Comparative study of two types of attachments for mandibular implant-retained single complete overdenture

Maha M Abo Shady; Ibrahim R Eltorky; Zeinb M Abd Eaal

doi:10.4103/1687-8574.191434

ORIGINAL ARTICLE

Year : 2016 | Volume : 13 | Issue : 3 | Page : 157-161

Comparative study of two types of attachments for mandibular implant-retained single complete overdenture

Maha M Abo Shady, Ibrahim R Eltorky, Zeinb M Abd Eaal
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

Correspondence Address:
Maha M Abo Shady
Prosthodontics Department, Faculty of Dentistry, Tanta University, Tanta
Egypt

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/1687-8574.191434

Abstract

Objective: The aim of this work is to compare between balls versus locator attachment systems for mandibular implant-retained single complete overdenture, as regards to clinical and radiographic evaluation.
Materials and methods: Fourteen patients had lower edentulous jaw opposing almost natural dentition in the upper jaw was selected with their age ranging from 55 to 65 years. The patients were divided into two groups. Group I received single mandibular complete overdenture constructed over two implants, retained by ball attachments. Group II received single mandibular complete overdenture constructed over two implants, retained by locator attachments. Evaluation was carried out at regular appointments up to 1 year from time of loading of the implants. Each patient was presented to a questionnaire regarding retention, stability, comfort, chewing ability, esthetics, and speech. Clinically, the patients were evaluated as regards to gingival recession, pocket depth and implant stability. Radiographically, the patients were examined to determine the amount of marginal bone loss.
Results: All fixtures were successfully osseointegrated all over the follow-up period. The results showed no significant difference in patient satisfaction between both groups (P = 0.827). Slight increase in the gingival recession was found in both groups throughout the time of observations, with no significant difference between both groups (P = 0.166). There was insignificant increased of the probing depth around the implants in both groups (P = 0.600). There was insignificant increase in implant stability in both groups throughout the follow-up periods (P = 0.839). No significant differences in bone loss were observed between both groups throughout the follow-up periods (P = 0.524 and <0.05).
Conclusion: Two implants were sufficient to retain a single mandibular complete overdenture opposing maxillary natural dentition without hazardous effect on the implants.

Keywords: attachments, complete overdenture, implants

How to cite this article:
Abo Shady MM, Eltorky IR, Abd Eaal ZM. Comparative study of two types of attachments for mandibular implant-retained single complete overdenture. Tanta Dent J 2016;13:157-61

How to cite this URL:
Abo Shady MM, Eltorky IR, Abd Eaal ZM. Comparative study of two types of attachments for mandibular implant-retained single complete overdenture. Tanta Dent J [serial online] 2016 [cited 2023 May 28];13:157-61. Available from: http://www.tmj.eg.net/text.asp?2016/13/3/157/191434

Introduction

Dental restoration of the edentulous mandible opposing natural maxillary teeth is often associated with a number of problems, particularly in the occlusion, and an accelerated rate of alveolar bone resorption in the edentulous mandible resulting from occlusal load ^[1]. Treatment of the edentulous mandible using a conventional complete removable denture is a common clinical undertaking, yet at times it can be a difficult and challenging intervention ^[2]. Patients who wear conventional dentures often complain about the instability of the prosthesis. Denture instability leads to a feeling of insecurity, inefficient mastication, and overall dissatisfaction of the prosthesis ^[3]. Dental implants have become a predictable treatment option for restoring missing teeth with adequate function and esthetics and without affecting adjacent hard and/or soft tissue structures. The use of dental implants in oral rehabilitation has currently been increasing since clinical studies with dental implant treatment have revealed successful outcomes ^[4]. The advent of osseointegrated implants provides a treatment modality that allows the remaining maxillary teeth to be kept and maintains the level of alveolar bone in the edentulous mandible ^[5]. Clinical studies show greater implant survival in the mandible than in the upper maxilla, due to the area's characteristics. This survival is limited by bone quality – that is, bone density. Bone density and implant stability are important factors for implant osseointegration, which has been widely demonstrated by several authors ^[6]. Dental implant stability is a measure of the anchorage quality of an implant in the alveolar bone and is considered to be the consequential parameter in implant dentistry. Implant stability can occur at two different stages: primary and secondary ^[7]. Primary stability of an implant mostly comes from mechanical engagement with cortical bone. It thus prevents the formation of a connective tissue layer between implant and bone, consequently ensuring bone healing. Therefore, primary stability of an implant is a prerequisite to undisturbed peri-implant bone healing. Secondary stability, on the other hand, offers biological stability through bone regeneration and remodeling. Secondary stability, which is seen after the healing period, is primary stability with a further gain in stability because of bone formation around the implant ^[8]. A number of methods have been introduced to assess implant stability using both invasive and noninvasive ways; clinical settings require nondestructive techniques ^[9]. In recent years, Ostell device for resonance frequency analysis has been advocated to provide an objective measurement of implant primary stability and to monitor implant stability over the healing period and in the long term in a nondestructive manner ^[10],[11]. Several attachment systems are available for two implant-retained mandibular overdentures. The attachment mechanism in the implant overdenture provides enhanced retention and stability compared with the conventional denture. The support is gained from both the intraoral tissues and dental implants. The connection should minimize denture movement without increasing the stress on the implants ^[12],[13]. With new types of connectors regularly being introduced to the market, the efficiency of ball attachments is well-documented. In 2001, Zest Anchors introduced Locator attachment, which provides an improved design that combines the best features of the ball, ERA (Sterngold), and cap attachment types ^[14],[15]. Although locator attachments appear to function reasonably well, there is a lack of clinical studies on the Locator system ^[16]. Therefore, the present study was done to compare between ball versus locator attachment systems for mandibular implant-retained single complete overdenture, as regards to clinical and radiographic evaluation.

Patients and Methods

Patient selection

Fourteen patients had lower edentulous jaw opposing almost natural dentition in the upper jaw were selected from outpatients' clinic of Prosthodontics Department, Faculty of Dentistry, Tanta University, for this study, with their age ranging from 55 to 65 years ([Figure. 1]). The patients were divided into two groups, group I and group II. Each group comprised seven patients. A single mandibular complete overdenture constructed over two implants was made for each patient, retained by ball attachments in case of group I and locator attachments in case of group II.

Figure 1: Patient had lower edentulous jaw opposing natural dentition in the upper jaw.

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Patient preparation

Thorough preoperative clinical and radiographic evaluation was carried out for assessment the quantity and morphology of the bone that would host the implants ([Figure. 2]).

Figure 2: Topography of the bony ridge on the cut surface.

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Preprosthetic treatment procedures

Periodontal maintenance principles were carried out for the upper natural teeth. Occlusal adjustment of the maxillary natural teeth was usually required before the construction of a single mandibular complete denture ^[17], according to Yurkstas technique.

Prosthetic treatment procedures

An acrylic mandibular complete denture was constructed for each patient. The finished mandibular denture was duplicated to produce a clear surgical template ([Figure. 3]). The surgical template was modified for surgery by creating window-like openings in the areas of proposed implant sites to aid implant placement.

Figure 3: Clear acrylic surgical stent duplicated from the mandibular complete acrylic denture.

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Surgical procedures

Two dental implants with a diameter of 3.8 mm and length of 12 mm were placed into the canine region of the mandibular alveolar ridge using flapless implant surgery.

Pick-up of the housing (chair-side pick-up procedures)

After 3 months, each patient was presented for denture insertion. The cover screws were removed with screw driver. The ball abutments were positioned and tightened with the abutment driver to the implant fixtures for group I, while the locator abutments were positioned and tightened with the locator abutment driver (part of locator core tool) for group II ([Figure 4]a and [Figure 4]b).

Figure 4: (a, b) Ball and Locator attachments screwed into the implants inside the patients mouth.

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The overdenture was then inserted in the patient's mouth. Postinsertion instructions were given to the patient regarding its maintenance, nutrition and hygiene.

Implant evaluation

Each patient was evaluated clinically and radiographically at the time of denture insertion, 6 and 12 months after insertion as follows:

Clinical evaluation

Each patient was asked to fill out a satisfaction questionnaire regarding aspects of ^[18]:

I feel comfortable when I chew on my implant prosthesis.
I am pleased with the esthetic results.
I feel secure that my implant prosthesis will stay in place while eating and speaking.
I haven't felt uncomfortable because of food packing during chewing.
I can speak well with my denture.
I haven't been to the clinic because the prosthesis had come loose.
I am satisfied with my implant prosthesis.
The cost of the treatment was reasonable.

Responses to statements were given on the Likert response scale ^[19]:

5, strongly agree.
4, agree.
3, neither agree nor disagree.
2, disagree.
1, strongly disagree for each of these parameters.

The gingival recession was measured as the distance from the top of the abutment to the gingival margin at four sides: mesial, distal, labial, and lingual ^[20]. The pocket depth was measured on four surfaces of the implants using a periodontal probe, which was inserted parallel to the long axis of the implant ^[20]. Magnetic technology resonance frequency analyzer (Osstell Mentor) was used in this study to measure implant stability ([Figure 5]a and [Figure 5]b) ^[21].

Figure 5: (a, b) Stability test using Osstell (implant stability quotient).

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Radiographic evaluation

Digital panoramic radiographic film was used to measure the marginal bone loss ^[22].

Mesial and distal marginal bone levels of all implants were determined at base line and recall evaluations.

Statistical analysis

All the data from clinical and radiographic evaluations were organized, tabulated, and statically analyzed using statistical package for the social sciences (SPSS, version 12; SPSS Inc., Chicago, Illinois, USA) software. Significance was adopted at P value less than 0.05 for interpretation of results of tests of significance ^[23].

Results

Clinical parameters

All fixtures were successfully osseointegrated all over the follow-up period. There was no mobility, no pain and radiographically, the fixtures were surrounded by normal bone tissue in intimate contact with their surfaces. The results of the present study showed no significant difference in patient satisfaction and preference between the two types of attachments. No significant differences between the two types of attachments were observed with regard to gingival recession, pocket depth, and implant stability throughout the observation period (t-test, P > 0.05) ([Table 1]).

Table 1: Results from clinical measurements

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Radiographic parameter

The marginal bone loss as a function of time is shown in [Table 2]. No significant differences in bone loss were observed between both groups (t-test, P > 0.05).

Table 2: Results from radiographic measurements

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Discussion

A number of practical problems may be encountered when a dentist attempts to make a mandibular complete denture in the presence of natural maxillary teeth. The position of the maxillary teeth will influence the positions in which it is possible to set the mandibular teeth ^[24]. In each case, the prosthetic problems relating to the presence of the natural teeth have carried forward to the implant-retained prosthesis ^[5]. In this study two implants were placed in the mandibular intraforaminal region. Clinical reports had indicated a higher survival rate for dental implants in the mandible, particularly in the anterior region, which had been associated with better volume and density of the bone ^[4],[25]. Increasing the numbers of implants not appeared critical in reducing the stress in an atrophic mandible, as regarded by Meijer et al. ^[26], nor were significant differences noted in stress distribution in the bone containing two or four implants. The results of the present study showed no significant difference in patient satisfaction and preference between the two types of attachments. Slight increase in the gingival recession was found in both groups throughout the time of observations which may be due to irritation of the gingival margin induced by movement of the denture base during function which may exert pumping action on the gingival margin. Such recession was decreased after relief of acrylic resin of the overdenture over the inflamed gingival tissue. There was no significant difference in the gingival recession between both groups. In this study, there was insignificant increased of the probing depth around the implants in both groups throughout the follow-up periods. Still the maximum pocket depth 2.57 mm in group I and 2.60 mm in group II in the end of follow-up period, which falls within the physiologic range. These might be due to maintenance of oral hygiene. Resonance frequency analysis was performed using Ostell Mentor to measure implant stability.

Bischof et al. ^[11] found that, implant stability is anticipated to decrease during the early weeks of healing, this is followed by an increase in stability. This is related to the biologic reaction of the bone to surgical trauma. During the initial bone remodeling phase, bone and necrotic material are resorbed by osteoclastic activity, which is reflected by a reduction in the implant stability quotient value. This process is followed by new bone apposition initiated by osteoblastic activity – that is, adaptive bone remodeling around the implant ^[11]. In this study, there was insignificant increase in implant stability in both groups throughout the follow-up periods. The marginal bone around the implant crestal region was usually a significant indicator of implant health. The level of the crestal bone may be measured from the crestal position of the implant at the initial implant surgery. Dental implants were subjected to initial remodeling around the coronal part of the implant (1.5 mm during the first year and 0.1 mm per year thereafter) ^[5]. In this study, the maximum bone loss was 1.02 mm in group I and 1.06 mm in group II in the end of follow-up period, which falls within the physiologic range. Hence, all implants were considered successful. No significant differences in bone loss were observed between both groups in this study throughout the follow-up periods.

Conclusion

Two implants were sufficient to retain a single mandibular complete overdenture opposing maxillary natural dentition without hazardous effect on the implants. 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 them. Successful osseointegration of the implants, with no significant difference between the two groups. Longer time was needed for this research to give better results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Clark RK, Comfort MB. The edentulous mandible opposed by natural maxillary teeth: a report of six cases treated with implant-retained prostheses. Quintessence Int 1994; 25:15–22. [PUBMED]
2.	Feine JS, Carlsson GE, Awad MA, Chehade A, Duncan WJ, Gizani S, et al. The McGill consensus statement on overdentures. Mandibular two-implant overdentures as first choice standard of care for edentulous patients. Montreal, Quebec, May 24–25, 2002. Int J Oral Maxillofac Implants 2002; 17:601–602.
3.	Kimoto K, Garrett NR. Effect of mandibular ridge height on masticatory performance with mandibular conventional and implant-assisted overdentures. Int J Oral Maxillofac Implants 2003; 18:523–530.
4.	Turkyilmaz I, Aksoy U, McGlumphy EA. Two alternative surgical techniques for enhancing primary implant stability in the posterior maxilla: a clinical study including bone density, insertion torque, and resonance frequency analysis data. Clin Implant Dent Relat Res 2008; 10:231–237.
5.	Adell R, Lekholm U, Rockler B, Branemark PI. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1981; 10:387–416.
6.	Molly L. Bone density and primary stability in implant therapy. Clin Oral Implants Res 2006; 17(Suppl 2):124–135.
7.	Atsumi M, Park SH, Wang HL. Methods used to assess implant stability: current status. Int J Oral Maxillofac Implants 2007; 22:743–754.
8.	O'Sullivan D, Sennerby L, Jagger D, Meredith N. A comparison of two methods of enhancing implant primary stability. Clin Implant Dent Relat Res 2004; 6:48–57.
9.	Meredith N. Assessment of implant stability as a prognostic determinant. Int J Prosthodont 1998; 11:491–501.
10.	Rasmusson L, Kahnberg KE, Tan A. Effects of implant design and surface on bone regeneration and implant stability: an experimental study in the dog mandible. Clin Implant Dent Relat Res 2001; 3:2–8.
11.	Bischof M, Nedir R, Szmukler-Moncler S, Bernard JP, Samson J. Implant stability measurement of delayed and immediately loaded implants during healing. Clin Oral Implants Res 2004; 15:529–539.
12.	Donatsky O. Osseointegrated dental implants with ball attachments supporting overdentures in patients with mandibular alveolar ridge atrophy. Int J Oral Maxillofac Implants 1993; 8:162–166.
13.	Takanashi Y, Penrod JR, Lund JP, Feine JS. A cost comparison of mandibular two-implant overdenture and conventional denture treatment. Int J Prosthodont 2004; 17:181–186.
14.	Schneider AL, Kurtzman GM. Bar overdentures utilizing the Locator attachment. Gen Dent 2001; 49:210–214.
15.	Büttel AE, Bühler NM, Marinello CP. Locator or ball attachment: a guide for clinical decision making. Schweiz Monatsschr Zahnmed 2009; 119:901–918.
16.	Kleis WK, Kämmerer PW, Hartmann S, Al-Nawas B, Wagner W. A comparison of three different attachment systems for mandibular two-implant overdentures: one-year report. Clin Implant Dent Relat Res 2010; 12:209–218.
17.	Nallaswamy D, Ramaingagam K, Bhatt V. Textbook of prosthodontics. New Delhi: Jaypee Brother Medical Publisher; 2003. 250–255.
18.	Heo YY, Heo SJ, Chang MW, Park JM. The patients' satisfaction following implant treatment. J Korean Acad Prosthodont 2008; 46:569–576.
19.	Nemoto T, Beglar D. Likert-Scale Questionnaires. JALT 2014; 1–8.
20.	Akagawa Y, Matsumoto T, Hashimoto M, Tsuru H. Clinical evaluation of the gingiva around single-crystal sapphire endosseous implant after experimental ligature-induced plaque accumulation in monkeys. J Prosthet Dent 1992; 68:111–115.
21.	Sim CP, Lang NP. Factors influencing resonance frequency analysis assessed by Osstell™ Mentor during implant tissue integration: instrument positioning, bone structure, implant length. Clin Oral Implants Res 2010; 21:598–604.
22.	Park JB. The evaluation of digital panoramic radiographs taken for implant dentistry in the daily practice. Med Oral Patol Oral Cir Bucal 2010; 15:e663–e666.
23.	Petrie A, Sabin C. Medical statistics at a glance. John Wiley & Sons; 2013.
24.	Ellinger CW, Rayson JH, Henderson D. Single complete dentures. J Prosthet Dent 1971; 26:4–10.
25.	Drage NA, Palmer RM, Blake G, Wilson R, Crane F, Fogelman I. A comparison of bone mineral density in the spine, hip and jaws of edentulous subjects. Clin Oral Implants Res 2007; 18:496–500.
26.	Meijer HJ, Starmans FJ, Steen WH, Bosman F. Location of implants in the interforaminal region of the mandible and the consequences for the design of the superstructure. J Oral Rehabil 1994; 21:47–56.

Figures

[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

Tables

[Table 1], [Table 2]

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