Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Francesca Bonino
Luigi Gaudioso
implants for removable reconstruc-
Marcel Zwahlen tions? A systematic review on
Henny J.A. Meijer
implant-supported overdentures
Authors affiliations: Key words: dental implants, denture, edentulous mandible, edentulous maxilla, implant fail-
Mario Roccuzzo, Luigi Gaudioso, Private Practice, ure, overdenture, overlay, patient-centered outcomes, systematic review
Torino, Italy
Department of Maxillofacial Surgery, University of
Torino, Italy Abstract
Francesca Bonino, Department of Periodontology,
Tufts University School of Dental Medicine,
Objectives: The aim of this systematic review was to assess the optimal number of implants for
Boston, MA, USA removable reconstructions.
Marcel Zwahlen, Institute of Social and Preventive Material and methods: Medline and The Cochrane Central Register of Controlled Trials were
Medicine, University of Bern, Switzerland
Henny J.A. Meijer, Department of Prosthetic searched and complemented by hand searching. All trials published in English to October 2011
Dentistry & Department of Oral and Maxillofacial were included, in which overdentures, supported by a various number of implants, in adult
Surgery, University Medical Center Groningen, edentulous individuals were compared. Only randomized controlled trials with at least 12 months
University of Groningen, Groningen, The
Netherlands follow-up were selected. The outcomes of interest were implant loss, the amount of peri-implant
bone loss, the incidence of complications and the patient satisfaction.
Corresponding author: Results: No articles were found providing information regarding the maxilla. Eleven studies on the
Dr. Mario Roccuzzo
Corso Tassoni, 14, 10143 Torino, Italy mandible were included for the final comparative analysis. It was possible to make a comparison
Tel.: +39 011 7714732 among four categories: (i) 1 vs. 2 implants; (ii) 2 implants with ball attachments vs. 4 implants with
Fax: +39 011 7714732
a bar; (iii) 2 implants with a bar vs. 4 implants with a bar; (iv) 2 implants splinted with a bar vs. 2
e-mail: mroccuzzo@iol.it
unsplinted implants.
Conflicts of interest: Conclusion: For the maxilla there are no studies, at the present time, that can be utilized to
The authors have not declared any potential conflicts.
address the question of how many implants should support an overdenture. For the mandible, it
cannot be concluded that bone loss, patient satisfaction, or number of complications is
significantly related to the number of implants supporting the overdenture. Furthermore, splinting
two implants does not seem to offer additional value. Well conducted research is needed to
identify the prognostic factors for long-term success.
sensitive, and more accommodating of only one implant could increase patient satis- the mandible or implant supported mandibu-
tapered arches. However, ball attachments faction. For the maxilla, no studies were lar OD opposed by a new conventional den-
seemed to be less retentive than the bar found that could explicitly address the ques- ture in the maxilla. As a result, no data were
design. The use of immediately loaded tion. presented regarding the upper jaw.
implants in the anterior mandible for the OD The Annual Conference of the BSSPD (Brit- The aim of this review was to determine if
design seemed a promising treatment con- ish Society for the Study of Prosthetic Den- there are reasons to recommend a certain
cept. An OD retained by two implants in the tistry) was held in York on 6 and 7 April number of implants for retaining or support-
anterior mandible appeared to demonstrate a 2009 (Thomason et al. 2009). At the sympo- ing maxillary or mandibular OD, in terms of
higher burden of maintenance during the first sium on mandibular ODs, presenters offered implant loss, the amount of peri-implant
year than in subsequent years. Controversy a synopsis of the research available on the bone loss, the incidence of complications and
persisted as to whether the ball or bar design efficacy of an implant-supported OD in the the patient satisfaction.
requires more maintenance. There appeared edentulous mandible. The Consensus conclu-
to be no statistical difference when long-term sion was that a large body of evidence sup-
Material and methods
maintenance was compared among mandibu- ports the proposal of a two implant-supported
lar implant OD retained by two implants mandibular overdenture as the minimum
The first step in the review process was the
compared with those retained by three or offered to edentulous patients. No informa-
development of a protocol detailing all meth-
more implants. tion, however, was given regarding the type
ods of the review a priori. The focused (PICO)
On May 2425, 2002, a symposium was of attachment or regarding a comparison with
question for the review was: In edentulous
held at McGill University in Montreal, Que- multiple implants therapy.
patients rehabilitated with maxillary and/or
bec, Canada, during which experts presented The purpose of the systematic review by
mandibular implant-supported overdenture,
15 papers on the efficacy of OD for the treat- Cehreli et al. (2010) was to evaluate the
what is the optimal number of implants in
ment of edentulous patients (Feine et al. effects of implant design and attachment type
terms of lower incidence of biological/
2002). The consensus conclusion was that on marginal bone loss in implant-retained/
mechanical/technical complications and a
the two-implant supported OD should supported ODs. Based on the meta-analysis
higher level of patient satisfaction?
become the first choice of treatment for the of the literature that identified a total of
A second question came up after the initial
edentulous mandible, even though no infor- 4200 implants from 13 manufacturers, there
search and was: In patients with a mandibu-
mation was given regarding the ideal type of was no difference in marginal bone loss
lar 2 implant-supported OD, is there a differ-
attachment. around implants retaining/supporting a man-
ence between splinted and un-splinted
Sadowsky (2007) searched articles to estab- dibular OD relative to implant type or
implants in terms of lower incidence of bio-
lish treatment considerations for maxillary attachment designs.
logical/mechanical/technical complications
implant overdentures. The conclusions were In a systematic review on maxillary over-
and a higher level of patient satisfaction?
limited by the fact that he found a limited dentures Slot et al. (2010) assessed the sur-
number of articles relative to the design and vival of implants, survival of maxillary
Criteria for including studies
selection of the maxillary implant overden- overdentures and the condition of hard and
To be eligible for inclusion in the review,
ture treatment modality. The final statement soft tissues after a follow-up period of at least
studies, in English only, had to be random-
was that until a stronger hierarchy of evi- 1 year. A meta-analysis showed an implant
ized controlled trials (RCT) of at least
dence is available, emphasis on patient-medi- survival rate of 98.2% per year in case of six
12 months follow-up.
ated considerations should direct treatment implants and a bar anchorage. In case of four
Studies were considered for inclusion if
planning decisions. implants and a bar anchorage, the implant
they were:
In August 2007, the Scandinavian Society survival rate was 96.3%. In case of four
for Prosthetic Dentistry in collaboration with implants and a ball anchorage, the implant -conducted on patients >18 years;
the Danish Society of Oral Implantology survival rate was 95.2%. However, in this -fully edentulous;
arranged a consensus conference. Klemetti study, different studies with various designs -with information regarding opposing denti-
(2008) presented a systematic review address- were included, which weakens the evidence. tion;
ing the following clinical question: Is there One of the most recent studies is by Tho- -presenting interproximal radiographic exami-
a certain number of implants needed to mason et al. (2012). The study aimed to pres- nation.
retain an overdenture? According to his ent the current evidence and rationale to
Exclusion criteria:
research, in the maxilla and in the mandible, support the McGill and York consensus
patient satisfaction or function of the pros- statements. The conclusion was that there is -comparison of implant ODs to conventional
thesis are not dependent on the number of now overwhelming evidence to support the dentures;
implants or type of attachment. In the man- proposal that a two-implant OD should -comparison of implant ODs to FDP;
dible, an OD with two implants and with bar become the first choice of treatment for the -comparison of implant surfaces, geometries,
attachment has the least number of compli- edentulous mandible. No information was, characteristics;
cations. The consensus statement (Gotfred- however, given regarding the various options -comparison of different prosthetic designs;
sen et al. 2008) concerning the mandible, was in attachment systems, i.e. bars, ball attach- -comparison of loading protocols;
that it was not possible to conclude that ment, locator and/or possible adjunctive ben- -comparison of retention systems.
patient satisfaction, dentures function, or efits with the use of additional implants. The
implant survival improved by increasing the studies included were all comparisons where Methods of the review
number of implants. Moreover, studies were patients received either new complete con- A MEDLINE (PubMed search form) search of
found indicating that a mandibular OD with ventional dentures in both the maxilla and the literature was conducted up to and
230 | Clin. Oral Implants Res. 23(Suppl. 6), 2012/229237 2012 John Wiley & Sons A/S
Roccuzzo et al Implants & overdentures
2012 John Wiley & Sons A/S 231 | Clin. Oral Implants Res. 23(Suppl. 6), 2012/229237
Roccuzzo et al Implants & overdentures
Table 2. List of excluded studies and reasons for exclusion heterogeneity was I2 = 92.6% (P < 0.001). The
Author Year Reason for exclusion mean difference between splinted and un-
ten Bruggenkate et al. 1991 Opposing dentition & radiological parameters not reported splinted implants was 0.00 (CI 95%: 0.26;
Hooghe & Naert 1997 Not comparing different implant protocols 0.26) with low statistical heterogeneity.
Walmsley & Frame 1997 One single attachment system analyzed
Tang et al. 1997 Variable number of implants
Payne & Solomons 2000 Data extraction not possible
Discussion
Kiener et al. 2001 Retrospective study
Mau et al. 2003 Opposing dentition not reported Every patient should be offered sound advice
Yengopal 2004 Data not clearly stated
based on the best available evidence. Physi-
Schwartz-Arad et al. 2005 Single implant protocol analyzed
Rocha 2005 Opposing dentition not reported cian recommendations should always include
Visser et al. 2007 Not a prospective study the rationale, expected outcome, and alterna-
de Lange & van Gool 2007 Not a prospective study tives (Keirns & Goold 2009). This systematic
Karabuda et al. 2008 Opposing dentition and radiological parameters not reported
review aimed at identifying published infor-
MacEntee 2008 Financial costs analyzed
Strong 2009 Case report mation that allows assessing the optimal
Pieri et al. 2009 Single implant protocol analyzed number of implants for mandibular remov-
Balaguer et al. 2011 Retrospective study able reconstructions, in terms of implant loss
Ueda et al. 2011 Retrospective study
Cakarer et al. 2011 Different attachment systems analyzed and peri-implant bone loss. The question
Suzuki et al. 2012 Partial edentulous included whether there is an optimal number of
implants in mandibular implant retained or
supported overdentures has been raised for
four implants was 0.01 (CI 95%: 0.02; Bone loss several years.
0.03). The risk difference between 2 bar The amount of bone loss varied from 0.1 The first authors, who performed an RCT
implants and four implants was 0.00 (CI (Gotfredsen & Holm 2000) to 1.75 mm on the above mentioned topic, were Wismei-
95%: 0.01; 0.02). The risk difference (Stoker et al. 2011). Weighted mean differ- jer et al. (1997). They evaluated in over 100
between 1 and 2 implants was 0.00 (CI 95%: ence in bone loss and its 95% confidence patients the satisfaction by means of a ques-
0.04; 0.03). The risk difference between interval as well as the I2 statistics are tionnaire among a mandibular OD supported
splinted and unsplinted implants was 0.01 reported in Fig. 3. The difference in mean by two implants with ball attachments, two
(CI 95%: 0.04; 0.02). In all comparisons bone loss between 2 bar implants and implants with an interconnecting bar, and
statistical heterogeneity of results between four implants was 0.78 (CI 95%: 1.20; four interconnected implants. As no signifi-
studies was low to moderate. 0.36), but estimated with high statistical cant differences were found between the
232 | Clin. Oral Implants Res. 23(Suppl. 6), 2012/229237 2012 John Wiley & Sons A/S
Roccuzzo et al Implants & overdentures
1 implant 2 implants
1 2 Patient
Authors Implants Loading Follow-up Preloading Postloading Preloading Postloading implant implants satisfaction D
^
Walton et al. 4288 6 weeks 12 months 0/42 0/42 5/88 0/83 4 2 VAS
(2009)
*
Kronstrom et al. 1420 Immediate 12 months 3/14 7/20 1 0 NO
(2010)
^
No significant differences in baseline and 1 year result.
*
Both groups had high failure rates. Implant number does not impact the outcome.
Authors Implants Loading Follow-up 2 ball 4bar 2 ball 4 bar Patient satisfaction Complications D
*
Wismeijer et al. (1997) 68144 12w 16mo Questionnaire
Wismeijer et al. (1999) 64144 12w 19mo 0/64 0/140 1.3 0.27 (L) 1.4 0.23 (L1)
1.4 0.21 (R) 2.3 0.27(L2)
1.9 0.36 (R2)
1.4 0.26 (R1)
Timmerman et al. (2004) 64140 12w 8.3y Questionnaire
Stoker et al. (2007) 64140 12w 8.3y N; type
Stoker et al. (2011) 12w 8.3y 3/64 0/136 1.04 1.01 1.73 1.93
**
Burns et al. (2011) 54108 1624w 1y Questionnaire CIP
*
No differences in patient satisfaction.
The central two implants have more bone loss; less BOP in 2 ball implants than 4 bar implants.
No differences in patient satisfaction. In 2 ball less satisfaction at 8.3 y than at 19 mo.
No differences in the number of check-ups. In 2ball more demand for simple re-adjustment.
4bar implants have more bone loss and PI than 2 ball implants.
**
More retention in 4 bar than in 2 ball. No differences in clinical implant performance (CIP scale).
three treatment modalities, it was concluded implants and 30 patients with an OD on four support an OD, However, the follow-up was
that an OD retained by two ball attachments identical implants. No significant differences 1 year only.
was sufficient. The follow-up was limited to were observed with regard to peri-implant Wismeijer et al. (1999) presented the 19-
16 months only. clinical data and radiographic bone loss. It month results, based on the same population
The year later, Batenburg et al. (1998) trea- was concluded that there seemed not to be a of the previous study, on implant loss, PI,
ted 30 patients with an OD supported by two need to insert more than two implants to PD, attachment level, and bone loss. The
2012 John Wiley & Sons A/S 233 | Clin. Oral Implants Res. 23(Suppl. 6), 2012/229237
Roccuzzo et al Implants & overdentures
et al. (2010)
Stoker et al. 12w 8.3y 0/66 0/136 0.95 0.99 1.73 1.93
(2011)
Burns et al. 54108 1624w 1y Questionnaire CIP
(2011)
*
No differences in patient satisfaction.
No significant differences in clinical and radiographic parameters.
The central 2 implants have more bone loss.
No significant differences in clinical, radiographic parameters and patient satisfaction. In Meijer et al. (2009) in 4 bar more complications.
No differences in the number of check-ups.
**
No significant differences in patient satisfaction; rigid prosthesis anchorage was associated with fewer complications.
Higher bone loss in four implants bar in contrast to Visser et al. (2005) and Mejer et al. (2009).
No differences in clinical implant performance (CIP scale).
bleeding index was significantly lower for the ticipants with an OD on two implants with was an increased demand for aftercare in the
two Implant Ball Attachment group than ball attachments, decreased over time (from two implants with ball attachments group for
both two Implant Single Bar and four Implant 19 months to 8 years), the authors suggested simple readjustments, such as re-activating
Triple Bar groups two implants with ball that a mandibular OD retained by two the matrices. The authors concluded that an
attachment are best treatment. The radio- implants interconnected by a single bar OD with a bar on two implants was the most
graphic analysis revealed that the bone loss might be the best treatment strategy, in the efficient in the long term.
around the central two implants in the four long term. Meijer et al. (2009) reported the 10-year
Implant Triple Bar group was significantly Visser et al. (2005) presented the 5-year data of the previously published paper of Bat-
higher than all the others. results of a previous study (Batenburg enburg et al. (1998) and concluded that there
The 8-year results of the same study popu- et al.1998), with the addition of a question- was no statistically significant difference
lation (110 participants at baseline, 103 for naire on patient satisfaction and data on pros- between patients treated with a two or four
final examination) are presented by Timmer- thetic and surgical aftercare. There was no implant mandibular OD with respect to: clin-
man et al. (2004). Participants completed a difference in clinical and radiographical state ical state of soft tissues, radiographic bone
questionnaire focusing on several aspects of of patients treated with an OD on two or loss, patient satisfaction and surgical and
denture satisfaction and social functioning. four implants. Patients of both groups were prosthetic altercare. For reasons of cost-effec-
The responses showed no differences among equally satisfied with their OD. tiveness, a two-implant OD was advised.
the three treatment groups at the 8-year eval- Stoker et al. (2007) presented the 8-year Walton et al. (2009) compared, in a RCT,
uation. In the 19-month and 8-year evalua- results of the RCT of Wismeijer et al. (1997), satisfaction and prosthetic outcomes with
tions, the tests demonstrated a significant on over 100 patients, regarding the aftercare mandibular ODs retained by one or two
difference in satisfaction among the 3 groups and cost-analysis with three types of mandib- implants in 85 patients. The median satisfac-
for retention and stability of the mandibular ular implant-retained OD. The three groups tion was 93 (maximum 100) in the single-
OD. Since the score on the item retention showed no mutually significant differences implant group and 94 in the two-implant
and stability of the overdenture, for the par- in the total number of check-ups, but there group. Within each group, median improve-
234 | Clin. Oral Implants Res. 23(Suppl. 6), 2012/229237 2012 John Wiley & Sons A/S
Roccuzzo et al Implants & overdentures
Year of Events/N in
OD retained by a single midline implant
Author publication intervention and control RD (95% CI)
appeared to warrant consideration as an alter-
2ball vs 4bar
native to the standard 2-implant OD.
Stoker 2011 3/66 vs 0/136 0.05 (0.01, 0.10) A similar study design, comparing 1 vs. 2
Burns 2011 0/54 vs 0/108 0.00 (0.03, 0.03)
implants, was presented by Kronstrom et al.
Subtotal (I-squared = 53.0%, p = 0.145) 0.01 (0.02, 0.03)
(2010) in an immediate loading protocol on
2bar vs 4bar
36 subjects. Ten implants in nine subjects
Mejer 2009 3/54 vs 0/92 0.06 (0.01, 0.12) failed during the observation period, and
Stoker 2011 0/54 vs 0/136 0.00 (0.03, 0.03) three subjects with two implants each with-
Burns 2011 0/54 vs 0/108 0.00 (0.03, 0.03)
drew from the study, resulting in a 12-month
Subtotal (I-squared = 19.7%, p = 0.288) 0.00 (0.01, 0.02)
implant survival rate of 81.8%. Three sub-
1ball vs 2ball jects lost their only implant and one patient
Walton 2009 0/42 vs 0/81 0.00 (0.04, 0.04) lost both implants. The remaining five sub-
Kronstrom 2010 3/17 vs 7/32 0.04 (0.27, 0.19)
jects lost one of their two implants. Six of
Subtotal (I-squared = 0.0%, p = 0.723) 0.00 (0.04, 0.03)
the failures occurred during the first month
splinted vs unsplinted after placement. The 1-year examination was
Burns 2011 0/54 vs 0/54 0.00 (0.04, 0.04) carried out on 24 patients only. Immediate
Gotfredsen 2000 0/22 vs 0/30 0.00 (0.07, 0.07)
loading of one or two implants with a ball
Naert 2004 0/14 vs 0/18 0.00 (0.12, 0.12)
2012 John Wiley & Sons A/S 235 | Clin. Oral Implants Res. 23(Suppl. 6), 2012/229237
Roccuzzo et al Implants & overdentures
to zero between for all comparisons (2 ball In the last decade, a new self-aligning Conclusion
implants vs. 4 implants, 2 bar implants vs. 4 attachment system (Locator; Zest Anchors
implants, 1 vs. 2 implants, and splinted vs. LLC, Escondido, CA, USA) for implant- On the basis of available data it is difficult to
unsplinted implants). These results suggest retained OD has seen an increasing popular- demonstrate that a particular number of
that, in mandibular implant retained or sup- ity. Several recent studies have concluded implants offered better outcome as compared
ported OD, the risk of implant loss does not that the Locator system showed equal or to another. This should not be interpreted as
vary substantially by number of implants. superior clinical results than the ball and the meaning that implant supported OD are inef-
For peri-implant bone loss, the weight bar attachments, with regard to the rate of fective. The main limit encountered in this
mean difference was 0.26 (CI 95%: 0.57; prosthodontic complications and the mainte- review has been the overall poor methodolog-
0.05) between 2 bar implants and four nance of the oral function (Kleis et al. 2010; ical quality of the published articles, which
implants and 0.00 (CI 95%: 0.26; 0.26) Bilhan et al. 2011b; Cakarer et al. 2011; Mac- produced a limited number of selected arti-
between splinted and unsplinted implants. In kie et al. 2011; Cordaro et al. 2012). Never- cles for the mandible and none for the max-
2 bar implant supported OD mean bone loss theless, none of the included studies in this illa. Therefore, larger well-designed long-term
is less pronounced than four implants. In the review presented data including the use of trials are needed. Long-term prospective stud-
light of the small number of studies and a this type of tool. Further research with the ies comparing OD supported by a different
high heterogeneity across studies (I2 of aim to compare OD with 2 vs. 3 vs. 4 number of implants with Locator attach-
92.6%), these results should be interpreted implant Locator attachments should be ments should be encouraged, both in the
with caution. encouraged. maxilla and the mandible.
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