ISSN: 2320-5407 Int. J. Adv. Res.

10(05), 639-646

Journal Homepage: - www.journalijar.com

Article DOI: 10.21474/IJAR01/14749

DOI URL: http://dx.doi.org/10.21474/IJAR01/14749

RESEARCH ARTICLE
RADIOGRAPHIC EVALUATION OF CRESTAL BONE LOSS FOR BAR RETAINEDIMPLANT
OVERDENTURE SUPPORTED BY FOUR IMPLANTS VERSUS ALL ON 4 SCREW RETAINED
PROSTHESIS

Mohamed Shady1, Islam Kandil2 and Heba Abo-Elfetouh Elsheikh3

1. Lecturer of Prosthodontics, Faculty of Dentistry, Mansoura University.
2. Lecturer of Oral Medicine and Periodontology, Faculty of Dentistry, Mansoura University.
3. Lecturer of Oral and Maxillofacial Surgery, Faculty of Dentistry, Mansoura University.
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Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History To compare in-vivo conventional 4 parallelimplant placement and bar
Received: 19 March 2022 attachment with cantilever supporting complete overdenture with All-on four
Final Accepted: 25 April 2022 configuration supporting fixed screw-retained denture in the term of crestal
Published: May 2022 bone loss around implants
Materials and methods:Twelve male patients with good health and firm
mucosa were selected to participate in this study. Each patient received four
implants in the canine and second premolar areas of the mandible. The
patients were randomly classified according to posterior implants angulation
into two equal groups,Group(A) received four parallel implants in the canine
and second premolar areas, bar-clip attachment with cantilever retaining
complete overdenture while Group(B) recievedTwo anterior parallel implants
in the canine region and two posteriorly 30° tilted implants in the second
premolar area supporting fixed screw retained prosthesis. Crestal bone loss
around implants was measured for each patient by using cone beam computed
tomography (CBCT) and evaluation made at T6 and T12
Results:Therewassignificantdifference during comparing Marginal bone loss
at 6 months with that of 12 months at mesial, distal, buccal and palatal bone
for Group (A)(P=0.01, 0.025, 0.0001 and 0.007 respectively) and Group (B)
(P=0.03, 0.028, 0.007 and 0.001 respectively). Comparing the two groups,
there was no statistical difference at 6 months or 12 months.
Conclusion: Despite the limitations in this study, it can be denoted than both
treatment options provide the same values of marginal bone loss Only the
patient desire is still the contributing factor for choosing the type of
restoration, if the patient desire fixed prosthesis with reduced extensions then
treatment option used for group(B) (fixed detachable prosthesis screwed to
four implants with the posterior implants tilted 30° posteriorly) however when
access for oral hygiene measures is more important with patients that can't
maintain hygiene with fixed prosthesis, then the selection of group (A) will be
more appropriate.

Copy Right, IJAR, 2022,. All rights reserved.

……………………………………………………………………………………………………....

Corresponding Author:- Mohamed Shady

Address:- Lecturer of Prosthodontics, Faculty of Dentistry, Mansoura University.
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Introduction:-
For several years it was known to use implant for supporting complete overdenture to treat completely edentulous patients
that used complete dentures with limited retention and stability, the use of implants has improved the stability, retention
and support of removable prosthesis also improved the neuro-muscular adaptation and thus improving function1.

There is a wide variety of implant overdenture attachments, these attachments are either splinted as bar attachment or
solitary attachments as ball, telescopic, locator and magnetic attachments 2.

A mandibular implant-supported overdenture with four implants and a bar has been shown to produce the highest quality
of life scores. At the same time, it has been noted that patient satisfaction is not dependent on the number of implants or
the attachment type3.More implants may make the attachment system more rigid, producing more stability and retention.

Sometimes it’s impossible to place dental implants such as in cases with sever resorption of the alveolar ridge without
some sophisticated procedures as nerve transpositioning of maxillary sinus lifting or either bone grafting in the posterior
areas of the maxillary and mandibular arches in such cases there is a solution introduced by tilting the posterior implants
backward thus giving possibility of using longer implants providing better anchorage, decreasing the cantilever arm and
increasing the anteroposterior spread4.

Implant overdentures are indicated in patients with advanced bone loss as it offers artificial replacement to lost dental
tissues and supporting bone and is also considered a cost-effective treatment modality that implant supporting fixed
prosthesis5. However, many patients don't prefer restoration with removable prosthesis and desire fixed rather than
removable one 10,11. and though selecting the appropriate treatment plan would increase the quality and the satisfaction
level of patients.

Combining tilted and straight implants for supporting fixed prostheses can be considered a viable treatment modality
because of the high survival rate.16 However, the stability of peri-implant tissue and, especially, the marginal bone level
for these tilted implants has not been extensively studied. Unfavorable loading direction could cause more marginal bone
loss around these implants. In vitro studies have suggested accentuated stresses around implant necks that were nonaxially
placed.6,7 In addition, it is not known if angled implants are associated with a higher incidence of biomechanical
complications. For that reason, the primary aim of this study is to compare bar retained overdenture with distal cantilever
versus fixed screw retained prosthesis over implants placed according to all on 4 concept regarding crestal bone loss
around implants evaluated with CBCT.

Radiographs are valuable diagnostic tools as an adjunct to the clinical examination. Two-dimensional (2D) periapical and
panoramic radiographs are routinely used for assessing bone levels. In 2D imaging, evaluation of bone craters, lamina
dura and periodontal bone level is limited by projection geometry and superimpositions of adjacent anatomical structures.
These limitations of 2D radiographs can be eliminated by three-dimensional (3D) imaging techniques such as computed
tomography8. Cone beam computed tomography generates 3D volumetric images and is commonly used in dentistry. All
CBCT units provide axial, coronal and sagital multi-planar reconstructed images without magnification. Also, panoramic
images without distortion and magnification can be generated with curved planar reformation; CBCT displays 3D images
that are necessary for the diagnosis of intra-bony defects9

Materials And Methods:-

A number of twelve patients with healthy mucosa and good oral and general health were included in the study and
collected from the prosthodontic department in faculty of dentistry mansoura university and are characterized by that all
patients have acceptable amount to be sufficient for placing dental implants either in height and width related to
mandibular arch and verified by CBCT imaging, a minimum of 1 year after the time of last extraction, no old denture
experience and of class I Angles classification, and a good interarch space. any patient experiencing smoking alcoholism
radiation in the head and neck region, with any TMJ disorders was excluded

Presurgical and surgical phases:

Each patient received a complete denture and left to use for one month then a CBCT was made for the sake of construction
of a computer guided stereo lithographic surgical stent.

All patients were classified into 2 groups according to the angulation of implants placed within bone into:

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- Group A: Four parallel implants were planned in the edentulous mandible Two Implants in the canine regions and Two
implants in the second premolar region by the aid of implant software.
- Group B: Four implants were planned in the edentulous mandible Two axial Implants in the canine regions and Two
implants in the second premolar region with intended 30° posterior tilt by the aid of implant softwareFig(1).

Fig (1) Group (A) receiving 4 parallel implants while Group (B) receiving 4 implants according to All on 4 configuration

A computer guided surgical stent that is supported upon mucosa was used during surgery that help in placing implants in
the exact positions and angulations planned.

All patients received local anaesthesia and four tapered internal dental implants were placed in the canine and second
premolar regions by the aid of mucosal supported stereolithographic surgical stent according to the intended planned
positions and angulations(Fig 2).

Fig 2:- Surgical procedure for guided implant placement.

Prosthetic phase:
After three months of osseo-integration period exposure of implants were done, cover screws were removed then straight
multiunit abutments were placed in group (A) and anterior implants in group(B) whereas angled multiunit abutments (30°)
were placed on posterior implants in group (B)Fig (3). Then direct transfer open tray impression technique was made for
every patient to transfer the exact position of dental implants using long multiunit transfer copings in tray with opening
corresponding to implant sites, splinting of transfer copings with ligaturewire and composite resin then impression using
rubberbase impression material, multiunit implant analogues were attached to the transfer copings, finally pouring of the
impression was done after injection of tissue mimic material around analoguesFig(4).

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Fig 3:- Multiunit abutments were attached to 4 implants after ooseointegration period.

Fig 4:- Direct implant transfer impression.

Regarding the type of final prosthesis Group (A) will receive bar attachment connecting 4 implants with cantilever of
length 10 mm distally, complete overdenture will be retained via 3 yellow plastic clips.

While in Group (B) the bar will be incorporated within the final prosthesis with perforations corresponding to implants
sites that will aid in fixation.

Bar construction:
Four plastic multiunit abutments were screwed to the multiunit analogues on the master cast and screwed into position
with abutment screws. quadrilateral 3 bars (multi-purpose bar)with distal cantilever of length 13 mm with clip attachment
was fabricated and luted to plastic abutments with duralay resin while in group (B) bar with cantilever of length 7 mm was

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fabricated with dimensions ( height 2mm and width 2mm) to be incorporated in denture base. At least 1mm clearance
space should be left between the bars and the ridge to facilitate tissue cleansing under the bars.

Bars after construction (Casting,finishing and polishing) were tried inside patients’ mouth then a new mandibular denture
was constructed for each patient as follows:

For Group (A)Pick up of three yellow plastic clips was done for three bar assembly, block out under bar was done using
wax then direct pickup was done using self cure acrylic resin while patient biting in centric relation.

ForGroup (B)Final prosthesis was designed with no flanges and bar was incorporated inside final prosthesis with
perforations corresponding to implant sites that will aid in fixation (Fig 5)

Fig 5:- Bar-clip attachment for group (A) and screw retained prosthesis for group (B).

Marginal bone loss evaluation:

Radiographic evaluation was done by using Cone Beam CT (CBCT) immediately, 6 months and 12 months postoperative.
OnDemand3D program was used for image reconstruction and analysis.

For the calculation of marginal bone loss (MBL), the implant was used as a reference by adjusting the cross-
sectional and panoramic long axis in the centre of the implant and bisecting it (showing the buccolingual and
mesiodistaldimensions).

Cross-sectional view ofCBCT:

A line was drawn just parallel to the implant, starting at the crest of the buccal plate of bone and ending at the
apical level of the implant; height was recorded in millimeters immediately, 6 months and 12 months postoperative.
The same process was repeated from the palataldirection.

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Panoramic view ofCBCT:

The panoramic view was utilized to calculate the mesial and distal bone heights in millimeters immediately, 6 months
and 12 months postoperative.

Results:-
Table 1:- Showing no statistical difference regarding to marginal bone loss between two groups after 6 months of follow
up:
Groups
Marginal bone loss at 6 month Overdenture All on 4group P
group
Mean ±SD Mean ±SD
Mesial 0.78 0.50 0.77 0.48 0.95
Distal 0.59 0.44 0.79 0.67 0.5
Buccal 0.35 0.23 0.37 0.19 0.9
Palatal 0.73 0.45 0.57 0.32 0.46
SD:Standarddeviation P:Probability P: Significancewhen<0.05

Table 2:- Showing no statistical difference regarding to marginal bone loss between two groups after 12 months of follow
up:
Groups
Marginal bone loss at 12 Overdenture All on 4group P
months group
Mean ±SD Mean ±SD
Mesial 1.04 0.47 1.09 0.44 0.85
Distal 1.37 1.00 1.20 0.94 0.74
Buccal 0.60 0.23 0.65 0.21 0.68
Palatal 0.98 0.55 0.84 0.33 0.59
SD:Standarddeviation P:Probability P: Significancewhen<0.05

For Group (A) At 6 months, the mean of MBL were 0.78±0.5 mm mesially, 0.59±0.44 mm distally, 0.35±0.23 mm
buccally and 0.73±0.45 mm palatally.

At12months,themeanofMBLwere1.04±0.47mmmesially, 1.37±1 mm distally, 0.60±0.23 mm buccally and

0.98±0.55mmpalatally.

Mesial,distal,buccalandpalatal,thereweresignificantdifference during comparing MBL at 6 months with that of 12

months,(P=0.01, 0.025, 0.0001 and 0.007 respectively).

For Group (B) At 6 months, the mean of MBL were 0.77±0.48 mm mesially, 0.79±0.67 mm distally, 0.37±0.19 mm
buccally and 0.57±0.32 mm palatally.

At 12 months, the mean of MBL were 1.09±0.44 mm mesially, 1.2±0.94 mm distally, 0.65±0.21 mm buccally and
0.84±0.33 mm palatally.

Mesial, distal, buccal and palatal, there were significant difference during comparing MBL at 6 months with that of 12
months, (P=0.03, 0.028, 0.007 and 0.001 respectively).

Comparing the two groups, there was no statistical difference at 6 months or 12 months.

Discussion:-
In this study, calculations of bone loss were done by measuring the bone height 6 months and 12 months after insertion of
final prosthesisfor each implant surface in both groups, from the bottom to the top of the implant (which was used as a
reference), in order to measure the amount (in millimetres) and percentage of resorption for each surface and to compare
them with those of the other group10.

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CBCT was used for evaluation of marginal bone loss in this study as evidence shows that compared to conventional
radiography or 2D digital techniques, CBCT enables the clinician to visualize structures in thin sections without
superimposition of anatomical structures and also enables more accurate evaluation of bony changes due to periodontal
diseases.11,12

Studies comparing the use of 3D volumetric images and 2D images in detection of artificial bone defects have shown that
CBCT has a sensitivity of 80–100% in the detection of bone defects; while intraoral radiographs provide a sensitivity of
63–67%. When compared with periapical and panoramic images, CBCT has also shown an absence of distortion and
overlapping and the dimensions it presents are compatible with the actual size 13.

There was no significant difference in marginal bone loss around tilted and vertical implants of both groups, perhaps for
the following reasons: (1) the length of the implants used was long and (2) the splinting effect. To engage more bone to
maximize implant stability, most included studies utilized implants with a length of at least 10 and up to 20 mm. With
increasing implant length, more effective stress distributions for cancellous bone were found 14. Another finite element
study15 suggested that longer implants distributed stress better, resulting in reduced gap distances between bone and
implant. A prospective study16 did report that long implants (14 to 16 mm) had significantly less marginal bone loss than
average length (12 mm) implants at 1-year postloading. The comparable marginal bone loss for tilted implants could have
been partially due to their long length.

A more probable method to reduce stress around the neck of a tilted implant is splinting and reduction of the cantilever
length rather than increasing the implant length. 17,18 In all cases included in the present review, tilted implants were
splinted into a fixed prosthesis, either for a partial or full arch. The reduction of the cantilever span by tilted implants and
the rigidity of the prostheses could have helped to reduce stress. Some recent three-dimensional finite element
studies19,20suggested that tilted implants could benefit stress distribution by reducing cantilever length and, therefore, may
be a viable option. These computersimulation studies could have partially explained the favorable marginal bone level
around tilted implants

Conclusion:-
Despite the limitations in this study, it can be denoted than both treatment options provide the same values of marginal
bone loss

Only the patient desire is still the contributing factor for choosing the type of restoration, if the patient desire fixed
prosthesis with reduced extensions then treatment option used for group II (fixed detachable prosthesis screwed to four
implants with the posterior implants tilted 30° posteriorly) however when access for oral hygiene measures is more
important with patients that can't maintain hygiene with fixed prosthesis, then the selection of group II will be more
appropriate

Recommendations:-
Further extensive study with additional number of patients and more investigation methods is recommended for
comparingbetween the two treatment modalities and comparing them with others

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