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.
• Restricted Vertical 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.
• Universal Resilient Attachments:
These attachments provide vertical,
hinge, translation, and rotation
movements.
• This type of attachment offers 95
percent load relief to the supporting
implants.
• Ex: Magnetic attachments are the
best example of the
universal resilient attachments.
 Classification of Prosthesis Movement (PM):

• PM-0: no movement and requires implant support similar to a fixed

prosthesis.
• PM-2: A prosthesis with a hinge motion is PM-2, and
• PM-3:A prosthesis with an apical and hinge motion .
• PM-4: allows movement in four directions,
• PM-6: has ranges of PM in all directions.
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

• Implant position: 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.
• Implant position 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.
• If the 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.
• As a general rule the bar should be
perpendicular to the line that bisects
the angle formed by the two
posterior mandibular arch segments.
 Available bone volume
In the case of multiple extractions, this often
means a 4-mm vertical bone loss within
the first 6 months.
• This bone loss continues over
the next 25 years, with the mandible
experiencing a fourfold greater vertical bone
loss than the maxilla.
• As the bony ridge resorbs in height, the
muscle attachments become level with the
edentulous ridge which affect the retantion,
stability and support of the denture.
Classification of completely edentulous patient
1-Kent and the Louisiana Dental School classification
• for ridge augmentation with HA and a conventional denture. This classification treats
all regions of an edentulous arch in a similar fashion and does not address regional
variation.
2-the classification of Lekholm and Zarb
• only addressed the anterior maxilla and mandible, always resulted in
root form implants without regard for bone grafting,
• used a fixed prosthesis regardless of biomechanical considerations.
3- classification of Misch and Judy
• Depend on the previous MISCH classification of bone volume.
• communication of not only the volume of bone but also its location.
• It organizes the most common implant options of prosthodontic support for
completely edentulous patients.
The classification divide the mandible into
three segments
 Type 1:

In a type 1 edentulous arch, the division of bone

is similar in all three anatomical segments.
• Therefore, four different categories of type 1 edentulous
arches are present.
• div. A,: Abundant bone Mand. 5-9 Implants ,, Max: 7-10
implants
• div B, : narrow diameter implants with increase the
number of implants
• div C-w,: width deficiency
• div C-h,: Height deficiency
• div D.: severely atrophied ridge
 Type 2:

• In a type 2 completely edentulous arch, the

posterior sections of bone are similar but differ
from the anterior segment.
• These edentulous ridges are described in the
completely edentulous classification with two
division letters following type 2, with the anterior
segment being listed first because it often
determines the overall treatment plan.
• Ex: type 2, division A, B arch
 Type 3:
• In type 3 edentulous arches, the posterior
sections of the maxilla or mandible differ
from each other.
• This condition is less common than the other
two types and is found more frequently in
the maxilla than the mandible.
• The anterior bone volume is listed first and
then the right posterior followed by the left
posterior segment.
• Ex: Type 3 division A, B, D arch
 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 to increase stability
• 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.
 Shape of the arch
• Affects the 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.
• Shape of 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
• Bar attachment 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 (lab experience)

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 conventional 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.