P R O S T H O D O NPTRI O

C SS T H O D O N T I C S

Implant Complications and Failures:

The Complete Overdenture
C.J.WATSON, D.TINSLEY AND S. SHARMA

of the implant-retained overdenture is

Abstract: The implant-retained overdenture has been advocated as an effective relatively straightforward, as the
method of restoring the edentulous patient with an appliance that offers significant
techniques used are similar to those for
benefits over conventional prosthetics. However, the success and survival of such
appliances have been shown to vary considerably, depending on which jaw is treated: conventional overdentures using natural
implants supporting overdentures in the maxilla have a significantly higher failure teeth. However, it has to be appreciated
rate. The restoration also requires considerable maintenance, which is both time that the costs of long-term maintenance
consuming and costly. The purpose of this paper is to look at common restorative of these restorations can be high7–10 in
complications and maintenance problems following the placement of dental implants to both time and money and this should be
support an overdenture. A number of implant systems have been reviewed and the explained to the patient before treatment
results of the authors’ clinical experiences with referred and their own cases are is undertaken. The overdenture needs to
reported. be carefully reviewed as potential
resorption of the alveolar bone in the
Dent Update 2001; 28: 234-240
saddle areas means that frequent relines
Clinical Relevance: Implant-retained overdentures require all the prosthetic skills or replacement of the denture may be
of conventional treatment combined with a clear appreciation for the need for careful necessary.10,11
long-term maintenance. Planning the implant position is essential. Using attachments The purpose of this paper is to
that are easy to replace can simplify maintenance and reduce ongoing costs. discuss the common problems
encountered with implant- retained
overdentures in a review and referral
clinic at the Leeds Dental Institute.

I 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.1–3 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

234 Dental Update – June 2001


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
Dental Update – June 2001
P R O S T H O D O N T I C S
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 buccal–lingual 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
a b
Figure 4. (a) Lingually placed implant causing trauma to the lingual frenal attachments. (b)
Labially placed implants supporting magnets.
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 patient’s 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 patient’s
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
235
 P R O S T H O D O N T I C S
Figure 5. Clear copy of maxillary denture
modified to form a maxillary stent.
Figure 6. Failing maxillary implant, possibly due to
occlusal overload on short implants in vascular bone.
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.
Occlusal Problems
Lack of interocclusal space restricts the
type of attachment that can be used. It
236
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 implant-
retained 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.
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
a b
c
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 7. (a) Radiographic appearance of
failing Brånemark implants. (b)
Inflammation around failing implants. (c)
The transmucosal element with debris
clearly visible around the neck.
Dental Update – June 2001
 P R O S T H O D O N T I C S
Figure 8. Fracture of an overdenture due to thin
acrylic over attachment housing.
Figure 9. Fractured gold clip.
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 non-
cantilevered 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
238
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.
Figure 10. A fractured distal cantilever bar.
Figure 11. Fracture of a magnetic keeper.
Dental Update – June 2001
 P R O S T H O D O N T I C S
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
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abutments to retain mandibular overdentures.
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 haven’t
changed, there is an ever increasing
amount of new research, which has
implications about how we treat our
patients.
It’s important that students, general
practitioners and specialists keep up-
to-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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Adjustments and complications of mandibular
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10. Walton JN, MacEntee MI. A retrospective study
on the maintenance and repair of implant-
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11. Tinsley D, Watson CJ, Russell JL. A comparison
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
of hydroxylapatite coated implant retained fixed
and removable mandibular prostheses over 4 to
6 years. Clin Oral Implant Res 2001; 12: 159–166.
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retrospective multicenter evaluation of
osseointegrated implants supporting
overdentures. Int J Oral Maxillofac Implant 1988;
3: 129–134.
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overdentures – the Birmingham experience. J
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complications in 92 consecutively inserted
overdentures supported by Brånemark implants
in severely resorbed edentulous maxillae: A study
from prosthetic treatment to first annual check-
up. Int J Oral Maxillofac Implant 1992; 7: 162–167.
15. 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 Brånemark implants. Int J Oral
Maxillofac Implant 1995; 10: 33–42.
16. Walton JN, Ruse ND. In vitro changes in clips and
bars used to retain implant overdentures. J
Prosthet Dent 1995; 74: 482–486.
17. 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: 195–202.
18. Naert I, Quirynen M, Hooghe M, Steenberghe D.
A comparative prospective study of splinted and
unsplinted Brånemark implants in mandibular
overdenture therapy: A preliminary report. J
Prosthet Dent 1994; 71: 486–492.

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