* Lecturer of Removable Prosthodontics, Faculty of Dental Medicine, AL-Azhar University. Cairo, Egypt.

INTRODUCTION
Some people do not succeed in
acquiring new skills with their dentures
and thus suffer psychologically because of impaired
function, comfort, self-image and social interaction.
Because of the good prognoses of some endosseous
implant systems, these patients can be successfully
treated with implant-retained overdentures. Several
1 4
08
RADIOGRAPHIC EVALUATION OF MID-SYMPHYSEAL
SINGLE IMMEDIATE LOADING MANDIBULAR IMPLANTS
RETAINED OVERDENTURE WITH DIFFERENT OCCLUSAL
FORMS OF POSTERIOR TEETH
Mostafa Ibrahim Fayad
*
ABSTRACT
Purpose: The aim of this study was to investigate radiographically the effect of different
occlusal forms of posterior teeth on mid-symphyseal single immediate loading mandibular implants
retained overdenture.
Material and methods: Fifteen patients were chosen for this study. They were ranged in age
between 55 and 73 years (average 64). Patients sharing in this study were randomly divided into three
equal groups according to occlusal forms of posterior teeth (anatomic, semi anatomic,zero degree).
A new complete denture was constructed for each patient with specifc tooth form according to
the patient group. After rehabilitation with new complete denture (two months adaptation period),
a single mid-symphyseal immediate loading mandibular implant was inserted. All patients were
evaluated radiographically with cone beam CT, immediately after implant loading with overdenture
6, 12 and 18 months. Radiographic assessment of the marginal bone loss around dental implants
was performed utilizing cone beam computerized tomography.
Results: The results of the present study showed that there is no statistical signifcant difference
in marginal bone height between different groups of patients immediately after implant loading
with over denture and after 6 or12 month. After 18 months there is statistical signifcant difference
in marginal bone height between different groups of patients.
Conclusion: within the limitation of this study, using fat teeth with mid-symphyseal single
immediate loading mandibular implants retained overdenture was result in less marginal bone loss
around dental implant.
(2) Mostafa Ibrahim Fayad E.D.J. Vol. 60, No. 4
studies reported the clear benefts of overdenture
treatment, versus the conventional denture for
a number of aspects such as: aesthetics, speech,
chewing, ft and retention, function and quality of
life.
(1)
Use of single implant placed in the symphyseal
midline to retain an overdenture has been
documented by many authors with excellent success
according to the success criteria of albrektsson. Also
can be used as an economical therapeutic alternative
to the conventional mandibular complete denture.
(2)
Immediate loading of oral implants has been
defned as a situation where the superstructure is
attached to the implants no later than 72 h after
surgery
(3)
.
With immediate loading implant, the total
treatment time is decreased, the number of surgical
procedures is reduced, and the overall cost is
reduced. There is better acceptance of the treatment
plan by the patient, the healing phase is shorter in
general and Improves bone healing and enhance
bone formation
(4)
.
Several factors may infuence the results of
immediate implant loading. These could be divided
into the following four categories: surgery, host,
implant, and occlusion-related factors. Surgical
factors consist of primary implant stability and
surgical technique. Host factors comprise the
quality and quantity of cortical and trabecular
bone, wound healing, and modeling/remodeling
activity. Implant factors include designs, surface
textures, and dimensions of the implant. Occlusal
factors involve the quality and quantity of force and
prosthetic design
(5-7)
.
In an animal study, data demonstrated that
brief exposure to extremely low-amplitude
mechanical strains could enhance the biologic
fxation of cementless implants. In conclusion, it
can be speculated that immediate loading of dental
implants may accelerate bone formation, but it
is also imperative to state that primary stability is
essential for this process to occur
(8)
.
Another animal study used to evaluate bone
reactions and the bone-titanium interface in
immediate loaded implants in monkeys compared
with unloaded implants in the same arch several
months after immediate loading. And demonstrated
greater bone contact in immediately loaded
implants at 9 months. No fbrous tissue was found
at the interface. After 15 months, both unloaded and
immediate loaded implants were compared, and
loaded implants exhibited greater (almost twice)
direct bone contact at the interface
(9)
.
The Academy of Prosthodontics defnes a tooth
form as the characteristics of the curves, lines,
angles, and contours of various teeth that permit
their identifcation and differentiation
(3)
.
The tooth forms were classifed into anatomic
tooth form (33 degree), semi anatomic ,zero degree
teeth, non anatomic and unusual non anatomic tooth
form.
(10)
The selection of posterior tooth form by dentists
can be based on the biomechanical needs of each
patient.No one form is best for all patients there are
advantage as well as problems with anatomic and
non-anatomic teeth. The selection of the posterior
tooth form so that they meet individual requirements
according to the residual ridge resistance form and
inter arch distance by control of the horizontal
force by bucco-lingual cusp height reduction was
advocated.
(11)
Clinical trial comparing anatomic, lingualized,
and zero-degree posterior occlusal forms for
complete dentures, concluded that participants
provided with complete dentures having lingualized
or anatomic posterior occlusal forms exhibited
signifcantly higher levels of self-perceived
satisfaction compared to those with 0-degree
posterior occlusal forms.
(11)
Chewing effciency tests and patient preference
ratings showed that 30 degree teeth and lingual
RADIOGRAPHIC EVALUATION OF MID-SYMPHYSEAL SINGLE (3)
contact provided better chewing effciency than 0
degree teeth.
(12)

Whereas the natural dentition is capable of
physiologically adapting to traumatic occlusions,
the absence of a periodontal ligament means that
dental implants are more easily overloaded and this
can lead to implant failure.
(12)
The infuence of occlusal surface design on
the longitudinal success of implant treatment is
believed to be signifcant. It has been established
that trauma from occlusion may be a factor in the
etiology of implant failure. It has been suggested
that a radiological appearance of (saucerisation
or furrowing) is associated with occlusal
overload.
(13-14)
Controlling functional forces is one of the
ingredients for obtaining success of immediate
implant loading
(15-17)
.
Vertical forces applied during function are less
detrimental to implant stability rather than oblique
or horizontal forces. The occlusal load direction may
affect the remodelling rate. Therefore, some authors
considered bruxism /occlusal overload as a possible
contraindication for immediate implant loading
due to higher implant failure rates. They further
speculate that occlusal load control is essential for
maintaining success
(18-20)
.
In the present study, radiographic evaluation
of the infuence of the occlusal surface designs in
mid-symphyseal single Immediate Loading implant
retained over denture was done.
MATERIAL AND METHODS
Fifteen completely edentulous patients
were selected from the outpatient clinic of the
Prosthodontic Department Faculty of Dental
Medicine, Al- Azhar University. The patients were
free from any systemic or local diseases that may
contraindicate the placement of dental implants. All
patients were informed about the line of treatment;
also written consent was taken from each patient.
Patients sharing in this study were randomly
divided into three equal groups:
Group A: Patients receiving immediately
loaded mid-symphyseal single implant retained
mandibular complete overdenture with ball and
socket attachment where complete denture was
constructed with anatomic occlusal form of
posterior teeth.
Group B: Patients receiving immediately
loaded mid-symphyseal single implant retained
mandibular complete overdenture with ball and
socket attachment where complete denture was
constructed with semi anatomic occlusal form of
posterior teeth.
Group C: Patients receiving immediately
loaded mid-symphyseal single implant retained
mandibular complete overdenture with ball and
socket attachment where complete denture was
constructed with zero degree occlusal form of
posterior teeth.
Procedures
Diagnostic casts were made in alginate
impression with dental stone to aid in analysis of
jaw relationships, inter arch distance as well as
positions of implants. For each patient new upper
and lower complete dentures were constructed as
usual manner with specifc tooth form according
to the patient group. The patient received the new
conventional complete denture and was left for two
months to be adapted to the new denture.
FIG. (1) Panoramic view of completely edentoulous patients.
(4) Mostafa Ibrahim Fayad E.D.J. Vol. 60, No. 4
Each patient received med symphyseal single
octa titanium implants with 3.75mm diameter and
14mm length. The implant is cylinder with reversed
screw and hydroxyapetite coat. Patients received
gingival former having the same diameter and 2mm
or 4mm gingival height. Ball head abutment driver
was used to insert ball head abutment with 2mm
colar.
The rubber O-rings were incorporated into the
ball abutments and the mandibular denture was
checked for stability over the ball abutment with
socket in place. Undercuts under the socket were
blocked out with soft wax.
The maxillary and mandibular dentures were
inserted into the patient mouth and the patient was
asked to bite forcibly on the mandibular denture at
centric occlusion with Pink self cured acrylic resin
in socket holes until complete setting of the acrylic
resin.
All patients were evaluated radiographically
with cone beam CT, immediately after implant
loading with overdenture delivery and after 6, 12
months.
The obtained data were collected and tabulated for
statistical analysis. Statistical analysis was performed
using SPSS software for windows. P values less than
0.05 are considered to be statistically signifcant.
RESULTS
The mean value of bone height of group I at
insertion was 13 mm with standard deviation (SD)
0.01 and for group II it was 13.01 mm with standard
deviation 0.01 and for group III it was 13 mm with
standard deviation 0.01. There is no statistically
signifcance difference.
After 6 months of follow up period, the mean
value of bone height of group I was 11.98 mm with
standard deviation (SD) 0.08 and for group II it was
11.97 mm with standard deviation 0.04, and for
group III it was 11.95 with standard deviation 0.01.
There is no statistically signifcance difference.
After 12 months of follow up period, the mean
value of bone height of group I was 11.35 mm with
FIG. (2): Gingival former.
FIG. (3) Implant retained over denture with fat teeth.
FIG. 4 : Cone beam CT of mandible.
RADIOGRAPHIC EVALUATION OF MID-SYMPHYSEAL SINGLE (5)
standard deviation (SD) 0.05 and for group II it was
11.40 mm with standard deviation 0.04, and for
group III it was 11.38 with standard deviation 0.04.
There is no statistically signifcance difference.
After 18 months of follow up period, the mean
value of bone height of group I was 10.95 mm with
standard deviation (SD) 0.01 and for group II it was
11.15 mm with standard deviation 0.04, and for
group III it was 11.36 with standard deviation 0.04.
There is a statistically signifcance difference.
DISCUSSION
Patients were free from abnormal habits such as
clenching and bruxism because they are associated
with increased pressure on the implants and results
in surrounding bone loss. A standardized implant
size was selected for all patients to eliminate the
effect of the implant surface area on the integration
process or the implant marginal bone
(11)
.
Screw type self tapping implants were used as
they need less surgical procedures , short operating
time, so decrease post operative complications.
Also the threads of the screws maximize the implant
bone surface area, resulting in excellent primary
stabilization and good force distribution.
[2]
The changes in marginal bone height around
the implants of each group appeared after 6 month,
which may be due to the immediate loading. This
changes was statically signifcant after 12, 18 and
24 months of follow up period particularly around
the implant of group I this may be due to lateral
forces which increase in group I than group II
than group III , in contrast with khamis et al
(9)
and
agreement with Batenburg et al
(11)
.
Change in marginal bone height on mesial ,
distal, buccal and lingual surfaces of the implant
of group I showed much more resorption than
around the implant of group II more than implant
of group III with no mobility in any group after 6
month of follow up period, this is in agreement with
Ericsson I. et al, which concluded that the bone to
implant bio-integration determined by many factors
including surface character of the implant, surgical
technique, loading time and occlusal form of the
over denture
(16)
.
FIG. (5) Mean values of marginal bone heights of different
groups.
TABLE (1) Changes in marginal bone height of different groups .
Time
Group A Group B Group C
P
Mean SD Mean SD Mean SD
At time of insertion 13.0 0.01 13.01 0.01 13.0 0.01 0.072
6 months 11.98 0.08 11.97 0.04 11.95 0.01 0.062
12 months 11.35 0.05 11.40 0.04 11.38 0.04 0.067
18 months 10.95 0.01 11.15 0.04 11.36 0.07 0.002
*
F: F test (ANOVA)
*: Statistically signifcant at p 0.05
(6) Mostafa Ibrahim Fayad E.D.J. Vol. 60, No. 4
The decrease in the alveolar bone height
measurements around implants did not exceed a
mean of 1.3mm at the end of 12 month and followed
by less than .2mm bone loss till the end of follow-
up period for both groups. This marginal bone loss
occurring in both immediate and delayed loaded
groups was considered within accepted permissible
limits occurring with most dental implants. In this
study, both groups showed very slight bone loss
but the immediately loaded implants showed a
decreased amount of bone loss compared to delayed
loaded implants.
This may be attributed to the lack of a second
stage surgical trauma in case of immediately loaded
implants. This explanation is in agreement with
many authors, as they pointed out that any surgical
act such as periosteal stripping is accompanied
by some loss of underlying bone as it kills lots of
osteo-progenitor cells leading to a reduction in
the osteogenic reaction thus limiting the healing
response Moreover, in delayed loaded implants
the exposure of marginal bone during abutment
connection leads to marginal bone loss
(5-6)
.
The results of bone loss in this study did not
agree with some authors, reported more marginal
bone loss in immediately loaded implants. They
attributed the increased bone loss with immediately
loaded implants to the possible movement between
implants and abutments resulting in micro gap
formation which could signifcantly infuence
crestal bone changes around the two-piece non-
submerged titanium implants
(20)
.
Weng D.et al.,
(7)
found that the bone loss of 1.0-
1.5mm occurring after the frst year of functional
loading of dental implants and .2 mm in the next
years was considered normal. Radiographically
measured bone loss is expected to be less than 1mm
following placement and loading of dental implants.
This is in agreement with the results of this study.
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