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JPOR-127; No. of Pages 5

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Journal of Prosthodontic Research xxx (2011) xxxxxx www.elsevier.com/locate/jpor

Original article

Long-term clinical evaluation of implant over denture

Yasunori Suzuki DMD, PhDa,*, Hidekazu Osada DMDb, Mariko Kobayashi DMD, PhDa, Michio Katoh DMD, PhDa, Yuji Kokubo DMD, PhDc, Jun-ichi Sato DMD, PhDa, Chikahiro Ohkubo DMD, PhDb
a

Division of Oral and Maxillofacial Implantology, Tsurumi University School of Dental Medicine, 2-1-3 Tsurumi, Tsurumi-ku, Yokohama 230-8501, Japan b Department of Removable Prosthodontics, Tsurumi University School of Dental Medicine, Yokohama, Japan c Department of Fixed Prosthodontics, Tsurumi University School of Dental Medicine, Yokohama, Japan Received 17 January 2011; received in revised form 1 April 2011; accepted 15 May 2011

Abstract Purpose: The use of implants to treat edentulous jaws has become a well-established and accepted contemporary clinical method. The aim of this study was to analyze information about the implants used, patients, denture modality, and complications after denture insertion in partially and fully edentulous patients with implant overdentures placed. Methods: A survey was performed about patients rehabilitated using implant dentures at the Tsurumi University Dental Hospital during 8 years. A total of 201 implants were placed: 112 in the maxilla and 89 in the mandible. Descriptive statistics were used for each patient, such as the implant positions and numbers, retainer designs, denture modalities, implant survival rate and prosthetic complications. Results: The positions of implant placement were: incisor (44%); canine (26%); premolar (18%); and molar (12%). Approximately 70% of the retainers were bar attachments and magnet attachments. The majority of the prostheses were metal-based dentures (84%) compared to only 10 acrylic dentures (16%). Fully edentulous, fourteen (12 maxillary, 2 mandibular) of 171 implants failed. Partially edentulous, three (3 maxillary, 0 mandibular) of 30 implants failed. The denture complications observed during maintenance were denture fracture, retainer breakage and articial tooth fracture. Conclusion: Although the mandibular implant dentures placed were exceedingly reliable for rehabilitation with a high survival rate, the maxillary implant dentures exhibited a low survival rate and more frequent complications. Signicantly higher implant failures and prosthetic complications were observed in the initial period after placement than in the following years. # 2011 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved.
Keywords: Implant denture; Edentulous patient; Survival rate; Prosthetic complication

1. Introduction Removable denture function in fully edentulous patients is often inadequate. In particular, severe absorption of the alveolar ridges frequently makes it very difcult for patients to wear conventional dentures due to the lack of retention and the instability of the denture. Together with the poor load-bearing capacity of the tissues, this situation can lead to oral pain and discomfort and poor oral function. The use of implants to treat edentulous jaws has become a well-established and accepted contemporary clinical method [1]. Interest in the use of implants for fully or partially edentulous patients has increased.

* Corresponding author. Tel.: +81 45 581 1001; fax: +81 45 573 9599. E-mail address: suzuki-ys@tsurumi-u.ac.jp (Y. Suzuki).

There is sound evidence that an implant overdenture signicantly reduces certain problems compared to conventional complete dentures [2,3]. Implant overdentures have developed into a reliable treatment option in cases of edentulism both in the mandible and maxilla. On the other hand, there are several treatment options for rehabilitation of partial edentulism with free-end missing (Kennedy classication I or II). A well-constructed removable partial denture (RPD) can usually be considered as a costeffective and acceptable alternative treatment option for the rehabilitation of partially dentate patients. To improve the retention and stability of distal extension RPDs, implants are placed at the distal position to transform a Kennedy class I and II to Kennedy class III situation. Using implant tooth-supported RPDs, distal occlusal support can be increased, and denture movement can be reduced during chewing [47]. However,

1883-1958/$ see front matter # 2011 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved. doi:10.1016/j.jpor.2011.05.002

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3. Results A total of 201 implants were placed: 112 (56%) of these were maxillary and 89 (44%) were mandibular implants. The average number of implants was 3.6 in the maxilla and 2.8 in the mandible; maxillary implants were placed approximately 1.3 times more often than mandibular implants. The positions of implant placement were: incisor (87 implants; 44%); canine (53 implants; 26%); premolar (36 implants; 18%); and molar (25 implants; 12%) (Fig. 2). A greater number of implants were anterior compared to posterior in both the maxilla and mandible. Approximately 19% (12) of the patients were partially edentulous, and 81% (51) were fully edentulous (Fig. 3). The clinical situation for about half of the partially edentulous patients (6) was free-end missing (Kennedy classication I or II). The average period after the prostheses were delivered was about 4 years in both maxilla and mandible. Approximately 70% of the retainers were bar attachments (23; 36%) or magnet attachments (22; 35%). The bar attachments were selected for CM bar, Dolder bar (CM) and Hader bar (Hader). A healing abutment (6; 10%) was selected for the retainers of the implant-supported distal extension removable partial dentures and it connected directly to denture base using overlay technique (Fig. 4). The telescope system and O-ring attachment system were included as other retainer systems. The majority of the prostheses were metal-based dentures (53; 84%) compared to only 10 acrylic dentures (16%) (Fig. 5). Seventeen (15 maxillary, 2 mandibular) of 201 implants failed because of the lack of osseointegration. Of the fully edentulous, fourteen (12 maxillary, 2 mandibular) of 171 implants were failed. The implants have functioned at a rate of 92% (88% maxillary; 97% mandibular) (Table 1). Four implants (3 maxillary, 1 mandibular) were lost during the no-loading period, and ve implants (4 maxillary, 1 mandibular) were lost during the rst one year after placement. Within the partially edentulous, three (3 maxillary, 0 mandibular) of 30 implants were failed. The implants functioned at a rate of 90% (79% maxillary; 100% mandibular) (Table 1). Three implants (3 maxillary) were lost in the rst two years after placement. Both fully and partially edentulous, the survival rate were signicant different between the maxilla and the mandibular. The denture complications observed during maintenance are shown in Table 2. Denture fracture in 4 patients, retainer breakage in 5 patients, retainer removal in 4 patients, and articial tooth fracture in 5 patients were observed in fully edentulous. Denture fracture in 1 patient, retainer removal in 1 patient and articial tooth fracture in 1 patient were observed in partially edentulous. All of the complications due to articial tooth fracture were found in the anterior part of the maxillary prostheses. Denture fracture in 4 patients was observed in the acrylic resin base. The total number of attachment repairs was higher in the bar group (5 patients) compared to the ball (2 patients) and magnet (2 patients) groups in fully edentulos. But there were no signicant differences among the types of attachment.

Fig. 1. Frequency and distribution of age and gender.

there is little evidence-based research that conrms such a treatment for partial edentulism. The aim of this study was to analyze information about the implants used, patients, denture modality, and complications after denture insertion in partially and fully edentulous patients with implant overdentures placed at Tsurumi University Dental Hospital during approximately 8 years.

2. Materials and methods A survey was performed about patients rehabilitated using implant dentures at the Tsurumi University Dental Hospital between January 2001 and March 2009. When treatment started, the patients were in fair health conditions as follows: no diabetes (dependence on insulin), bisphosphonates, irradiation, or chemotherapy, congenital or acquired oral defects, Sjogrens Syndrome, long-term intake of steroids, history of heart attack/chronic venous insufciency during the last 12 months, or anticoagulation (thrombocyte aggregation inhibitors were accepted). Patients suffering from high blood pressure were not excluded if it was well controlled by medication. The information from the clinicians records on each implant placed in all the patients was entered into an implant database chart. A total of 63 implant dentures were placed in 56 patients (26 men and 30 women); 31 maxillae and 32 mandibles were restored. The mean age of these patients was 69 years (in a range from 53 to 90 years) (Fig. 1). Four different implant systems were used: 55 (27%) were ITI implants (Straumann Institute, Waldenburg, Switzerland), 82 (42%) were Branemark implants (Nobel Biocare, Goteborg, Sweden), 51 (25%) were Nobel Replace implants (Nobel Biocare) and 13 (6%) were Nobel direct implants (Nobel Biocare). The patients were treated using either a conventional 2-stage loading protocol or a 1-stage immediate loading protocol. The implant length varied from 8.5 to 16 mm, depending on the amount of bone available. One hundred and ten (55%) implants were 10 mm or less in length. The implant diameter varied from 3.3 to 5.0 mm; 19 (9%) of the implants had a narrow diameter. Descriptive statistics were used for each patient, such as the implant positions and number, retainer designs, denture designs, implant survival rate and prosthetic complications. Statistical comparisons were carried out using Chi-square test at signicance level (a = 0.05).

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Fig. 2. Frequency and distribution of implant.

Fig. 3. Missing teeth situations.

4. Discussion The average numbers of maxillary implants placed were greater than the mandibular implants since the density and mechanical properties of the bone, amount of denture displacement during biting and direction of occlusal force are different in each jaw. For anatomical reasons, the numbers of implants placed at the anterior position were greater than at the posterior. There were greater variations in attachment designs observed in the reports on mandibular implant dentures. Both splinted (bar attachment) and non-splinted (often ball or magnet attachments) designs were utilized, with no clinically signicant differences in the implant survival rate [8]. In the present study, most of the retainers were bar or magnet attachments. The attachment selection was determined by the implant position, the direction of implant placement, and the denture space on the implant platform. The maxillary and mandibular overdentures were often fabricated with an acrylic resin base reinforced with a metal framework [9,10]. In this study, most of the prostheses were metal-based dentures instead of acrylic dentures in order to prevent denture breakage around the retainer above the implants.
Fig. 4. Retainer designs.

Of the removable prostheses, the implant survival rates were found, ranging from 71.3% to 83.7% in the maxilla and 83% to 100% in the mandible [8,1115]. Hutton et al. [16] reported that the 3-year implant failure rate of implant-supported overdentures was 6% in the mandible and 28% in the maxilla, but a multivariate statistical analysis nevertheless showed that the dental arch was not a signicant predictor of implant failure, the difference being mainly because of the interaction between the bone quality and quantity. The implants placed functioned at a rate of 92% (88% maxillary; 97% mandibular), which was clinically similar to results reported in recent studies [8,1115]. The implant failure rate in the rst year after delivery of the denture was 33% in the maxilla and 50% in the mandible. The reason why most of the implants failed was the lack of osseointegration in the rst year after delivery. The higher failure rate of the maxillary implants was in agreement with results reported previously [1719]. It should be observed,

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Y. Suzuki et al. / Journal of Prosthodontic Research xxx (2011) xxxxxx Table 2 Prosthetic complications. Prosthetic complications Denture fracture Magnet attachment detachment Ball attachment detachment Bar fracture Clip fracture Articial tooth fracture Fully edentulous 51 cases 4 2 2 2 3 5 Partial edentulous 12 cases 1 1 0 0 0 1

Fig. 5. Denture modalities.

Table 1 Number of implant failures (survival rate). Years Fully edentulous Maxilla (98) Before 2-stage surgery After loading 01 12 3 Total (survival rate) 3 4 3 2 12 (88%) Mandible (73) 1 1 0 0 2 (97%) Partial edentulous Maxilla (14) 0 1 2 0 3 (79%) Mandible (16) 0 0 0 0 0 (100%)

compared to the other attachments. The fracture of bar attachment was observed soldering point between the gold cylinder and the bar. It is attributed to inadequate soldering strength. The total number of repairs in a recent study was higher in the bar group than in the ball and magnet group; it was generally more time-consuming to replace clips and bars in the bar group compared to the matrices and overdentures in the ball and magnet group [28]. However, some of the attachment loosening and fracture may also be attributed to normal function, including patient insertion and removal of the prostheses. Therefore, it seems to be important that controls for these complication risks be made at regular intervals in the clinic.

5. Conclusion A total of 201 implants were placed for implant dentures: 112 in the maxilla and 89 in the mandible using bar and magnet attachments at the rate of approximately 70%. The majority of the prostheses were metal-based dentures compared to acrylic dentures. In fully and partially edentulous, fourteen (12 maxillary, 2 mandibular) of 171, and three (3 maxillary, 0 mandibular) of 30 implants were failed, respectively. Although the mandibular implant dentures placed were exceedingly reliable for rehabilitation with a high survival rate, the maxillary implant dentures exhibited a low survival rate and more frequent complications. Signicantly higher implant failures and prosthetic complications were observed in the initial period after placement (two years) than in the following years.

however, that all of the failed maxillary implants in the present study were lost during the healing period, and none were lost after the connection of the prostheses. The prosthetic success rate ranged widely across studies and prosthetic types. The evaluation of continuous prosthesis stability yielded high rates of success, generally exceeding 75% [8]. As reported in various clinical studies, it was observed that initially (in the rst two years), more prosthetic service had to be provided and the complication rate was signicantly higher than in the following years [20]. The prosthetic complications were somewhat higher than those seen in most other studies [2126]. Denture fractures were observed in one metal base and four acrylic bases dentures, there were signicant differences between them. Metal framework fracture was attributed to inadequate metal thickness. Fractures of the acrylic resin bases for implant overdentures might be caused by inadequate space for the resin between the attachments and the denture teeth, which thereby weakened the denture. The use of metal-reinforced overdenture bases can minimize this complication [27]. The number of articial tooth fractures was very high among the prosthetic complications. Maxillary implant overdentures exhibited a signicantly greater number of anterior articial tooth fractures compared to mandibular fractures because the maxillae receive the brunt of horizontal component of the occlusal force. In this study, the bar attachment underwent a greater number of repairs

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