|Year : 2016 | Volume
| Issue : 3 | Page : 139-146
Comparative evaluation of two different implant lengths for implant-assisted complete mandibular overdenture
Mohamed G Elkafrawy, Fadel A Abd Elfatah, Ften A Abu Talep
Prosthodontics Department, Faculty of Dentistry, Tanta University, Tanta, Egypt
|Date of Submission||25-Mar-2016|
|Date of Acceptance||27-Mar-2016|
|Date of Web Publication||29-Sep-2016|
Mohamed G Elkafrawy
Prosthodontics Department, Faculty of Dentistry, Tanta University, Tanta
Source of Support: None, Conflict of Interest: None
Purpose: To compare clinically and radiographically between two different implant lengths for implant-assisted complete mandibular overdenture.
Patients and methods: Twenty completely edentulous male patients with age range 55–65 years old were equally divided into two groups, for group I a maxillary complete denture and a mandibular implant-assisted complete overdenture were constructed for each patient using two implants with 3.6-mm diameter and 10-mm length with O-ring attachments were placed at the canine regions of the mandibular alveolar ridge while for group II a maxillary complete denture and a mandibular implant-assisted complete overdenture were constructed for each patient using two implants with 3.6-mm diameter and 12-mm length with O-ring attachments and placed at the canine regions of the mandibular alveolar ridge. Each patient was evaluated clinically as regards to patient satisfaction, gingival recession, probing depth, and stability test by using Osstell ISQ and radiographically by panoramic evaluation at denture insertion then after 3, 6, and 12 months. Data were collected and statistically analyzed using the unpaired t-test between the two groups and paired t-test within the same group.
Results: There was no statistical significance difference between the two groups as regards to clinical and radiographic evaluation; on the other hand, there was significant difference within the same group.
Conclusion: Two dental implants with length 10 mm are sufficient to assist complete mandibular overdenture with opposing conventional maxillary complete denture and there was no significance difference in implant stability between 10 and 12 mm dental implant length by using Osstell ISQ. According to the clinical results, based on the clinical parameters used in this study, the findings revealed healthy peri-implant conditions throughout the study period in both groups, with no significant difference between the two groups.
Keywords: gingival recession and pocket depth, implant overdenture, O-ring attachment, patient satisfaction, stability test (Osstell ISQ)
|How to cite this article:|
Elkafrawy MG, Abd Elfatah FA, Abu Talep FA. Comparative evaluation of two different implant lengths for implant-assisted complete mandibular overdenture. Tanta Dent J 2016;13:139-46
|How to cite this URL:|
Elkafrawy MG, Abd Elfatah FA, Abu Talep FA. Comparative evaluation of two different implant lengths for implant-assisted complete mandibular overdenture. Tanta Dent J [serial online] 2016 [cited 2022 Jan 17];13:139-46. Available from: http://www.tmj.eg.net/text.asp?2016/13/3/139/191432
| Introduction|| |
Problems associated with complete dentures are apparent to every dentist. One of those problems which are the most important is resorption of the alveolar ridge and atrophy of the denture supporting areas leading to ill-fitting denture, lack of stability, and impaired masticatory efficiency. These routinely practice problems forced dentists to try different methods of surgical interference in attempt to solve these problems, starting by vestibuloplasty, ridge augmentation, and finally implantation . The mandibular implant-assisted overdenture is a treatment that has been proposed for edentulous patients as an alternative to removable or implant supported fixed full prostheses .
Immediate loading protocol provides patients with immediate function, improved esthetics, and consequently patient satisfaction following implant placement . With the trend of shortening treatment time and reducing patient discomfort, flapless implant surgery has emerged as an alternate approach .
Several methods have been used in clinical practice to determine implant stability, the most accurate of which has been found resonance frequency analysis (RFA). The only commercially available device based on RFA is Osstell, later modified to Osstell Mentor . Panoramic radiography is a widely used technique because it has the advantage of providing, in a single film, the image of both jaws, with a relatively low radiation dose, in a short period of time, and at lower cost than other sophisticated techniques . So, the aim of this study is to compare clinically and radiographically between two different implant lengths for implant-assisted complete mandibular overdenture.
| Patients and Methods|| |
This study was carried out on 20 completely edentulous male patients selected from Outpatient's Clinic of Prosthodontics Department, Faculty of Dentistry, Tanta University, with age ranging from 55 to 65 years old. All Patients were informed about the steps of this research and signed a written consent according to the committee of ethics approved by Faculty of Dentistry, Tanta University. They should be in good general health and free from any relevant systemic diseases that might have an effect on bone resorption and healing, they should have enough interarch space with class I angle classification. Patients should have good oral hygiene with positive mental attitude. The bone height and width is accepted for the selected implant length and diameter at the prospective implant site according to the ridge mapping process . Patients must not have para functional habits and must not be heavy smoking.
Patients were equally divided into two groups according to varying implant length. Group I: for each patient, a maxillary complete denture and a mandibular implant-assisted complete overdenture were constructed using two implants with 3.6-mm diameter and 10-mm length with O-ring attachments were placed at the canine regions of the mandibular alveolar ridge. Group II: for each patient, a maxillary complete denture and a mandibular implant-assisted complete overdenture were constructed using two implants with 3.6-mm diameter and 12-mm length with O-ring attachments were placed at the canine regions of the mandibular alveolar ridge.
| Preprosthetic Procedures|| |
Clinical examination for the upper and lower ridges was done, then diagnostic casts were made for each patient to study the case, conventional denture was constructed, ridge mapping was done to check the width of the ridge  and surgical guide was fabricated by duplicating the lower conventional complete denture using transparent acrylic resin.
The implant selection
Dentium two-piece (ball type) dental implant (Dentium Implant System; Dentium, Seoul, Korea) was used in this study with diameter of 3.6 mm and length of 10 or 12 mm according to the patient group and a metal housing with rubber O-ring.
The surgical procedures
Two Dentium ball type implants were placed in the mandibular intraforaminal region using the following steps:
Marking of the drilling sites
Using a skin marker or indelible pencil to determine the drilling positions of the implants. The area was palpated, only one perforation pilot drill passing through the surgical guide was used for preparation and no flaps were raised.
Removal of the implant
The implant was removed from its vial using the implant driver. The implant was rotated clockwise for approximately three revolutions or until the implant driver can no longer rotate the implant. Complete the implant placement with the driver and ratchet ([Figure. 1]).
A transferable mark is placed on top of each ball-top and then the denture was seated in the patient's mouth to determine where the denture needs to be relieved ([Figure. 2] and [Figure 3]), holes were made in the denture at the premarked locations by using a laboratory bur then the metal housing abutments were placed on the implants making sure that they were securely seated then try in the denture for full seating.
Pick-up of the housing
The relieved areas of the denture base were filled with self-cure acrylic resin and the denture was placed over the housings. The patient was instructed to close gently on the denture to confirm correct seating until the acrylic was set. The denture was removed and the security of the housing inside the denture was assessed. Any excess was removed and the denture was trimmed and polished ([Figure. 4]). Each patient was instructed how to insert and remove his denture. The patient was then scheduled for clinical and radiographic follow-up.
Each case was evaluated clinically and radiographically at denture insertion, 3, 6, and 12 months after insertion.
Each patient was evaluated clinically regarding patient satisfaction. Every patient was asked to answer a printed questionnaire concerning to the completed procedures and his satisfaction toward the procedures done .
- The cost of the treatment was reasonable.
- I feel comfortable when I chew on my implant prosthesis.
- I am pleased with the esthetic results.
- I can chew on my prosthesis very well.
- I have not feel uncomfortable because of food packing during chewing.
- I can speak well with my prosthesis.
- I have not been to the clinic because the prosthesis had come loose and I feel secure that my implant prosthesis will stay in place while eating and speaking.
- I am satisfied with my implant prosthesis.
Gingival recession: the gingival recession was measured as the distance from the top of the abutment to the gingival margin . The pocket depth: pocket depth measurements were carried out using a plastic periodontal probe . And finally stability test by using Osstell ISQ (Osstell Mentor, Gothenburg, Sweden) . Smart peg was inserted inside the fixture and firmly screwed into it. The probe of Osstell was directed toward the smart peg without touching it (3 mm away from it) in two directions, buccolingual and mesiodistal ([Figure. 5]). The average of two readings was calculated. An increase in ISQ value during long-term examination implies that the implant became more stable . Reports indicate that ISQ values are proportional to the extent of bone formation . Reading above 50 ISQ indicate stable implants ([Figure. 6]).
Digital panoramic X-ray film was taken for each patient after insertion, 3, 6, and 12 months after insertion. By using a software called Sidexis, the marginal bone loss was calculated by measuring distance between the apex of the implant screw and the most coronal points of the bone attachment. This was measured mesially and distally to each implant . The average was calculated and considered as the amount of marginal bone height surrounding the implant ([Figure. 7]) and by subtraction from the original bone length, the real bone loss was obtained.
The collected data was organized, tabulated, and statistically analyzed using statistical package for the social sciences (SPSS; SPSS Inc., Chicago, Illinois, USA) software. For quantitative variables, the range, mean and SD were calculated. The difference between groups was statistically analyzed using the unpaired Student's t-test. The difference between means within the same group in relation to different periods of follow-up as compared with baselines was done using the paired t-test.
| Results|| |
Regarding patient satisfaction
There was no significant difference in patient satisfaction between group I and group II (P > 0.05) as shown in [Table 1].
As regard gingival recession
There was no significant difference between the two groups (P > 0.05). During all periods of follow-up as shown in [Table 2].
|Table 2: Comparison of gingival recession between the two groups at different follow-up periods|
Click here to view
While for the pocket depth
There was no significant difference between the two groups (P > 0.05). During all follow-up periods as shown in [Table 3].
|Table 3: Comparison of pocket depth between the two groups at different follow-up periods|
Click here to view
As regard stability test (Osstell ISQ)
There was no significant difference between the two groups (P > 0.05). During all follow-up periods as shown in [Table 4].
|Table 4: Comparison of implant stability between the two groups at different follow-up periods|
Click here to view
Radiographic evaluation (marginal bone loss)
There was no significant difference between the two groups (P > 0.05) during all follow-up periods as shown in [Table 5].
|Table 5: Comparison of marginal bone loss between the two groups at different follow-up periods|
Click here to view
| Discussion|| |
Male patients were selected in this study so that the measurements for amount of bone loss would not be contributed to any influential feminine related factor and to exclude the adverse effect of the post menopause on osseointegration rather than the questionable bone density in females ,. Twenty male patients were selected with their age ranging from 55 to 65 years as selection of patients with the same age eliminate its effect on biting force and bone metabolism ,.
The patient selection process excluded the patients with uncontrolled diabetes mellitus history due to the interference with osseointegration with dental implant . Smokers were excluded because smoking has a role in reducing oxygen in bone cells which reduce the chance of bone formation causing peri-implantitis, deep mucosal pockets around dental implants, increased bleeding index, and increased resorption of peri-implant bone are documented local results of smoking .
All patients included in the study have sufficient interarch space, more than 8 mm between soft tissue of the maxillomandibular arches, this height space needed to set denture teeth without modification, and provide room for attachments, space for soft liners, and adequate bulk of acrylic resin above metal denture base . Patients were selected with no bad habits as bruxism, clenching or taping which are the most common cause of implant bone loss or lack of rigid fixation during the first year after implant treatment . The height, width, and contour of the ridge was visually assessed and clinically palpated, the presence of depressions are usually readily detected. Ridge mapping was done as it gives a better indication of the bone profile than simple palpation .
A panoramic radiograph was done to assess whether or not the patient has sufficient residual bone available for implant placement, detect any bony abnormalities or pathology that may interfere with implant placement and visualize the approximation to important anatomical landmarks .
In this study an acrylic complete denture was fabricated for each patient using the conventional standardized technique. Semianatomic teeth were selected and arranged according to lingualized occlusion. Lingualized occlusion provides a useful combination of several occlusal concepts ,. The canine area was the site of implantation after complete confirmation with radiograph to ensure the sufficient bone length for implant. The location of the site of implant insertion was determined by implant placement stent. The endosteal root form threaded implant was selected to increase primary stability of implant fixture .
Two dental implants with ball attachments are usually sufficient in facilitating proper implant supported overdenture functionally . The ball attachment is less sensitive technique, less costly, and makes peri-implant hygiene easier for older patients. In addition, it can be used with an existing conventional denture. The ball attachments provide greater stability and more even distribution of load . The resilient O-ring attachment was chosen as it appears to transfer stress in a more favorable manner, being a shock absorber, pressure and torque reducer .
Dental implants with 3.6-mm diameter was used to be suitable to the bone width as it is critical that there must be at least 1 mm of buccal or lingual bone beyond the implant periphery to minimize the occurrence of a dehiscence or fenestration . Dental implants with 10 mm length were used for group I as clinical success of implants 10 mm or shorter was comparable with that of implants greater than 10 mm in length . And short dental implants may support most prosthetic restorations quite adequately . Dental implants with 12 mm length was used for group II as there is no statistically significant difference in survival between short (≤8 or < 10 mm) and conventional (≥10 mm) rough-surface implants placed in totally or partially edentulous patients .
In this study, two fixtures were implanted in the mandibular intraforaminal area, the bone in this area is dense osseous and free from any significant anatomical structures . Implants placed with the flapless technique have been successful in both partially and completely edentulous alveolar ridges, when the patient presents with adequate bone and keratinized tissue ,,.
The screw implant design develops higher mechanical retention, higher primary stability as well as good force distribution ,.
Immediate loading has gained popularity due to less tissue trauma, reduced overall treatment time, decreased patient's anxiety and discomfort, high patient acceptance and better function and esthetics . Oral hygiene instructions were given to all patients early in their treatment and reinforced during the subsequent appointments so as to decrease the possibility of plaque accumulation and tissue inflammation around the implants . The patients were followed up for 1 year, as the maximum bone changes occur mostly during the first year after loading .
Evaluation of the tissue health of both implants was carried out using clinical parameters including patient satisfaction, gingival recession, pocket depth, and implant stability. They were selected as they have shown to be the most definitive criteria to determine the status of peri-implant tissue health . RFA is the basis for the Osstell unit. In RFA, implants were forced to oscillate and the frequency at which they oscillate at maximum amplitude was registered as their resonance frequency ,. Panoramic radiographs are used to measure crestal bone level, defined as the distance from the top of the implant to the position of the bone on the implant surface, because it has been suggested as an indicator for implant success .
As regard clinical evaluation
After overdenture insertion, all patients were satisfied with their prosthesis till the end of follow-up period. There was no significant difference in patient satisfaction between group I and group II. These results were in agreement with Albrektsson et al.  that all the implants were characterized by absence of persistent or irreversible signs and symptoms such as pain, infection, neuropathy, paresthesia, or violation of the mandibular canal.
Slight increase in the gingival recession was found in both groups during the follow-up period. This may be due to irritation of the gingival margin, which was aggravated by movement of the denture base during function which may exert pumping action of the gingival margin. This was decreased after relief in acrylic resin of the overdenture over the inflamed gingival tissue . Gingival recession may occur when oral hygiene procedures are discontinued, so plaque accumulation leads to gingivitis in 10–21 days or peri-implant mucositis ,. There was no significant difference in the gingival recession between the two groups. These results are in agreement with Khamis et al. and El-Attar and Garrana .
There was insignificant increase of the probing depth around the implants in both groups through the follow-up period. These results are in agreement with Mensor who found an increase in probing depth in 1 year follow-up period. On the other hand, International Team of Implantology classified failing implants as having 6 mm or greater probing depths and presentation of suppuration and pain as peri-implant bone sites appeared to have deeper pocket depths, were symptomatic .
In this study, all the Osstell ISQ values are more than 50 and there was insignificant increase in implant stability between the two groups, this was in agreement with Atsumi and colleagues ,. Also there was significant increase of implant stability within the same group; this indicates successful osseointegration . In other words, implant stability is a critical factor that determines the long-term success of dental implants ,.
Regarding to radiographic evaluation, the difference between the bone losses around the implant fixtures in the two groups was not statistically significant during the follow-up periods. In this study, crestal bone resorption related to implant abutments in both groups after 1 year follow-up did not exceed 1 mm, hence all implants were considered successful, this was in agreement with Albrektsson et al. . Also, this was in agreement with Adell et al. , who found that crestal bone loss around dental implants, typically seen during the first year of implant function was about 1.2 mm up to the end of the first year of function, and a mean loss of 0.1 mm annually thereafter. From the study of Albrektsson et al. , success criteria for osseointegrated dental implants were proposed to include a level of marginal bone loss of up to 1.5 mm in the first year, and then no more than 0.2 mm annually . On the other hand, bone loss observed within the first year of function is about 1.5–2.0 mm ,,.
| Conclusion|| |
Two immediately loaded dental implants with length 10 mm are sufficient to assist complete mandibular overdenture with opposing conventional maxillary complete denture and there was no significance difference between 10 and 12 mm dental implant length. Osstell ISQ is very effective noninvasive test in evaluating dental implant stability.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]