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QUINTESSENCE INTERNATIONAL

Overdentures represent a valuable and reli-

able alternative for completely edentulous

patients.1,2 Patients wearing overdentures

have demonstrated a significant increase in

their chewing ability, nutritional status, emo-

tional stability, and esthetics.3–6 Moreover, the

rigid anchorage of a mandibular overdenture

with a bar combines the prosthodontic

advantages of a removable and fixed pros-

thesis.7 However, a disadvantage of treat-

ment with overdentures is the time necessary

for healing before the insertion of the defini-

tive prosthesis.4 Usually, the matrices of the

bar or the freestanding attachments are con-

nected 3 to 6 months after implant insertion.2

Subsequently, a series of interventions

aimed at the relining of the prosthesis are

needed to maintain the stability and cleanli-

ness 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 possibil-

ity of an immediate loading of dental implants

supporting overdentures to minimize the

delay between the surgical and prosthetic

phases.1,8–10 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 load-

ing did not negatively affect osseointegration

in mandibular overdentures,11 and no differ-

ences in the results between conventionally

loaded and immediately loaded implants

supporting overdentures were found.4

A new treatment concept for immediate loadingof 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 interforami-

nal 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 con-

cept presented here resulted in stable complete denture retention, reduced the denture

base, and improved oral hygiene. (Quintessence Int 2010;41:489–495)

Key words: complete dentures, dental implants, edentulous mandible, immediate loading,

overdentures, prefabricated telescopic restorations

1Private Practice, Naples, Italy.

2Private Practice, Caserta, Italy.

3Dental School, University of Chieti-Pescara, Chieti, Italy.

Correspondence: Prof Adriano Piattelli, Via F. Sciucchi 63, 66100

Chieti, Italy. Fax: 11-39-0871-3554076. Email:[email protected]




Eccel lente et a l

In 1997, Chiapasco et al12 published a mul-

ticenter retrospective study on 904 immedi-

ately loaded implants retaining mandibular

overdentures. The overall survival rate (SRR,

ie, implants still in place at the end of the fol-

low-up) was 96.9% with a mean follow-up of

6.4 years. Subsequently, the same group con-

ducted a series of prospective studies inwhich they demonstrated that the overall sur-

vival and success rates (SCR, ie, good clinical

and radiologic outcome) were comparable

with those obtained with a two-stage proce-

dure.13,14 In a clinical study with two immedi-

ately loaded implants supporting a ball

attachment retaining mandibular overden-

tures, a survival rate of 100% was reported

after 1-year follow-up.2 A stable and retentive

prosthesis may allow proper healing of the

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 implant-

supported overdentures.15

The aim of the present study was to clini-

cally evaluate patients with mandibular over-

dentures supported by the AnkylosSynCone

system.

METHOD AND MATERIALS

Between January 2002 and November

2005, 39 consecutive patients with edentu-

lous mandibles were treated with 156

Ankylos implants (Dentsply Friadent) placed

by two oral surgeons (T.E. and M.P.) in a pri-

vate practice. Table 1 shows the dimensions

of the examined implants. The patient popu-

lation 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 inclu-

sion criteria were sufficient bone volume

(minimum bone height of 12 mm, minimumbone width of 5 mm) for the insertion of four

interforaminal implants and a completely

edentulous mandible needing a total rehabil-

itation. Exclusion criteria were systemic

diseases likely to compromise the implant

surgery, uncontrolled diabetes, leukocyte

dysfunction, chemotherapy, drug and alco-

hol 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 wasinduced by infiltration of mepivacaine buccal-

ly 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.

Diameter

Length (mm) 3.5 mm 4.5 mm

9.5 5 111 66 28

14 54 2

Total 125 31

Tabl e 1 Dimension and distribution of implants




Eccel lente et a

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 bonedefects 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 muco-

periosteal 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 contin-

uously 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 limita-

tions were also lifted after these 4 weeks.

Approximately 10 weeks after implant place-

ment, the patients were instructed to take out

and put in the denture at least once per day.

Twenty-five patients received a new den-

ture (18 with metallic framework) after a heal-

ing 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 peri-

od. Panoramic radiographs were taken at

implant placement, after 6 and 12 months,

and at different time intervals during the

observation period (Fig 5).

Fig 2 Clinical view of four interforaminal implantsafter insertion.

Fig 3 The SynCone abutments in situ beforesuturing.

Fig 4 The SynCone copings are polymerized intothe denture base directly in the mouth of the

patients.

Fig 5 Postoperative radiograph.




Eccel lente et a l

Technical complications were recorded.

Patient satisfaction was evaluated 4 weeks

after surgery and 1 year later.

RESULTS

No sensory disturbance was recorded fol-

lowing 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 peri-

implant soft tissue conditions showing lowvalue of clinical parameters (mSBI = 1; mPI =

1) (Figs 6 and 7). Swelling or suppuration

were not observed. Radiographic examina-

tion showed excellent bone healing and sta-

ble 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.

During the observation period, abutment

screw loosening occurred in two cases (in 2

patients). Fourteen partial breaks of the den-

ture 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).

DISCUSSION

Previous reports have described a method

that uses four implants rigidly connected by a

U-shaped bar.12,14,17–20 This technique allows

good stabilization of the implants despite the

immediate loading. Thus, implants seem not

to be exposed to movements that may com-

promise 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 fac-

tors or financial problems, and overdentures

may represent a more affordable treatment.1

The success of the overdenture treatment isrelated 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 con-

ditions, healthy soft tissues, good oral

hygiene, acceptable peri-implant marginalbone loss, low incidence of prosthodontic

maintenance, and high patient satisfaction.

The results of the present study were in

agreement with these studies with a cumula-

tive implant survival rate of 98.7%.

The Ankylos SynCone conical crown sys-

tem consists of four implants inserted and

immediately loaded in the mandibular inter-

foraminal area.15 Bone quality, a host-related

factor, is believed to be the strongest predictor

Implant Reason

Time of length Time of for

Sex/age Site implantation (mm) failure failure

Female/70 y Right first Immediate 14 8 wk Mobilitypremolar

Male/71 y Right lateral Late 11 6 wk Mobility

incisor

Table 2 Failure analysis

Time Implant at Failures Success Cumulative

interval interval Implants during rate survival

(y) start Dropouts at risk interval (%) (%)

0–1 156 0 0 2 98.7 98.7

1–2 154 0 0 0 100 98.7

2–3 110 0 0 0 100 98.7

3–4 70 0 0 0 100 98.74–5 38 0 0 0 100 98.7

Table 3 Life table




Eccel lente et a

Fig 6 Clinical and radiographicviews 6 months after treatment.

Fig 7 Clinical and radiographicviews 5 years later.

of outcome in immediate loading.23–27 Misch

and Degidi28 have reported that most immedi-

ately loaded implants are placed in anatomi-

cal sites with bone quality D1 or D2. It is

well-known that the mandible (especially the

interforaminal region) has a better bone quali-

ty 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 pro-

cedure may be executed in the dental office

without the use of a dental laboratory. Indeed,

it consists of the implant insertion and abut-

ment connection; subsequently, the gold

matrices were inserted on the abutments and

polymerized in the prosthetic base directly in

the patient’s mouth. The entire procedure



(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 pros-

thesis was supported by only the implants, a

situation similar to a full-arch restoration.15

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 advan-

tages were its low cost, fast realization, high

stability of prosthetic restoration, and easy

management of the prosthetic phases.

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.

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Eccel lente et a l

How do you evaluate the . . . Insufficient Sufficient Excellent Not evaluable

. . . operative phase? 3 27 7 2

. . . postoperative phase? 2 16 21 0

. . . phonetics? 2 17 20 0

. . . masticatory function? 0 12 27 0

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. . . self–oral hygiene? 0 14 24 1

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How do you evaluate the . . . Insufficient Sufficient Excellent Not evaluable

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. . . postoperative phase? 3 18 18 0

. . . phonetics? 5 22 9 3

. . . masticatory function? 2 18 8 11

. . . esthetics? 3 17 12 7

. . . denture stability? 0 17 18 4

. . . self–oral hygiene? 11 13 4 11

Table 4 Patient satisfaction 4 weeks after surgery (n = 39)




Eccel lente et a

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