PRACTITIONER SECTION

Guidelines for treatment planning of mandibular

implant overdenture
Siddharth Bansal, Meena A Aras, Vidya Chitre
ABSTRACT

Implant overdenture (OD) is the common treatment modality for the rehabilitation of complete
mandibular edentulism with dental implants. The purpose of this review was to collect the data
regarding various factors contributing to the selection of implant OD design and to provide
comprehensive guidelines for the clinicians in planning the OD design.
KEY WORDS: Attachments, implant overdenture, implant retained prosthesis, implant supported

prosthesis

INTRODUCTION
Edentulous patients with severely resorbed maxillary
and mandibular arches commonly experience problems
with retention, stability and support and the related
compromise in chewing ability with conventional
complete dentures. As the successful use of dental
implants in the treatment of mandibular edentulism is
well-documented in the literature[1] for both fixed and
removable prosthetic rehabilitations,[2] these problems
can be easily solved by using implant retained prosthesis
(IRP)/implant supported prosthesis (ISP). IRP achieves
support from both implants and tissues whereas ISP
achieves support only from implants.
The purpose of the review was to collect the data
regarding factors contributing to the selection of implant
overdenture (OD) design and to provide comprehensive
guidelines for the clinicians in planning the OD design.
Factors which contribute to the determination of the OD
Department of Prosthodontics, Goa Dental College and Hospital, Panaji,
Bambolim, Goa, India
Address for correspondence: Dr. Siddharth Bansal,
Department of Prosthodontics, Goa Dental College and Hospital, Panaji,
Bambolim, Goa - 403 202, India.
E-mail: siddharthbansal42@gmail.com

Access this article online

Quick Response Code:

Website:
www.jdionline.org

DOI:
10.4103/0974-6781.131014

design are grouped under the following subheadings:

indications, biomechanical principles, prosthetic space
analysis and type of attachment (interconnected vs.
solitary implants), optimum number of implants
required, prosthesis design, implant location, prosthesis
maintenance, patient satisfaction and success rate.[3]

INDICATIONS
IRP with 2 implants is contraindicated in younger patients
or those who are edentulous for <10 years due to anterior
posterior rotation of prosthesis, which causes increased
bone resorption in posterior edentulous region [Table 1].[4-6]

BIOMECHANICAL PRINCIPLES
According to Misch, as ISP is stabilized on multiple bars
between implants, the attachment clips located on each bar
are frequently not parallel to one another or perpendicular
to the posterior ridges. Therefore, the clips can bind in
function, limiting prosthesis movement. This can produce
Table 1: Indications of ISP and IRP
ISP

IRP

Patient with severe ridge

resorption
Superficially placed mental
nerve

Patient with good

posterior ridge anatomy
Moderate to good
retention and stability of
the denture
Financial limitations

High muscle attachments

Knife edge ridge
Sharp mylohyoid
projections

ISP: Implant supported prosthesis, IRP: Implant retained prosthesis

86

Journal of Dental Implants | Jan - Jun 2014 | Vol 4 | Issue 1

Bansal, et al.: Implant overdenture treatment planning

a reduced range of motion between the prosthesis and

bar attachment, increased prosthesis support from the
implants and increased applied torsional forces to the
implants.[6] In clinical situations involving poor posterior
ridge form, reducing posterior mucosal support in this
manner may be advantageous as it prevents rotational
movements of the prosthesis. Similar to a fixed prosthesis,
it creates a stable occlusal plane and prosthesis position
reducing possible jaw resorption in posterior mandibular
and anterior maxillary regions.[7,8]
IRP with ball or bar and clip attachments design allows
a significant amount of rotation and vertical movement
due to soft-tissue resiliency and leads to residual ridge
bone loss. Therefore for the functional success of an IRP,
an optimal extension and fit of the denture is important.

PROSTHETIC SPACE ANALYSIS

For successful implant OD treatment planning prosthetic
space analysis should be taken under consideration for
selection of the prosthetic components of the implant
attachment system. At least 13-14 mm interocclusal space
is required for bar supported OD considering teeth size,
denture base thickness, bar thickness for the rigidity, the
space from the mucosa to the bar for hygiene and the
soft-tissue thickness.[9] Minimum space requirement[10,11]
for ball attachment is 10-12 mm and for locators is 8.5 mm.
Inadequate space for prosthetic components can result in
an overcontoured prosthesis, excessive occlusal vertical
dimension, fractured teeth adjacent to the attachments,
attachments separating from the denture, fracture of the
prosthesis and overall patient dissatisfaction.

TYPE OF ATTACHMENTS (INTERCONNECTED VS

SOLITARY IMPLANTS)
Next is to decide which type of attachment is to be used,
whether to splint implants with a rigid bar fixation or
an independent implant attachment system is to be
used. Guidelines to assist with this treatment decision
are also limited and controversial in the literature. The
attachment selection is affected by the implant number,
distribution and alignment, bone quality, arch shape,
retention, and denture design.[12]
The attachments used for implant ODs are mainly
divided into the bar type and the solitary type and into
the resilient type and the rigid type, depending on the
movement allowance. Popular OD attachments used are:
1. Ball attachments with rubber o-rings and/or metal
housings
2. Bar attachments with clips
3. Locators
4. Magnets
5. Bar with locators cast or tapped into the framework.
Journal of Dental Implants | Jan - Jun 2014 | Vol 4 | Issue 1

Abutment parallelism is very critical for the solitary

implants as abutment non parallelism leads to faster
wear of the matrix. Therefore with increase in number
of implants, splinting should be done as abutment
parallelism becomes more difficult.
In a V shaped anterior mandibular ridge, if bar is placed
at canine locations, it encroaches on the tongue space
and if placed anteriorly, length of the bar becomes
inadequate. Therefore in such cases, ball attachments
or 3-4 implants with a connecting bar supported OD is
indicated.[13]
Use of a bar may complicate the procedure, increase
the cost of the prosthesis, is more technique sensitive[14]
and generally require more space than individual
attachments. One perceived advantage of the bar is that
it can accommodate divergent implants.[4] However
individual attachments can also be used for divergent
implants.[15]
The available data supports the use of independent
implants for a mandibular OD.[16-18] Stress transmitted
to implants by ball attachment or bar attachment is
controversial in the literature.
A study by Kenney and Richards[19] evaluated the photo
elastic stress patterns produced by implant-retained
ODs. They found that independent O-ring attachments
transferred less stress to implants than the bar-clip
attachments when their model was subjected to posterior
vertical load.
Celik and Uludag[20] in their study have reported that
more stress was observed in the solitary type than in
the bar splinting type when the photoelastic stress
distribution was assessed in ODs with three mandibular
implants according to the retention mechanism.
Wismeijer et al.[21] studied 110 patients who had received
mandibular implant OD treatment. Subjects received
either 2 implants with ball attachments, 2 implants with
an interconnecting bar, or 4 interconnected implants.
Subjects completed questionnaires designed to elicit
opinion regarding individual treatment outcome.
Sixteen months after treatment, almost all subjects were
generally satisfied. No significant difference was found
between the 3 treatment strategies.
Meijer et al.[22] using three-dimensional finite-element
analysis, studied the stress distribution in the anterior
mandibular bone around implants under conditions in
which either 2 or 4 implants were used. They concluded
that there was no reduction of the principal stresses in
bone when the occlusal load was distributed over an
increasing number of implants.
87

Bansal, et al.: Implant overdenture treatment planning

OPTIMUM NUMBER OF IMPLANTS

Next question comes about what is the optimum number
of implants required for removable IRP/ISP. The answer
to this question is controversial because adequate data
to address this concern is lacking. Some practitioners
believe that using more implants for OD treatment
results in a better treatment outcome, but supporting
evidence is limited.
Zarb and Schmitt et al.[23] support the concept that fewer
implants can be equally effective for the OD prosthesis.
However, the placement of additional implants for the
proposed prosthodontic treatment probably provides
a means for contingency planning against the loss of
implants, if tissue integration fails.
Sadowsky suggested multiple implants for mandibular
OD when sensitive jaw anatomy, increased occlusal
forces, or high retention needs are present or when
implant length <8 mm or implant width <3.5 mm are
employed.[4]
One of the most recent studies is by Thomason et al.
The study aimed to present the current evidence and
rationale to support the McGill (2002) and York (2009)
consensus statements.[38,39] The conclusion was that there
is overwhelming evidence to support the proposal that
a two-implant OD should become the first choice of
treatment for the edentulous mandible. No information
was, however, given regarding the various options in
attachment systems, i.e. bars, ball attachment, locator
and/or possible adjunctive benefits with the use of
additional implants.[24]
Four to six implants for Implant-supported ODs splinted
with a bar, are usually prescribed to achieve a sufficient
amount of support, stability and retention. In this type
of prosthesis, more support is derived from the implants
than the alveolar ridge mucosa eliminating the need for
extension of denture base.
According to Wismeijer et al.,[21] Timmerman et al.[40],
Visser et al.[41], Meijer et al.[42], increase in number of
implants did not significantly improve the patient
satisfaction.[25]

LOCATION OF IMPLANT PLACEMENT

According to Taylor,[26] for a 2-implantretained mandibular
OD, placement of implants in the lateral incisor area rather
than the canine position offers a mechanical advantage,
providing better stability for the OD.
The implants act as a fulcrum with 2 potential lever
arms: (1) From the fulcrum to the posterior extension of
88

the denture and (2) from the fulcrum anteriorly to the

incisal edge. Forces on either lever arm will produce
rotation. However, the primary and secondary bearing
areas of the OD will resist occlusal forces placed on the
posterior lever arm, but forces on the anterior lever arm,
such as incisive movements, may cause more noticeable
rotation. By moving the implants from the canine to the
lateral incisor position, the effective anterior lever arm
is reduced, thus minimizing the tipping forces on the
OD. Various implant overdenture prostheses designs
are described based on number of implants and type of
attachments [Table 2].[13]

PROSTHESIS DESIGN
Maintenance and complications
One of the main problems with implant ODs is the
potential complication associated with the attachment
mechanisms. Controversy persisted as to whether
the ball or bar design requires more maintenance.
Some studies suggest that a bar attachment requires
less maintenance [27,28] whereas others suggest the
opposite.[29,30] However in recent literature, studies have
shown that bar supported ODs requires less prosthetic
maintenance than ball attachments.[31,32]
In one of the study, Walton et al. [33] found a high
complication rate with a ball attachment matrix which
could be due to misaligned implants. Most common
prosthetic maintenance and complications occurred
with magnetic attachments are due to wear and
corrosion.[34] Various complications are loss of retention,
clip or attachment fracture, opposing prosthesis fracture,
acrylic resin base fracture, prosthesis or abutment screw
loosening and implant fracture.[35]

Success rate
Success rates (as measured by the continual
osseointegration of implants) of 1-10 years which
supported the ODs in the mandible, ranged from 91.7% to
100% and the mean implant survival rate was over 98%,
both of this supports the presumption that this treatment
Table 2: Prosthesis design
Location in
mandibular
arch

No. of
implants

Interforaminal
region

3-4
4-6

Type of prosthesis

Overdenture bar/ball anchor/

locator/magnet attachment
with complete denture design
Overdenture bar/ball anchor/
locator/magnet attachment
Fixed detachable hybrid
prosthesis or bridge with
distal cantilever

Journal of Dental Implants | Jan - Jun 2014 | Vol 4 | Issue 1

Bansal, et al.: Implant overdenture treatment planning

has a good prognosis in a long-term perspective.[34,36] No

difference has been found among the success rates of the
different attachment mechanisms.[37] However, direct
comparisons of these reports are difficult owing to the
variety of attachment mechanisms and different implant
manufacturing systems employed.

SUMMARY
Following objectives should be taken into considerations
for planning of ISP/IRP:
Determine the optimum location and number of
implants in the context of the morphological aspects
of the residual ridge.
Design a favorable distribution for occlusal stresses
on the implants and the prosthesis bearing tissues.
Avoid discrepancies among the design of the
dentures, the implants location and the attachment
system.

REFERENCES
1.

2.
3.
4.
5.

6.

7.

8.

9.

10.

11.
12.

13.

Jemt T, Chai J, Harnett J, Heath MR, Hutton JE, Johns RB,

et al. A 5-year prospective multicenter follow-up report on
overdentures supported by osseointegrated implants. Int J Oral
Maxillofac Implants 1996;11:291-8.
Sadowsky SJ. The implant-supported prosthesis for the edentulous
arch: Design considerations. J Prosthet Dent 1997;78:28-33.
Burns DR. Mandibular implant overdenture treatment:
Consensus and controversy. J Prosthodont 2000;9:37-46.
Sadowsky SJ. Mandibular implant-retained overdentures:
A literature review. J Prosthet Dent 2001;86:468-73.
Batenburg RH, Meijer HJ, Raghoebar GM, Vissink A. Treatment
concept for mandibular overdentures supported by endosseous
implants: A literature review. Int J Oral Maxillofac Implants
1998;13:539-45.
Misch CE, Dietsh-Misch F. Diagnostic casts, preimplant
prosthodontics, treatment prosthesis, and surgical templates.
In: Misch CE, editor. Contemporary Implant Dentistry. 2nd ed.
St. Louis, MO: Mosby; 1999. p. 135-40.
Jacobs R, Schotte A, van Steenberghe D, Quirynen M,
Naert I. Posterior jaw bone resorption in osseointegrated
implant-supported overdentures. Clin Oral Implants Res
1992;3:63-70.
Kreisler M, Behneke N, Behneke A, dHoedt B. Residual
ridge resorption in the edentulous maxilla in patients with
implant-supported mandibular overdentures: An 8-year
retrospective study. Int J Prosthodont 2003;16:295-300.
Pasciuta M, Grossmann Y, Finger IM. A prosthetic solution to
restoring the edentulous mandible with limited interarch space
using an implant-tissue-supported overdenture: A clinical report.
J Prosthet Dent 2005;93:116-20.
Lee CK, Agar JR. Surgical and prosthetic planning for a
two-implant-retained mandibular overdenture: A clinical report.
J Prosthet Dent 2006;95:102-5.
Ahuja S, Cagna DR. Dening available restorative space for
implant overdentures. J Prosthet Dent 2010;104:133-6.
Trakas T, Michalakis K, Kang K, Hirayama H. Attachment systems
for implant retained overdentures: A literature review. Implant
Dent 2006;15:24-34.
Mericske-Stern RD, Taylor TD, Belser U. Management of the

Journal of Dental Implants | Jan - Jun 2014 | Vol 4 | Issue 1

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

edentulous patient. Clin Oral Implants Res 2000;11 Suppl

1:108-25.
Naert I, Quirynen M, Theuniers G, van Steenberghe D. Prosthetic
aspects of osseointegrated xtures supporting overdentures.
A 4-year report. J Prosthet Dent 1991;65:671-80.
Wiemeyer AS, Agar JR, Kazemi RB. Orientation of retentive
matrices on spherical attachments independent of implant
parallelism. J Prosthet Dent 2001;86:434-7.
Mericske-Stern R. Clinical evaluation of overdenture restorations
supported by osseointegrated titanium implants: A retrospective
study. Int J Oral Maxillofac Implants 1990;5:375-83.
Donatsky O. Osseointegrated dental implants with ball attachments
supporting overdentures in patients with mandibular alveolar
ridge atrophy. Int J Oral Maxillofac Implants 1993;8:162-6.
Jennings KJ. ITI hollow-cylinder and hollow-screw implants:
Prosthodontic management of edentulous patients using
overdentures. Int J Oral Maxillofac Implants 1991;6:202-6.
Kenney R, Richards MW. Photoelastic stress patterns
produced by implant-retained overdentures. J Prosthet Dent
1998;80:559-64.
Celik G, Uludag B. Photoelastic stress analysis of various
retention mechanisms on 3-implant-retained mandibular
overdentures. J Prosthet Dent 2007;97:229-35.
Wismeijer D, Van Waas MA, Vermeeren JI, Mulder J,
Kalk W. Patient satisfaction with implant-supported mandibular
overdentures. A comparison of three treatment strategies with
ITI-dental implants. Int J Oral Maxillofac Surg 1997;26:263-7.
Meijer HJ, Starmans FJ, Steen WH, Bosman F. A three-dimensional
nite element study on two versus four implants in an edentulous
mandible. Int J Prosthodont 1994;7:271-9.
Zarb GA, Schmitt A. The longitudinal clinical effectiveness of
osseointegrated dental implants: The Toronto Study. Part II: The
prosthetic results. J Prosthet Dent 1990;64:53-61.
Thomason JM, Kelly SA, Bendkowski A, Ellis JS. Two
implant retained overdentures A review of the literature
supporting the McGill and York consensus statements. J Dent
2012;40:22-34.
Lee JY, Kim HY, Shin SW, Bryant SR. Number of implants for
mandibular implant overdentures: A systematic review. J Adv
Prosthodont 2012;4:204-9.
Taylor TD. Indications and treatment planning for mandibular
implant overdentures. In: Feine JS, Carlsson GE, editors. Implant
Overdentures as the Standard of Care for Edentulous Patients.
Chicago: Quintessence; 2003. p. 71-81.
van Kampen F, Cune M, van der Bilt A, Bosman F. Retention
and postinsertion maintenance of bar-clip, ball and magnet
attachments in mandibular implant overdenture treatment:
An in vivo comparison after 3 months of function. Clin Oral
Implants Res 2003;14:720-6.
MacEntee MI, Walton JN, Glick N. A clinical trial of patient
satisfaction and prosthodontic needs with ball and bar
attachments for implant-retained complete overdentures:
Three-year results. J Prosthet Dent 2005;93:28-37.
Naert I, Alsaadi G, Quirynen M. Prosthetic aspects and patient
satisfaction with two-implant-retained mandibular overdentures:
A 10-year randomized clinical study. Int J Prosthodont
2004;17:401-10.
Gotfredsen K, Holm B. Implant-supported mandibular
overdentures retained with ball or bar attachments: A randomized
prospective 5-year study. Int J Prosthodont 2000;13:125-30.
Stoumpis C, Kohal RJ. To splint or not to splint oral implants
in the implant-supported overdenture therapy? A systematic
literature review. J Oral Rehabil 2011;38:857-69.
Al-Ansari A. No difference between splinted and unsplinted
89

Bansal, et al.: Implant overdenture treatment planning

33.

34.

35.

36.

37.

38.

90

implants to support overdentures. Evid Based Dent

2012;13:54-5.
Walton JN, Huizinga SC, Peck CC. Implant
angulation: A measurement technique, implant overdenture
maintenance, and the influence of surgical experience. Int J
Prosthodont 2001;14:523-30.
Kim HY, Lee JY, Shin SW, Bryant SR. Attachment systems for
mandibular implant overdentures: A systematic review. J Adv
Prosthodont 2012;4:197-203.
Andreiotelli M, Att W, Strub JR. Prosthodontic complications
with implant overdentures: A systematic literature review. Int J
Prosthodont 2010;23:195-203.
Hemmings KW, Schmitt A, Zarb GA. Complications and
maintenance requirements for xed prostheses and overdentures
in the edentulous mandible: A 5-year report. Int J Oral Maxillofac
Implants 1994;9:191-6.
Bergendal T, Engquist B. Implant-supported overdentures:
A longitudinal prospective study. Int J Oral Maxillofac Implants
1998;13:253-62.
The McGill consensus statement on overdentures. Eur J
Prosthodont Restor Dent. 2002;10:95-6.

39. The York consensus statement on implant-supported

overdentures. Eur J Prosthodont Restor Dent. 2009;17:4:164-5.
40. Timmerman R, Stoker GT, Wismeijer D, Oosterveld P,
Vermeeren JI, van Waas MA. An eight-year follow-up to a
randomized clinical trial of participant satisfaction with three
types of mandibular implant-retained overdentures. J Dent Res.
2004;83:630-33.
41. Visser A, Raghoebar GM, Meijer HJ, Batenburg RH, Vissink A.
Mandibular overdentures supported by two or four endosseous
implants. A 5-year prospective study. Clin Oral Implants Res.
2005;16:19-25.
42. Meijer HJ, Raghoebar GM, Batenburg RH, Visser A, Vissink A.
Mandibular overdentures supported by two or four endosseous
implants: A 10-year clinical trial. Clin Oral Implants Res.
2009;20:722-28.
How to cite this article: Bansal S, Aras MA, Chitre V. Guidelines for
treatment planning of mandibular implant overdenture. J Dent Implant
2014;4:86-90.
Source of Support: Nil, Conflict of Interest: None.

Journal of Dental Implants | Jan - Jun 2014 | Vol 4 | Issue 1

Copyright of Journal of Dental Implants is the property of Medknow Publications & Media
Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv
without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.