Duplicating the Implant O-ring Abutment Retainer for Using on Tooth Copy in Mandibular Implant-tooth Partial Overdenture: Radiographic Evaluations
Aisha Zakaria Hashem Mustafa
In rehabilitation of partially edentulous cases with removable prosthesis it is desirable to equalize the retention bilaterally, to allow the removable prosthesis to function accurately without affecting the health of remaining structure. This can be achieved when few remaining teeth is present unilaterally by strategic multiplication of abutment using dental implant. This study describes a treatment approach for oral rehabilitation of patients with remaining teeth on one posterior quarter of the mandibular arch. In mandibular arch one implant was inserted in the canine region to be used in conjunction with natural canine as abutments for removable partial overdenture. For every patient a temporary mandibular RPD were constructed and relined with soft liner to be used during the osseointegration period. After this duplication of implant O-ring ball abutment to be used with metal coping and dowel on the canine then construction of the final RPD and clinical pick up of the O-ring attachments. Marginal bone loss and mobility test were assessed immediately after insertion of the prosthesis and after 3 years of functioning loading of the implant. Regular follow-up visits, through 3 years, revealed that the periodontal and peri-implant conditions were stable; there were no intrusion or mobility problems of the teeth and very minor changes in the bone levels of the natural teeth and implants were measured on radiographs using Corel Draw No.11 software. Duplication of implant O-ring ball abutment to be used with metal coping and dowel on the canine abutment allow even distribution of the load on the implant and canine tooth leading to statistically no significant difference between the bone loss of the implant and tooth or between the mesial and distal sides of the implant or canine tooth.
Received: July 18, 2012;
Accepted: August 31, 2012;
Published: November 08, 2012
In rehabilitation of partially edentulous cases with removable prosthesis,
the retention and stability of RPDs is dependent on the state of the alveolar
ridge and available teeth to be clasped. Poor RPD retention and stability occurs
with highly resorbed ridges and an inadequate number of suitable abutment teeth.
RPDs with distal extensions, Kennedy Class I and II, generally have less stability
than those of bounded saddle (Brudvik, 1999; Car
and Brown, 2011).
Removable Partial Denture (RPD) is a common treatment option available for
the restoration of a long-span or distal extension edentulous area where in
a fixed partial denture is not indicated. The type of retainer used with the
RPD affect the remaining structures (Itoh et al.,
2008; Costa et al., 2009). Equalization of
the retainer bilaterally can be obtained through tilting the cast laterally
to establish reasonable uniformity of retention which is necessary for successful
removable partial denture (Car and Brown, 2011).
Clasping anterior teeth creates several problems. First, unacceptable aesthetic
results can occur when anterior teeth are clasped and are visible during smiling
of the patient. Second, anterior teeth provide inadequate retention for distal
extension RPDs (Zitzmann, 2005). Third, anterior teeth
can be lost or the clasp can be fractured due to excessive loading (Car
and Brown, 2011).
The use of dental implants to aid in support and retention of partial overdentures
is one prosthetic option primarily described in the literature in the form of
various clinical reports and researches (Keltjens et
al., 1993; Giffin, 1996; Uludag
and Celik, 2006; Chang et al., 2007; Chikunov
et al., 2008; Ohkubo et al., 2008;
Grossmann et al., 2009; Vogel,
The quantity of prosthesis retention and stability depend on attachment type,
design, alignment and position (Walton, 1999; Williams
et al., 2001). Different methods have been expected for connecting
overdentures to underlying implants. Independent connections to each implant
abutment or constant bar retainers are the most frequent approaches (Mijiritsky
and Karas, 2004; Uludag and Celik, 2006; Schneid
and Mattie, 2008).
Root overdenture philosophy postulated a transfer of occlusal forces to the
alveolar bone through the periodontal ligament of the retained roots. Proprioceptive
feedback from the periodontal ligament was envisaged to act to prevent occlusal
overload and consequently avoid residual ridge resorption adjacent to the roots
and the rest of the residual ridge because of excessive forces (Crum
and Loiselle, 1972; Crum and Rooney, 1978; Renner
et al., 1984; Carlsson, 2004). They also
provided improved function compared to conventional complete dentures such as
improved biting force and chewing efficiency and even phonetics (Rissin
et al., 1978; Ghi and McGivney, 1979; Renner
et al., 1984). The stability of tooth supported overdentures greater
than the non tooth supported overdentures (Murakami et
When the remaining teeth present in unilateral (in one side of the arch) the
lifting movement of long saddle of the removable partial denture well be difficult
to be counteracted by conventional clasping. A properly positioned implant can
permit the fabrication of a retentive and stable RPD that was not possible before
and improve the masticatory function (Van Kampen et al.,
2004). In addition, the use of an overdenture abutment eliminates the need
for an unaesthetic clasping system (Mijiritsky, 2007).
A strategically placed dental implant can establish an improved removable partial
denture by significantly reducing the effort arm and improving the fulcrum line
position (Mijiritsky, 2007; Car and
Implant assisted removable partial denture increase support, retention and
stability in order to limit the dentures movement, leading to reduction
of the tension forces generated on the abutment teeth and supporting structure,
favoring the maintenance of the supporting structure. Also, it provides patients
functional and psychological comfort (Shahmiri and Atieh,
2010; De Silva et al., 2011). This well enhances
the patient quality of life from both nutritional and social point of view (Spitzl
et al., 2012).
This study evaluate radiographically cases treated with Removable Partial Overdentures (RPOD) supported by both implants and natural teeth. Three years after functional loading, the clinical and radiographic changes for implants and natural teeth were reported.
MATERIALS AND METHODS
Ten patients come to clinic of removable prosthodontic, Mansoura University.
The patients have remaining mandibular canine and posterior teeth in one side
of the arch (Fig. 1a).
|| The case before treatment (a) Intraoral view and (b) Panoramic
||(a) Maxillary zinc-oxide eugenol impression, (b) Plastic dowel
in prepared canine and (c) Mandibular pick-up impression (with plastic dowel
and implant analog)
They are free of any systemic disease that affect implant placement. For every
patient, a panoramic radiograph were done (Fig. 1b) then strategic
implant was inserted opposite to mandibular canine, in canine region for construction
of mandibular implant tooth retained partial overdenture.
Step by step technique for every patient:
||After maxillary and mandibular impressions were made, root
canal treatments were done in the mandibular canine and preparation was
done for dowel.
||After construction of custom trays, secondary impressions were done and
the casts were poured. Then jaw relation was done using record blocks.
||After try in, the temporary denture were constructed (mandibular acrylic
removable partial denture) opposing either maxillary single or overdenture.
Then it was inserted intraoral. It was used as surgical stent during implant
||After one week of insertion of the one piece implant (13 mm height- 3.9
mm width) in right mandibular canine region, the temporary mandibular partial
denture were relived in implant region and relined with soft liner to be
used in the osseointegration phase of the implant.
||After 4 months, the final prosthesis was constructed. Secondary maxillary
impression were done using zinc oxide eugenol impression material (Fig.
2a) and poured in dental stone. Mandibular pick-up impression of the
implant and plastic post was done (Fig. 2b, c).
||For duplication of the O-ring abutment a rubber base heavy type were used
to take impression of abutment analog on the cast. Wire was used to give
air way escape during pouring of the wax (Fig. 3a). Then
the rubber base sectioned with scalpel passing through the implant ball
and reposition the two part to each other and blue inlay wax used to pour
this mould (Fig. 3b).
||After pouring the wax ball abutment, it was fixed to waxed up copy of
the tooth then the copy with waxed ball abutment casted (Fig.
||For constructing record base for jaw relation a wax relief made on two
ball abutments. Then a jaw relation recorded.
||After setting, try-in was done. In the lab, the two ball abutments were
blocked out during the denture processing.
||After correction of occlusal error related to laboratory processing of
acrylic resin, widen the opining at the implant and tooth O-ring attachment
to allow escape of excess acrylic resin during clinical pick up of O-ring
||Spacers were used during clinical pick-up of the O-ring attachment. They
were made from tin foil (Fig. 5a).
||The prosthesis extraoral and intraoral (Fig. 5b, c).
||Three years radiographic and clinical evaluations (mobility test) were
done to monitor the cases. And to measure the alveolar bone level around
the mandibular canine and the crestal bone level around the implant.
||No need for relining was found.
Radiographic measurement of the marginal bone level: Corel Draw No.11
software was used to measure the bone level of the canine and implant (Fig.
||(a) Rubber base impression of ball abutment and (b) The rubber
mould after pouring ball abutment that duplicated implant ball
||(a) The copy with duplicated ball, (b) O-ring positioned on
implant and tooth copy with duplicated ball on the cast and (c) Intraoral
||(a) The O-ring and spacer with prepared denture, (b) The final
prosthesis after clinical pick-up of O-ring attachment and (c) Intraoral
|| Digital panoramic X-ray after 3 years with CorelDraw 11 software
To eliminate the radiographic magnification error of panoramic radiograph,
the scale of measurement was adjusted according to the actual length of the
implant. A standardized digital panoramic radiograph was taken for each patient
at denture insertion (functioning loading) and after 3 year to measure the alveolar
bone level around the mandibular canine and the crestal bone level around the
implant abutments at mesial and distal sides. The mean marginal bone was calculated
The mean marginal bone level on the implant = (AA'+BB')/2 and
(AC+BD)/2 for canine
Mobility index: Implant and canine mobility was assessed manually by
the handles of two dental mirrors put on either sides of implant and canine
abutments buccolingually as recommended by Gatti et al.
Statistical analysis: A Students t-test was used for the statistical
analysis of Tooth alveolar bone change after three years of denture insertion
in comparison to the implant crestal bone change. Also it used to compare the
mesial with the distal bone change of the implant and tooth. The p-value was
set to 0.05 to detect the level of significance. Analysis was performed using
SAS software, version 9 (SAS, 2004).
Table 1 shows the mean implant crestal bone loss and the mean tooth alveolar bone loss after 3 years of functional loading. It was 0.494±0.110 for the implant and 0.594±0.186 for the tooth. There was no statistically significant difference between the mean bone loss of the implant and tooth in the study period (t =1.46 and p = 0.16). The mean mesial implant crestal bone loss and the mean mesial tooth alveolar bone loss after 3 years of functional loading. It was 0.512±0.149 for the implant and 0.588±0.191 for the tooth. There was no statistically significant difference between the mesial bone loss of the implant and tooth in the study period (t = 0.99 and p = 0.3337). The mean distal implant crestal bone loss and the mean distal tooth alveolar bone loss after 3 years of functional loading. It was 0.476±0.092 for the implant and 0.6±0.206 for the tooth. There was no statistically significant difference between the distal bone loss of the implant and tooth in the study period (t = 1.74 and p = 0.986).
Table 2 shows that there was no statistically significant difference between the mean bone loss of the implant at the mesial and at the distal side (t = 0.65 and p = 0.5231). Also there was no statistically significant difference between the mean bone loss of the tooth at the mesial and at the distal side (t = 0.14 and p = 0.8939).
Mobility index: Mobility index showed zero score during the period of study for both the implant and canine tooth.
|| The mean implant crestal bone loss and the mean tooth alveolar
bone loss after 3 years of functional loading
|Value are significant if p<0.05
|| The t-test for comparing the implant bone loss at mesial
and distal sides and also tooth bone loss at mesial and distal sides
|Value are significant if p<0.05
The primary goal of removable prosthodontic is not only to restore what is
missing but also to preserve what is remain. Tooth overdenture considered a
treatment option to preserve the remaining tissue (Ghi and
McGivney, 1979; Spitzl et al., 2012). Traditional
overdentures depend on the position of the remaining teeth. When these teeth
distributed in a manner that compromise the treatment, implants may be placed
in planned, specific sites for overdenture to improve the prosthetic rehabilitation
Limited numbers of implants are used to improve the RPD support, enhance retention
and stability, preserve the residual ridge underneath the denture base, reduce
the stress applied on the abutment teeth, eliminate the need for unesthetic
clasp assemblies and modify unfavorable arch configurations (Zitzmann,
2005; Mijiritsky, 2007). Mijiritsky
et al. (2005) point out that: implant-retained RPD, provides distinct
biomechanical advantage in improving the fulcrum line position, as well as offering
superior retention. Also, Phoenix et al. (2008)
added that: implant-assisted RPD increase patient comfort and satisfaction.
One of the appropriate positions for the implants in RPD was on the canine positions
to provide vertical support and retention.
In this study to offer patients affordable prostheses with better retention,
the removable partial denture was retained by a combination of implants and
natural teeth by using implant-tooth overdenture. This prosthesis will combine
the advantage of implant and the advantage of proprioception of tooth overdenture.
To equalize the retention bilaterally an implant inserted in the canine region
at the same distance from the midline as the distance to the canine used as
overdenture abutment. Also the O-ring abutment of the implant was duplicated
for the canine overdenture. Torabinejad and Goodacre (2006)
stated that, teeth that have undergone endodontic treatment well be functional
over long time as the dental implant. So that, tooth and dental implant was
functioning as overdenture abutments for removable partial denture. Also in
this study mandibular temporary removable partial denture was constructed and
lined with soft liner to be wearied during the Osseo integration period. According
to Mutluay and Ruyter (2005) and Chestnut
and Gibson (2007). The relived temporary prosthesis, relined with soft liner,
to be used during the osseointegration periods, to prevent any trauma to the
implant from the denture or hard foods and to minimize direct pressure to the
Due to the difference in resiliency between both, tooth and implant, resilient
attachments (O-ring) were used in this study. Srinivasan
and Padmanabhan (2008) mentioned that: because of the difference between
structures of implants and natural teeth, their mobility also differs. Attempts
to incorporate both implants and natural teeth with rigid connection in prostheses
should not be made. Intrusion of natural tooth may be caused by reasons other
than excessive forces.
To optimize stress distribution and minimize forces to the implant and tooth
in overdenture, the resilient ball/O-ring attachment may provide adequate retention
while possibly reducing stress on the implant bodies (Kenney
and Richards, 1998; Misch, 2005). Also resilient attachments
allowed for an increase of the mastication load transiting through denture bearing
surface (Daas et al., 2008).
The patient examined regularly to reduce the risk of experiencing caries and
periodontal disease of tooth overdenture (Ettinger and Qian,
2004). If the combination of implants and natural teeth is necessary, overloading
of implants and intrusion of natural teeth should be monitored carefully (Chang
et al., 2007). Three years follow up reveled that there was no intrusion
or mobility of the teeth, very minor changes in the bone levels of the natural
teeth (0.594±0.186) or implants (0.494±0.110) measured on radiographs.
Albrektsson et al. (1986) and Laurell
and Lundgren (2011) suggested that: one of the parameters of implant success
was the amount of Marginal Bone Loss (MBL). During the first year after abutment
connection, 1 mm of MBL is allowed followed by 0.2 mm per year.
This study revealed that there was no statistically significant difference between the mean implant and tooth bone loss in the study period (t = 1.46 and p = 0.16). There was no statistically significant difference between the mesial bone loss of the implant and tooth in the study period (t = 0.99 and p = 0.3337). There was no statistically significant difference between the distal bone loss of the implant and tooth in the study period (t = 1.74 and p = 0.986). This may be attributed to the use of resilient O-ring attachment on the implant and duplication of this attachment to be used on the natural tooth (canine).
O-ring attachment is the most flexible of all the resilient attachment and
is therefore of greatest use in situations where implant support is minimal
(Brudvik, 1999). The O-ring performs the function of retention
and enabling universal free rotation. When the vertical loading is applied to
the O-ring attachment, the load can be separated from the implant by the clearance,
black plastic ring in its interior and soft tissue. This gives the buffer effect
under vertical loading. The non-direct loading produces very low stresses on
the implant which can be neglected (Tseng and Jiang, 2004).
The O-ring may allow motion in six different directions depending on the resilient
depression of the O-rings and the presence of spacer over the post head (Misch,
2005). During the clinical pick up of O-ring attachment on either the implant
or the canine a spacer was used to preserve the resiliency of the attachment
during functional loading. Misch (2008) stated that: if
a superstructure contacts the implant, the range of motion, of implant resilient
There was no statistically significant difference between the mean bone loss
of the implant at the mesial and at the distal side (t = 0.65 and p = 0.5231).
Also there was no statistically significant difference between the mean bone
loss of the tooth at the mesial and at the distal side (t = 0.14 and p = 0.8939).
Phoenix et al. (2008) stated that: in implant assisted
RPD when resilient attachment are used occlusal load are transmitted to implant
and ridge. This may be one of the causes that prevent the implant overloading
in this study.
This study found that in the case of implant- tooth partial overdenture opposed by maxillary single or overdenture on two canine, most supportive forces were born by the mucosa, whereas the implant and tooth of overdenture provided mainly for retention and duplication of the resilient O-ring attachment were done for equalization of retention bilaterally, so that overloading was less likely to occur to either the natural tooth or implant. Patient satisfaction with this prosthesis appears in term of function and aesthetics.
The use of strategically placed implant in the canine region to assist a claspless removable partial denture considered a good treatment option for rehabilitation of the patient with unilaterally present few remaining teeth. The benefits gain from this implant was elimination of the lifting movement of the long free end saddle that crosses the midline. This prosthesis will combine the advantage of implant and the advantage of proprioception of tooth overdenture. Duplicating the implant O-ring attachment to be used with metal coping and dowel on the natural tooth (canine) was important to equalize the retention bilateral and allow even distribution of functional load without overloading or compromising both, the implant and natural tooth. Patient satisfaction with implant-tooth removable partial overdenture appears in term of function and aesthetics.
I am thankful to Professor. Dr. Ahmed Habib who make the surgery of implant insertion.
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