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15]

Original Article

An in vitro comparative study to evaluate the retention

of different attachment systems used in implant‑retained
overdentures
Tejomaya Shastry, N. M. Anupama, Shilpa Shetty, M. Nalinakshamma
Department of Prosthodontics and Crown and Bridge, VS Dental College and Hospital, Bengaluru, Karnataka, India

Abstract Aim: The aim of this in vitro study was to compare the change in the retentive force and removal torque of
three attachment systems during simulation of insertion‑removal cycles.
Methodology: Edentulous mandibular models were made with heat‑cured polymethyl methacrylate
resin. Two implant replicas (CMI), of 3.75 mm diameter and 10 mm length, were placed in the
intraforaminal region. Acrylic resin mandibular overdentures were fabricated and provision was made to
receive three different overdenture attachment systems, prefabricated ball/o‑ring attachment (Lifecare
Biosystems, Thane, India), Hader bar and clip attachment (Sterngold, Attleboro, MA), and
Locator® implant overdenture attachment stud type (Zest Anchors LLC, USA). Using a universal testing
machine, each of the models were subjected to 100 pulls each to dislodge the overdenture from the
acrylic model, and the force values as indicated on the digital indicator were tabulated both before
and after thermocycling (AT).
Statistical Analysis Used: Statistical analysis comprised Kolmogorov–Smirnov test, Friedman test, and
Wilcoxon signed ranks test.
Results: The statistical model revealed a significantly different behavior of the attachment systems both
before and AT. The ball/o‑ring and bar attachments developed higher retentive force as compared to the
locator attachment. The bar and clip attachment exhibited the highest peak as well as the highest mean
retention force at the end of the study. The Locator® attachment showed a decrease in retentive potential
after an early peak.
Conclusions and Clinical Implications: The ball/o‑ring and bar and clip attachments exhibit higher retentive
capacities than the Locator® attachment over time.

Key Words: Dislodging cycles, Locator, overdenture attachment, retentive force, thermocycling

Address for correspondence:

Dr. Tejomaya Shastry, Room No. 110, KIMS Men’s Hostel, 18th Cross, 24th Main, Banashankari 2nd Stage, Bengaluru ‑ 560 070, Karnataka, India.
E‑mail: [email protected]
Received: 18th June, 2015, Accepted: 11th October, 2015

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How to cite this article: Shastry T, Anupama NM, Shetty S, Nalinakshamma

DOI: M. An in vitro comparative study to evaluate the retention of different
10.4103/0972-4052.176520 attachment systems used in implant-retained overdentures. J Indian
Prosthodont Soc 2016;16:159-66.

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Shastry, et al.: Retension of implant retained overdentures attachments

INTRODUCTION wear and thus resistance to repetitive removal and insertion

cycles.[21,22]
The most common problem associated with the management
of edentulous patients is the severely resorbed mandibular In addition to this, a change in retentive capacity of the
ridge, especially in older age when adaptive capacities are attachment systems is expected when the overdenture is
reduced.[1‑5] This compromised situation consequently results in subjected to a period of service in the oral cavity under the
the fabrication of unsatisfactory dentures with poor retention influence of inherently present fluids and ingested food and
and stability which can further precipitate psychosocial liquids during mastication and insertion and removal of the
problems.[6‑9] prosthesis. Micro‑ and macro‑movement between the retentive
surfaces of an attachment during mastication and removal of
The stabilization of the lower denture with two interforaminal the overdenture will lead to wear and diminish retentive forces
implants has provided reliable and predictable treatment over time.[23]
outcomes. It is regarded as the minimum standard of care for
edentulous patients.[10] Thus, the aim of this in vitro study was to test the hypothesis
that the new unsplinted attachment system experiences less
The prognosis of the prosthesis depends on two important change of retentive force after repeated insertion‑removal
factors: (1) Retention and (2) stress distribution. Retention cycles compared to clinically established splinted attachment
is the function of and is directly related to the attachment systems.
system employed. The success of implant‑retained overdentures
primarily depends on the retentive capacity of its attachment Aim of the study
element to sustain its long‑term functionality.[11] The aim of this study was to assess and evaluate the retentive
capacity of three most commonly employed attachment systems
The choice of the attachment is dependent upon the retention in implant‑retained overdentures.
required, jaw morphology, anatomy, mucosal ridge, oral
function, and patient compliance for recall.[12] Objectives
• To measure the retentive capacity of different implant
Ball attachments and bar units for implant overdentures have overdenture attachment systems
evolved from the early 1960’s. Ball attachments were considered • To compare the retentive capacity of these attachment
the simplest type of attachments for clinical application with systems
tooth‑ or implant‑supported overdentures.[13] However, it is • To compare the change in the retentive force of different
also well‑documented that o‑rings gradually loose retention, attachment systems during simulation of insertion‑removal
and must be replaced periodically. On the other hand, increased cycles.
technique sensitivity and costs but with favorable stability
have been reported regarding the bar attachments. Other Materials and equipment
disadvantages of the bar system include mucosal hyperplasia, • Edentulous mandibular acrylic resin models made
hygiene problems, and the necessity of the retention clip’s with heat polymerized polymethyl methacrylate resin ‑
activation.[14‑16] (DPI Heat Cure, DPI, Mumbai, Maharashtra, India)
• Two implant replicas (CMI) ‑ 3.75 mm diameter, 10 mm
The Locator attachment (Zest Anchors Inc., Homepage,
®
length [Figure 1a].
Escondido, CA, USA) which was introduced in 2001, is a
new system, which does not use the splinting of implants. Acrylic resin mandibular overdentures fabricated with heat
This attachment is self‑aligning and has dual retention in polymerized polymethyl methacrylate resin ‑ (DPI Heat Cure,
different colors with different retention values.[12,17,18] Locator® DPI, Mumbai, Maharashtra, India).
attachments are available in different vertical heights, they • Acrylic denture teeth ‑ (Acryl‑Rock)
are resilient, retentive, and durable, and have some built‑in • Prefabricated ball/o‑ring attachment (Lifecare Biosystems,
angulation compensation. In addition, repair and replacement Thane, India)
are fast and easy. There is a lack of clinical studies on the • Hader bar and clip attachment (Sterngold, Attleboro, MA)
Locator® system.[19,20] • Locator® implant overdenture attachment‑stud type
(Zest Anchors LLC, USA)
Typically, the combination of materials in overdenture • Resin cement (Relyx™, 3M ESPE)
attachments comprises a metal–metal or metal–plastic/nylon • Universal testing machine (UTM) ‑ Instron 5567
contact which might show differences regarding surface compression tension tensile meter

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Shastry, et al.: Retension of implant retained overdentures attachments

a a

c
b
Figure 2: (a) Prefabricated ball/o‑ring attachment. (b) Bar attachment.
Figure 1: (a) Two implant replicas (CMI) ‑ 3.75 mm diameter, 10 mm
(c) Locator attachment with various components
length. (b) Edentulous mandibular acrylic resin model with the two
implant replicas placed in the intraforaminal region (22 mm apart) and
retained with resin cement. (c) Mandibular overdenture fabricated in a A metallic housing with a rubber o‑ring component was
conventional manner using heat polymerized polymethyl methacrylate used for the ball and ring attachment.
resin
• Hader bar and clip attachment [Figure 2b]
A castable Hader bar of length = 22 mm;
• Manual thermocycling unit ‑ two S‑U‑Polytub, Schuler
diameter = 1.8 mm = 13 gauge.
Dental, Germany
Nylon rider‑length = 5 mm; width = 2.6 mm ‑ moderate
• Surveyor table and metallic clips.
retention
METHODOLOGY • Locator® attachment (Zest Anchors LLC, USA) [Figure 2c]
Tissue cuff length = 1.0 mm; diameter = 3.86 mm
Fabrication of study models Locator male blue inserts retention force = 1.5 lbs (6.7 N)
Edentulous mandibular models were made from heat Maximum convergence = 20°.
polymerized polymethyl methacrylate resin‑(DPI Heat Cure,
DPI, Mumbai, Maharashtra, India) [Figure 1b]. Each attachment system was secured into the implant replicas
on the acrylic resin model and the overdentures with the
Mandibular Overdentures were fabricated in a conventional corresponding housing were subsequently placed on it and
manner using heat polymerized polymethyl methacrylate tightened to 35 Ncm [Figure 3a‑f].
resin‑(DPI Heat Cure, DPI, Mumbai, Maharashtra, India)
[Figure 1c]. Experimental setup
Acrylic overdentures with respective attachment systems were
Three overdenture models were prepared and five denture placed on the acrylic edentulous mandibular models.
samples were prepared for each group.
• Group 1 ‑ Ball/o‑ring attachment Metallic clips were attached to the dentures and secured with
• Group 2 ‑ Bar and clip attachment clear autopolymerized acrylic resin (DPI Cold Cure, Clear,
• Group 3 ‑ Locator® attachment. DPI, Mumbai, Maharashtra, India).

The implant analogs (CMI 3.75 mm × 10 mm) were placed The edentulous acrylic model was secured in place using a
in the acrylic models using physiodispenser, simulating the surveyor table [Figure 4].
conventional placement of implant in osteotomy site in
Retention force testing before thermocycling
the mandible and subsequently secured with resin cement
With the UTM (Instron 5567 compression tension tensile
(Relyx™, 3M ESPE, USA) [Figure 1b].
meter), each of the models were subjected to 100 pulls each
IMPLANT OVERDENTURE ATTACHMENT to dislodge the overdenture from the acrylic model, and
SYSTEMS the force values as indicated on the digital indicator were
tabulated [Figures 5 and 6]. The dislodging force was applied
• Prefabricated ball/o‑ring attachment (Lifecare Biosystems, in a vertical direction in the center of the acrylic block joining
Thane, India) [Figure 2a] the two metallic clamps holding the overdenture with the UTM

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Shastry, et al.: Retension of implant retained overdentures attachments

a d

b e

c f
Figure 4: Edentulous mandibular acrylic resin model and overdenture
Figure 3: (a‑c) Ball attachment, bar attachment, and Locator® attachment with clips attached secured in place using a surveyor table
secured on to the implant replica on the acrylic resin model. (d‑f) Acrylic
resin overdenture with the o‑ring housing for ball attachment, nylon ryder
for the bar attachment, and the Locator male blue insert

Figure 6: Digital values as seen on the universal testing machine

Figure 5: Universal testing machine ‑ Instron 5567 compression tension the force values as indicated on the digital indicator were
tensile meter used to dislodge the overdentures from the models tabulated.

operating at a crosshead speed of 2 mm/30 ms. The readings RESULTS

were taken from the start of the test.
The Kolmogorov–Smirnov tests for normality revealed no
Thermocycling normal distribution (P < 0.05) for the data; thus, normal
All the overdentures with the attachments placed on the distribution was not assumed.
edentulous models were subjected to manual thermocycling
using S‑U‑Polytubs; one maintained at 5 ± 1° and other at Comparison of the repeated measures was performed using
55 ± 1° [Figure 7]. The test samples were subjected to a total Friedman’s test showing a statistically significant decrease in
of 5000 cycles with each cycle equivalent to 30 s of dwell concentration.
time in each temperature controlled tub with a transfer time of
10 s, with 5000 thermal cycles being equivalent to 6 months In Group 1, χ2 (1) =30.556, P < 0.001. Post‑hoc analysis
of service in the oral cavity.[24] None of the samples failed. with Wilcoxon signed‑rank test was conducted with a
Bonferroni correction applied, resulting in a significance
Retention force testing after thermocycling level set at P < 0.001. The mean concentration (± standard
Each of the models was again subjected to 100 pulls each deviation [SD]) was 56.26 (9.77) at baseline, 51.30 (5.08)
to dislodge the overdenture from the acrylic model and at after thermocycling (AT). A significant decrease was seen

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Shastry, et al.: Retension of implant retained overdentures attachments

between AT and baseline (Z = −5.969, P < 0.001) after the seen between AT and baseline (Z = −4.446, P < 0.001)
completion of 5000 thermal cycles [Tables 1‑5]. [Tables 1‑5].

In Group 2, χ2 (1) =45.343, P < 0.001. Post‑hoc analysis with Interpretation

Wilcoxon signed‑rank test was conducted with a Bonferroni The bar and clip attachment showed the highest mean retentive
correction applied, resulting in a significance level set at force of 70.66 N and 65.18 N before and AT, respectively.
P < 0.001. The mean concentration (±SD) was 70.66 (12.09) The maximum retentive force was exhibited by the bar and
at baseline, 65.18 (10.89) at AT. A significant decrease was
seen between AT and baseline (Z = −7.728, P < 0.001)
[Tables 1‑5].

In Group 3, χ2 (1) =17.640, P < 0.001. Post‑hoc analysis with

Wilcoxon signed‑rank test was conducted with a Bonferroni
correction applied, resulting in a significance level set at
P < 0.001. The mean concentration (±SD) was 41.72 (6.53)
at baseline, 36.74 (9.32) at AT. A significant decrease was

Table 1: Friedman test descriptive statistics

Group n Mean (SD)
Group 1
BT 100 56.26 (9.77)
AT 100 51.30 (5.08)
Group 2 Figure 7: Manual thermocycling unit S‑U‑Polytub, Schuler Dental,
BT 100 70.66 (12.09) Germany
AT 100 65.18 (10.89)
Group 3
Table 4: Wilcoxon signed ranks test‑ranks
BT 100 41.72 (6.53)
AT 100 36.74 (9.32) Group n Mean rank Sum of ranks
SD: Standard deviation, BT: Before thermocycling, AT: After thermocycling Group 1
AT‑BT
Negative ranks 77a 54.35 4185.00
Table 2: Friedman test mean rank
Positive ranks 22b 34.77 765.00
Group Mean rank Ties 1c
Group 1 Total 100
BT 1.78 Group 2
AT 1.23 AT‑BT
Group 2 Negative ranks 83a 56.49 4689.00
BT 1.84 Positive ranks 16b 16.31 261.00
AT 1.17 Ties 1c
Group 3 Total 100
BT 1.71 Group 3
AT 1.29 AT‑BT
BT: Before thermocycling, AT: After thermocycling Negative ranks 71a 53.77 3818.00
Positive ranks 29b 42.48 1232.00
Ties 0c
Table 3: Friedman test statistics Total 100
Group a
AT < BT, bAT > BT, cAT=BT. BT: Before thermocycling, AT: After
Group 1 thermocycling
n 100
Chi‑square 30.556
df 1 Table 5: Wilcoxon test‑statistics
Asymptotic significance 0.000 Group AT‑BT
Group 2 Group 1
n 100 Z −5.969a
Chi‑square 45.343 Asymptotic significance (two‑tailed) 0.000
df 1 Group 2
Asymptotic significance 0.000 Z −7.728a
Group 3 Asymptotic significance (two‑tailed) 0.000
n 100 Group 3
Chi‑square 17.640 Z −4.446a
df 1 Asymptotic significance (two‑tailed) 0.000
Asymptotic significance 0.000
Based on positive ranks. BT: Before thermocycling, AT: After thermocycling
a

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Shastry, et al.: Retension of implant retained overdentures attachments

clip attachment, 82.3 N (cycle no. 56); followed by Locator® overdentures. The experimental set‑up, however, may have had
attachment, 66.7 N (cycle no. 41); and ball/o‑ring attachment, a few limitations. The sample size of the specimen used was
65.4 N (cycle no. 13). A decrease in the retention force was relatively small, but was in accordance with previous similar
observed in all the three attachment systems after subjecting experiments.[30]
them to thermal cycles and this decrease was found to be
statistically significant (P < 0.05). It has to be kept in mind that for the current in vitro
experiment, only mono‑directional forces were applied, which
The results obtained are summarized in Table 6. does not represent a realistic model for a clinical situation with
overdentures. There, the main forces are generated in the region
DISCUSSION of the first molars which will lead to rotational forces on the
attachments through leverage.[31-33]
T he underlying principle in employing retentive
implant‑overdenture systems for the treatment of edentulous During the course of the study, the different attachments
patients is to increase denture retention and stability, thereby showed a complex evolution with peaks as well as increasing
promoting chewing function as well as patient comfort and and/or decreasing mean retentive forces. The statistical model
compliance.[25,26] revealed a significantly different behavior of the attachment
systems both before and AT [Figures 8 and 9].
Stud type, ball, and conventional bar attachments are the
commonly used anchorage systems in implant‑supported The ball/o‑ring and bar attachments developed higher
overdentures and their efficacy is scientifically supported.[27‑30] retentive force as compared to the Locator® attachments.
Hence, these attachment systems were chosen for this study. The bar and clip attachment exhibited the highest peak as
well as the highest mean retention force at the end of the
Splinted conventional bar attachments have demonstrated study [Table 6].
superior retentive capacities over unsplinted systems. However,
they have a few disadvantages; they are initially more expensive, The Locator® attachment showed a decrease in retentive
difficult to repair, and maintaining oral hygiene seems difficult, potential after an early peak.
especially for fragile elderly individuals.[27]

In comparison with the bar attachments, ball anchors were

preferred by clinicians because they were less technique sensitive,
cost‑effective, easy to use and to repair.[13]

Stud type attachments such as the Locator® were introduced as a

concept to simplify restorative procedures in implant‑supported
overdentures. This system is relatively easy in fabrication
and demonstrated clinically superior results when compared
with ball and bar attachments relative to prosthodontic
complications and hygiene.[29]

This study was performed under a controlled experimental

simulation to evaluate the retentive forces of three different Figure 8: Progression of mean retentive forces of the three attachment
types of anchorage systems used for implant‑supported systems (each group n = 10) before thermocycling

Table 6: Summary of statistical analysis

Parameter Ball/o‑ring attachment Bar and clip attachment Locator® attachment
Mean±SD
BT 56.26 70.66 44.72
AT 51.30 65.18 36.74
Initial mean retentive force 40.3±15.83 N 46.9±13.9 N 33.5±9.77 N
Minimum retentive force 20.6 N 39.5 N 33.1 N
Maximum retentive force 65.4 N (cycle number 13) 82.3 N (cycle number 56) 66.7 N (cycle number 41)
Change in retentive force after thermocycling Decreases Decreases Decreases
P <0.001 statistically significant <0.001 statistically significant <0.001 statistically significant
SD: Standard deviation, BT: Before thermocycling, AT: After thermocycling

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Shastry, et al.: Retension of implant retained overdentures attachments

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