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Various Movements Allowed by Resilient

Attachments:

Vertical Movement
Hinge Movement
Rotation Movement
Translation
Combination between any type of
movement.
TYPES OF ATTACHMENTS BASED ON
RESILIENCY
 Rigid Non-Resilient Attachments (the implant
receives 100 percent of the chewing forces)
 This type of attachment needs sufficient number of
implants.
Ex: A screw-retained hybrid overdenture.
 RestrictedVertical Resilient Attachments:
This type of attachment provides 5–10
percent load relief to the supporting
implants, and the
prosthesis can move up and down with no
lateral movement.
Ex: telescopic attachment with vertical
relief.(Syncone abutment)
 Hinge Resilient Attachments: Hinge resilient
attachments provide almost 30–35 percent load
relief to the supporting implant.
 vertical
components of the masticatory forces
are shared between the attachments and the
posterior portions of the residual ridge—the
buccal shelf and retro molar pad.
 Ex: A Hader bar or any other kind of round
bar can provide hinge resiliency
 Combination Resilient
Attachments: allow unrestricted
vertical and hinge movements.
 This type of attachment offers
45–55 percent load relief to the
supporting implants. Ex:The
Dolder bar joint (egg shaped) is a
combination resilient
attachment.
Rotary Resilient Attachments: This type of attachment
provides vertical hinge and rotation movements. Rotary resilient
attachments transfer both the vertical and horizontal components of
masticatory forces to the residual ridge. this type of attachment
provides 75–85 percent load relief to the supporting implants. Ex. The
stud attachment.
 UniversalResilient
Attachments: These
attachments provide vertical,
hinge, translation, and
rotation movements.
 Thistype of attachment
offers 95 percent load relief
to the supporting implants.
Ex: Magnetic attachments are
the best example of the
universal resilient attachments.
FACTORS INFLUENCING THE DESIGN AND RESILIENCY
LEVEL OF THE ATTACHMENT ASSEMBLY

Shape of the arch


Distribution of the implants in the arch
Length of the implants and degree of
implant bone interface
Distance between the most anterior and the
most posterior implants
Factors affecting the attachment selection
Implant position and angulation

 Implantposition: The final location of the implant will


help decide the type of attachments; this should be
determined at the diagnosis and treatment planning
phase before the placement of implants.
 Implantposition should be determined in relation to
the bone and the prosthetic teeth.
 In order for the individual
attachments to provide adequate
retention, all the implants need to
be placed as parallel to each other
as possible. If the implants cannot
be placed relatively parallel to each
other, then a bar design would be
our next choice to be fabricated for
the patient
 The presence of angled locator
that can correct the angulation
of the abutment.
Zest plus in place implant system

 Angled narrow
diameter implant
allow the
placement of the
implant in the
anterior maxilla.
Sphero Flex

The unique Sphero Flex is a self paralleling ball


attachment designed for use on implant cases
where there is up to 15º of deviation between
implants.
Implant
position
selection
Implants at A & E
positions shouldn’t
be splinted.

Additional implant
at C position is
required For bar
connection
The center of the implants
should be 24–26mm apart if
standard diameter 4mm
implants are being used.
The length of the bar will be
20–22mm to accommodate two
clips/riders to have proper
retention.
 Ifthe two implants are too
close, the short bar cannot
provide enough retention
and stability for the
overdenture
 If the implants are placed too
far distally, a straight-line bar
will interfere with the tongue
space and create problems in
fabricating the prosthesis, also
it will be at risk of bending.
 Asa general rule the bar should
be perpendicular to the line that
bisects the angle formed by the
two posterior mandibular arch
segments.
Retention required

 Chung et al 2004 compare the retention


characteristics of various overdenture
attachment systems commonly used to
retain overdentures to dental implants.
They compare between 9 commercially
available attachment types.

Journal of Prosthodontics, Vol 13, No 4 ( December), 2004: pp 221-226


they use the universal testing
machine to dislodge a metal-
reinforced experimental
overdenture from the model.

Results suggest that the


attachment systems evaluated may
be grouped into high (ERA gray),
medium (Locator LR white,
Spheroflex ball, Hader bar & metal
clip, ERA white), low (Locator LR
pink), and very low (Shiner
magnet, Maxi magnet, Magnedisc
magnet) retention characteristics.
Attachments for Implant Overdentures
Desire for cross arch stabilization

 In patients with shallow vestibules and atrophic ridges, bars


are indicated to resist lateral loads by providing cross arch
stabilization.
 They also help improve the stability of the prosthesis by
providing a distal cantilever usually one to 2 teeth distal to
the posterior most implant.
 In situations where the prosthesis is stable, and only
improved prosthesis retention is required, the use of
individual attachments can be utilized with predictable
results.
Prosthesis size
 When patients require minimum size of the final
prosthesis, specifically designed milled bars are a
good choice.
 Utilizing the principles of anterior-posterior spread
and cross arch stabilization, the size of the
prosthesis can be decreased without increasing the
lateral loads on the implants.
A-P spread rule
 The anterior-posterior distance
rule is good for determining the
distal cantilever extension of the
bar or distal extension of the
hybrid (fixed detachable)
prosthesis from the most
posterior implants.
 Shapeof the arch affect the
degree of posterior cantilever
No cantilever with two implants
 Capturing the patient’s
individualized muscle bound
neutral zone recording will
define the horizontal space
available in determining the
implant and attachment
position.
Sore spots
 It has been observed and reported that patients who
are xerostomic and/or prone to soft-tissue sore spots
are more comfortable with a bar, since the denture can
be entirely bar supported without impinging on tissue
surfaces. When using individual attachments, the
denture is supported by the tissue bearing surfaces and
compressive forces are present allowing soreness in the
sensitive patient.
Effect of bone quality

 In general, poor bone quality and bone volume, short implant length, and
poor initial stability are factors associated with the lower success rate for
implants in the maxilla compared with the mandible.
 because of the poor bone quality, splinting of implants in the maxilla using a
rigid bar connector has been suggested to reduce unfavorable loading.
 Different retention systems for implant-supported overdentures have been
presented in the literature. Whereas unsplinted systems, such as various
types of ball attachments, have been frequently used in the mandible,
prefabricated bar systems in combination with clips for denture retention
seem to be the most preferred concept in the maxilla.

Christin Widbom 2005


Oral hygiene
Patients with bars who exhibit poor oral
hygiene are prone to mucosal hyperplasia
underneath the bar and inflammation of
the soft tissue around the implants.
Wide Gap: There is 2mm or more
between the bottom of the bar and the
soft tissue. This distance allows easy
passage of saliva and food particles as
well as cleaning tools. Hygiene
maintenance in this situation is very easy.
Economics
(financial effect)
The cost of fabrication of the bar attachments in contrast
to stud abutments will be much higher in most instances.In today’s
economy, many times this may dictate the patient’s decision
process. However, dedicated patients can be upgraded to bars if
their financial situation improves over time. The author provides
the optimal treatment recommendations and the option of
upgrading in the future in detail in written form. However, in all
cases, the interim or chosen treatment restoration must follow
recognized guidelines conducive to the health and welfare of all
patients. Treatment options should never solely be based on
finances.
Interocclusal space
Factors such as interocclusal rest space, phonetics, and aesthetics must also be
considered when defining available restorative space.
A reported minimum space requirement for implant-suported overdentures
with Locator attachments is 8.5 mm of vertical space and 9 mm of horizontal
space.
A separate report on maxillary implant overdentures suggested that a minimum
of 13 to 14 mm of vertical space is required for bar supported overdentures,
and 10 to 12 mm for overdentures supported by other individual attachments.
There are various techniques for evaluating restorative space in edentulous
patients. These procedures should be implemented prior to implant placement,
when treatment options are being considered.
Different attachment with different
vertical heights
 Barattachment require at
least 12mm from the mucosa
to the occlusal plane for
mandibular implant
overdenture
High vertical dimension due to
bar construction without
proper diagnosis to the
available inter arch space.
Aesthetic space
This is the space between the ridge crest and the
corresponding lips at repose(rest). Removable
restorations supported by individual attachments will
require less aesthetic space than those supported by a
bar. The aesthetic space can be measured at the initial
visit of the patient using the lip ruler (Nobilium [CMP
Industries]) . The lip ruler can be utilized to determine
the vertical distance between the ridge crests to the
corresponding lip at repose. This vertical distance
allows the dentist to determine the space allowed for
the prosthesis (implant stud attachments, bars or fixed
restorations). On average, to make an aesthetic and
functional restoration, the prosthetic teeth should not
extend 2 to 3.0 mm occlusal to this vertical distance.
In the mandibular arch, this generally results in the
incisal edges of the anterior teeth being positioned
vertically 2 to 3.0 mm above the lower lip at repose.
Ease of fabrication/repair

Ease of fabrication/repair: Removable restorations


supported by a bar are more challenging to
fabricate and repair than removable restorations
supported by individual stud attachments
Opposing arch
It is necessary to identify the opposing arch in the decision making process.
For example, if a patient is treatment planned to receive a complete maxillary
denture and an implant-supported mandibular overdenture, it would be advised
to treatment plan the mandibular implant overdenture with individual stud
attachments.
A common complaint reported by dentists, in this treatment scenario of a bar-
retained mandibular overdenture opposing a complete denture, is that patients
will eventually complain that their maxillary prosthesis feels loose in
comparison to their previous maxillary denture.
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