|Year : 2022 | Volume
| Issue : 1 | Page : 36-42
Functional evaluation of edentulous Patients rehabilitated with immediate loaded implant retained mandibular overdenture: An in-vivo study
Kiran Laxmikant Awchat1, SR Iyer2, Dinesh Kumar3, VS Legha4, KV Arun Kumar4, Vinay Wadhwa3, Deepa Bhat5
1 Classified Specialist, Prosthodontics and Crown & Bridge, 14 Corps Dental Unit, C/o 56 APO, New Delhi, India
2 Command Military Dental Centre (Western Command), New Delhi, India
3 Senior Specialist, Army Dental Centre, Research and Referral Hospital, New Delhi, India
4 Classified Specialist, Prosthodontics and Crown & Bridge, Army Dental Centre, Research and Referral Hospital, New Delhi, India
5 Reader, Department of Pedodontics and Preventive Dentistry, Awadh Dental College and Hospital, Jamshedpur, Jharkhand, India
|Date of Submission||03-Jun-2021|
|Date of Acceptance||31-Jan-2022|
|Date of Web Publication||05-Apr-2022|
Kiran Laxmikant Awchat
Classified Specialist Prosthodontics and Crown & Bridge, 14 Corps Dental Unit, C/o 56 APO
Source of Support: None, Conflict of Interest: None
Background: Implant number, loading time and patient satisfaction are the critical issues in management of completely edentulous patients with implant prosthesis. Literature has mentioned the success of immediately loaded implant overdenture but only few studies are there in Indian scenario.
Methods: 15 completely edentulous patients in the age range of 40-70 years were selected for this study. Balanced occlusion Complete dentures were fabricated and inserted in the patient's mouth. Same patients were taken up for implant placement after 2 months and implants were evaluated for clinical parameters
Results: The patient responded favourably to this modality of treatment. The questionnaire method used for assessing masticatory capacity and general satisfaction showed positive impact at 6-month and 12-month follow-up compared to the baseline scores (P-value<0.001 for both).
Conclusion: Patient's satisfaction and masticatory capacity improved significantly with immediately loaded implant overdenture in this study. Study with more elaborate sample size is recommended to verify the results of this study.
Keywords: Immediate loading, implants, overdentures
|How to cite this article:|
Awchat KL, Iyer S R, Kumar D, Legha V S, Arun Kumar K V, Wadhwa V, Bhat D. Functional evaluation of edentulous Patients rehabilitated with immediate loaded implant retained mandibular overdenture: An in-vivo study. J Dent Def Sect. 2022;16:36-42
|How to cite this URL:|
Awchat KL, Iyer S R, Kumar D, Legha V S, Arun Kumar K V, Wadhwa V, Bhat D. Functional evaluation of edentulous Patients rehabilitated with immediate loaded implant retained mandibular overdenture: An in-vivo study. J Dent Def Sect. [serial online] 2022 [cited 2022 Jun 27];16:36-42. Available from: http://www.journaldds.org/text.asp?2022/16/1/36/342640
| Introduction|| |
Management of complete edentulism should address the biomechanical problems of the prosthesis while keeping the stomatognathic system in a healthy state. The treatment options in the management of completely edentulous patients include conventional complete denture and implant-supported/retained prosthesis.
Implant overdenture is a prosthesis that covers and rests on one or more dental implants and is partially supported by them (GPT-8). Different protocols have been described in the literature for surgical placement and prosthetic loading of implant-supported overdentures.
Some authors have questioned the gold standard of 'two-stage protocol recommended by Branemark., They were of the opinion that one-stage protocol with immediate loading is equally effective as the two-stage protocol. They also reported that root-form implants may successfully osseointegrate when kept above the bone during the stages of early bone remodeling. This surgical approach has been called one stage or nonsubmerged implant protocol because it eliminates the second stage implant surgery and aids in immediate prosthetic rehabilitation of the patient.
Experimental studies have shown that immediate loading of threaded implants does not necessarily lead to fibrous tissue healing. Instead, a bone-to-implant contact develops over a period, which is comparable to those obtained with implants that are loaded conventionally.
Even though the success of immediately loaded implant overdentures has been reported in the literature, yet limited studies are available regarding the outcome of this treatment modality in the Indian population. This study was therefore undertaken to evaluate the treatment outcomes of implant-supported mandibular overdentures retained with O-ring
| Materials and Methods|| |
- Patients (male or female) within the age group of 40–70 years
- The absence of any systemic disease
- Completely edentulous maxillary and mandibular arches
- Adequate inter-arch space
- Adequate bone quality (Type I, II, and III bone density according to Lekholm and Zarb Classification) and quantity (Division A and B bone)
- Patients with good oral hygiene.
- Any medical condition that would complicate the outcome of the study, such as alcohol or drug dependency, history of smoking, poor health or any other medical, physical or psychological condition that could have affected the surgical procedure or the subsequent prosthodontic rehabilitation
- Insufficient bone (Division C and D) and density (Type IV bone density according to Lekholm and Zarb classification) to place implants in the mandible.
This was a prospective cohort study. After obtaining ethical clearance from competent authority fifteen completely edentulous patients (male or female) coming to the Dental Outpatient Department of AFMC Pune, in the age group of 40–70 years were selected. A written consent was obtained from patients. Procedure for this prospective study was explained to patients. Complete dentures were fabricated with a balanced occlusion and inserted in the patient's mouth. After 2 months, the same patient was taken up for implant placement at B and D positions of the mandibular arch and immediately loaded.
The Myriad-Snap™ one-stage, single-piece implant was used in this study. These implants are with trabecular metal material. The transmucosal element of the implant consists of an abutment with a 3 mm long polished collar that transitions to a ball head. The osseous element of the implant features the Bioprofile™ thread and the Nanopore™ surface. The Bioprofile™ thread is an asymmetrical, self-tapping and surface extensive thread design. Bioprofile™ thread essentially comprises one synchronized self-tapping thread composed of three distinct thread profiles that are adapted to three different levels of bone biology. The Nanopore™ surface is patented calcium oxidized, nano-porous surface that features 3-dimensional interconnecting porosities. The information about the implants is as per the manufacturer (Equinox Medical Technologies, The Netherlands).
Strict asepsis was followed during surgeries and performed under local anesthesia. Incisions were placed on the site indicated for implants placement and a full-thickness flap was elevated using a periosteal elevator. Drilling in bone was done in sequential manner with a lot of cold saline till the desired dimensions were achieved. Myriad snap implants (equinox) of selected dimension were placed and only those cases were included in the study which showed an insertion torque (IT) value of 35 and above, for primary stability of implants [Figure 1]. The flaps were sutured with 3-0 silk suture after implant placement [Figure 2]. The O-ring attachment assemblies were placed over the implants; undercuts were blocked out and auto polymerizing acrylic resin was used for direct pickup of O-ring attachments [Figure 3] and [Figure 4]. The dentures were finished and polished following standard protocols. Postoperative antibiotics and analgesics were prescribed. The patients were advised only nocturnal removal of dentures to reduce the unwanted forces on implants for 1 month. Oral hygiene instructions were given and each patient was kept on a semisolid diet for the initial 15 days. Follow-up examination was carried out after 1 week, 15 days, and 1 month for any postsurgical pain or swelling or postinsertion complaints related to overdentures.
Postoperatively, all the implants were evaluated for the following clinical parameters at baseline and 12 months.
- Probing depths were recorded using peri-implant Hu Friedy plastic periodontal probe
- General satisfaction levels of each patient and their ability to masticate (comfort, self-assurance, esthetics or appearance) were recorded and quantified with a questionnaire and a verbal rating scale (VRS), before implant placement and 12 months, following insertion of Implant retained prosthesis. Each patient was asked to rate his/her score from 0 to 5 for questionnaire and 0–10 for VRSs respectively. The same questionnaire was translated to the local language (Hindi/Marathi) for patients who were not able to understand English.
| Results|| |
Amongst 15 cases studied, 7 (46.7%) were male and 8 (53.3%) were female. Seven cases (46.7%) had age <55 years and 8 cases (53.3%) had aged more than 55 years. The mean ± standard deviation of age of the group was 54.6 ± 5.1 years. The entire group had age ranged between 48.0 and 65.0 years.
[Table 1] shows the comparison of scores of probing depth at baseline and 12 months of implant placement at “B” and “D” position. [Graph 1] denotes graphical representation probing depths around implants at “B” and “D” position at mesial, distal, buccal and lingual sites, respectively. The mean Probing depth (“B” and “D” Position) across all sites is significantly higher at 12-month follow-up compared to the baseline Probing depth (”B” and “D” Position) (P < 0.001 for all).
|Table 1: The pair-wise comparison of probing depth (“B” and “D” position) at each site|
Click here to view
[Table 2] shows the comparison of scores of general satisfaction questionnaires and VRS for general satisfaction at baseline and 12 months of implant placement. [Graph 2] denoted a graphical representation of scores of questionnaire for general satisfaction and VRS for general satisfaction. The mean general satisfaction score (By Questionnaire) significantly increased at 12-month follow-up compared to the baseline Score (P < 0.001 for both). The mean VRS for General satisfaction significantly increased at 12-month follow-ups compared to the baseline Score (P < 0.001 for both).
|Table 2: The pair-wise comparison of general satisfaction score and Visual Rating Scale|
Click here to view
[Table 3] shows the comparison of scores of problems in masticatory capability questionnaires and VRS for masticatory capability at baseline and 12 months of implant placement. [Graph 3] denoted a graphical representation of scores of questionnaire for problems in masticatory capability and VRS for masticatory capability. The mean Masticatory capability score (By Questionnaire) significantly decreased at 12-month follow-ups compared to the baseline Score (P < 0.001 for both). The mean VRS for Masticatory capability significantly increased at 12-month follow-up compared to the baseline Score (P < 0.001 for both).
|Table 3: The pair-wise comparison of masticatory capability score and visual rating scale|
Click here to view
| Discussion|| |
The delayed occlusal loading protocol refers to the loading of an implant after 3 months of implant placement in the mandible and 6 months in the maxilla. Early occlusal loading refers to functional loading between 2 weeks and 3 months of implant placement. Immediate occlusal loading refers to an implant restoration in occlusion within 72 h after implant placement.
The immediate loading concept challenges the conventional time of 3–6 months, since prosthesis in the former concept, is loaded on the day of implant surgery. In 1986 Babbush et al. first demonstrated the technique of immediately loading four implants in mandibular symphysis with an overdenture. Since then, numerous clinical studies have proved that immediate loading in completely edentulous patients is a reality and has more than 90% survival rate.,
Two implant mandibular overdenture has been recommended as the standard of care for rehabilitating edentulous mandibular arch. The type of loading protocol and the type of implant to be used are still the subject of continuing research. Two-piece implants have shown predictable outcomes with all three types of loading protocols. On the other hand; the use of single-piece implants for the purpose of retaining an overdenture, especially in the case of a resorbed ridge is gaining popularity. Implant success and survival are based on the evaluation of the surrounding tissue. The most commonly used methods are the measurement of marginal bone loss and assessment of gingival health with the help of different indices.
Numerous studies regarding the immediate loading of unsplinted implants supporting mandibular overdentures have reported promising results.,, These studies concentrated on the evaluation of treatment outcomes of immediately loaded implants based on clinical parameters such as peri-implant tissue health and marginal bone loss. However, only a few studies have been carried out for a comprehensive evaluation of treatment outcomes including patient satisfaction and masticatory capacity in the Indian scenario. Therefore, the present study was planned to evaluate general satisfaction and functional efficiency in the form of masticatory capacity of completely edentulous patients, rehabilitated with immediately loaded implant-retained mandibular overdenture in the Indian population.
In this study, participants were selected based on a strict inclusion and exclusion criteria. The quality and quantity of bone were evaluated based on routine clinical evaluation and radiographic investigations including cone-beam computerized tomography (CBCT). The use of CBCT provided an accurate presurgical assessment of bone quality and quantity for ideal implant placement. Other researchers also recommend CBCT for diagnosis and treatment planning for dental implants.
In the present study, two implants were placed at B and D locations, respectively, in the inter-foramina region. Various researchers have recommended either one or two implants in the inter-foramina region of the mandible for increased retention. Even though the increase in the number of implants enhances retention and support, yet it also increases the cost and complicates the design considerations. Few clinical studies have indicated that an increase in the number of implants used to retain an overdenture does not proportionately influence the treatment outcomes and is not in this favor. Other systematic reviews and randomized clinical trials have concluded that two implants retained overdenture should be the minimum standard of care for edentulous patients. However, almost all of them are based on delayed loading and there are only a few studies for immediate loading, especially concerning the Indian population; hence, this study was undertaken.
Here, implants were inserted in the designated location following standard surgical protocol. Absolute parallelism was ensured during osteotomy with implant direction indicators and verified by intermediate radiovisiography.
It is reported that primary stability after implant placement is achieved by the physical congruence between the surgically created bone bed and the implant. Bicortical stabilization is required for such stability. IT and radiofrequency analysis are the most common clinical methods to assess the primary stability of implants. In this study the primary stability of implants with IT values of more than 35 Ncm, as measured with the help of a torque wrench, were included.
The criteria for implant failure as proposed by Smith and Zarb include; peri-implant radiolucency noted on the intraoral periapical radiograph, clinical mobility of implant, pain, or discomfort. All the implants survived during evaluation in the present study. Comparable implant success rates were reported when two free-standing implants were used to retain mandibular overdenture using immediate loading (94% to 100%).
Unnecessary loading and health of peri-implant tissues are major factors that govern implant success. To minimize tensile forces on the implants, the patients were instructed to remove the overdentures not more than once a day for cleaning, during the first 4 weeks after implant placement. For peri-implant health, several studies have advocated periodontal indices like gingival index, modified plaque index, and probing depth to assess peri-implant tissue health. In this study, the peri-implant tissue health was evaluated by assessing the probing depth. A calibrated plastic periodontal probe was used to measure the probing depth. There was a significant increase in probing depth at 6th and 12th months when compared to baseline. The increase in probing depths may be because of loss of crestal bone due to the deprivation of blood supply resulting from reflection of mucoperiosteal flap and also could be a resultant effect of immediate loading with the denture. This factor of crestal bone loss has been mentioned in the study by Roe et al. which has shown that raising flaps will lead to bone resorption. Another reason for an increase in probing depth could be attributed to inadequate oral hygiene and plaque deposition resulting in inflammatory changes in marginal gingiva, leading to pseudo pockets. In this study, the probing depth from the 6th to 12th months increased only marginally. This may be because of the reinforcement of oral hygiene instructions to the patient during the study. Proper oral hygiene maintenance has been an important factor in maintaining soft tissue health around implants, as was brought out by Bilhan et al. A randomized control trial by Elsyad et al. on immediately loaded two implants supported mandibular overdentures have observed a significant increase in probing depth around peri-implant tissue during follow-up at 2 weeks, 6 months, and 12 months interval. Similar studies of immediately loaded implant-supported overdentures have indicated a significant loss of marginal bone while not mentioning probing depth around implant. However, there are other studies for delayed loaded implant-supported mandibular overdentures, which did not report any significant difference in probing depths around implants over a period of 1–10 years.
Patient satisfaction with treatment is a highly complex phenomenon that is influenced by various factors such as lifestyle, patient expectation, and attitude toward treatment. Patient satisfaction is one of the important goals in the rehabilitation of edentulous patients. Various studies have shown that delayed loaded implant-supported overdentures provided better patient satisfaction (more than 95%) when compared with conventional dentures. Various methods are in use for the evaluation of patient satisfaction such as Questionnaire, Visual Analog Scales, VRSs, and Oral Health Impact Profile. Questionnaire and VRSs were utilized in this study to evaluate patient satisfaction and masticatory capacity. The questionnaire on general satisfaction included the questions related to pleasure, chewing, appearance, comfort, self-assurance, social impact, and speech. The questionnaire on problems in masticatory capability included questions related to interrupted meals, special food, chewing difficulty, fragmentation, embarrassment, denture stability, and chewing sticky foods.
The scores of questionnaire for general satisfaction showed significant improvement after overdenture insertion of 12 months compared to baseline.
The scores of questionnaire for problems in masticatory capacity showed a significant decrease after overdenture insertion of 12 months compared to baseline This could be attributed to the better retention and stability provided by overdenture which in turn could have translated into better masticatory efficiency, phonetics, etc., as a result of better control of prosthesis.
The VRS on overall general satisfaction and masticatory capacity included a 10 point scale. The VRS for general satisfaction as well as masticatory capability showed significant improvement after overdenture insertion at 12 months.
Most of the studies have found similar results with more than 96% general satisfaction levels and 95% masticatory capacity when compared to conventional complete dentures.,,,, However, these studies were limited to delayed loaded two to four implant-supported overdentures. However, in these studies patients had to wait for a prolonged healing period of 3 months and more. This delay in the final rehabilitation is increasingly unacceptable to patients especially when it is impractical to use conventional dentures over the implants, during the healing periods ranging from 3 to 6 months.
This study involved a small population and useful information was found. This limitation should be acknowledged and a larger sample size, with a control group and long-term follow-up, will undoubtedly provide more insight regarding the viability of this procedure.
| Conclusion|| |
Immediately loaded two implants supported mandibular overdenture is an effective treatment modality in the rehabilitation of completely edentulous arches with improved patient satisfaction and masticatory capacity. It can be a rehabilitative modality of choice over the conventional complete denture in the mandibular edentulous arch if the patient's medical condition is conducive and the primary stability of implants can be achieved.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]