Full Arch Overdenture or Free-Standing Implants?

Dr. M asks:
I am doing my first full arch case. It is an edentulous maxilla with excellent bone volume and density opposing a mandibular removable partial denture.

My surgeon recommends that he place 6 dental implants and that I do a full arch bar overdenture. He says the bone will eventually fail around single free-standing dental implants in the maxilla. However, the attachment manufacturer says that all I need is 4 free-standing dental implants placed in the second premolar and canine areas. My lab says either design will work and they are doing both kinds of designs for their doctors. Money is not an object. What have you been doing in dental implant cases like this?

42 thoughts on “Full Arch Overdenture or Free-Standing Implants?

  1. Your surgeon is misinformed. The literature is pretty clear on this: there is no difference in terms of outcome between splinted and free standing implants supporting an overdenture.
    Free standing implants with locator attachments simplify the restorative procedures, require the least amount of inter-occlusal space and minimize costs.
    Splinting is necessary only when implants are poorly aligned (> 40 degrees).

  2. Dear Dr. Fabrizio
    will you please give me more info on peer review studies which claims “there is no difference in outcomes between splinted and free standing implants in MAXILLARY over denture?
    Thanks in advance.

  3. The more implants you have, the better. 6 is better than 4, and 8 better than 6. Common sense would suggest that implants splinted together have a mechanical advantage over free-standing implants.

  4. in reply to Dr. Yoshi satish:
    Click Here for the study.

    I also recently attended a lecture by David Felton, editor of the journal of prosthetic dentistry where he illustrated the point.

  5. The second study is on the maxilla.

    MATERIAL AND METHODS: A photoelastic model of an edentulous maxilla was fabricated with four 3.75 x 13-mm 3i

  6. IF you have the ample bone you claim and money is not an issue then a fixed case on 8 or nine implants SPLINTED would be a beautiful restoration. If however there is a discrepancy with the soft tissue height or other hard or soft tissue concerns the bar overdenture could work beautifully. I would spend the time and money to fabricate a bar to splint these implants then place any retentive elements you want on the bar.The locator is a real winner.

  7. Your lab and the manufacturer and Dr. Fabrizio are wrong. The surgeon is correct. You cannot have free standing implants in the maxilla unless you have a denture that has a palatal strap instead of a horseshoe design. The palatal strap provides cross-arch stabilization of the prostheses. A horseshoe shaped denture will experience flexing causing torsion on the implants. Dr. Rob Schroering of Kentucky noticed that these free standing implants were fine for thr first 6- 7 years. After that the bone loss and subsequent failures occurred.
    If you want a long standing prostheses then go with the six implatns splinted with the bar.
    I don’t have literature to back this up, only what I hear is going on in the real world

  8. I fully agree with Dr Michael Weinberg-a splinted implants solution, no matter how- with a bar or a conventional horseshoe full upper bridge over 6 or 8 implants is safer than free standing implants under an overdenture for the following reasons:
    1.The splinting helps redistributing the load over the implants- in a way similar like in natural teeth
    2.Splinting eliminates or drastically reduces the risk of the resulting lateral forces (translation), during mastication, known to be one of the main reasons for implant falure. As we all know-implants can withstand better vertical load than horisontal ones. If you have the chance, take a look at “Risk factors in implant dentistry”-by Franck Renouard and Bo Rangert. A very well written book, which although published in 1999 is still actual. Most of these problems and solutions are perfectly explained from biological and biomechanical point of view.
    Good luck

  9. I always believed what Dr. wienberg says.I looked at links provided by dr. fabrizio and those articles do not give clear indication about NO difference in long lasting outcome between splinted and free standing implants in MAXILLARY ARCH.

  10. Always remember, the Maxilla is a different animal than the Mandible. Generally poorer bone, less favorable force vectors, more critical esthetics and shape for comfort to the tongue and other soft tissues. Mandible: poor for dentures, great for implant assisted overdentures. Maxila: generally good for dentures, generally problematic for implant assisted overdentures. Fully implant supported overdentures are different and are generally highly acceptable for the maxilla( e.g. spark erosion) Good luck Dr. M!

  11. Fully edentulous maxillas are the most difficult restoration to do. if you are new to the implant arena, don’t try it. If you must, do a diagnostic waxup first to make sure you have enough room for a bar/clip (my favorite is the spark erosion type) prosthesis. Ideally at least 9-12mm between the ridge crest and the opposing dentition. If there less space (Class II skeletal, hypertrophic maxilla) then a ceramometal prosthesis is indicated. The ceramometal style is great because it is fixed, but from a design point of view it is tough because the implants need to be aligned with the proposed tooth positions. An overdenture is less taxing since the implants can be placed less precisely. My view on a Maxilla is similar to the other blogs: splint the implants!! Also, since the maxilla is usually a good denture foundation, only do implants if the patient wants the palate opened. If this is the case, a horseshoe design works, and requires at least 6 implants and a bar. Don’t ever compromise your treatment on the maxilla. Free standing implants can come back to bite you (has for me). To me, maxillas are all (6 implants, bar/clip, open palate or 6-8 implants and C and B)or nothing (a denture); no in between.

    Good luck, and spend lots of time on your planning!

  12. to reply to dr Meese,
    -IS your patient has any sign of bruxism
    -second, in my experience i beleive that splinted implants specially in maxilla is always mandatory for long term sucess for the implants and prosthesis

  13. Experience is an amazing thing and reading the literature and learning from others is a whole lot better.
    The answer is simple and clear. The maxilla has different bone than the mandible. The mandible flexs and the maxilla does not.
    The stress placed on the maxillary pros is different and the stress load on the implants are different.
    In my weak minded, humble, and limited experence, I will never and that is never use a free standing implant to support even a tissue borne denture in the maxilla because it will fail as far as retaining the implants over a long period.
    But you may ask, will you do an Imtec mini implant in the maxilla. Yes I will, once I have explained to the patient about 2000 times that in my office that they are transitional.
    In the Max, in my office a bar is the only option.
    ASK ME HOW I KNOW……

  14. Not once have we considered the force factors associated with a successful outcome. Why so many “standards” knowing the individuality that exists among patients? We know the etiology of early crestal loss so what is the big deal? What are the force factors? Masticatory musculature dynamics? Opposing? Lever arms generated? Parafunction? Prosthesis height? Bone quality? Bone quantity? Implant number and size? As a rule, unsplinting maxillary implants (D4 – D2,3 bone) will not distribute peak forces to the superstructure but rather to idividual implants and the pathologic overload window in D3 bone is quite low on the stress / strain curve which leads to inevitable resorption. If it opposing a lower complete denture? Go ahead without splinting and you won’t have to worry about excess forces from a soft tissue borne complete lower. Natural teeth? You better use six and cross arch stabilization or you will quickly remember that your implants don’t have a PDL and are in much softer maxillary bone.

    Implants aren’t that big of a mystery anymore luckily. Your clenchers are the ones that will sneak up on you and wish you had overengineered the foundation. :(

    Good discussion.

    Jackson

  15. 4-implants strategically placed in the maxilla will work if you have full palatal coverage and resilient attachments.

  16. I have had posts implanted in the roots of two upper broken teeth and an overdenture button to fasten into a partial. Both failed in the root of the original teeth, perhaps because I am a grinder. If I were to have mini-implants would the same fate likely befall me?

  17. Dr. Mosery is accurate in his evaluation. There are reams of literature confirming splinting of maxillary implants when the force factors or bone conditions are less than ideal.

    Please email me above if you want the citations.

    Jackson

  18. Nice dicussion. Being new at this in placing implants, I have successfully placed six maxillary implants and it was suggested by my lab that I do two bars rather than one as he thinks a bar in the anterior area can preclude ideal tooth set up. I was going to use two Lew passive attachments.

    What are your opionions on one bar connecting all six vs two bars connecting 3 each?

    I did a spark erosion case twenty years ago that was successful, but cost can be an issue.

  19. Do denture setup first, do try in and then design bar.If set up try in is ok then decide whether anterior bar portion is coming in the way or not.
    you should not sacrifice proper esthetics and function for the sake of cross arch stabilization.

  20. Bar overdentures are a retarded design, I recommend placing 8 implants and doing a fixed bridge if bone volume is adequate and there’s no need for much lip support, or just go for 4 big implants and ball and socket overdenture.

  21. Dr. Ron Hass/A prosthodontist/others – who is doing your spark erosion and how much is lab charging you per unit – can you share?
    Also, with laser welding, 3-D milling – are you still EDMing your parts?
    Thanks in advance,
    LCM

  22. Take a look at Misch’s Dental Implant Prosthetics. He recommends a minimum of 4 implants ONLY splinted with a bar. Single implants, per Misch, will fail. If money is not an object, a minimum of 7 is recommended. It is a great book–check it out. Where is everyone else getting their info?

  23. I have been placing and restoring implants for 17 years as a surgical prosthodontist. I have placed over 500 mini implants. The failure rate is higher for mini implants in soft bone period. Soft bone requires delayed loading. The photo elastic studies that have been done over the years show that an unsplinted implant with a ball and o-ring retainer will have less stress that the bar over dentures on the implants. The bar overdenture are more difficult for most patients to maintain and usually require a metal substructure to prevent breakage of the denture.

    Use of a Locator abutment or similar semi rigid connector will provide more load on the implants. More load requires more implants to distribute the forces. It is always better to over engineer the support than to underengineer it and have it fail.

  24. Anyone used the ILS (Implant Location System)of Tactile Technologies ?? I have heard a very impressive lecture in the EAO meeting in Zurich by Prof Haim Tal from Tel Aviv , but he is one of the developers so I am looking for non-biassed information.

  25. LCM- I mentioned Spark Erosion as an acceptable Maxillary Implant Removable solution but I don’t recommend them to pts. The main justification and motivation for implants for me and my patients is to avoid a removable prosthesis. Spark Erosion prostheses were very helpful when enough implants were available but in non-ideal positions. My main choices in the edentulous Maxilla are fixed hybrids, PFMs, or conventional CDs. Only in selected instances will an implant overdenture be a choice. My findings are that pts do not like when their implant overdentures move during function. If they don’t move,then the implants are receiving forces similar to a fixed case and are at risk if few in number. Only pts who hate the palatal coverage are good candidates in my mind. Everyone else is a risky candidate as we do not know what level of stability they will be satisfied with. Hope this is helpful. -Ron

  26. Tx planning for such a restoration should follow some steps and an unbiased view of the literature. what’s on the opposing arch? what’s the interarch distance? General rule mandible should have a stronger enginearing than mandible.
    interarch distance:
    9-12mm c and b fixed full arch implant restorations
    12-16mm fixed full arch implant restorations with gingival tinted porcelain
    16mm or more overdenture on splinted or unsplinted implants. in this situation consider the opposing arch:
    natural dentition or RPD 6 or more splinted implants with group function or anterior guidance
    complete denture 4 unsplinted implants with balanced occlusion
    fixed implant supported restoration 6 or more splinted implants with group function or anterior guidance. Always add 2 implants more than those on the mandible
    removable implant tissue supported overdenture 4 unsplinted implants with group function
    And a comment on previous posts:
    HORSESHOE FRAMEWORK HAS LESS FLEXURE THAN A PALATAL STRAP.

  27. I like to start from a prosthodontic view. Ask your technician what is possible to do after you make a set-up. What your technician can make in your case will predict what your implant planning will be and how many! Bridge, a rigid -overdenture (splinting the implants too) or an acrylic-overdenture. Then look to the loading factors from your patient point of view. The more load the more implants and the same for the type of bone. Bruxism is I think the most worst case scenario. I refer them to more experience docters, since I am a novice in this area.

  28. Where did the 8 implant fixed detachable standard come from? I do not recall reading it anywhere and would be interested in the citing in the literature. Thanks

  29. I am not a doctor or a dentist, but I do have an implant supported denture. I have two free standing posts in my jaw about opposite of what I would call the eye teeth. I have had the implants for about 4 years and have not had a problem with them. However, the dentures (both upper and lower) while fitting quite well and being comfortable. Have had problem with teeth cracking and popping out. My general dentist who did these cannot figure it out. I had a consultation with a prostodontists and he says the reason they break and pop out is because the flex and need metal reinforcements. He wants 6000 dollars to make a new upper and lower metal reinforced set. I would love to hear your comments and am sorry if it is inappropriate to post this here

  30. Dr. Ron Hass/A prosthodontist,
    Thanks for the response. Did EDM for a while and my thesis was on this. Seemed to have hear less and less about it nowadays.
    Quick note about FD’s query – I do not think anyone should be discussing fees in such forums, and without seeing the actual case, I do not think anyone of us would be confident enough to try and diagnose a problem, let alone make suggestion as to how to address it. The theory proposed seems very plausible but no one can tell if it applies to your case. If you are in doubt, you should always feel free to get a second opinion.
    LCM

  31. Even for the experience bruxism remains a horror, even with fixed arches, especially in cases with the lower front in situ. If this is the case: extract them and replace them by a prosthesis on 2 implants only! Cave:The Full arch is a problem for loading with noctural bruxism. Simply, because the lower bar can touch the central part of the fixed arch. Maybe in these cases two single arches in the lateral parts might be better. Another solution might be botox. Has anyone experience with this last solution?

  32. FD, RUN for a second opinion and a different
    lab. I’m not a dentist but experienced the same
    problem when my dentist changed labs. He went
    back to the old lab and I got new teeth free.

  33. just wanted to ask if we do full arch fixed bridge on the foundation of 6 implants instead of bar retained over denture? will it last longer?

  34. In my oppinion, the support of upper lip and the quality and quantity of bone, make the choice. On the other hand, there patients that want overdentures, because it is easier to clean. That´s the only case that I do overdentures. I always go for fixed, screw, total full mouth in the maxilla, with at least 6 implants. Rarely with 8. Overdentures, in my opinion, are very unstable in the long term: patients need new proshtesis in 4 to 5 years, the retention is very stromg in the beggining but poor after 10-12 months. Patients with over dentures can be pain in the ass. another discussion is what type of prosthesis will you do in the maxilla. A classic PFM total bridge screwed without pink ceramic or a metal-acrylic screwed brigde, with or without pink acrylic…..but this is another discussion. In a few words, I always go for fixed screwed full mouth unless patients ask for overdentures. JR

  35. I know I’m getting old and the desert sun has probably cooked what little brain-power I ever had, but experience has shown that most dentists don’t like to do CD’s because they have problems, or more accurately put, their patient have problems because of the way the dentures were constructed. We keep repeating mistakes because that was what we were taught and now we believe using implants will solve all our problems. Anterior hyper-function and laterial forces (bending moment anyone) can’t be eliminated using group function and so-called balanced occlusion. A lot of problems can be eliminated with a different concept of occlusion (linear non-interceptive both anterior and posterior), but we will never be able to satisfy everyone or solve all those bad habits no matter how much money our patients throw at us. Keep in mind that what we as dentists can give our patients will NEVER replace what God gave us in the first place.

  36. nobody talked about the positions of the implants for overdentures,ie in upper jaw overdenture in canine areas are the best but if you want to place four,where would you place them.what about lower jaw.
    thanks in advance

  37. i am new to implant dentistry and one of my case is u cd. pt have 1 root canal treated lt. canine with no mobility till now. he is diabetic with bs level between 140 to 180 since last 6 months. i am planing to give him 3 implants: 1 in rt canine region and 2 in max tuberosity region with a ball and o ring attachments in 3 implants and 1 retained canine.

    suggestions please.

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