IMPLANT OVERDENTURES

Implant Dentistry

Charles J. Goodacre, DDS, MSD

Professor, Restorative Dentistry
Loma Linda University
Loma Linda, California

INTRODUCTION

Osseointegrated implants have been successfully used to support/retain overdentures in

the maxilla and mandible and considerable information has emerged regarding
comparisons with other prostheses, design guidelines, clinical procedures, and
success/failure/complications.1-49

Natural Tooth Overdentures and Implant Overdentures Compared

For decades, natural teeth have been retained in the mouths of debilitated patients
(frequently both canines in an arch) to support/retain overdentures and preserve bone.
Overdentures supported by natural teeth1 have been studied and the types of
complications that occur have been identified (reference 1).

Endosseous root form implants have also been successfully used to enhance the support,
retention and stability of overdentures. Hemmings, Schmitt and Zarb, in their 1994
article,5 attributed this idea to Stalblad in 1983. It has been stated21 that overdentures
supported by implants have a higher probability of success than mandibular overdentures
supported by the roots of natural teeth (Mericske-Stern, 1994).

Conventional Dentures and Implant Overdentures Compared

There have been publications comparing implant overdentures with conventional
complete dentures. Patient satisfaction improved when prosthesis retention and stability
increased22 (Burns, 1995) and therefore satisfaction increased when mandibular implant
overdentures were used instead of conventional complete dentures23-25 (Burns, 1995;
Boerrigter, 1995). Implant overdentures generally offer the advantages of improved
comfort, support, retention, and stability. In addition, it has been shown that annual bone
resorption is more pronounced in patients who wear conventional complete dentures than
in those who wear implant overdentures26 (Jacobs, 1993).

Implant overdentures have typically been complete arch prostheses (figures 1A, 1B, 1C,
1D, 2A, 2B, 2C, 2D, 3A, 3B, 3C, 3D, 3E) but partial overdentures have also been used,
whereby natural teeth function in conjunction with implants (figures 4A, 4B, 4C, 4D, 4E,
4F, 5A, 5B, 5C, 5D, 6A, 6B, 6C, 6D, 6E, 6F,7A ,7B ,7C).

Patients have generally adapted well to implant overdentures2, including maxillary

implant overdentures (reference 2).

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 Implant Fixed Complete Dentures and Implant Overdentures Compared
While fixed complete dentures provide unparalleled prosthesis stability, clinicians have
identified the following advantages of implant overdentures compared to implant fixed
complete dentures:
1. A smaller number of implants are required and that decreases the cost27,28
(Johns, 1992; Cune, 1994).
2. It is possible to provide better support of the facial soft tissues27-29 (Johns,
1992; Cune, 1994; Mericske-Stern, 1998).
3. There is improved phonetics for completely edentulous patients2,3,28,29 (Jemt,
1992; Smedberg, 1993; Cune, 1994; Mericske-Stern, 1998).
4. Patients have enhanced access for oral hygiene27,29 (Johns, 1992; Mericske-
Stern, 1998).
5. There is a better result when unfavorable jaw relationships are present28
(Cune, 1994).
6. When there is an opposing complete denture, it will be more stable;
particularly when there is a resorbed residual ridge7,27 (Johns, 1992; Hutton,
1995).
7. It is easier to make modifications to the prosthesis base29 (Mericske-Stern,
1998).
8. There is better access for inspection of the surgical site when surgically
created oral defects are present29 (Mericske-Stern, 1998).

The most frequently cited disadvantage of implant overdentures has been their incidence
of complications which is higher than other implant prostheses3-6 (references 3, 4, 5, 6).

SUCCESS, FAILURE, COMPLICATIONS DATA

Implant overdentures are associated with more complications than any other type of
implant prosthesis (Table 1). However, the complications do not negate the benefits
these prostheses provide for patients. Implant overdentures have been more successful in
the mandible than maxilla7-9 (references 7, 8, 9).

Implant Loss
Six clinical studies2,3,7,11,28,30 provide data regarding implant loss in the maxilla. Of 930
implants placed, 198 were lost (21% mean loss).

There are 21 clinical studies5,7,10,11,14-16,18,28,30-41 that evaluated mandibular implant loss

associated with overdentures. Of 4200 implants placed, 191 were lost (5% mean loss).

Thirteen studies2,3,5,10,14,15,27,30,32-34,37,39 provide data regarding the time (preprosthetic or

postprosthetic) when the implants were lost. Sixty percent of the implants were lost
preprosthetically and forty percent were lost postprosthetically.

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 Other Complications
The other complications identified in the clinical studies have included the need for:
activation of the mechanical retention (33%);2,3,5,12,27,42 patients not satisfied with the
retention of the opposing complete denture (24%);5,16,37,38 the need for a reline
(20%);2,3,5,10,11,16,27,33,38 gingival inflammation/proliferation (19%)3,5,11,18,28,30,38 (figures
8A, 8B); fracture/dislodgement of the mechanical retention device (16%)2,3,5,16,27,33,35,42
(figure 9A); neurosensory disturbance after surgery (14%);27,33,38,42 fracture of the
overdenture (12%);3,5,10,16,27,33,37,38,42 opposing prosthesis fracture (8%);5,11,42 prosthesis
screw fractures (5%)5,11 (figure 9B); abutment screw loosening (3%);3,5,11,12,37 and metal
bar fractures (2%)3,27,35 (figures 9C, 9D).

These incidences are specific to implant overdentures and therefore they differ from the
data presented in the implant complications portion of this CD (which was calculated by
combining the data from all types of prostheses).

DESIGN PRINCIPLES

Number of Implants
The number of implants used with overdentures has included one midline implant, two
individual implants(figures 1A, 1B, 10) two implants connected by a bar (figures 11A,
11B, 11C), and 3 or more implants connected by a bar (figures 2A, 2B, 3A, 3D, 11D,
11E). Placing several implants in the maxilla (because of the higher maxillary implant
loss data) that are connected by bars permits the prosthesis to continue functioning should
there be loss of an implant.

It has been proposed29(Mericske-Stern, 1998) that maxillary overdentures be supported

by at least 4 implants, evenly distributed around the arch and connected by a bar.

In the mandible, the use of 4 implants and a bar was compared with 2 implants and a bar.
The authors43 evaluated plaque, calculus, and bleeding scores, probing depths, gingival
recession, implant percussion, and made standardized radiographs. No differences were
noted in the clinical or radiographic parameters and the authors suggest that 2 implants
may be sufficient in the mandible. However, they did theorize that 4 implants might be
beneficial for patients with sore, painful mandibular ridges since more force would be
supported by the implants and bar rather than the edentulous mucosa43 (Batenburg, 1998).

Individual Versus Connected (Splinted) Implants

Several clinical studies10-17 have compared individual implants with implants connected
by a bar. A study44 of photoelastic stress patterns indicated that individual implants with
ball/o-ring attachments transferred less stress to the implants than the design that used 2
implants connected by a bar (Kenney, 1998). Four studies10,12,14,16 indicate there were no
biologic differences between the 2 designs but greater prosthesis retention was attained
when the implants were connected by a bar. There were conflicting findings10-16
regarding the amount of maintenance associated with the 2 designs (references 10, 11,
12, 13, 14, 15, 16). In one study10 (Mericske-Stern, 1990), it was not possible to identify

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substantive differences in the ability of patients to clean bar devices versus individual
implants.

The purpose of another study17 was to determine if more maintenance was required when
mandibular overdentures were retained by one bar and two implants compared with more
than two implants and multiple bars (reference 17).

There have been 3 studies11,13,47 that found greater bone loss when individual implants
were used in the maxilla. While the number of prostheses evaluated was limited (5 in
one study,13 6 in another study,11 and 8 in the third study47), the information suggests it
may be prudent to connect implants together in the maxilla until more definitive data
becomes available.

Since no clear biologic advantages have been associated with the number of implants
used in the mandible (individual or connected), the numerical decision should be based
on retention requirements. For many patients, two individual implants with associated
retentive mechanisms provide good patient satisfaction and the treatment is less costly
than a bar overdenture. For patients where retention is a primary requirement (as
evidenced by active oral musculature and functionally demanding eating expectations),
the use of 3, 4, or more implants and interconnecting bars with multiple retentive
mechanisms is recommended.

Location of the Implants

The implants should be located so they are contained within the normal form of the
denture base. Their form and location should ideally not produce substantial changes in
the dimensions of the denture base. The canine areas often serve as appropriate locations
for implants. It is important to determine the location of the prosthetic teeth and the size
and form of the denture base prior to implant placement. These characteristics are
identified through development of a wax trial denture using conventional complete
denture procedures. The clinical procedures are described later.

Implants that support/retain overdentures are commonly located in the anterior area of the
mouth and they should be centered beneath the prosthetic teeth or slightly lingual to the
center of the prosthetic teeth. When the implants are located anterior to the teeth (figures
12A, 12B) or substantially posterior to the teeth (figures 12C, 12D), the denture base has
to be enlarged to encompass the implant and retentive mechanism. The enlarged base
dimensions prolong the time it takes for a patient to adapt to the new prosthesis and can
make the adaptation challenging.

There is another negative aspect of placing implants too far facially or lingually. With
malaligned implants, efforts are commonly made to reduce the amount of resin base
overcontouring and this process frequently leaves only thin areas of resin over the
retentive mechanisms. The thin resin is more prone to fracture.
When implants are placed posteriorly, they should be centered beneath the prosthetic
teeth (figures 4C, 4D, 4E, 5B, 5C).

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When using 2 implants, a theoretical proposal18 has been made to facilitate free rotation
of the prosthesis around the bar/implants (reference 18).

A 5-year study49 of 90 mandibular overdenture patients measured the parallelism of the

virtual implant axis or bar with the transverse horizontal axis (hinge axis). There was
parallelism in 7 patients. The study failed to show any highly significant advantages of
achieving parallelism between the implant axis and the opening-closing axis of the
mandible (Otterli, 2001).

Implant Alignment
Implants that are parallel to each other or have their long axes nearly aligned with each
other facilitate the prosthodontic phase of treatment by allowing the use of standardized
components. When individual implants will be used with o-ring retention, malalignment
can make prosthesis placement more difficult and the o-rings are pinched more often
during placement and removal, producing o-ring wear and earlier loss of retention.

The master casts of 41 patients who had received 2 implants and ball abutment/o-ring
overdentures were measured48 to determine the effect of implant alignment on the
number of adjustments/repairs. When a perpendicular relationship of the implant to the
residual ridges was used as a reference angulation, implants that were inclined about 6
degrees to the facial or lingual were associated with a significantly higher number of
repairs (Walton, 2001).

When an implant is placed substantially out of alignment with other sources of retention,
the fabrication of custom components may be necessary (figures 13A, 13B, 13C).

To facilitate axial loading of the implants, it has been recommended that implants be
aligned so their long axes are perpendicular to the occlusal plane. This theoretically
advantageous orientation19 has been evaluated (reference 19).

Implant Component/Retentive Mechanism Height Above the Soft Tissue

After development of the wax trial denture, it is important to assess base dimensions to
determine the amount of space available for implant components and retentive devices.
The height of implant components and retentive mechanisms should be reduced as much
as possible since they weaken the prosthesis base. However, the height should be
sufficient to allow bars to be fabricated in such a manner that some space is present
beneath the bar.

It is recommended that a 1-2 millimeter space be present between the underside of metal
bars and the edentulous ridge mucosa. It is felt that the potential for adverse soft tissue
responses is related to minimal spaces underneath a bar.

It has also been suggested30 in one publication that adverse responses under bars occur
more often when unattached mucosa is present (Engquist, 1988). In contrast, a study10 of
62 patients found that attached mucosa was not a prerequisite for the maintenance of
healthy function (Mericske-Stern, 1990).

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Peri-implant soft tissue complications were more frequently encountered with maxillary
implant overdentures3 (Jemt, 1992) and it has been suggested27 (Johns, 1992) that the
reason may be related to the reduced vertical space available in the maxilla. Mandibular
resorption frequently creates more vertical space than occurs in the maxilla causing
retentive bars to be placed closer to the soft tissue in the maxilla. It has been stated18
(Naert, 1988) that good oral hygiene is the main factor in preventing adverse soft tissue
responses.

A 5-year longitudinal study49 investigated the effect of the retentive mechanism on peri-
implant parameters (plaque index, bleeding index, probing depth, and clinical probing
attachment level). The retentive devices included round bars (both straight and curved to
follow the arch form), U-shaped bars with and without distal extensions, and individual
ball abutments. The authors concluded that the type of retentive mechanism appears to
have little or no influence on peri-implant parameters.

Some peri-implant soft tissue complications are severe enough to require surgery. One
paper reported that 11 of 25 patients had peri-implant inflammation/hyperplasia and 2 of
those patients required surgery5 (Hemmings, 1994).

Retentive mechanisms vary in incisocervical and faciolingual dimensions. For example,

ball attachments for o-rings can be as small as 2 millimeters in diameter (figure 14A) or
as large as 3.5 millimeters in diameter (figure 14B). The height of ball attachments
(including the height of the ball abutment and the overlying o-ring) is about 5-6
millimeters. The same height is occupied by ball abutments and metal caps that snap
over the ball.

Bars and clips are frequently 2-4 millimeters occlusocervically and 2-3 millimeters
faciolingually (figures 11B, 11D). Bars that accept snap type attachments (Ceka) are
about 1.5 millimeters in height with a faciolingual dimension of 2-4 millimeters (figure
2A). The overlying attachment that snaps into the recess in the bar is 1.5 to 2.5
millimeters in height for a total of up to 5 millimeters.

It is advantageous to have 2 or more millimeters of resin thickness surrounding the

retentive mechanism when possible (figures 1B, 3D, 5C, 11E). Available base thickness
will help determine the type of mechanism that can be used.

In summary, all retentive mechanisms require an occlusocervical space of about 8

millimeters (including retentive mechanism, overlying base material, and space under
bars).

When there is not sufficient space available, a change in the type of retentive mechanism
may be necessary or the base may have to be thickened. For diagnostic purposes, the
wax trial denture can be duplicated in clear acrylic resin and used in conjunction with a
wax pattern of the proposed retentive mechanism to assess available space (figures 15A,
15B, 15C).

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 Retentive Mechanisms
There are several types of retentive mechanisms available, including the ball/o-ring
figures 1A, 1B), bar(s)/clip(s) (figures 11D, 11E, 16A, 16B), magnet (figures 17A, 17B,
17C), and other types of mechanical attachments (figures 2A, 3A, 10, 11D, 11E).

The choice has largely been determined by practitioner preference with bars/clips being
one of the mechanisms frequently selected to support/retain overdentures. When bars are
used, it has been proposed that the bar be fabricated so it is parallel to the plane of
occlusion45 (Misch, 1999).

Ideally, the retentive mechanism should be positioned so it cannot be seen through the
visible portion of the denture base, does not interfere with proper positioning of
prosthetic teeth, and does not excessively enlarge the denture base.

Comparison of Rententive Mechanisms

When bars are used, a casting is required which increases cost and complexity. Bars
have been found to provide greater retention than balls/o-rings which may be important
with patients exhibiting high functional activity and the need for maximal retention. One
study22 (Burns, 1995) indicated that o-rings provided significantly better retention and
stability than magnets.

Bars and associated retentive devices require more space within the denture base than do
o-rings. When implants will be used separately (not connected), the ball/o-ring
mechanism or metal cap/stud type of design has frequently been used.

All mechanisms are subject to retention deterioration over time and the need for regular
adjustment/replacement.

Base Reinforcement
When the denture base will be thin or there are heavy occlusal forces present, it may be
prudent to reinforce the denture base with a metal mesh/framework incorporated into the
denture base (figures 18A, 18B, 18C, 18D, 18E) or use a metal base (figure 19).
Evaluating prosthetic tooth wear on an existing prosthesis provides an indication of the
magnitude of forces present. When aggressive wear facets are noted on the prosthetic
teeth of an exisitng denture, a hostile environment is likely to be present and the use of
reinforcement may be advisable.

It is also important to remember that patients who have implants can place greater
occlusal force on the prosthesis than they could with their conventional complete
denture20 (reference 20). However, the maximal occlusal force applied by patients with
mandibular implant overdentures was found to be less than the force developed by
patients with teeth and patients who have fixed complete dentures46 (Mericske-Stern et al,
1992).

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 Occlusion, Tooth Positioning
While there is no clinical data documenting the effect of occlusion upon implant success,
clinicians have felt that occlusion can affect implant success. Lang and Razzoog50 stated
that the occlusal interface may ultimately be the prime factor in the lifetime survival rate
of dental implants. Strub, Witkowkski, and Einsele51 indicate the importance of a
harmonic occlusion and articulation should not be underrated.

Clinicians have frequently recommended that a balanced occlusion be used with implant
overdentures.52,53

The 1972 International Prosthodontic Workshop on Complete Denture Occlusion54

stated the following: "At present, the choice of a posterior tooth form or arrangement for
complete dentures is an empirical procedure. Little or no supporting research is available
to the profession relative to the overall effect on esthetics, function, and the long term
maintenance of the supporting tissues."

Lang and Razzoog50 indicate there are four factors that are universal to all edentulous
patients during occlusal rehabilitation:
1. Maximum intercuspation must occur at centric jaw relation position.
2. An absence of deflective occlusal contacts or tooth interferences must be
observed between opposing teeth.
3. The arrangement and articulation of artificial teeth must provide enough cusp
height to permit selective occlusal reshaping to achieve an absence of
interferences.
4. A natural and pleasing appearance must be achievable with the tooth
arrangement.
The authors indicate that lingualized integration (lingualized occlusion) represents an
occlusal scheme using specific tooth molds designed to improve the likelihood of
maximum intercuspation and an absence of deflective occlusal contacts, provide cusp
height for selective occlusal reshaping, and achieve a natural and pleasing appearance.
They propose that this concept seems appropriate for the implant patient where functional
and nonfunctional activities approach those of patients with natural dentitions.

SYNOPSIS OF DESIGN GUIDELINES

In the mandible, as few as 2 implants can be used, and from the standpoint of implant
success they can be left unattached (separate from one another).
Because of the higher implant loss in the maxilla (21%), place a sufficient number of
implants that the prosthesis can still function satisfactorily should an implant be lost.
In the maxilla, it is considered prudent to connect the implants together using a bar
so the prosthesis can continue to function should an implant be lost.
Position the implants so they are contained within the normal form of the denture
base and centered beneath the prosthetic teeth. For anterior implants, a location
slightly lingual to the center of the prosthetic teeth is also appropriate.

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 Align the implants so they are parallel or nearly parallel to one another whenever
possible.
Minimize the height of the implant components and retentive mechanisms.
The choice of retentive mechanism is based on personal preference and the need for
maximal retention in certain patients. Bars and associated retentive devices provide
the greatest retention.
When the denture base will be thin or there are heavy occlusal forces present
(parafunction), the use of metal reinforcement in the resin base will help prevent
prosthesis fracture.

CLINICAL PROCEDURES

Examination/Diagnosis and Treatment Planning

A clinical examination, medical and dental history, a panoramic radiograph, and mounted
casts (with prosthetic teeth appropriately arranged and articulated) are required to plan
treatment. In addition, linear tomograms, a CT scan, or volumetric radiographic image
may be needed to relate the prosthetic tooth positions to the underlying bone and vital
structures.

The medical and dental history are used to identify patients where implant failure is more
likely to occur so a thorough assessment of the risks/benefits of the treatment can be
made. The history information also helps identify patients where implant treatment is
contraindicated.

The clinical examination and radiographic information are used to evaluate bone health,
bone quality, and incisocervical/occlusocervical bone dimensions.

The positions of the prosthetic teeth determine where the implants should be located.
Several factors determine the most appropriate prosthetic tooth positions and they include
(1) esthetics; (2) tooth-lip relationships; (3) phonetics; (4) anatomic landmarks; (5)
occlusal vertical dimension; and (6) muscular neutrality (neutral zone).

The clinical and laboratory steps required to locate the most appropriate prosthetic tooth
positions include the following conventional complete denture procedures:

1. Custom trays, border molding and definitive impressions of the edentulous

ridges that includes all appropriate anatomic landmarks;
2. A mandibular neutral zone impression made on the occlusal surface of the
impression tray to aid location of the most desirable muscular position for the
teeth and to guide formation of the wax occlusion rim;
3. Laboratory fabrication of working casts, resin record bases and wax occlusion
rims.
4. Clinical use of the wax rims to establish tooth positions (based on facial soft
tissue support and desired amount of esthetic tooth display);
5. Facebow record;

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 6. Determination of the occlusal vertical dimension and making of a centric
relation interocclusal record;
7. Mounting the casts in a semi-adjustable articulator and arranging the teeth;
8. Completion of the clinical wax trial placement appointment completed
including any required positional changes and finalization of the base form;
9. Obtain signed approval of tooth form, shade, esthetics and phonetics from
patient.

Complete Denture Impressions

Conventional complete denture impressions are made using custom trays and the
preferred border molding material (figure 20). A nonaqueous elastomer such as poly
(vinyl siloxane) is recommended for the edentulous ridge impression since it can be
removed from the cast and replaced multiple times which is important to the techniques
that will be described. It also possesses good dimensional stability over time which
allows the impression to relate to the cast adequately over extended time periods.

A custom tray is fabricated with the handle extending vertically to the height of the
occlusal plane (lower lip) and then projecting anteriorly so it can pass between the lips.
The vertical portion of the handle should be thin anteroposteriorly (figure 21). A
conventional mandibular complete denture impression is made and then a neutral zone
impression is made on the occlusal surface of the tray.

Neutral Zone Impression

Any excess impression material that flowed over the occlusal surface of the tray during
the conventional impression procedures of the ridge is trimmed away while retaining the
impression borders (figure 21). The occlusal surface of the tray is coated with poly
(vinyl siloxane) adhesive (figure 22A) and heavy body poly (vinyl siloxane) is
dispensed from a cartridge-mixing gun onto the occlusal surface of the tray (figure 22B).
The material should be applied along the entire occlusal surface (from the second molar
region of the tray to the handle) and should possess sufficient vertical thickness to reach
the base of the retromolar pads. Work expeditiously so there will be time for the ensuing
steps.

The tray is then reseated in the patients mouth and they are asked to swallow three times
in succession while forcibly pressing their lips together. They are told to create suction
(as if sipping vigorously through a straw) around the tray handle. These actions activate
the oral musculature so it compresses the impression material between the lip, cheek and
tongue muscles, thereby locating the neutral zone. It is good to practice the muscular
actions with the patient (figure 23A), then reseat the impression tray in their mouth and
practice again (figure 23B) before applying the heavy body material.

The impression can be removed in as short a time as two minutes, if needed, for patient
comfort. While the material will not be completely polymerized, sufficient viscosity will
have been developed that the desired form will be established. The tongue will create a
depression in the lingual surface and the cheek and lip muscles will form the impression
material facially (figures 24A, 24B, 24C, 24D). It has been interesting to note that the

10
depth of the lingual depression (figures 24B, 24D) is located vertically at about the
center of the retromolar pads. It is felt that the depth of this depression represents the
approximate superior-inferior height of the occlusal plane.

A scalpel is used to cut through the impression material faciolingually by following the
depth of the lingual depression (figures 25A, 25B). All impression material located
occlusal to the lingual depression is thereby removed and a flat occlusal platform is
produced (figures 25C, 25D). The width of this platform varies between patients. The
neutral zone is now readily visible and can be used to locate the faciolingual positions
best suited for the prosthetic teeth. The occlusocervical level of the flat surface identifies
the approximate height of the occlusal surfaces of the posterior teeth.

A cast is poured and trimmed (figure 26A). The impression is reseated on the cast
(figure 26B) so facial and lingual indices of the neutral zone impression can be made
using a putty poly (vinyl siloxane) material (figures 26C, 26D)

Record Bases/Wax Occlusion Rims

A resin record base is fabricated and the indices are used to form the wax occlusion rim
(figures 27A, 27B, 27C, 27D). The occlusion rims are then used clinically in the usual
manner to develop appropriate facial soft tissue support, identify the midline and
occlusal plane, establish the occlusal vertical dimension and record centric relation using
the preferred methodology.

After a facebow record and mounting of the casts, teeth are set into the occlusion rims.
In the mandible, the tooth positions and external base form are developed using the
neutral zone indices.

Wax Trial Placement

A wax trial placement appointment is completed to verify esthetics, phonetics, occlusal
vertical dimension and centric relation. When needed, the wax trial dentures are
duplicated in resin for use as a radiographic template (figures 28A, 28B).

Radiographic Template
A radiographic template is fabricated that identifies the specific position of each tooth to
be replaced. The template is made using the tooth positions established at the wax trial
placement apppointment. The template is placed into the edentulous area and the desired
radiographs made (linear tomogram, CT scan or 3D volumetric image) (figures 29A,
29B). The template can incorporate porcelain teeth or be made with barium impregnated
resin teeth.

If a CT scan or 3D volumetric image is used, the data can be digitized and analyzed in a
computer. The CT scan and computer analysis permits the implants to be placed in the
bone through simulation and will help answer the following questions.
1. Where are vital structures located?
2. How much bone is present and what will be the maximum implant length that
can be placed in available bone?

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 3. What is the bone density (quality)?
4. How many implants can be placed and what is their proximity to vital
structures?
5. Can the implants be ideally located beneath the prosthetic teeth?
6. Will the implants be contained within the normal base dimensions of the
prosthesis (along with access to the screw that will attach the prosthesis to the
implants)?

Surgical Template
The radiographic template can be modified to form a surgical template or a separate
surgical template fabricated (figure 30A). The template should be shaped so it identifies
desired implant locations and angulations. It should also be shaped to permit surgical
access and to meet specific preferences identified by the surgeon (figures 30B, 30C,
30D).

Implant Placement/Provisional Prosthesis

Using the surgical template, implants are placed (figures 31A, 31B, 31C, 31D, 31E,
31F, 31G, 31H) and the soft tissue sutured. The patient is advised to not wear any
prosthesis for 10 days. After that time, sutures are removed and the existing prosthesis
relined so a 3 millimeter thickness of provisional soft liner can be placed in the
prosthesis over the area where the implants are located (figures 32A, 32B, 32C, 32D,
32E). The soft liner is replaced as often as necessary to assure resiliency in the liner
(usually 2-6 weeks). After an appropriate healing period, the implants are uncovered and
healing abutments attached (figures 33A, 33B).

Impression
Following soft tissue healing, an impression is required. The impression can either be
made at the implant level or an abutment placed and the impression made (figures 34A,
34B, 34C, 34D, 34E). There is an increasing tendency for implant level impressions to
be made, thereby permitting the abutment selection to be determined on a cast.

Impression copings are either attached to the implants or abutments and their proper
seating verified radiographically when they are located subgingivally.

When there is good alignment of the implants and remaining teeth, tapered impression
copings and a closed tray impression process is used. When undercuts are present due to
implant alignment variances, then geometrically formed copings with mechanical
undercuts are used in conjunction with an open tray impression (figure 34B).

When using ball/o-ring attachments, the ball abutments can be attached to the implants
and an impression made of the ball abutments (figure 1A).

Working Cast/Prosthesis Fabrication

After impression removal, implant or abutment analogs (depending on whether an
implant or abutment impression was made) are attached to the copings. A cast is then
poured so the prosthesis can be fabricated (figure 34E) using either individual implants

12
or implants connected by a bar. When ball abutments have been attached to the implants
(figure 1A), an impression is made of the edentulous ridge and the ball abutments,
analogs are placed into the impression, and a cast poured (figure 35).

The wax trial denture is frequently processed with the attachments incorporated into the
resin (figure 31G) but alternately the attachments can be picked up in the mouth
(figures 36A, 36B, 36C, 36D).

TABLE

Table 1
Implant Overdenture Complications*

# Studies
Providing Data Total # (%)
Mechanical retention (clip/attachment)
activation 6 111 of 335 prostheses (33)
Patients not satisfied with retention of
opposing complete denture 4 40 of 170 patients (24)
Maxillary implant loss 6 198 of 930 implants (21)
Relines required 9 112 of 554 prostheses (20)
Gingival inflammation/proliferation 7 395 of 2101 implants (19)
66 of 352 prostheses (19)
Mechanical retention (clip/attachment)
fractures 8 71 of 449 prostheses (16)
Neurosensory disturbance after surgery 4 39 of 276 patients (14)
Overdenture fractures (teeth and/or base) 9 63 of 545 prostheses (12)
Opposing prosthesis fractures 3 12 of 148 prostheses (8)
Mandibular implant loss 21 191 of 4200 implants (5)
Prosthesis screw fractures 2 12 of 241 screws (5)
Abutment screw loosening 5 30 of 859 screws (3)
Metal bar fractures 3 4 of 231 bars (2)

REFERENCES

1. Ettinger, RL, Taylor TD, Scandrett FR. Treatment needs of overdenture patients in a
longitudinal study: Five-year results. J Prosthet Dent 1984;52:532-537.

The authors reported on 44 patients with 135 natural teeth that supported overdentures.
The patients had been followed for at least 5 years.
Periodontal problems were recorded more frequently in the mandible than maxilla. Deep
scaling of pockets was needed around 41% of the abutments and surgery needed around
13% of the teeth. Four percent of the teeth were extracted due to periodontal problems.

13
Prosthesis complications included the need for relines (21% of the prostheses),
adjustments (13%), repairs (6%), and remakes (3%). The most frequent repair was
related to holes developing in the denture base over the teeth due to thin resin. The repair
was frequently accompanied by further reduction in the height of the tooth.

The caries rate varied from 3% of the teeth examined after one year to 21% of the teeth
after 3 years (14% average). No teeth were extracted due to caries. No difference in
caries was noted between teeth restored with amalgam and those restored with gold
copings.

Complications (listed in order of frequency):

Deep scaling 41%
Relines 21%
Caries 14%
Periodontal surgery 13%
Denture adjustments 13%
Denture repairs 6%
Denture remakes 3%

2. Smedberg J-I, Lothigius E, Bodin I, Frykholm A, Nilner K. A clinical and

radiological two-year follow-up study of maxillary overdentures on osseointegrated
implants. Clin Oral Impl Res 1993;4:39-46.
All 20 patients in this study of maxillary implant overdentures adapted well to the
prosthesis in terms of comfort and phonetics. The authors indicate there were no
phonetic problems worth noting.

Three of the 20 patients did not like the esthetics of the prosthesis because the base metal
reinforcing meshwork cast a gray color through the resin base.

3. Jemt T, Book K, Lindn B, Urde G. Failures and complications in 92 consecutively

inserted overdentures supported by Brnemark implants in severely resorbed
edentulous maxillae: A study from prosthetic treatement to first annual check-up. Int
J Oral Maxillofac Implants 1992;7:162-167.

When overdentures were placed in 92 patients with severly resorbed maxillae, there were
more postplacement complications (mechanical and peri-implant mucosal complications)
than with fixed complete dentures. There were also fewer phonetic problems with
overdentures.

4. Walton J, MacEntee M. A retrospective study on the maintenance and repair of

implant-supported prostheses. Int J Prosthodont 1993;6:451-455.

Implant overdentures required substantially more postplacement adjustments and repairs

than implant fixed complete dentures. Over 50% of the overdentures required adjustment

14
or repair and over one-third of the patients required 3 or more provisional relines between
the first and second stage surgeries.

5. 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 Implants 1994;9:191-196.

In this study, 25 patients with implant overdentures were compared with 25 patients that
had been treated with implant fixed complete dentures. Post-placement adjustments
during the first year were more common with implant overdentures. Thereafter, implant
fixed complete dentures had more complications and required more maintenance.

6. 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. British Dent J 1996;181:321-327.

Over a five-year period, 20 patients with mandibular implant overdentures were

compared with 20 patients treated with mandiublar fixed complete dentures.

Significantly more post-placement care was needed with implant overdentures than
implant fixed complete dentures. Patients with overdentures required about 6 more post-
treatment appointments over the 5-year period.

7. Hutton JE, Heath MR, Chai JY, Harnett J, Jemt T, Johns RB, McKenna S, McNamara
DC, van Steenberghe D, Taylor R, Watson RM, Herrmann I. 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 Implants 1995;10:33-41.
Implant overdenture treatment has been highly successful but maxillary failures (28%)
were much higher than expected. The dental arch and bone quality were found to be
significant predictors of overdenture failure.

8. Jemt T, Chai J, Harnett J, Heath MR, Hutton JE, Johns RB, McKenna S, McNamara
DC, van Steenberghe D, Taylor R, Watson RM, Herrmann I. A 5-year prospective
multicenter follow-up report on overdentures supported by osseointegrated implants.
Int J Oral Maxillofac Implants 1996;11:291-298.

This paper reports the results of a 5-year prospective study from 9 international centers.
There was a 95% implant success rate in the mandible and a 72% success rate in the
maxilla.

15
9. Watson RM, Jemt T, Chai J, Harnett J, Heath MR, Hutton JE, Johns RB, Lithner B,
McKenna S, McNamara DC, Naert I, Taylor R. Prosthodontic treatment, patient
response, and the need for maintenance of complete implant-supported overdentures:
an appraisal of 5 years of prospective study. Int J Pros 1997;10:345-354.

In evaluating 92 patients treated with 16 maxillary overdentures and 76 mandibular

overdentures, the authors recorded a much higher number of mechanical problems with
maxillary overdentures. They reported a better outcome with mandibular overdentures.

10. Mericske-Stern R. Clinical evaluation of overdenture restorations supported by

osseointegrated titanium implants: a restrospective study. Int J Oral Maxillofac
Implants 1990;5:375-382.

Mandibular implant overdentures retained by 2 individual implants were compared with

prostheses attached to 2 implants and a bar and prostheses attached to 3 or 4 implants and
a bar. All patients from the 3 groups were satisfied with their dentures. No biologic
advantages were noted by attaching the implants together or increasing the number of
implants beyond two.

Retention/stability was improved in the patients with 3-4 implants and a bar compared to
the patients with only 2 implants, particularly when the residual ridge resorption was
severe. Adverse biologic responses could not be positively correlated with a lack of
attached mucosa.

11. Naert I, Quirynen M, Theuniers G, van Steenberghe D. Prosthetic aspects of

osseointegrated fixtures supporting overdentures. A 4-year report. J Prosthet Dent
1991;65:671-680.

Maintenance/adjustments of a bar retained overdenture requires more effort from the

dentist and technician than prostheses retained by individual impants.

12. Naert I, Quirynen M, Hooghe M, van Steenberghe MD. A comparative prospective

study of splinted and unsplinted Brnemark implants in mandibular overdenture
therapy: A preliminary report. J Prosthet Dent 1994;71:486-492.

Naert et al compared prostheses supported by 2 individual implants (with either o-ring or

magnet retention) with those supported by 2 implants and a bar. During a mean post-
treatment time of 12 months, more adjustments to the denture flanges and more mucosal
ulcerations were noted with the prostheses supported by individual implants compared to
prostheses attaching to a bar.

16
There was no difference in the bone loss between individual and connected implants.
Individual implants provided less retention. There was less maintenance associated with
the bars.

13. Nrhi TO, Hevinga M, Voorsmit RACA, Kalk W. Maxillary overdentures retained
by splinted and unsplinted implants: a retrospective study. Int J Oral Maxillofac
Implants 2001;16:259-266.

Individual implants and implants connected by bars were compared in 16 patients with
maxillary overdentures. No differences in mean bone loss were noted although the
authors suggest there is an increased possibility of bone loss when using individual
maxillary implants because one patient with ball-retained overdentures experienced bone
loss that exceeded one-half of the implant length.

14. Naert I, Gizani S, Vuylsteke M, van Steenberghe D. A 5-year randomized clinical

trial on the influence of splinted and unsplinted oral implants in the mandibular
overdenture therapy. Part I: peri-implant outcome. Clin Oral Impl Res 1998;9:170-
177.

This 5-year study of mandibular implant overdentures and Nobel Biocare implants
compared the following 3 groups of 12 patients each: 1) two implants and a connecting
bar; 2) two individual implants and magnetic retention; and 3) two individual implants
and ball/o-ring attachements. There were no significant differences in bleeding on
probing, marginal bone levels, attachment levels, or Periotest values at either year 1 or
year 5.

15. Wismeijer D, van Waas MAJ, Mulder J, Vermeeren JIJF, Kalk W. Clinical and
radiological results of patients treated with three treatment modalities for
overdentures on implants of the ITI Dental Implant System. A randomized
controlled clinical trial. Clin Oral Impl Res 1999;10:297-306.

One hundred-ten patients were treated with ITI implants. The patients were divided into
the following 3 groups: 1) two implants and individual ball attachments; 2) two implants
and a single bar connection; and 3) four implants and three connecting bars.

After implant surgery and at 9 and 19 months afterward, radiographic bone changes were
assessed along with a periodontal evaluation based on measuring the plaque index,
bleeding index, probing depth and the distance from the crest of the peri-implant mucosa
to top of the one-stage implant.

After 19 months, there was less bleeding around the 2 individual implants and a
significant difference was noted between the groups. There were no significant
differences in the plaque index or probing depths between the 3 groups.

17
Based on bone change measurements made from panoramic radiographs, the authors
noted more bone loss in the 4 implant/3 bar group but only around the anterior two
implants (the centrally located implants).

16. Gotfredsen K, Holm B. Implant-supported mandibular overdentures retained with

ball or bar attachments: a randomized prospective 5-year study. Int J Prosthodont
2000;13:125-130.

Twenty-six patients each received 2 Astra Tech dental implants in the mandible. Eleven
patients received a bar retained overdenture and fifteen patients received a ball/o-ring
attachment overdenture.

After 5 years, no significant differences were recorded in the evaluation variables (plaque
index, gingival index, probing depth, Periotest values, and radiographic bone changes
that were assessed using intraoral radiographs and special holders that were screwed onto
the abutments).

The average number of complications per year was 0.6 for the ball/o-ring group and 1.0
for the bar group. All patients reported good prosthesis stability.

17. Payne AGT, Solomons YF. Mandibular implant-supported overdentures: a

prospective evaluation of the burden of prosthetic maintenance with 3 different
attachment systems. Int J Prosthodont 2000;13:246-253.

Mandibular implant overdentures were compared on the basis of required maintenance.

The authors indicated there were sufficient numbers of bars connected to 2 implants (20
prostheses) and connected to 3-4 implants (21 prostheses) to permit a comparison of the 2
connected designs.
No significant differences were noted in the required maintenance between the bars
connected to 2 implants and those connected to 3 or 4 implants. The maintenance
requirements were greatest during the first year with 75% of the adjustments occurring
during that time. One patient required 12 adjustments during the first year. Most of these
adjustments were to ridge contacting areas.

18. Naert I, De Clercq M, Theuniers G, Schepers E. Overdentures supported by

osseointegrated fixtures for the edentulous mandible: a 2.5-year report. Int J Oral
Maxillofac Implants 1988;3:191-196.

When using 2 implants, the authors proposed that the implants be placed so that a straight
line connecting the implants would be as parallel as possible to the transverse horizontal
axis (hinge axis). They also indicated the preferred location is almost always the canine
area.

18
19. Mericske-Stern R. Forces on implants supporting overdentures: a preliminary study
of morpologic and cephalometric considerations. Int J Oral Maxillofac Implants
1993;8:254-263.

Forty-four patients with mandibular overdentures were cephalometrically evaluated to

determine the relationship of the implant long axis and the occlusal plane. Seventy
percent of the implants were inclined facially, 115 lingually, and 19% were located
perpendicular to the occlusal plane. The long axis of the implant did not exert a negative
influence on implant success or peri-implant soft tissue health.

20. Fontijn-Tekamp FA, Slagter AP, vant Hof MA, Geertman ME, Kalk W. Bite forces
with mandibular implant-retained overdentures. J Dent Res 1998;77:1832-1839.

Sixty-eight patients participated in this study that compared the bite force applied by
conventional complete dentures and by implant supported overdentures. About half the
implant overdentures were attached to transmandibular implants using 5 clips and
multiple bars. The other half of the overdentures attached to 2 root form implants and
used one bar/clip.

Bite forces were measured using miniature strain gauge transducers and a mechanical bite
fork. Significantly higher unilateral and bilateral bite forces were achieved with the
patients who had implant overdentures. There were no differences in the mean biting
force between the overdentures attached to multiple bars/clips and those attached to one
bar/clip.

REFERENCE LIST

1. Ettinger RL, Taylor TD, Scandrett FR. Treatment needs of overdenture patients in a
longitudinal study: Five-year results. J Prosthet Dent 1984;52:532-537.
2. Smedberg J-I, Lothigius E, Bodin I, Frykholm A, Nilner K. A clinical and
radiological two-year follow-up study of maxillary overdentures on osseointegrated
implants. Clin Oral Impl Res 1993;4:39-46.
3. Jemt T, Book K, Lindn B, Urde G. Failures and complications in 92 consesecutively
inserted overdentures supported by Brnemark implants in severely resorbed
edentulous maxillae: A study from prosthetic treatment to first annual check-up. Int
J Oral Maxillofac Implants 1992;7:162-167.
4. Walton J, MacEntee M. A retrospective study on the maintenance and repair of
implant-supported prostheses. Int J Prosthodont 1993;6:451-455.

19
5. 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 Implants 1994;9:191-196.
6. 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;181:321-327.
7. Hutton JE, Heath MR, Chai JY, Harnett J, Jemt T, Johns RB, McKenna S, McNamara
DC, van Steenberghe D, Taylor R, Watson RM, Herrmann I. 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 Implants 1995;10:33-41.
8. Jemt T, Chai J, Harnett J, Heath MR, Hutton JE, Johns RB, McKenna S, McNamara
DC, van Steenberghe D, Taylor R, Watson RM, Herrmann I. A 5-year prospective
multicenter follow-up report on overdentures supported by osseointegrated implants.
Int J Oral Maxillofac Implants 1996;11:291-298.
9. Watson RM, Jemt T, Chai J, Harnett J, Heath MR, Hutton JE, Johns RB, Lithner B,
McKenna S, McNamara DC, Naert I, Taylor R. Prosthodontic treatment, patient
response, and the need for maintenance of complete implant-supported overdentures:
an appraisal of 5 years of prospective study. Int J Pros 1997;10:345-354.
10. Mericske-Stern R. Clinical evaluation of overdenture restorations supported by
osseointegrated titanium implants: a retrospective study. Int J Oral Maxillofac
Implants 1990;5:375-382
11. Naert I, Quirynen M, Theuniers G, van Steenberghe D. Prosthetic aspects of
osseointegrated fixtures supporting overdentures. A 4-year report. J Prosthet Dent
1991;65:671-680.
12. Naert I, Quirynen M, Hooghe M, van Steenberghe MD. A comparative prospective
study of splinted and unsplinted Brnemark implants in mandibular overdenture
therapy: A preliminary report. J Prosthet Dent 1994;71:486-492.
13. Nrhi TO, Hevinga M, Voorsmit RACA, Kalk W. Maxillary overdentures retained
by splinted and unsplinted implants: a retrospective study. Int J Oral Maxillofac
Implants 2001;16:259-266.

14. Naert I, Gizani S, Vuylsteke M, van Steenberghe D. A 5-year radomized clinical trial
on the influence of splinted and unsplinted oral implants in the mandibular
overdenture therapy. Part I: peri-implant outcome. Clin Oral Impl Res 1998;9:170-
177.
15. Wismeijer D, van Waas MAJ, Mulder J, Vermeeren JIJF, Kalk W. Clinical and
radiological results of patients treated with three treatment modalities for
overdentures on implants of the ITI Dental Implant System. A randomized
controlled clinical trial. Clin Oral Impl Res 1999;10:297-306.
16. Gotfredsen K, Holm B. Implant-supported mandibular overdentures retained with
ball or bar attachments: a randomized prospective 5-year study. Int J Prosthodont
2000;13:125-130.
17. Payne AGT, Solomons YF. Mandibular implant-supported overdentures: a
prospective evaluation of the burden of prosthetic maintenance with 3 different
attachment systems. Int J Prosthodont 2000;13:246-253.

20
18. Naert I, De Clercq M, Theuniers G, Schepers E. Overdentures supported by
osseointegrated fixtures for the edentulous mandible: a 2.5-year report. Int J Oral
Maxillofac Implants 1988;3:191-196.
19. Mericske-Stern R. Forces on implants supporting overdentures: a preliminary study
of morphologic and cephalometric considerations. Int J Oral Maxillofac Implants
1993;8:254-263.
20. Fontijn-Tekamp FA, Slagter AP, vant Hof MA, Geertman ME, Kalk W. Bite forces
with mandibular implant-retained overdentures. J Dent Res 1998;77:1832-1839.
21. Mericske-Stern R. Overdentures with roots or implants for elderly patients: A
comparison. J Prosthet Dent 1994;72:543-550.
22. Burns DR, Under JW, Elswick Jr. RK, Beck DA. Prospective clinical evaluation of
mandibular implant overdentures: Part I retention, stability, and tissue response. J
Prosthet Dent 1995;73:354-363.
23. Burns DR, Unger JW, Elswick Jr. RK, Giglio JA. Prospective clinical evaluation of
mandibular implant overdentures: Part II patient satisfaction and preference. J
Prosthet Dent 1994;73:364-369.
24. Boerrigter EM, Stegenga B, Raghoebar GM, Boering G. Patient satisfaction and
chewing ability with implant-retained mandibular overdentures: A comparison with
new complete dentures with or without preprosthetic surgery. J Oral Maxillofac Surg
1995;53:1167-1173
25. Boerrigter EM, Geertman ME, Van Oort RP, Bouma J, Raghoebar GM, van Waas
MAJ, vant Hof MA, Boering G, Kalk W. Patient satisfaction with implant-retained
mandibular overdentures. A comparison with new complete dentures not retained by
implants a multicentre randomized clinical trial. Br J Oral Maxillofac Surg
1995;33:282-288.
26. Jacobs R, van Steenberghe D, Nys M, Naert I. Maxillary bone resorption in patients
with mandibular implant-supported overdentures or fixed prostheses. J Prosthet Dent
1993;70:135-140.
27. Johns RB, Jemt T, Heath MR, Hutton JE, McKenna S, McNamara DC, van
Steenberghe D, Taylor R, Watson RM, Herrmann I. A multicenter study of
overdentures supported by Brnemark implants. Int J Oral Maxillofac Implants
1992;7:513-522.
28. Cune MS, de Putter C, Hoogstraten J. Treatment outcome with implant-retained
overdentures: Part I Clinical findings and predictability of clinical treatment
outcome. J Prosthet Dent 1994;72:144-151.
29. Mericske-Stern R. Treatment outcomes with implant-supported overdentures:
Clinical considerations. J Prosthet Dent 1998;79:66-73.
30. Engquist B, Bergendal T, Kallus T, Linden U. A retrospective multicenter evaluation
of osseointegrated implants supporting overdentures. Int J Oral Maxillofac Implants
1988;3:129-134.
31. Leimola-Virtanen R, Peltola J, Oksana E, Helenius H, Happonen RP. ITI titanium
plasma-sprayed screw implants in the treatment of edentulous mandibles: A follow-
up study of 39 patients. Int J Oral Maxillofac Implants 1995;10(3):373-378.
32. Versteegh PAM, van Beek GJ, Slagter AP, Ottervanger JP. Clinical evaluation of
mandiublar overdentures supported by multiple-bar fabrication: a follow-up study of
two implant systems. Int J Oral Maxillofac Implants 1995;10(5):595-603.

21
33. Wismeyer D, van Waas MAJ, Vermeeren JIJF. Overdentures supported by ITI
implants: A 6.5-year evaluation of patient satisfaction and prosthetic aftercare. Int J
Oral Maxillofac Implants 1995;10:744-749.
34. Buchs AU, Hahn J, Vassos DM. Efficacy of threaded hydroxyapatite-coated implants
in the anterior mandible supporting overdentures. Implant Dent 1996;5:188-192.
35. Makkonen TA, Holmberg S, Niemi L, Olsson C, Tammisalo T, Peltola J. A 5-year
prospective clinical study of Astra Tech dental implants supporting fixed bridges or
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36. Deporter D, Watson P, Pharoah M, Levy D, Todescan R. Five-to six-year results of a
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37. Cooper LF, Scurria MS, Lang LA, Guckes AD, Moriarty JD, Felton DA. Treatment
of edentulism using Astra Tech implants and ball abutments to retain mandibular
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38. Meijer HJ, Raghoebar GM, Vant Hof MA, Visser A, Geertman ME, Van Oort RP.
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results of clinical aspects and after care of IMZ implants and Brnemark implants.
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39. Olson JW, Shernoff AF, Tarlow JL, Colwell JA, Scheetz JP, Bingham SF. Dental
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40. Gatti C, Haefliger W, Chiapasco M. Implant-retained mandibular overdentures with
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41. Roynesdal AK, Amundrud B, Hannaes HR. A comparative clinical investigation of 2
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42. Allen PF, McMillan AS, Smith DG. Complications and maintenance requirements of
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43. Batenburg RHK, Raghoebar GM, Van Oort RP, Heijdenrijk K, Boering G.
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44. Kenney R, Richards MW. Photoelastic stress patterns produced by implant-retained
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45. Misch CE. Contemporary Implant Dentistry (ed 2). St Louis, MO, Mosby, 1999.
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47. Quirynen M, Naert I, van Steenberghe D. Fixture design and overload influence
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48. Walton JN, Huizinga SC, Peck CC. Implant angulation: A measurement technique,
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