Q U I N T E S S E N C E I N T E R N AT I O N A L

A new treatment concept for immediate loading of implants inserted in the edentulous mandible
Tammaro Eccellente, MD, DDS1/Michele Piombino, MD, DDS2/ Adriano Piattelli, MD, DDS3/Vittoria Perrotti, DDS, PhD3/ Giovanna Iezzi, DDS, PhD3

Objectives: Retention of mandibular complete dentures on two or four interforaminal implants is considered the most reliable procedure in implant therapy. There are different retention elements available for all implant systems. The aim of the present study was to clinically evaluate patients with a mandibular overdenture supported by the Ankylos SynCone system (Dentsply). Method and Materials: Thirty-nine patients were treated with 156 implants. The treatment method was based on immediate loading of four interforaminal implants without the use of a bar retainer. The denture was placed on and retained by prefabricated conical crowns that were inserted into the existing denture base by direct intraoral polymerization immediately after surgery and supported by the corresponding conical primary implant abutments. Results: The cumulative implant survival rate was 98.7% (two failures), while the prosthesis survival rate was 100%. After a total observation of 30.3 months (range 12 to 60 months), all other implants presented healthy peri-implant soft tissue conditions showing low value of clinical parameters. Conclusion: This method facilitates secondary splinting of the inserted complete denture. The conical crowns concept presented here resulted in stable complete denture retention, reduced the denture base, and improved oral hygiene. (Quintessence Int 2010;41:489495)

Key words: complete dentures, dental implants, edentulous mandible, immediate loading, overdentures, prefabricated telescopic restorations

Overdentures represent a valuable and reliable alternative for completely edentulous patients.1,2 Patients wearing overdentures have demonstrated a significant increase in their chewing ability, nutritional status, emotional stability, and esthetics.36 Moreover, the rigid anchorage of a mandibular overdenture with a bar combines the prosthodontic advantages of a removable and fixed prosthesis.7 However, a disadvantage of treatment with overdentures is the time necessary for healing before the insertion of the definitive prosthesis.4 Usually, the matrices of the bar or the freestanding attachments are connected 3 to 6 months after implant insertion.2

Private Practice, Naples, Italy. Private Practice, Caserta, Italy. Dental School, University of Chieti-Pescara, Chieti, Italy.

Correspondence: Prof Adriano Piattelli, Via F. Sciucchi 63, 66100 Chieti, Italy. Fax: 11-39-0871-3554076. Email:apiattelli@unich.it

Subsequently, a series of interventions aimed at the relining of the prosthesis are needed to maintain the stability and cleanliness of the denture with no impairment of the implant healing. Early and immediate loading of dental implants has been shown to result in very good histologic and clinical results. Recently, several authors have focused on the possibility of an immediate loading of dental implants supporting overdentures to minimize the delay between the surgical and prosthetic phases.1,810 Immediate loading means to place the final or provisional prosthetic restoration within 48 hours of the surgical procedure, and, therefore, it is a potentially cost- and time-saving procedure. Early loading did not negatively affect osseointegration in mandibular overdentures,11 and no differences in the results between conventionally loaded and immediately loaded implants supporting overdentures were found.4

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Ta b l e 1

Dimension and distribution of implants

Diameter

Length (mm)

3.5 mm

4.5 mm

9.5 11 14 Total

5 66 54 125

1 28 2 31

immediately loaded implants by reducing excessive micromotion.2 The Ankylos SynCone conical crown system (Dentsply Friadent) could potentially provide adequate and constant retentive force to retain implantsupported overdentures.15 The aim of the present study was to clinically evaluate patients with mandibular overdentures supported by the Ankylos SynCone system.

METHOD AND MATERIALS

Between January 2002 and November 2005, 39 consecutive patients with edentulous mandibles were treated with 156 Ankylos implants (Dentsply Friadent) placed by two oral surgeons (T.E. and M.P.) in a private practice. Table 1 shows the dimensions of the examined implants. The patient population consisted of 21 women (53.8%) and 18 men (46.2%). Age at implant placement ranged between 42 and 82 years, and the mean age was 62.3 years. Twenty-eight patients were smokers. All participants signed an informed consent form. The inclusion criteria were sufficient bone volume (minimum bone height of 12 mm, minimum bone width of 5 mm) for the insertion of four interforaminal implants and a completely edentulous mandible needing a total rehabilitation. Exclusion criteria were systemic diseases likely to compromise the implant surgery, uncontrolled diabetes, leukocyte dysfunction, chemotherapy, drug and alcohol abuse, and psychiatric contraindications. Preoperative panoramic radiograph and computerized axial tomography (Fig 1) were used for the surgical evaluation of the selected sites for each patient. Local anesthesia was induced by infiltration of mepivacaine buccally and lingually in the canine regions in the mandible. A midcrestal incision was made in the keratinized mucosa, and a flap was raised to expose the bone. The sites were prepared according to the standard procedure for Ankylos implants, and four clinically stable implants were placed in each patient (Fig 2). All implants were inserted at least 1 mm below the crestal bone (range 1 to 3 mm).

Fig 1

Preoperative computerized axial tomography.

In 1997, Chiapasco et al12 published a multicenter retrospective study on 904 immediately loaded implants retaining mandibular overdentures. The overall survival rate (SRR, ie, implants still in place at the end of the follow-up) was 96.9% with a mean follow-up of 6.4 years. Subsequently, the same group conducted a series of prospective studies in which they demonstrated that the overall survival and success rates (SCR, ie, good clinical and radiologic outcome) were comparable with those obtained with a two-stage procedure.13,14 In a clinical study with two immediately loaded implants supporting a ball attachment retaining mandibular overdentures, a survival rate of 100% was reported after 1-year follow-up.2 A stable and retentive prosthesis may allow proper healing of the

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Fig 2 Clinical view of four interforaminal implants after insertion.

Fig 3 The SynCone abutments in situ before suturing.

Fig 4 The SynCone copings are polymerized into the denture base directly in the mouth of the patients.

Fig 5

Postoperative radiograph.

Sixty-two implants were immediately placed after tooth extraction, 21 implants were inserted after 4 to 10 weeks, and 73 were inserted after 6 months or more. Autogenous bone grafts without barrier membranes were used to fill the original peri-implant bone defects that frequently occurred when placing immediate or delayed implants. Following implant placement, the SynCone abutments (Dentsply Friadent) were screwed to the implants before suturing (Fig 3). A mucoperiosteal flap closure was performed using interrupted or horizontal mattress sutures. The SynCone abutments were manufactured with a precise fit to prefabricated secondary conical copings. These prefabricated copings were polymerized into the denture base directly in the mouth of the patients (Fig 4). Postsurgical treatment was administered with amoxicillin 2 g daily for 7 days, with 100 mg nimesulide twice daily for 3 days, and chlorhexidine digluconate solution 0.12% twice daily for 1 minute for oral hygiene. Oral hygiene instructions were provided. Patients were instructed to wear the fixed denture continuously and consume a soft diet. One week after surgery, the denture was taken out by the dental clinician, the sutures were

removed, and the denture was again continuously worn for a further 6 weeks, except for examination by the clinician, if needed. After these 6 weeks, the denture was removed again by the clinician to check the implants and the condition of peri-implant soft tissues; it was then cleaned and reinserted. For another 2 to 4 weeks, the denture was taken out by the clinician weekly. Nutritional limitations were also lifted after these 4 weeks. Approximately 10 weeks after implant placement, the patients were instructed to take out and put in the denture at least once per day. Twenty-five patients received a new denture (18 with metallic framework) after a healing period of 4 to 6 months. The dentition in the opposing maxilla was as follows: 6 patients with complete denture, 12 patients with fixed restorations, and 21 patients with partial removable dentures. The modified Sulcus Bleeding Index (mSBI) and modified Plaque Index (mPI)16 were recorded 2 months after surgery and at various intervals during the observation period. Panoramic radiographs were taken at implant placement, after 6 and 12 months, and at different time intervals during the observation period (Fig 5).

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Ta b l e 2

Failure analysis
Implant Time of length implantation (mm) Reason for failure

Sex/age

Site

Time of failure

Female/70 y Right first premolar Male/71 y Right lateral incisor

Immediate Late

14 11

8 wk 6 wk

Mobility Mobility

During the observation period, abutment screw loosening occurred in two cases (in 2 patients). Fourteen partial breaks of the denture base (in 10 patients) occurred and were quickly repaired. Most patients were satisfied about the time and modality of treatment. Two patients were not satisfied with the esthetics of the rehabilitation. All other patients the appreciated function, esthetics, and retention of the restoration (Tables 4 and 5).

Ta b l e 3

Life table
Failures Success Cumulative during rate survival interval (%) (%)

Time Implant at interval interval Implants (y) start Dropouts at risk

DISCUSSION
Previous reports have described a method that uses four implants rigidly connected by a U-shaped bar.12,14,1720 This technique allows good stabilization of the implants despite the immediate loading. Thus, implants seem not to be exposed to movements that may compromise osseointegration. The objective of using a mandibular overdenture is a high implant survival, preservation of crestal bone, and high patient satisfaction.21 The use of a fixed restoration to treat an edentulous mandible can be impeded by anatomical factors or financial problems, and overdentures may represent a more affordable treatment.1 The success of the overdenture treatment is related to the primary stability, prosthetic design, and control of the occlusal forces.2 Recently, clinical studies have demonstrated a high percentage of implant and prosthesis survival rates. Gotfredsen et al22 reported a 98% implant and 100% prosthesis survival rate at a 5-year recall, with excellent maintenance of marginal bone and absence of mucositis. Krennmair et al7 found a cumulative survival rate of 99%, with excellent peri-implant conditions, healthy soft tissues, good oral hygiene, acceptable peri-implant marginal bone loss, low incidence of prosthodontic maintenance, and high patient satisfaction. The results of the present study were in agreement with these studies with a cumulative implant survival rate of 98.7%. The Ankylos SynCone conical crown system consists of four implants inserted and immediately loaded in the mandibular interforaminal area.15 Bone quality, a host-related factor, is believed to be the strongest predictor

01 12 23 34 45

156 154 110 70 38

0 0 0 0 0

0 0 0 0 0

2 0 0 0 0

98.7 100 100 100 100

98.7 98.7 98.7 98.7 98.7

Technical complications were recorded. Patient satisfaction was evaluated 4 weeks after surgery and 1 year later.

RESULTS
No sensory disturbance was recorded following surgery. Two implants were removed for mobility during the healing period (Table 2). The cumulative implant survival rate was 98.7% (Table 3), while the prosthesis survival rate was 100%. After a total observation of 30.3 months (range 12 to 60 months), all other implants presented healthy periimplant soft tissue conditions showing low value of clinical parameters (mSBI = 1; mPI = 1) (Figs 6 and 7). Swelling or suppuration were not observed. Radiographic examination showed excellent bone healing and stable crestal bone level. Most bone loss was observed 6 months after implantation in immediate and delayed implants. Ninety-two implants (59.7%) showed bone contact close or above the implant-abutment connection after the total observation period.

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Fig 6 Clinical and radiographic views 6 months after treatment.

Fig 7 Clinical and radiographic views 5 years later.

of outcome in immediate loading.2327 Misch and Degidi28 have reported that most immediately loaded implants are placed in anatomical sites with bone quality D1 or D2. It is well-known that the mandible (especially the interforaminal region) has a better bone quality than the maxilla, and this fact was probably why several reports were available regarding immediately loaded implants inserted in the mandible with a high survival rate.29,30

In the system used in the present study, abutments and conical crowns with a 4-degree inclination were provided. The complete procedure may be executed in the dental office without the use of a dental laboratory. Indeed, it consists of the implant insertion and abutment connection; subsequently, the gold matrices were inserted on the abutments and polymerized in the prosthetic base directly in the patients mouth. The entire procedure

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Ta b l e 4

Patient satisfaction 4 weeks after surgery (n = 39)

Insufficient Sufficient Excellent Not evaluable

How do you evaluate the . . .

. . . operative phase? . . . postoperative phase? . . . phonetics? . . . masticatory function? . . . esthetics? . . . denture stability? . . . selforal hygiene?

5 3 5 2 3 0 11

21 18 22 18 17 17 13

13 18 9 8 12 18 4

0 0 3 11 7 4 11

Ta b l e 5

Patient satisfaction 12 months later (n = 39)

Insufficient Sufficient Excellent Not evaluable

How do you evaluate the . . .

. . . operative phase? . . . postoperative phase? . . . phonetics? . . . masticatory function? . . . esthetics? . . . denture stability? . . . selforal hygiene?

3 2 2 0 2 0 0

27 16 17 12 16 13 14

7 21 20 27 21 26 24

2 0 0 0 0 0 1

(surgery and prosthodontics) lasted no more than 2 to 3 hours. The conical retention was stable as shown in the present study, where a 100% prosthesis survival rate was achieved and few prosthetic complications occurred. Moreover, no mucosal support of the final prosthesis was needed, because the prosthesis was supported by only the implants, a situation similar to a full-arch restoration.15

ACKNOWLEDGMENTS
This work was partially supported by the National Research Council (CNR), Rome, and by the Ministry of the Education, University, Research (MIUR), Rome, Italy.

REFERENCES
1. Liddelow GJ, Henry PJ. Prospective study of immediately loaded single implant-retained mandibular overdentures: Preliminary one-year results.

CONCLUSION
This method facilitates secondary splinting of the inserted complete denture. The conical crowns concept presented resulted in stable complete denture retention, reduced denture base, and improved oral hygiene. Its advantages were its low cost, fast realization, high stability of prosthetic restoration, and easy management of the prosthetic phases.

J Prosthet Dent 2007;97:S126S137. 2. Marzola R, Scotti R, Fazi G, Schincaglia GP. Immediate loading of two implants supporting a ball attachmentretained mandibular overdenture: A prospective clinical study. Clin Implant Dent Relat Res 2007; 9:136143. 3. Vogel RC. Implant overdentures: A new standard of care for edentulous patients. Current concepts and techniques. Compend Contin Educ Dent 2008;29: 270276.

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Schellenberg M. Within-subject comparison of two rigid bar designs connecting two interforaminal implants: Patients satisfaction and prosthetic results. Clin Implant Dent Relat Res 2009;11: 228232.

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