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Three Design Concepts of Four-Implant Assisted Mandibular Complete Overdentures: Implant Stability and Marginal Alveolar Bone Loss

Authors:
  • Faculty of Dentistry, Mansoura University, Al Mansourah, Egypt

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Background. The rehabilitation of edentulous patients continues to be a major challenge to dentistry. Treating edentulous mandible with implant-assisted complete overdenture is aimed to reduce pain and discomfort, improve function (retention, stability) and stimulate psychosocial well-being.
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E.D.J. Vol. 59, No. 2 Mohammed M Fouad, et al.
Three Design Concepts of 4-Implants Assisted
Mandibular Complete Overdentures: Implant
Mobility and Marginal Alveolar Bone loss
  -  ./ 0--
*Prosthodontic Department, Faculty of Dentistry, Mansoura University.
** Oral and Maxillofacial Surgery Department, Faculty of Dentistry, Mansoura University.
ABSTRACT:
Background.  ' "  !   ' 6
  +   ' 7 !$
! )      !   " !) " 
8 '+9   !+   7$'
Purpose.  !! "  + 7  !  $  ! "
' ! )  '+ #$!   !
'+   ) ' 
Materials and Methods.  ! " "" #$!$ '
! ) 7 * % ! &   ' #$!$
 ) 7  '+ " + '    ! ,
  ' #$!$ ) 7  '+  '
 ' ! '     !    '
#$!$ ) 7  '+ 7 ' ! 
6 ' %! '+   ) '  7 )
   "   8:9  ; 8<9 < 89 =<> 8?9  "
Results. @!     %! '+  
) '  ) "7 '+ @! & 7 @! ,   
7 ) 1 !  "     %!
'+   ) '  )   !
Conclusions. %  !'    * 8<9 $!$
' ! )  '+  '  ' !
'    '   '   !   +
  ! '+  !) " !$!  )
' 89 5    !  "$!$ )
 '   !  ! " ' !+
 '
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E.D.J. Vol. 59, No. 2 Mohammed M Fouad, et al.
Key words %!  ) ' ! )
' #$%!  ! )  ! )
INTRODUCTION:
!$ 7 "B+ ! !' 7
 + "  +! +  '+ !   '+
"  ' ! 86$/!   :::9
  " ! )  )   !'
  !)  ' '   $  " +  
! 8@"   <>C D6   < <E <
  /$4   <# :::9
 !+  "   ! 7
!$ )     !   " 
!) "  8 '+9    !+  
7$' 8) ::9
  "   ' " !   B "
! !!    "   '"  
! 8(    ::#9  ) "  )
 + '+ 7  !  ! '+   
8<;9 C ! ! !! '+      
"  '         
     "  "   '   
!     !   !!  
7 "   
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E.D.J. Vol. 59, No. 2 Mohammed M Fouad, et al.
  "   7 !  '   
 ' )      B
    '+ 8 /$4   :::9<? 5
 /$4  +  2 ,  " 
 !  ( %! 5 << 8:::9 !! <:>F<
7 5   4 ! G  ,+  4 ! 8:9
& 7 ! ! + '  ) 
 7 ! !    '   
!)  ) "  ! 8A   ::?
 A   ::>9
   '. " !  '
)  !) '+ " "  $'  
   !    '  ! '  
8   <;  76   <9
,    + !' 7  6+ " 
! + + )' 82   ::E9 4
8::;)   '$ )  ' !  
 $+$ "
1+   8:::9    !! '+ 7 ' ! 
'+ !) "  ' ) +  
) $  ' ' ! 7  ! 
! !   " 84 ::;).
5 + !$"'   6 '  ' ! 
 +  7 +   )+ ! " 89 !
3
E.D.J. Vol. 59, No. 2 Mohammed M Fouad, et al.
! % 6 "  + "+ $"   !
!    " <>H 7   "3  7 
 " 6' '    '  ! 6$/
+ 8, ::#9
%  )+ !  /7  ""  " +  
 !   7$' "  !  +  
!  $  ! " ' !
)  '+ #$!   ! '+
  ) ' 
MATERIAL AND METHODS
Patient Selection
<  !  '7 $;: + 7   "
 + + 7 + 7  +    
' ! +  !+  3 
' 7 ""  $  !     7
+  7  '+ '  ! 0+ "
 !+ /        7
3    7 " ' 
+ 7 !)   ! !   +  
" 
Surgical and prosthetic procedures
4  ! 7 !+ '   
!   !    ! 
 ! !  !"'   + ! 7
4
E.D.J. Vol. 59, No. 2 Mohammed M Fouad, et al.
 ' 7   )  ) '  !!
! !  '   )      
 !! !  5 !! 7    
7 "    +     "  
!  7   " )+ ! &" 
 "     + ! 7  J "
 7   ! ! ! 8   "
 9  '     J" ! ! 
&"    " & $  5 
8&59  7 +! "3 8+ 03 K  %! 0L?;
   <<  9 7  +  8
  "   " '  ) 9
   "!    B 8 <9
 <  !  
'   " 

1$ ! ! 7   ) 
!    ! 8 9
E.D.J. Vol. 59, No. 2 Mohammed M Fouad, et al.
  1$ !
!
4'  ' 8+ 0 &' ( 9
7  7   "3 8 ?9
 ? 0 '
 7   "3
7  + !)  !  8& 
M' ::9 '  7 !+ ) " 
 '   ! 7     ) 
   7 7/ " +   '
7 !  '+ '      ' 7 
6
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7 "  &" ?   !     
! '+  ") )  
&    ' #$!$ !
)   !    +  ! 7
+ "   B !*
@! 8&9* % 7   ' #$!$ )
7  '+ "  '   8 #9
 #  ! 
' ) 
'+ "  '  
7
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@! 8,9* % 7   ' #$!$ )
7  '+   6 ' 8%&,9  7 !
 '   8 9
   ! 
' )
 '+  
6 ' 8%&,9  7
!  '
 
@! 89* % 7   ' #$!$ )
7  '+ 7 ' ! %&, 8;9
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 ;  !
 '
)  '+ 7
' ! %&,
% ! &  ,   ' <   7 ! 
   '       8+ , 3
NI  ! 9 7    '    ' 7
"+ )  )"+ B !  )   
! "   !!    7 !" 
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  "  3   +    !  "   +
 8! /$! 9 7 !!   )  " 
   7    !  7 " "
!   ! 7    +  
    "   +   3   + 
7 ) "     "  "  
% ! ,     !$"'  % &6 ,
7      "    8,
::#9  "7* 7 %&, (  3 ' "  
7    7 "3 7    7)
  '7   "  7 ' ' 7
  '  #      %& , 5 
 !!      7 !  %& , 5
7  '7   7 6  %& , "3  7 7
  !    ' 7 %&,   7
 !  +   !! " "   " 
' )  !+.   "7
   ' '+    6 <
+   7 !     7
3 "+ " + 6  ) 7
)   ! 7     ) 
)   
%! '+ 8  1 +9  
) '  8 !!  !9 7 )  
 "   8:9  ; 8<9 < 89 =<> 8?9 
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E.D.J. Vol. 59, No. 2 Mohammed M Fouad, et al.
"
 '+ "   ! 7    '
)   1 + 81C 4 ,
@+9     819   7 
    )    "B+   1 7
    +
5! ) 7   .
!!  $  !  B  !!  " 7
.  ' /  7     8& 4 
;:19  !  7 .  ;::  !
  8!9    "     '7 !
   !    !  7
  "+  !!  " !$! ' )
  !  '    )
I  "  ! 8 E9 7    
7 ! 8 7L >9 1$! 
) '  7   )   . !
 7  ' '+ +  4// 8:<:9   
'7 ! ' ' 8& !9  " '  !
  8, !9   )  ' )    '7
  ' ) 8 !9 O7  !   
! "    . '  8 9  
   $! "  8, 9P   !
!! +   . ' )   8,I(9 
. 80,I(9 '  7   '+ ' 
11
E.D.J. Vol. 59, No. 2 Mohammed M Fouad, et al.
! ' )  <   ? " ' )  :
   . '  7     
  "  "   !    7 '6  
  +
 E     "  ! "
   ' 
Statistical analysis
  ' "  7 )" '+ A)$
4)    7  !  1 ,I( 
0,I( 7 ! '7 !  ! A/$D
 4'B+ !   89 7  " ! 7
! '7 !  ! '7 ""
')  "   !   7  "7
'+ D 3Q  /  " ! '7   
 D+  7   ! '7  
12
E.D.J. Vol. 59, No. 2 Mohammed M Fouad, et al.
! !    ! 4!   7   
  '7 1  ,I(  0,I(   7
+.  4144K"7 ) <E 84144 %    %I
24&9 4  "   7   : "  +
RESULTS:
(" ;: ! !  7 ! ! " 8 
! &     ! 9 " <  + 
;ER    & !    "7 ! )
7 !   " ! 7 )  
 ! 7     ) 7
'  
 !)   " 1 ,I(  0,I(  !
 ' <   ? ! )+  7  + " 
""   1 8' <9 ,I( 8' 9  0,I( 8' ?9
'7  !   ')  8A/$D 
!S:<9 @!     1 ,I(  0,I(
) "7 '+ @! &  @! ,    7 )
8  !T:<  : "   ! !
! )+9
D 3 ! " 1 "  !  ! & 
1 ,I(  0,I( ) "" " + '7
')  8  !S:98  ! )+9
 1   " + 7 )  "   ! &
 ,     !   7 "    
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,I(  0,I(   ! 7 )  "  8D 3Q
 /  !S:9   " )  ' ! 7 "
  " ;  "  8<9   '  7
"7    ? 89
!   ! !   !
1 !  "     1
,I(  0,I(   ! 8 D+  !S:9
 !    ') !   ! ,   
') ! 89 8'#9
1  "  !)  7
,I( 84!   !T::  "" T#;9 
7 0,I( 84!   !T:E  "" T?9
Table 1: Comparison of Periotest values (PTVs) between groups:
6 months after
loading (T1)
12months after
loading (T2)
18 months after
loading (T3)
Anterior
implants
Posterior
implants
Anterior
implants
Posterior
implants
Anterior
implants
Posterior
implants
Group (A)
X±SD -7±1.58 -8±1.58 -9.2±1.48 -8±1.58 -9.8±1.30 -8.6±2.07
M(min:max) -7(-9:-5) -8(-10:-6) -9(-11:-7) -8(-10:-6) -10(-11:-8) -8(-12:-7)
Group (B)
X±SD -7.6±1.14 -8.8±1.30 -10.2±1.92 -8.2±1.48 -10.6±1.51 -9.6±1.51
M (min-max) -8(-9:-6) -9(-10:-7) -11(-12:-7) -8(-10:-6) -10(-13:-9) -9(-12:-8)
Group (C)
X±SD 14±1.94 .80±7.94 13.2±1.92 -.4±8 -1±7.9 13.6±3.5
M (min-max) 15(11-16) -3(-3:15) 13(11-15) -.4(-5:14) -4(-6:13) 14(10:19)
Kruskal-
Wallis test
(p value)
.008 .007 .006 .009 .008 .006
X: mean, SD: Standard Deviation, M: Median, Min: minimum, Max: maximum
Table 2: Comparison of vertical bone loss in mm (VBLO) between
groups:
6 months after 12months after 18 months after loading
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E.D.J. Vol. 59, No. 2 Mohammed M Fouad, et al.
" 7   !   ' ! 
8<<9 !      "   
+  " '  + 7   "+
!W !  '  "   8<;9 " 
!+    "  
3    "
1 7      " :  7
  "  +  !)  !  " !  " 
!     !   7 !! '+
5   A. 8:::9 7    
  '7  ! "  ! "3   
"  "  )  E  "  ' !  &
1   8::?9     ' B
  !     "   
   7 +  7  '+
'  !  7 '   "  "
 D  + 8::#9 !   
 ' !! B+  B+ " '  7  
!  !   !  "     '  '
! +  + '+ "  !  +  B 
  
 !)   " ! 7   
!)  )+ "  " !    
) '+
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  "  +  !$!  '
  @! &  ,   <  " <  "  
  "     ! '+ &   "
,I(  0,I(   ! 7 "   " ;  "
 8<9   '  7 "7  89  8?9.
 + '      "    
!$! '   "  ""  " ! ! 
!)  "   '    !
    7 A   ::?  A  
::> 7    7 ! ! !)
 ) "  !    !
  ' !
%  ! + @! ,    7 %!
'+   ) '  )   ')
  + '   "   '7 
) " ! !   ! ""  "  
'  !) 3   !    
  7    <#      <> @  
:::  5   :: 7 "  ! " +
 !  7  ' 7   ! "  7
!) 3   !      !)
 4   :<: !)  "  ' '7
!      + '   '
  7 ' ! 7   " +
  8'  9    '  
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 ' "   !
(      '   ! " !
   " B "  7  +
 !     '8&  M' ::9
)  @!     !
'+   ) '  )   ')
 !  '    "    7
  "  X )  )  
  7 !   "  !!  
)   80'//   ::?9
!   ! ! "  !  
+ ! !  "    
1 ,I(  0,I(   ! 4+ 5
 7 ::; !   "    !
' "       :: 
   !!    "  '  +   
$"  "   '
CONCLUSIONS:
%  !'    * 8<9 $!$
' ! )  '+  ' 
' ! '    '   ' 
 !   +   ! '+  !)
" !$!  ) ' 89 5  
 !  "$!$ )  ' 
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E.D.J. Vol. 59, No. 2 Mohammed M Fouad, et al.
 !  ! " ' !+
 '
RECOMMENDATION:
  7 ' )  ! '7 
$  !    !) " ' 
) 
BIBLIOGRAPHY:
§&   M' @&* %  + ! 
! * &  )7 "    1 
::C #*#$>
§&   A Y  @7 /* %"  "
   J !   (
3" 4 ::<C *<>
§,' 50 5' @  ( 51 066/ A
, @ ' ) !! '+ 7  "
 ! & !! ) !) + % (
3" 4 <>CE*#?$
§, 5A* + % &6 ,   
 +   ,F:EX::#C #$

§ @* D+ 7    !+[  & 
&  ::# ( C<?8<:9*<#?E$
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§ I* %  " !$"3 '
!* & !! ) <>$ "7$!   +$
!+ ! %!  ::<C <:*?$
§ &*  !  ! 7  
!   ( %!<<C <E*#<
§ D* %! !    "7 '
7 ! "  / %
(J3"  %!<;C <<*><
§5 2 D 7 / 5A , / &* 1! )  
) " ' ! )* 1 %$ 
'+   ! 1  <C E?* ?#$
?;?
§ &  /$4 5 5   
! !  " !$!! '
)* I$   %!   5
::C #* <$<
§+ & 4// &0 5  ) !  
""   !$!  " '$!$
' )* <$+    ! 
+  ( %! 5 :<:C<*#E?F#>:
§  ,     7 "3 ! 
)) ! %!  <?C*<$#
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§  %  A* + "    ,/
 ! %  1 5  ::C * $<
§ 1  1A )   ) I* &
! ) + "  !  ' ! J
1 5) ::C :*?;;
§6$/! & 4 &1 )  , & )Q 0" &
D  A/ D  * ,  7  )
"     J Dent Res. 2000;
E*<<F<#
§@  0" D  !  * %!$
' ) 7  * & !! )
+ " % !  % ( 3" %! :::C <*
?>?$?>>
§@  ,   D & ) ( 51
  !  "      " !$
' )  ! 7 )+ '
'  1  <;CE*<#$:#
§@ 1  A, I @5 &!!  " "  +
 ! +*  )7 "    1 
> 8::<9 F<<
§@" A 06F0  0  = 01
O  "! '  
!X!P' 8<>9?* ?EF#<
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§0      = +  8::?9  '  "
!$   " !   " "
 &  ?<* >$>??
§0'// & D 5  4 I* %  
! I   I) ::? ;?$>:= <<> !!
?$<>
§
!*XX777 X3!![!T"'L''L
+ )  $<$:<
§0  0 5  Y 0     5,
       "   ?$+ "7$!
   + " ) !! '+ ,/
! % ( 3" %! <C<:*??$#
§% /7  0   D 5   % ) +
" ' !$ )*  "  "
     "   !  " 
%  1  8<;9 ?#F?
§% * "  " "   !$! '  ( %!
5 ::;C <E* >$<>
§    0  & $+ !! )  
"7$! !  ) !! '+ 
! % ( 3" %! <;C<<*<$>
§A A   0 @  4 0 07  0 = 1/  4
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8::?9 ""  " ' !  !! 
 "  '  "  %
 " 1   5) + ?* <EE$<>?
§A  ,/  ,/ & = Q0 , 5
 !    3  ! 7
!$!! ' )*  >$+
! ) +  %  " 1 
::?C <;* F?::
§A @ A"   1  %!
!! 3+ )  7  '*
3+  ) 3+ !  !&
! ) + % ( 3" %! ::>C?*?#?$
?
§I 1 4 / 5A ,  I$
 " +  '$   14
 7 " < + " " *   ! "
$+$ ! % 1  5) 
<>C<>*$;?
§I'  @    ' 5 4 1 = )
4'  8::E9 & ! " 67  
B+  " '    7 $' 
! !+  $  !  %  "
(  3"  %! * ##;$##
§. *     7 ! )  '
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  ! !     + &
1+:::C *<:#
§6 2  2 +  4  0"" &  
4 2  D 01* 2 
 . "  !X' "  " +
  ! , ::#C * <$<;E
§ /$4 5 M' @& ()*  )
! + "  ! %  1
<?C;*:?$>
§ /F4 5 +  = , 2  " 
 !   ( %! 5  8:::9<<*
<:>F<
§ /F4544 ""1=@ &0
1$!   !  " %% ! !!
)* ")$+  +   (
%! 5  8<#9 * F<>
§  *  %! 1   )
'+ ::
§ . 4'5 = A/' \
 " ! '  7  
! + F  !\  6 "  ! 4 +
6+::C ?<>*;:
§  A &   (/  = &6  8::#9
27
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   + "    $  ' '+
$    ! !+   ( %!
5  <* E:$E#
§(  A D ,0 06 4  5 ! &&
1 + "  ""  " ! !!  )
!$!! )   1 
::#C<*#<$E
§1+ &@ 4 Y  !  
B " '    ! !!
) & )7 "  %  1 :::C<?*
?>$#?
§5 @ 7 @* % ) + " 
 " !   ! '*  $+
!! )   + " <  )  %  1
5  ::;C ;* #$ #;
§5  !   I.. &  1 @"  %
   @* %!$ ' ) 7
%% !* & ! " $+  '7 +
    ( %! 5 ::C <?* #$:<
§5  A  A YA* %+ 
' ! ' )* &   
!   % 1 5  :::C :*E<$
E 1 2   0!! 5   / 5*
!+ (  3"  +  '+
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::?  !! ?:$?#
§
4 1&D145'4)D0
$+  " ,/ ! +  7
"3 !  ! !  % ( 3"
%! <EC<*#$:?
§4B & & % I " &] %! 7 
' , () 5*  B " 
% 1! )   4+ 4. 
% ::<
§4 D 5' @ / & 0 4  6
0& & + )7 " !$!! 3+
) "   ') ! "   +
  1 :<:C ?E* >F<<:
§4 4  ) " ,$5  & $
5 %! ()*  5!  + 
::;
§ I ) 0   A*  !! )  
      !  & )7 1
 <>C >:*#
§) I*  " '   !  "
!$!!  " ! 7 '
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+*  ! ( 3" 4 ::
C;E8<9*<E>$>>
§2 , 4  / @ '  " 3+
!$!! )  '+ 7  '*
&   ! 1  + ::ECE*#$<
§.B. I 4   , 2 , 1* ""  + "
! !   !!) ! " !
' !* !! )   + " <E
 )+  !  ( %! 5 ::>
C<8<9*><$ !' ::E (  
§D6   D & =  % ()
!! '+ %% !*  ;$+ ) " !
"   ! "$  %  "
(  3"  %! 8<9 <:* E##FE#
§D6   D &   % =
A/ D       " !  7
   " )  ! " 
%%  %! 4+ & .   
   ( %! 5  8<9 <:* EF?:;
§D6   D &  %   =
A/ D 1 "  7 !$!! '
)& ! "    7
%%  ! %  " ( 
3"  4+ 8<E9 ;* ;?F;E
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§D 5  + 4* & )7 "   
  ) $'  ! " 
!* 5! "    3 1  "
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... Drawbacks such as higher plaque and/or calculus for bar attachment systems and less favorable handling properties for telescopic crown attachment systems considered a disadvantages of using these attachment systems for assisting the four implants mandibular overdentures. (59) According to Fouad et al., (60) Four-implant assisted mandibular complete overdentures retained by anterior bar and bilateral posterior ball attachments provide a better design concept for edentulous patient than either the four single ball attachments or the two bilateral posterior bar attachments regarding the implant stability and preservation of peri-implant alveolar bone. ...
... This explanation was confirmed byAlbrektsson et al., 2013 (187) who concluded that the marginal bone loss around oral implants depends on the foreign body response.Moreover, this result is consistent with the results of Fouad and Marzook, 2013(60) who measured the marginal alveolar bone height changes around four implants assisting mandibular complete overdenture at 6 th , 12 th and 18 th month of the study and found higher bone resorption during the first 6 months after prosthetic loading and then becomes slower during the second and third 6 months. Theyexplained their result by the localized remodeling and resorption in the peri-implant alveolar bone resulting from full functional occlusal loading of implants. ...
Thesis
Full-text available
Objectives: This study was done to compare between two designs of four implants used for assisting mandibular complete overdentures regarding the peri-implant alveolar bone height changes. Methods: Ten healthy male completely edentulous patients of age ranging from 50 to 60 years were selected for this study. All patients received conventional complete dentures. The patients were divided randomly into two equal groups according to the four-implants design concept. Group A: Received four axially placed implants in canine and second premolar areas and Group B: Received four implants (two axial implants in canine areas and two 30 degree distally inclined implants inserted in the first premolar areas). Ball attachments were screwed into implants to retain the overdentures. Peri-implant alveolar bone height was evaluated immediately, 6 months and 12 months after insertion of definitive overdenture. This was done using standardized periapical radiographs. Results: When comparing between the means of peri-implant vertical bone loss (VBL) during the first and second 6months in each group (anterior and posterior), a statistically insignificant difference was found, although the higher VBL during the first 6 months. When comparing between the means of VBL around the anterior and posterior implants of group (A) during the observation times of the study, a statistically insignificant difference was found, in spite of the increased resorption around the posterior implants. Also, the VBL around inclined posterior implants of group (B) was found to be insignificantly more than the VBL around vertical anterior implants through the first and second 6 months. Finally, the mean of VBL around implants in group (A) was statistically insignificant less than that around implants in group (B). Conclusions: Within the standard level of peri-implant bone resorption: (1) the four axially inserted implants and the four implants inserted according to the All-on-four design can be used for assisting the mandibular complete overdentures. (2) Assisting the mandibular complete overdentures by four axially inserted implants (in canines and second premolar areas) can be considered slightly more advantageous than the four implants inserted according to the All-on-four design. Recommendations: Other studies with long follow up time and more patients in addition to other methods of evaluation are recommended to differentiate between the two studied designs. Keywords: Implant assisted complete overdenture, Inclined implants, Vertical peri-implant bone loss.
... The rate of VBL was higher during the first 6 months after definitive loading then becomes slower afterwards at the second 6 months of study. This illustrated in the study performed by Fouad and Marzook (238) whom noticed that the localized remodeling and resorption in the peri-implant alveolar bone resulting from full functional occlusal loading of implants. This was in accordance with the study performed by Last et al. (239) who confirmed that full functional occlusal loading of implants by prostheses was expected to bring about localized remodeling. ...
... This significant decrease in peri-implant VBL in group B in the third 6 months might be due to the presence of posterior support using short implants that minimizes the rotational movements of the overdenture around the fulcrum axis formed by two anterior mini-implants in turn minimize the denture movement which reduce the unduly stresses to be transmitted to the mini-implants. This explanation was agreed with Fouad and Marzook (238) Finally, the result which was much more interested after current study was that means of vertical bone loss around mini-implants of group B were significantly lower than of group A during each interval of the study. ...
Thesis
Full-text available
Purpose: This study was conducted to evaluate the effect of posterior support using bilateral short implants on bone height changes around two anterior mini-implants used for retaining mandibular complete overdenture. Materials and Methods: Six completely edentulous patients of age ranged between 55 and 65 years were selected for this study. Patients were randomly classified into two equal groups. Group A: patients that would be delivered mandibular complete overdenture retained by two canine mini-implants with ball attachments without posterior support by short implants. Group B: patients that would be delivered mandibular complete overdenture retained by two canine mini-implants with ball attachments with posterior support by bilateral short implants with healing abutments (in first molar regions). The alveolar bone height changes around mini-implants were radiographically evaluated at the following time intervals: immediately (T0), 6 months (T6), 12 months (T12) and 18 months (T18) after mandibular complete overdenture insertion using standardized periapical radiographs. Results: - when comparing between the means of peri-implant VBL during the first and second 6 months in each group, a statistically insignificant difference was found, although the higher VBL during the first 6 months. - When comparing between peri-implant VBL during the second and third 6 months of the study, a statistically significant decrease in peri-implant VBL was found during the third 6 months in group B while a statistically insignificant decrease in peri-implant VBL was found in group A. - Finally, the result which was much more interested after current study was that means of vertical bone loss around mini-implants of group B were significantly lower than of group A during each interval of study. Conclusion: Posterior support using short implants can be considered an advantageous concept regarding preservation of the alveolar bone around mini-implants used for retaining mandibular complete overdenture. Recommendations: Other studies with other evaluation methods are recommended to determine the importance of posterior support using short implants when anterior two mini-implants used for retaining mandibular complete overdenture. Keywords: Implant overdentures, Mini-implants, Short implants, Immediate loading, Peri-implant vertical bone loss.
... This explanation is agreed with Romanos and Nentwig., 2006(12). Moreover, this result is consistent with the results of Fouad and Marzook, 2013 (13). They explained their results by the localized remodeling resulting from full functional occlusal loading and the increased inflammation resulting either from the post-surgical risk of bacterial infection or micromovements on the bone-implant interface. ...
Article
Full-text available
Objectives: This study was done to compare between two designs of four implants used for assisting mandibular complete overdentures regarding the peri-implant alveolar bone height changes. Methods: Ten healthy male completely edentulous patients of age ranging from 50 to 60 years were selected for this study. All patients received conventional complete dentures. The patients were divided randomly into two equal groups according to the four-implants design concept. Group A: Received four axially placed implants in canine and second premolar areas and Group B: Received four implants (two axial implants inserted in canine areas and two 30 degree distally inclined implants inserted in the first premolar areas). Ball attachments were screwed into implants to retain the overdentures. Peri-implant alveolar bone height was evaluated immediately, 6 months and 12 months after insertion of definitive overdenture. This was done using standardized periapical radiographs. Results: When comparing between the means of peri-implant vertical bone loss (VBL) during the first and second 6months in each group (anterior and posterior), a statistically insignificant difference was found, although the higher VBL during the first 6 months. When comparing between the means of VBL around the anterior and posterior implants of group (A) during the observation times of the study, a statistically insignificant difference was found, in spite of the increased resorption around the posterior implants. Also, the VBL around inclined posterior implants of group (B) was found to be insignificantly more than the VBL around vertical anterior implants through the first and second 6 months. Finally, the mean of VBL around implants in group (A) was statistically insignificant less than that around implants in group (B). Conclusions: Within the standard level of peri-implant bone resorption, the four axially inserted implants and the four implants inserted according to the All-on-four design can be used for assisting the mandibular complete overdentures. Assisting the mandibular complete overdentures by four axially inserted implants (in canines and second premolars areas) can be considered slightly more advantageous than the four implants inserted according to the All-on-four design. Recommendations: Other studies with long follow up time and more patients in addition to other methods of evaluation are recommended to differentiate between the two studied designs.
... Anterior values were found to be significantly increased than posterior values in group B. This could be related to the lower stability values of posterior implants as a result of elevated strain around tilted implants and less stress distribution unlike axial ones. This was in agreement with Lin et al. (260) Also, the result of this study was found to be in agreement with (261) who concluded that the implants installed in the canine areas provide better stability and less peri-implant alveolar bone loss than those installed in the first molar areas. They have interpreted their result by the nature of bone in the areas distal to the mental foramina, the amount of micro-motion that may occur to the implants in this area due to the stresses induced on the posterior implants by mandibular flexure and immediate prosthetic loading. ...
Thesis
Full-text available
Objectives: The aim of this study was to compare between two different designs used for assisting mandibular complete overdentures. One design was with four axially placed implants and the other was "all-on-four design" concerning periimplant soft tissue health and implant stability. Methods: Ten completely edentulous male patients were eligible for the present study. All patients received mandibular complete overdentures supported by four immediately loaded implants opposed by single maxillary dentures. The patients were randomly classified into 2 groups. Two axially placed implants were inserted at canine areas for both groups. Two implants were placed posteriorly, for group A; two axially parallel implants in 2nd premolar regions. While for Group B; the patients received two distally inclined implants of 30o in the 1st premolar regions. All implants were attached to the mandibular overdentures through ball and socket attachments. Peri-implant soft tissue health and implant stability evaluation were carried out immediately, 3 months and 6 months after insertion of definitive overdenture. Results: There was no significant difference between both groups when comparing peri-implant gingival, plaque, bleeding indices, probing depth and implant stability. Nonetheless, there was an improvement of all scores values and measures of all tested aspects through all time intervals in each group. Better values were noticed for anterior implants compared to posterior ones for both groups through all time intervals. Conclusions: The results of the study boost that both designs; four axially inserted implants and All-on-four design could be successful treatment options for assisting mandibular complete overdentures. Yet both designs revealed comparable results with respect to the standard levels of peri-implant soft tissue health and implant stability, All-on-four design could be a promising alternative when the four axial implants couldn't be inserted. Recommendations: More long-term studies following other loading protocols and variant evaluation methods are thus required to validate the results of this study. Keywords: Implants, Complete Overdenture, Distal inclined implants, gingival index, plaque index, probing depth, bleeding index, stability.
... Because of the trauma from placement of the implant the surrounding bone becomes necrotic and is replaced by woven bone. (205) Fouad and Marzook, (206) compared three different design-concepts for mandibular complete overdentures assisted by 4-implants regarding the implant stability and marginal alveolar bone loss. They revealed that the rate of marginal bone loss in all groups was fast during the first 6 months after loading, and then becomes slower afterwards at 12 and 18 months after loading. ...
Thesis
Full-text available
Purpose: This study aimed to evaluate the effect of inter-implant angulation on the bone height around two implants assisting mandibular complete overdenture by using locator attachment. Materials and Methods: A total of 6 edentulous male patients delivered mandibular complete overdenture assisted by two canine implants. After construction of complete dentures, the patients were classified into two equal groups: Group I received axial implants while Group II received 15 distal inclined implants. Radiographic assessment was done immediately (T1), 6 months (T2) and 12 months (T3) after insertion of definite overdenture. The peri-implant bone height changes were calculated during the 1st six months (T1-T2) and 2nd six months (T3-T2) months of study. Results: The means of vertical peri-implant bone resorption of Group I during the 1st six months (0.873± 0.009 mm) and in Group II (1.093± 0.016 mm) was found to be statistically significant. Also, the means of vertical peri-implant bone resorption of Group I during the 2nd six months was (0.591± 0.012 mm) and in Group II (0.605± 0.004 mm) was found to be statistically significant. The means of horizontal peri-implant bone resorption of Group I during the 1st six months (0.173± 0.014 mm) and in Group II (0.2± 0.012 mm) was found to be statistically significant. Also, the means of horizontal peri-implant bone resorption of Group I during the 2nd six months was (0.061± 0.001 mm) and in Group II (0.073± 0.003 mm) was found to be statistically significant. The means of vertical peri-implant bone resorption during the (12 months) of study in Group I (1.464± 0.015 mm) and in Group II (1.698± 0.014 mm) was found to be statistically significant. The means of horizontal peri-implant bone resorption during the (12 months) of study in Group I (0.234± 0.013 mm) and in Group II (0.273± 0.014 mm) was found to be statistically significant. Conclusion: Within the limitations of this study, the results revealed the following conclusions: (1) The 15 distally inclined implants inserted in the canine areas for assisting mandibular complete overdenture induce peri-implant bone loss more than the axially inserted implants. (2) Immediate loading accelerates the initial alveolar bone loss around implants used for assisting mandibular complete overdenture. Keywords: Implant assisted overdenture, Locator attachments, Inclined implants and immediate loading.
... Although splinting, the implants in the posterior region of the mandible cannot be proposed as a promising abutment for supporting mandibular overdenture retained with bilateral prefabricated bar.31When comparing three different design-concepts for mandibular complete overdentures assisted by 4-implants regarding the implant stability and marginal alveolar bone loss. It was found that four- implant assisted mandibular complete overdentures retained by anterior bar and bilateral posterior ball attachments provide a better design concept for edentulous patient than either the four single ball attachments or the two bilateral posterior bar attachments regarding the implant stability and preservation of peri-implant alveolar bone.32The study of evaluating the peri-implant tissue health when using bar-clips vs. silicone-resilient liners with bilateral posterior bars for retaining immediately loaded 4-implant-assisted mandibular overdentures concluded that Bar/liners can be considered better than the bar/clips33 ...
Presentation
Full-text available
The rehabilitation of edentulous patients continues to be a major challenge to dentistry. Implant assisted overdentures have become routine therapy because of their relative simplicity, minimal invasiveness, affordability, ease of usage, and minimizing or eliminating movement of the mandibular overdentures. Treating edentulous mandible with implant-assisted complete overdenture is aimed to reduce pain and discomfort, improve function (retention, stability) and stimulate psychosocial well-being. Prosthesis design is based on the amount of alveolar ridge resorption and fulfillment of prosthodontic criteria of support, stability, and retention. When considering the anatomic limitations of an edentulous jaw, the need for a properly designed prosthesis that results in favorable biomechanical stress distribution and fulfillment of patient needs, in regard to esthetics, phonetics, comfort, and hygiene, an overdenture prosthesis is usually the prosthesis of choice. In many prosthodontic studies comparing mandibular overdentures assisted with two or four dental implants, four implants having a statistically significant advantages over two implants. The purpose of this lecture is to focus on the different designs of four-implant assisted mandibular overdentures.
... (69) These problems of retention and corrosion cause decreasing the chewing efficiency making the patients with magnets have less satisfaction than those with bar and ball attachments. (71) Locators The locator attachment system is a self-aligning double retention cylinder with a female part of metallic cap with nylon insert that attached to the fitting surface of the denture and a male part that composed of implant screw metallic abutment. There are many advantages for the use of locator attachments like they don't need large prosthetic space and as the male parts are flexible they allow a resilient connection between the overdenture and the abutments in all directions so they can correct un parallel implants up to 40 degrees. ...
Thesis
Full-text available
Objectives: This study was conducted to compare between two “4-implant” designs used for assisting mandibular complete overdenture regarding the peri-implant metabolic activity. Methods: Ten healthy male completely edentulous patients of age ranging from 50 to 60 years were selected for this study. All patients received conventional complete dentures. When inserting the four implants for assisting the mandibular dentures, the patients were divided randomly into two equal groups, Group A: Patients received four axially parallel placed implants in canine and second premolar regions and Group B: Patients received four implants (two parallel implants in canine regions and two 300 distally inclined implants in the 1st molar regions). All implants were attached to the mandibular overdentures through ball and socket attachments. Metabolic evaluation of peri-implant tissue was done immediately, 3 months and 6 months after insertion of definitive overdenture. This was done by measuring glycosaminoglycans (GAGs) and chondroitin-4-sulphate (C4S) levels in the peri-implant sulcular fluid. Results: When comparing metabolic activities of anterior (or posterior) implants within each group in all intervals of study, there was a significant decrease in total values of glycosaminoglycans and chondroitin 4 sulfate. When comparing between the two groups regarding the total means of GAGs and C4S around all implants along the T3 and T6 intervals, there was an insignificant difference. Conclusions: Although the insignificant difference, assisting the mandibular complete overdenture by four parallel axially placed implants can be considered slightly more favorable than the “all-on-four” design regarding the peri-implant metabolic activity. Recommendation: Other studies with long follow up time and more number of patients in addition to other methods of evaluation are recommended to differentiate between the two studied designs. Keywords: Implants, Complete Overdenture, Distal inclined implants, Metabolic Activity.
Book
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Different Designs of Four-Implant Assisted Mandibular Overdentures
Article
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The aim of this study was to compare between the effects of resilient liner and clip attachments of bar-implant-retained mandibular overdenture on peri-implant tissues. In a randomized-controlled clinical trial, 30 edentulous male patients (mean age 62.5 years) were equally assigned to two groups. In each patient, two implants were inserted in the canine area of the mandible using a two-stage surgical protocol. After 3 months, the implants were connected with resilient bars. Mandibular overdentures were retained to the bars with either clips (group I) or silicone-resilient liners (group II). Peri-implant tissues were evaluated clinically (with regard to plaque scores, gingival scores and probing depths) and radiographically (with regard to peri-implant vertical and horizontal alveolar bone changes). Evaluations were performed at the time of overdenture insertion (T0), 6 months (T6) and 12 months (T12) after overdenture insertion. After 12 months of using bar-implant-retained mandibular overdenture, the resilient liner attachment had significantly decreased peri-implant plaque score, gingival score, probing depth, vertical and horizontal bone loss when compared with the clip attachment. Within the limitations of this study, and in terms of peri-implant tissue health of bar-implant-retained mandibular overdenture, we recommend resilient liner rather than clip attachment.
Article
This literature review summarizes research with the aim of providing dentists with evidence-based guidelines to apply when planning treatment with osseointegrated implants. Peer-reviewed literature published in the English language between 1969 and 2003 was reviewed using Medline and hand searches. Topics reviewed include systemic host factors such as age, gender, various medical conditions, and patient habits, local host factors involving the quantity and quality of bone and soft tissue, presence of present or past infection and occlusion, prosthetic design factors, including the number and arrangement of implants, size and coatings of implants, cantilevers and connections to natural teeth, and methods to improve outcomes of implant treatment in each category. The review demonstrated that there is no systemic factor or habit that is an absolute contraindication to the placement of osseointegrated implants in the adult patient, although cessation of smoking can improve outcome significantly. The most important local patient factor for successful treatment is the quality and quantity of bone available at the implant site. Specific design criteria are provided, including guidelines for spacing of implants, size, materials, occlusion, and fit. Limitations in the current body of knowledge are identified, and directions for future research are suggested.
Article
In a randomized controlled clinical trial carried out at the Ignatius teaching hospital in Breda, The Netherlands, I10 edentulous patients with severe mandibular bone loss were treated with implants of the ITI® Dental Implant System using 3 different treatment strategies: a mandibular overdenture supported by either 2 implants with ball attachments, 2 implants with an interconliecting bar, or by 4 interconnected implants. In this study, results of clinical and radiographic parameters were evaluated and compared over a period of 19 months after implant placement. A total of 283 ITP Dental Implants were placed. Six implants (2%) were lost during the osseointegration period. No further implant losses occurred after that, At the 19 month evaluation mean values and standard deviations for bleeding index were 0.51±0.5 (bleeding incidence=70%) and for plaque index they were 0.46±0.5 (plaque incidence=45%). The mean values and standard deviations for probing depth and loss of attachment were 2.7±1.1 mm and 0.26±O.6 mm respectively. The radiographic evaluation showed a mean bone loss of 1.5 mm± 0.26 after 19 months for all the implants. In cases with 4 interconnected implants there was significantly more bone loss around the central 2 implants (2.1±0.31 mm) in comparison with the lateral 2 (1.4±0.25 mm). No significant correlations were found between plaque and bleeding indices and bone loss.
Article
Recent measurements indicate that deformation of the mandible occurs during opening movements. This important phenomenon is of considerable clinical significance.Further investigation, with a measuring apparatus rigidly attached to the teeth and possibly using strain gauges attached to fixed restorations, is indicated. Meanwhile, it is advisable not to make mandibular impressions with the mouth wide open and to question the advisability of rigidly joining the lower teeth together with a cross-arch splint.
Article
The aim of the present systematic review of implant-supported maxillary overdentures was to assess the survival of implants, survival of maxillary overdentures and the condition of surrounding hard and soft tissues after a mean observation period of at least 1 year. MEDLINE (1950-August 2009), EMBASE (1966-August 2009) and CENTRAL (1800-August 2009) were searched to identify eligible studies. Two reviewers independently assessed the articles. Out of 147 primarily selected articles, 31 studies fulfilled the inclusion criteria. A meta-analysis showed an implant survival rate (SR) of 98.2% per year in case of six implants and a bar anchorage. In case of four implants and a bar anchorage, the implant SR was 96.3% per person. In case of four implants and a ball anchorage, the implant SR was 95.2% per year. In all three treatment options, the SR of the implants is more than 95%. The studies included reveal that a maxillary overdenture supported by six dental implants, which are connected with a bar, is the most successful treatment regarding survival of both the implants and overdenture. Second in line is the treatment option with four implants and a bar. The treatment option with four or less implants and a ball attachment system is the least successful.
Article
Combination syndrome (CS) is a pathologic condition of the stomatognathic system characterized by an edentulous maxilla with an atrophic anterior ridge, maxillary papillary hyperplasia, hypertrophic maxillary tuberosities, super-erupted mandibular anterior teeth, as well as atrophic mandibular posterior ridges. This condition can present a challenging situation to the clinician who needs to assemble evidence from all aspects of dentistry to formulate an appropriate treatment plan. One of the possible treatment choices for the fully edentulous patient with a CS is a full-arch implant-supported reconstruction for both maxilla and mandible. The purpose of this study is to illustrate and discuss a biomechanical complication-fractured maxillary meso bar in a patient with CS, and to present a description of how this complex case was corrected and successfully completed. The analysis of implant-supported and implant-retained full arch restorations in edentulous patients with CS is presented and treatment recommendations are given. A necessity of individualized approach for every implant reconstruction case, especially complicated with a CS, is suggested.
Article
The degree of mandibular flexure during forced opening of the jaws with various fixed splints in place was measured. Significant results indicate that: (1) all splints tested reduce the amount of mandibular flexure; (2) the reduction of measured mandibular flexure cannot be explained solely by tooth movement, rather it is indicative of a limitation of bony flexure by fixed splints; (3) extensive mandibular splints flex during forced opening; and (4) fixed prostheses involving many teeth do not completely inhibit mandibular flexure. Inhibition of mandibular flexure apparently increases as more teeth are splinted and more rigid attachments are used.
Article
A rotational aspect to mandibular flexure has been demonstrated by means of photographic comparisons. The importance of this movement in relation to anatomic considerations, periodontal therapy, restorative dentistry, and implant-supported prostheses, is discussed.
Article
A removable denture as rehabilitation for complete edentulousness is not always sufficient treatment. Some patients cannot achieve acceptable function with this treatment and psychosocial problems sometimes arise. In recent years an alternative treatment has been available for these patients, viz. treatment with overdentures supported by oral implants. An interview has been made with the first 10 patients. The treatment was 3 to 5 ITI-implants in the mandible between the mental foramina. A barconstruction stabilized the implants and barclips were placed in the denture. There was a very positively reaction to the treatment. The patients have an improvement in oral function and retention of the denture. Also the psychosocial sequelae from which some of them previously suffered were reduced or removed.