It is quite clear, however, that in the long term all overdentures require a high degree of maintenance. The attachment often proves to be the weakest link, and the incidence of fracture and wear is high. The necessity for relining becomes common after the first year due to ridge crest changes in the edentulous regions. The requirement for significant ongoing maintenance is something that the patient and clinician need to be aware of when considering this form of treatment.

the prosthesis, which is designed for easy replacement without the need for remake of the prosthesis. There is considerable variation in the shape and design of the bar. In a study that compared cantilevered with noncantilevered bars, Dunnen et al.9 found that the suprastructure was more likely to fracture in the cantilever group. In contrast, Engquist et al.12 found no evidence of increased fracture in cantilevered cast bars. Our experience with cantilevered cast bars is limited but from the referrals that we have seen their predisposition to fracture would seem to contraindicate their use (Figure 10). Magnets Magnets may be used to simplify restorative and technical procedures. They are helpful when a limited number of implants have been placed, or when short implants are necessary. Magnets can overcome angulation or positional problems and their use reduces non-axial loading from forces generated during mastication, because the magnetic forces are greatest in the vertical plane but allow horizontal movement of the denture. Magnetic keepers attached to the implant head keep the height to a minimum and take up less room within the denture than some other types of attachment, which
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Figure 10. A fractured distal cantilever bar.

Figure 11. Fracture of a magnetic keeper. Dental Update June 2001

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4.

Figure 12. Replacement of small metal clip, which is easily damaged during normal function.

ACKNOWLEDGEMENTS
We are grateful for the support from the Department of Medical and Dental Illustrations, Leeds Dental Institute.

REFERENCES
1. Hemmings KW, Schmitt A, Zarb GA. Complications and maintenance requirements for fixed prostheses and overdentures in the edentulous mandible: A 5-year report. Int J Oral Maxillofac Implant 1994; 9: 191196. Davis DM. Implant supported overdentures the Kings experience. J Dent 1997; 25: S33S37. Cooper LF, Scurria MS, Lang LA et al. Treatment of edentulism using Astra Tech Implants and ball abutments to retain mandibular overdentures.

2. 3.

Int J Oral Maxillofac Implant 1999; 14: 646653. Zitzmann NU, Marinello CP. Implant-supported removable overdentures in the edentulous maxilla: Clinical and technical aspects. Int J Prosthodont 1999; 12: 385390. 5. Goodacre CJ, Kan JYK, Rungcharassaeng K. Clinical complications of osseointegrated implants. J Prosthet Dent 1999; 81: 537552. 6. Watson RM, Jemt T, Chai J et al. Prosthodontic treatment, patient response, and the need for maintenance of complete implant-supported overdentures: an appraisal of 5 years of prospective study. Int J Prosthodont 1997; 10: 345354. 7. Chan MFW-Y, Johnston C, Howell RA. A retrospective study of the maintenance requirements associated with implant stabilised mandibular overdentures. Eur J Prosthodont Restor Dent 1996; 4: 3943. 8. Watson RM, Davis DM. Follow up and maintenance of implant supported prostheses: a comparison of 20 complete mandibular overdentures and 20 complete mandibular fixed cantilever prostheses. Br Dent J 1996; 181: 321327. 9. Dunnen ACL, Slagter AP, Baat C, Kalk W. Adjustments and complications of mandibular overdentures retained by four implants. A comparison between superstructures with and without cantilever extensions. Int J Prosthodont 1998; 11: 307311. 10. Walton JN, MacEntee MI. A retrospective study on the maintenance and repair of implantsupported prostheses. Int J Prosthodont 1993; 6: 451455. 11. Tinsley D, Watson CJ, Russell JL. A comparison

12.

13.

14.

15.

16.

17.

18.

of hydroxylapatite coated implant retained fixed and removable mandibular prostheses over 4 to 6 years. Clin Oral Implant Res 2001; 12: 159166. Engquist B, Bergendal T, Kallus T et al. A retrospective multicenter evaluation of osseointegrated implants supporting overdentures. Int J Oral Maxillofac Implant 1988; 3: 129134. Walmsley AD, Frame JW. Implant supported overdentures the Birmingham experience. J Dent 1997; 25: 4347. Jemt T, Book K, Linden B, Urde G. Failures and complications in 92 consecutively inserted overdentures supported by Brnemark implants in severely resorbed edentulous maxillae: A study from prosthetic treatment to first annual checkup. Int J Oral Maxillofac Implant 1992; 7: 162167. Hutton JE, Heath MR, Chai JY et al. Factors related to success and failure rates at 3-year follow-up in a multicenter study of overdentures supported by Brnemark implants. Int J Oral Maxillofac Implant 1995; 10: 3342. Walton JN, Ruse ND. In vitro changes in clips and bars used to retain implant overdentures. J Prosthet Dent 1995; 74: 482486. Naert I, Gizani S, Vuylsteke M, Van Steenberghe DV. A 5-year prospective randomized clinical trial on the influence of splinted and unsplinted oral implants retaining a mandibular overdenture: prosthetic aspects and patient satisfaction. J Oral Rehab 1999; 26: 195202. Naert I, Quirynen M, Hooghe M, Steenberghe D. A comparative prospective study of splinted and unsplinted Brnemark implants in mandibular overdenture therapy: A preliminary report. J Prosthet Dent 1994; 71: 486492.

BOOK REVIEW
Periodontics: Current Concepts and Treatment Strategies. By P.N. Galgut, S.A. Dowsett and M.J. Kowolik. Martin Dunitz Ltd, London, 2000 (208pp., 49.95). ISBN 1-85317-981-7. Periodontology is a fast moving subject and, although some of the basic principles of treatment havent changed, there is an ever increasing amount of new research, which has implications about how we treat our patients. Its important that students, general practitioners and specialists keep upto-date with current research, which can be difficult with the ever increasing number of research papers published. So any textbook that offers a review of the subject is welcomed. This textbook gives an overview of current research and its implications from a clinical point of view. The book
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contains 14 chapters and covers the following: The Periodontium in Health and Disease Epidemiology in the Study of Periodontal Disease The Microbiology of Periodontal Diseases The Host Response in Periodontal Diseases Systemic Influences and Periodontal Health Gingival Disease and Hyperplasia Early Onset Periodontal Disease Diagnosis and Treatment Planning in the Periodontitis Patient Mechanical Treatment of Periodontal Diseases The Role of Surgery in Periodontal Treatment Chemotherapeutic Agents in the Management of Gingivitis and Periodontal Diseases Restorative Considerations in the Periodontitis Patient

Peri-implantitis Current Dilemmas and Future Solutions The chapter Peri-implantitis covers, Reasons for failure, Implant management in practice (including monitoring and management), Instrumentation and management of the failing implant. As more implants are being placed, it is inevitable that we will all see more failed cases in our routine practice, and information on how to manage such cases is obviously very helpful. The final chapter gives insights into where research might be leading in the next few years, and includes sections on Advances in diagnosis, Risk factors, Therapeutics and tissue repair. In summary, this colour hardback textbook is clearly written and well illustrated and offers anyone with an interest in this specialty a fascinating update, and I would thoroughly recommend it. Mike Milward Birmingham Dental School
Dental Update June 2001