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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 10  |  Issue : 1  |  Page : 10-15

Evaluation of two different attachment systems used with mandibular implant-retained overdenture


1 Department of Prosthodontic, Faculty of Dentistry, Tanta University, Tanta, Egypt
2 Department of Restorative and Dental Sciences, Faculty of Dentistry, Taif University, Taif, KSA

Date of Submission20-Dec-2018
Date of Acceptance26-Apr-2019
Date of Web Publication08-Jul-2020

Correspondence Address:
Dr. Mohamed Yousef Abdelfattah
Department of Prosthodontic, Faculty of Dentistry, Taif University, Taif
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdi.jdi_23_18

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   Abstract 

Objectives: The aim of this study was to evaluate the effect of two different attachment systems on the retention and implant stability of implant-retained mandibular overdenture.
Materials and Methods: Fourteen completely edentulous patients with age ranged from 47 to 65 years planned to receive conventional complete denture. Following the treatment protocol, each patient received two implants in the mandibular anterior region, and after insurance of the osseointegration, the patients were randomly divided into two groups – Group A received Ball/O-Ring attachment and Group B received locator attachment. The retention of two groups was assessed by the digital force meter at three times (T): T0 – retention of conventional complete denture, T1 – at time of insertion of implant-retained mandibular overdenture, and T3 – retention after 3 months of insertion of implant-retained mandibular overdenture. The implant stability quotient (ISQ) was done using Magnetic Resonance Frequency Analyzer (Osstell, ISQ) at the time of loading then after 3 and 6 months.
Results: The retention values before the insertion of overdenture (T0) were considerably low in comparison with those at time of insertion of overdenture (T1) and after 3 months from denture insertion (T3). Regarding the ISQ values, there was no significant difference between the two groups before and at the time of insertion of implant while there was a significant difference between the two groups with better stability results in the locator attachment group after 3 months (P < 0.05).
Conclusion: Within the limitation of this study, both types of attachment systems, i.e., Ball/O-Ring and locator attachments are reliable modalities for improving the retention and stability of implant-retained mandibular overdenture with superior initial stability results for the locator attachment.

Keywords: Implant-retained overdenture, implant stability, locator attachment, resonance frequency analysis, retention, stud attachment


How to cite this article:
Abdelfattah MY, Fahmi MK. Evaluation of two different attachment systems used with mandibular implant-retained overdenture. J Dent Implant 2020;10:10-5

How to cite this URL:
Abdelfattah MY, Fahmi MK. Evaluation of two different attachment systems used with mandibular implant-retained overdenture. J Dent Implant [serial online] 2020 [cited 2020 Sep 19];10:10-5. Available from: http://www.jdionline.org/text.asp?2020/10/1/10/289235


   Introduction Top


Prosthetic rehabilitation with complete denture is the most well-known treatment for edentulous state, and its advantages and disadvantages have been explained and discussed.[1] The successful incorporation of the denture with the patient's oral functions in addition to the psychological acceptance of the dentures by the patient is an important factor to achieve favorable results of complete denture treatment.[2]

Different researches have confirmed that conventional mandibular dentures cannot restore masticatory function or enhance patient satisfaction and the quality of life.[3] Retention and stability problems of the mandibular complete denture affect the oral function and masticatory functions. To overcome these problems, the prosthetic management using implant-retained overdentures is extremely valuable.[4],[5] Rehabilitation with mandibular implant tissue-supported overdentures using two implants can be considered the main treatment modality when more implant cannot be placed.[6]

Many types of attachments can be used with implant overdentures such as magnets, Ball/O-Ring, bar(s)/clip(s), and locator attachments. To guarantee sufficient stability, finest shape, form, appearance, and comfort, the overdentures should be cautiously planned.[7] The interarch space, stress distribution between implant and mucosa, and the amount of retention and resistance needed are the main factors affecting attachment system selection.[8]

The simplicity of use and maintenance of Ball/O-Ring, its low cost, elimination of a superstructure bar, its wide range of movement, and great patient satisfaction are the main advantages of Ball/O-Ring which make it one of the most successful stud attachments to enhance the retention of implant- and tooth-supported complete and partial overdentures. On the other hand, it wears over time, steadily loses retention, and must be changed from time to time, and the ball attachments must be parallel to each other.[9]

The advantages of the locator attachment are its self-aligning and have double retention, rotational action, and built-in guide planes providing precise insertion; it can also be used in nonparallel situations, can be used in cases with reduced interarch spaces, and is available in different colors with different retention values, i.e., resilient, retentive, and durable. Besides, its repair and replacement are easy and fast.[10]

Implant stability is very important for dental implant success and it is provided initially by mechanical engaging in the implant bed bony walls. The secondary stability occurs during healing by deposition of bone on the implant surface (osseointegration).[11] Different methods have been used to measure implant stability such percussion and mobility testing by applying lateral forces with mirror handles, measuring cutting torque resistance, insertion torque values, reverse torque tests, periotest, dental fine tester, and Osstell electronic device. The Osstell instrument is a modern, noninvasive, and relatively precise technique, which enables the measuring using resonance frequency analysis (RFA) and provides both information on implant stability in the bone and a reliable guidance to further course of implant therapy.[12]

There are limited clinical data evaluating retention of the prosthesis and implant stability when Ball/O-Ring attachment and locator attachments are used with two implant-supported anterior overdentures. Hence, the aim of this study was to compare the effect of attachment type (Dentium Ball/O-Ring attachment and Zest Locator) on implant stability and retention of mandibular implant overdentures.


   Materials and Methods Top


Fourteen completely edentulous male patients ranging from 47 to 65 years of age were assigned in the current research according to the following criteria: at least 1 year of total edentulism in the maxilla and the mandible, mandibular residual alveolar ridge of at least 12 mm height and 6 mm width at the canine region, covered with firm, relatively even compressible mucosa, and Angle's Class I maxillomandibular relations with adequate interarch space. While the exclusion criteria included any systemic disease that may affect bone and soft-tissue health, temporomandibular joint disorders, abnormal habits, for example, bruxism and clenching, smokers, history of radiation therapy in the head-and-neck region, uncooperative patients. Any logistic, psychiatric, or physical reasons that could affect follow-up, and lack of motivation for adequate home care.

The study was planned and performed at the specialty clinics of Prosthodontic Department, Faculty of Dentistry, Taif University, in accordance with Declaration of Helsinki and approved by the Research and Ethics Committees in Faculty of Dentistry, Taif University. After the patients were informed about the line of treatment and need of their regular and frequent recall, they approved their treatment plan on a written consent to follow the study protocol throughout the total period of the research.

Routine medical and dental investigations were performed for each patient. Preoperative radiographic planning of the implant sites was conducted using cone-beam computed tomography and a replica of the patient's lower denture.

Following the conventional two-stage surgical approach [Figure 1], the patient received two identical implant fixtures (self-tapping vacuum titanium plasma-sprayed implant, Pitt-Easy implant, Oraltronics, Bremen, Germany) with the same length (10 mm) and diameter (4 mm) in the mandibular anterior region with low speed, high torque drilling, and double coolant preparation of implant osteotomy sites. Flap was sutured by continuous mattress suture using 3/zero black silk (M-Natur, International sutures manufacturing Co., Egypt) [Figure 2], and the patients were informed about postsurgical care, medications, and instructions. After 1 week, the old dentures were relieved at the implant sites and relined with tissue conditioner material (Alpha-dent, Alphadental products Co., Chicago, USA) and used for 3-month healing period.
Figure 1: Cover screws were screwed into the fixtures

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Figure 2: Continuous matrix suture of the mucoperiosteal flap

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After the 3-month healing period, the cover screws were loosened using the hex driver, and then, healing were screwed to the implants for 7 days. Healing abutments were removed, and the patients were randomly divided into two equal groups (each consists of seven patients) according to the type of attachment used: Group I – patients received mandibular overdenture retained by Ball/O-Ring attachment system (Dentium Co, Korea) [Figure 2] and Group II – patients received mandibular overdenture retained by locator attachment system (Zest Dental Solutions, USA) [Figure 3].
Figure 3: Ball abutments screwed into the fixture

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The matrices of the ball attachments and locator were integrated into the dentures with a direct intraoral pick-up technique using a cold-curing, MMA- free, hard relining material for chairside relining in one single session (Hardliner CD, Promedica, Germany) – a block out spacer was used to prevent adherence of the acrylic resin to the abutment or the implant [Figure 4] and [Figure 5].
Figure 4: Locator abutments with block out spacer at the time of loading

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Figure 5: O-Ring inserted into their sleeves inside the metal houses

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Evaluation

Retention

The retention of two groups was assessed at three times (T): T0 – retention of conventional complete denture, T1 – at time of insertion of implant-retained mandibular overdenture, and T3 – retention after 3 months of insertion of implant-retained mandibular overdenture. The digital force meter device was used to measure the retention of the mandibular complete overdenture. Metal hooks were prepared in the buccal surface of mandibular denture flange. A 0.9 mm orthodontic wire was placed buccal to the second premolar and first molar areas with cold-curing acrylic resin, so the force meter device could exert a vertical displacing force on the denture and test its retention. The hook attachment was placed on the shaft of the force meter device and the hook engaged the center of the wire loop [Figure 6]. The pull end of the force meter device was connected to the 0.9 mm orthodontic wire. The force meter device was pulled vertically until the denture was detached; the force reading was recorded in Newton. For each patient, >3 records were taken each time and divided to get the average.[13]
Figure 6: A patient during measuring retention

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The implant stability

Magnetic Resonance Frequency Analyzer (Osstell ISQ, Goteborg, Sweden) [Figure 7] was used to measure the implant stability quotient (ISQ) at the time of loading then after 3 and 6 months. A special SmartPeg was connected to the implant body at 4–5 N/cm torque, and measurements were made at 2–3 mm away so that the probe tip of the analyzer would point to the small magnet above the SmartPeg. Measurements were made in two directions: buccolingual and mesiodistal [Figure 8]. The measurements were made three times for each direction to ensure reproducibility. The mean of these values was used for statistical analysis.
Figure 7: Osstell implant stability quotient device

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Figure 8: SmartPeg connected to the implant for implant stability quotient measurement

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Statistical analysis

The collected data were analyzed using SPSS version 20.0 for Windows. Kolmogorov–Smirnov test was used as a test for normality, and the independent sample t-test was used to compare the two groups; the statistical significance level was set at P < 0.05.


   Results Top


All the 14 implants in this study were considered successfully osseointegrated as they show no signs of peri-implant pathology and successful rigid fixation clinically and radiologically.

The retention values (R) in the two groups at different observation times are presented in [Table 1]. There was no statistically significant difference between Group I and Group II before overdenture insertion (T0) while there was statistically significant difference between them at the time of loading (T1) and after 3 months (T3) with Group I being higher mean values than Group II (P < 0.05).
Table 1: Retention values in the two groups

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[Table 2] shows the mean ISQ values for both the groups. There was a decrease in the ISQ values in Group I from the loading (ISQ = 69.06) to the 3rd month (ISQ = 68.21), followed by an increase from the 3rd month to the 6th month (ISQ = 71.25). On the other hand, there was an increase in mean ISQ values Group II throughout the follow-up intervals from loading (ISQ = 70.25) to after 6 months (ISQ = 73.00). However, when comparing both the studied groups together, there was a statistically significant difference at the 3rd month follow-up (P = 0.047), while no statistically significance was found after 6 months of follow-up at P < 0.05.
Table 2: Mean implant stability quotient values at different intervals

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   Discussion Top


Fourteen patients were selected for this study with their age ranging from 47 to 65 years as it was found that the success rates might be less than optimal with advancing age.[14]

The variation in implant diameter and/or length may affect the biomechanics of dental implant, so a standardized implant size was used.[15]

Salvi and Lang, 2004, stated that the modalities used to evaluate oral implants during maintenance care must be highly sensitive and easy to measure and create reproducible data.[16]

Retention was measured in Newton using force meter before insertion of overdenture (T0), at time of insertion (T1), and 3 months (T3) after overdenture insertion. At each time, five records, with 1-min rest between each reading, were registered and take the average for each patient.[13]

Different techniques have been introduced to measure the implant stability such as percussion and mobility testing, measuring cutting torque resistance, insertion torque values, reverse torque tests, periotest, dental fine tester, and histomorphometric and histologic analyses of the bone-implant interface. All of these have some drawbacks such as debatable accuracy and reliability and an invasive or destructive nature.[17] Osstell electronic device, based on RFA, measures implant stability and quantifies it in ISQ values.[12] The Osstell instrument facilitates optimizing implant healing, prosthetic construction, and surgical protocol because it can provide repeated measurements of implant stability at placement, during healing, and during and after loading, allowing the clinician to detect implant instability and take appropriate steps to remedy it and to rescue an implant prior to failure.[18]

The results of the retention values in this study revealed that there was no statistically significant difference between Group I and Group II before overdenture insertion (T0) while there was statistically significant difference between them at the time of loading (T1) and after 3 months (T3) with higher mean values for Group I than Group II (P < 0.05).

Regarding the findings of the implant stability, there was an increase in the ISQ value of both the groups with time as there is an increase in the bone-implant contact area, and this was in accordance with other researches.[19] Comparing the ISQ results of both the groups, there was a statistically significant difference between the two groups at the 3rd month after loading with higher values for the locator group while no significance difference at the other follow-up periods. This can be explained by the difference in stiffness of the retentive components of the two systems and that the Ball/O-Ring system relocates high bending forces to the implants under lateral forces.[20],[21]


   Conclusion Top


Both the Ball/O-Ring and locator attachment systems are successful and useful. Regarding the retention, there was no statistically significant difference between Group I and Group II before overdenture insertion (T0) while there was a statistically significant difference between them at the time of loading (T1) and after 3 months (T3) with higher mean values for Group I than Group II (P < 0.05). Regarding the implant stability, there was a statistically significant difference between the two groups at the 3rd month after loading with higher values for the locator group while no significance difference at the other follow-up periods.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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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;12:209-18.  Back to cited text no. 10
    
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Huwiler MA, Pjetursson BE, Bosshardt DD, Salvi GE, Lang NP. Resonance frequency analysis in relation to jawbone characteristics and during early healing of implant installation. Clin Oral Implants Res 2007;18:275-80.  Back to cited text no. 11
    
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Burns DR, Unger JW, Coffey JP, Waldrop TC, Elswick RK Jr. Randomized, prospective, clinical evaluation of prosthodontic modalities for mandibular implant overdenture treatment. J Prosthet Dent 2011;106:12-22.  Back to cited text no. 13
    
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Porter JA, von Fraunhofer JA. Success or failure of dental implants? A literature review with treatment considerations. Gen Dent 2005;53:423-32.  Back to cited text no. 14
    
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Meijer HJ, Kuiper JH, Starmans FJ, Bosman F. Stress distribution around dental implants: Influence of superstructure, length of implants, and height of mandible. J Prosthet Dent 1992;68:96-102.  Back to cited text no. 15
    
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Salvi GE, Lang NP. Diagnostic parameters for monitoring peri-implant conditions. Int J Oral Maxillofac Implants 2004;19 Suppl: 116-27.  Back to cited text no. 16
    
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Herrero-Climent M, Santos-García R, Jaramillo-Santos R, Romero-Ruiz MM, Fernández-Palacin A, Lázaro-Calvo P, et al. Assessment of Osstell ISQ's reliability for implant stability measurement: A cross-sectional clinical study. Med Oral Patol Oral Cir Bucal 2013;18:e877-82.  Back to cited text no. 18
    
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Karakoca-Nemli S, Aydin C, Yilmaz H, Sarisoy S. Stability measurements of craniofacial implants by means of resonance frequency analysis: 1-year clinical pilot study. Int J Oral Maxillofac Implants 2012;27:187-93.  Back to cited text no. 19
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1], [Table 2]



 

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