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Authors affiliations:
Corina Marilena Cristache, Concordia Dent Clinic,
Bucharest, Romania
Ligia Adriana Stanca Muntianu, Removable
Prosthodontics, Faculty of Dental Medicine,
University of Medicine and Pharmacy Carol
Davila, Bucharest, Romania
Corina Marilena Cristache, Mihai Burlibasa,
Implantology, FMAM, University of Medicine and
Pharmacy Carol Davila, Bucharest, Romania
Andreea Cristiana Didilescu, Department of
Anatomy, Faculty of Medicine and Pharmacy,
Dunarea de Jos University, Galati, Romania
Andreea Cristiana Didilescu, Department of
Embryology, Faculty of Dental Medicine,
University of Medicine and Pharmacy Carol
Davila, Bucharest, Romania
Corresponding author:
Andreea Cristiana Didilescu
8, Blvd Eroilor Sanitari, 050474, Bucharest,
Romania
Tel.: +40 722536798
Fax: +40 21 3131298
e-mail: Andreea.Didilescu@gmail.com
Key words: complications, costs, locator, magnet, prosthetic maintenance, retentive anchor
Abstract
Objective: The objective is to compare, in a prospective randomized clinical trial, three types of
attachment systems for mandibular implant overdenture, focusing on costs, maintenance
requirements and complications from baseline to the end of 5-year follow-up period.
Materials and Methods: Sixty-nine fully mandibular and fully/partially maxillary edentulous
patients received two screw-type Straumann implants, in the mandibular canine region. New
overdentures with three types of attachment systems were inserted according to an early-loading
protocol: Group B (balls, divided into Subgroup B.1 retentive anchor with gold matrix and
Subgroup B.2 retentive anchor with titanium matrix) (n = 23), Group M (magnets) (n = 23) and
Group L (locator) (n = 23).
Results: The highest maintenance event number (195) was observed in Group B vs. 31 in Group L
and 15 in Group M. Significantly more complications were recorded in Subgroup B.1 than in
Subgroup B.2, Group M and Group L (P < 0.05). Group M registered the highest prosthetic success
(82.6%) in the 5 years, followed by Group L (78.2%). Subgroup B.1 had the lowest success rate
(50%). The magnet group recorded statistically significant higher costs, comparing with the other
two groups (P < 0.05).
Conclusions: The three attachment systems functioned well after 5 years. The magnets had a low
maintenance requirement and high success rate, despite the relatively increased initial costs.
Retentive anchor with titanium matrix and locator may be a better choice from a financial point of
view, taking into consideration the initial low cost of the components and also the reduced
number of complications.
Date:
Accepted 30 October 2012
To cite this article:
Cristache CM, Muntianu LAS, Burlibasa M, Didilescu AC.
Five-year clinical trial using three attachment systems for
implant overdentures.
Clin. Oral Impl. Res. 00, 2012, 18
doi: 10.1111/clr.12086
In case of the edentulous patients, the success of the denture therapy depends upon the
biomechanical prodigy of support, stability
and retention (Jacobson & Krol 1983b,c). The
mandibular denture generally presents the
major problem with regard to retention due
to a movable floor of the mouth, which
causes difficulty in establishing a lingual
border seal. Denture stability is minimised
by lack of ideal ridge height and conformation (Jacobson & Krol 1983a). Due to resorption, the remaining anatomic regions of the
mandible are not usually essential in providing dental support (Jacobson & Krol 1983c).
Problems regarding integrating dentures
are observed with a higher incidence for
mandibular than for maxillary dentures
(Mericske-Stern 1998). To overcome these
drawbacks, over the past 35 years, clinicians
have been restoring aesthetics and function in
edentulous patients with implant overdentures
using different retention systems and nowadays the cost-effectiveness and the simplicity of treatment become the main issues for
the choice of treatment (Zitzmann et al.
2006). The role of the attachment type is
very important (Kimoto et al. 2009): a rigid
connection between implants and denture
induces stress with potential implant failure
(Menicucci et al. 2006), especially when
hinge movements around the fulcrum line
occurs. Moreover, splinting implants by
means of a bar-clip construction is more
expensive, time-consuming, involves more
complications (Gotfredsen & Holm 2000)
and offers no marked differences in patient
satisfaction when compared with non-splinting attachments (Cune et al. 2010). Due to
these facts, resilient and magnetic attachment for implant overdentures, allowing
several types of movements, are extensively
used. The magnetic anchor is a non-rigid,
2 |
Each patient received two screw-type Straumann (Switzerland) standard soft tissue level
implants 4.1 mm diameter, with sandblasted
large-grit acid-etched (SLA) surface in the
canine region of the mandible with an interconnecting line approaching parallelism with
the terminal mandibular hinge axis (Naert
et al. 1998). The implant lengths were 10 or
12 mm. The choice of implant length was
dictated by the preoperative radiographic
assessment of bone height in the canine
region and drilling distance, with the principal concern of achieving primary stability.
Bone height in the canine region was
assessed on orthopantomograms. Jaw bone
quality was rated during the dental implant
surgery, by the tactile resistance during drilling. The same surgeon for all the cases
performed the implant surgery, allowing an
objective evaluation.
Both clinical and radiographic evaluation
permitted a classification according to the
Lekholm & Zarb (1985) index.
The implants were inserted under local
anaesthesia in a one-stage non-submerged
procedure according to a strict protocol (Weingart & ten Bruggenkate 2000).
Prosthodontic procedure
No. of patients
Patrix
Matrix
B, Subgroup B.1
12
B, Subgroup B.2
11
23
23
Denture
titanmagnetics
Straumann, Basel,
Switzerland
Steco system-technick,
Hamburg, Germany
Titanium matrix
Titanmagnetics insert,
height 3.25 mm,
titanium housing
Locator abutment 3 mm,
titanium alloy
Costs for each type of attachment were calculated according to all the procedures and complications at first year (T1) and fifth year (T5)
and were subdivided into direct and indirect
costs, being estimated based on the minimal
clinical charges for the procedures by the surgeon, prosthodontist and dental hygienist.
The direct costs included costs of dental laboratory, costs of materials (implants and components), pharmaceuticals, radiography and
charges for the procedures by the clinician
and the dental laboratory. The indirect costs
included the patients time and out-of-pocket
expenses (Penrod & Takanashi 2003).
In our calculation, the direct costs were
considered. Aftercare was defined as care and
maintenance provided during the evaluation
period, including check ups and cleaning.
Costs of complications (components, prosthodontist and dental laboratory fees) were
considered separately.
The costs of dental implants and components are from the Romanian Straumann representative February 2009. Costs of the
prosthetic complications per patient were
calculated in the following manner: total costs
of complications per group/subgroup divided
by n (i.e. number of patients in the group/
subgroup) = costs of prosthetic complications
per patient in the respective group/subgroup.
Assessment of implant failure
Data were expressed as mean values, standard deviations (SD), ranges, medians and
percentages, as appropriate. The Levene test
was used to verify the homogeneity of vari-
3 |
(a)
(b)
(c)
(e)
(d)
(g)
(f)
Fig. 1. Implant overdenture attachment systems: (a) Group B Retentive anchor abutments; (b) Subgroup B.1 Gold
matrix with variable retention; (c) Subgroup B.2 Titanium matrix with defined retention; (d) Group M Magnet abutments; (e) Group M Magnet denture insert; (f) Group L Locator abutments; (g) Group L Locator denture insert.
Results
The results confirmed group homogeneity.
There was no statistical difference between
groups for age, bone height in the canine
region and interimplant distance (P > 0.05,
one-way ANOVA test). No association was
recorded between any group and bone quality, bone quantity, gender or implant length
(P > 0.05, Pearson Chi-squared and Fishers
exact tests). No significant difference was
recorded between groups in terms of period
of edentulism (P > 0.05, KruskalWallis test).
Out of the 138 implants placed, four were
lost in three patients (two women and one
Year 1
Year 2
Year 3
Year 4
Year 5
31
7
8
7
26
0
0
0
35
1
0
0
48
0
6
11
44
3
1
13
B
B1
B2
M
L
4 |
B
(n = 23)
Age (years)
Mean (SD)
57.8 (8.8)
Median
58
Range
[4276]
Bone height in canine region (mm)
Mean (SD)
25.3 (5.6)
Median
24
Range
[1644]
Bone quality*
N (%)
Type I
4 (17.39)
Type II
13 (56.52)
Type III
6 (26.09)
Type IV
0
Bone quantity*
N (%)
Class A
1 (4.35)
Class B
7 (30.43)
Class C
8 (34.78)
Class D
7 (30.43)
Interimplant distance (mm)
Mean (SD)
20.1 (7.3)
Median
21
Range
[738]
*
M
(n = 23)
L
(N = 23)
63.4 (9.5)
64
[4784]
64 (9.6)
65
[4780]
26.2 (4.9)
25
[1836]
24.2 (3.7)
24
[18.530.8]
1 (4.35)
19 (82.61)
3 (13.04)
0
4 (17.39)
14 (60.87)
5 (21.74)
0
0
11 (47.83)
9 (39.13)
3 (13.04)
0
13 (56.52)
5 (21.74)
5 (21.74)
20.3 (5.8)
22
[431]
20.1 (4.9)
19.1
[11.634]
B.2
Group M
Group L
0
2
1
3
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
22
2
0
1
1
3
1
1
1
1
0
0
1
1
2
2
2
1
2
2
1
4
Table 5. Six-field table analysis of prosthodontic success after 5 years of functioning according to
Payne et al. (2001)
Group B
N (%)
B.1
N (%)
Success
Surviving
Deceased
Unknown
Retreatment (repair)
Retreatment (replace)
2012 John Wiley & Sons A/S.
14
6
0
0
0
9
6
(56.5)
(50)
(39.1)
(50)
0
B.2
N (%)
Group M
N (%)
Group L
N (%)
8 (72.7)
0
0
0
19 (82.6)
0
0
0
18 (78.3)
0
0
0
3 (27.3)
0
4 (17.4)
0
5(21.7)
0
patient comparing with the other groups/subgroup (60 EUR vs. 40 EUR) due to the higher
number of maintenance events.
The costs per patient/group/subgroup are
shown in Table 6. The magnet group recorded
statistically significant higher costs comparing with the other two groups, whilst no
statistical
significant
differences
were
observed between Group B and Group L, after
the 5-year evaluation (KruskalWallis and
MannWhitney U-tests). The complication
costs for Subgroup B.1 vs. B.2 during years two
to five were 309.5 Euro/patient and 3.63 Euro/
patient, respectively.
Discussion
The use, in our clinical study, of two implants
as attachment for overdentures is based on the
clearly demonstrated success (Mericske-Stern
& Zarb 1993; Naert et al. 1999, 2004a) of using
fewer (generally two) implants and in accordance with the proposed standard clinical
treatment protocol for edentulous elderly
patients in daily practice (Feine et al. 2002).
The implant survival rate of 97.1% after
5 years, including loss of implants during the
osseointegration period (early failure) is comparable with the studies of Buser et al. (1999)
(96.2%), Ferrigno et al. (2002) (95.9%) and
Lethaus et al. (2011) (96.7%), with the use of
the same implant system and the same surface treatment.
The 6-week loading protocol performed in
this study is considered an early-loading protocol. The absence of implant failures after
loading is in agreement with other studies
(Payne et al. 2002; Roccuzzo & Wilson 2002).
In the light of our findings, the overall number of prosthetic and soft tissue complications
were relatively low compared with other studies (Mackie et al. 2011). Most of the maintenance requirements were easy to handle:
screwing loosening abutments or activation of
the matrix to improve retention (Subgroup
B.1). Considerably more prosthetic maintenance requirements were registered in subgroup B.1, similar to the findings of Walton
et al. (2009), but different from Watson et al.
findings (Watson et al. 2002). The type of gold
matrix used in the present study consisted of
four lamellae functioning like a spring. All the
patients needed at least one activation of the
gold alloy matrix per year (i.e. 100% activation
per year). This result is different from Waltons findings who reported, in a 3-year study,
only 73% need of matrix activation (Walton
2003). Four patients needed fully replacement
of the gold matrices due to impossibility of
5 |
Table 6. Computed costs in EUR (Euro) per patient and per group/subgroup
Implants/components
Surgery
Dental technician
Prosthodontist
Costs at delivery
Costs at delivery per group
Aftercare and complications first year
Total costs first year
Aftercare 5 years
Costs of complications
per patient after 5 years
Total costs fifth year
Mean (SD)
Median
Range
Subgroup B.1
Subgroup B.2
Group M
Group L
694
350
200
350
1594
1630.34
60
1654
160
356.16
770
350
200
350
1670
40
1710
160
67.45
1118
350
200
350
2018
2018
40
2058
160
68.34
853
350
200
350
1753
1753
40
1793
160
56.30
2170.16 (183.61)
2106
19742564
1937.45 (115.89)
1890
18702237
2286.34 (224.13)
2218
22183298
2009.30 (89)
1978
19532364
References
Albrektsson, T., Zarb, G., Worthington, P. & Eriksson, A.R. (1986) The long-term efficacy of
currently used dental implants: a review and
6 |
Naert, I., Alsaadi, G. & Quirynen, M. (2004a). Prosthetic aspects and patient satisfaction with
two-implant-retained mandibular overdentures: a
10-year randomized clinical study. International
Journal of Prosthodontics 17: 401410.
Naert, I., Alsaadi, G., van Steenberghe, D. &
Quirynen, M. (2004b). A 10-year randomized
clinical trial on the influence of splinted and
unsplinted oral implants retaining mandibular
overdentures: peri-implant outcome. The International Journal of Oral & Maxillofacial
Implants 19: 695702.
Naert, I., Gizani, S., Vuylsteke, M. & van Steenberghe,
D. (1998). A 5-year randomized clinical trial on the
influence of splinted and unsplinted oral implants
in the mandibular overdenture therapy. Part i:
peri-implant outcome. Clinical Oral Implants
Research 9: 170177.
Naert, I., Gizani, S., Vuylsteke, M. & Van Steenberghe, D. (1999). A 5-year prospective randomized
clinical trial on the influence of splinted and
unsplinted oral implants retaining a mandibular
overdenture: prosthetic aspects and patient satisfaction. Journal of Oral Rehabilitation 26:
195202.
Payne, A.G., Tawse-Smith, A., Duncan, W.D. &
Kumara, R. (2002). Conventional and early loading
of unsplinted ITI implants supporting mandibular
overdentures. Clinical Oral Implants Research 13:
603609.
Payne, A.G., Walton, T.R., Walton, J.N. & Solomons, Y.F. (2001). The outcome of implant overdentures from a prosthodontic perspective:
proposal for a classification protocol. International Journal of Prosthodontics 14: 2732.
Penrod, J. & Takanashi, Y. (2003) Measuring the
cost of implant overdenture therapy. In: Feine,
J. & Carlsson, G., eds. Implant Overdentures:
The Standard of Care for Edentulous Patients,
p. 48. Hanover Park: Quintessence Publishing
Co.
Rentsch-Kollar, A., Huber, S. & Mericske-Stern, R.
(2010). Mandibular implant overdentures followed
for over 10 years: patient compliance and prosthetic maintenance. International Journal of Prosthodontics 23: 9198.
Roccuzzo, M. & Wilson, T. (2002). A prospective
study evaluating a protocol for 6 weeks loading
of sla implants in the posterior maxilla: one year
results. Clinical Oral Implants Research 13:
502507.
Schulz, K.F., Altman, D.G., Moher, D. & Group,
C. (2010) Consort 2010 statement: updated
guidelines for reporting parallel group randomized trials. Annals of Internal Medicine
152: 726732.
Vercruyssen, M., Marcelis, K., Coucke, W., Naert,
I. & Quirynen, M. (2010). Long-term, retrospective evaluation (implant and patient-centred
outcome) of the two-implants-supported overdenture in the mandible. Part 1: survival
rate. Clinical Oral Implants Research 21: 357
365.
Walmsley, D.A. (2005) Review of the clinical use of
magnets in implant retained overdentures. In:
Maeda, Y. & Walmsley, D.A., eds. Implant Dentistry with New Generation Magnetic Attachment: Maximum Result with Minimum Number
7 |
8 |
Watson, G.K., Payne, A.G., Purton, D.G. & Thomson, W.M. (2002) Mandibular overdentures: comparative evaluation of prosthodontic maintenance
of three different implant systems during the first
year of service. International Journal of Prosthodontics 15: 259266.
Weingart, D. & ten Bruggenkate, C.M. (2000) Treatment of fully edentulous patients with ITI
implants. Clinical Oral Implants Research 11
(Suppl 1): 6982.
Zitzmann, N.U., Marinello, C.P. & Sendi, P.
(2006). A cost-effectiveness analysis of implant
Supporting Information
Additional Supporting Information may be
found in the online version of this article:
Data S1. CONSORT 2010 checklist of information to include when reporting a randomised trial*