Anita Visser Gerry M. Raghoebar Henny J. A. Meijer Rutger H. K.

Batenburg Arjan Vissink

Mandibular overdentures supported by two or four endosseous implants

A 5-year prospective study

Authors afliations: Anita Visser, Gerry M. Raghoebar, Henny J. A. Meijer, Arjan Vissink, Department of Oral and Maxillofacial Surgery and Maxillofacial Prosthodontics, Groningen University Hospital, Groningen, the Netherlands Henny J. A. Meijer, Department of Oral Function and Prosthetic Dentistry, Dental School, Faculty of Medical Sciences, University of Groningen, Groningen, the Netherlands Rutger H. K. Batenburg, Department of Oral and Maxillofacial Surgery, Walcheren Hospital, Vlissingen, the Netherlands Correspondence to: A. Visser Department of Oral and Maxillofacial Surgery and Maxillofacial Prosthodontics University Hospital Groningen PO Box 30.001 NL-9700 RB Groningen The Netherlands Tel.: 31-(0)50-3613840 Fax: 31-(0)50-3611136 e-mail: a.visser@kchir.azg.nl

Key words: edentulous mandible, endosseous dental implants, overdentures, prospective study Abstract Objective: The aim of this 5-year prospective comparative study was to evaluate treatment outcome (survival rate, condition of hard and soft peri-implant tissues, patient satisfaction, prosthetic and surgical aftercare) of mandibular overdentures supported by two or four implants. Material and methods: Sixty edentulous patients with a mandibular height between 12 and 18 mm participated. Thirty patients were treated with an overdenture supported by two IMZ implants (group A) and 30 patients were treated with an overdenture supported by four IMZ implants (group B). Standardised clinical and radiographic parameters were evaluated 6 weeks after completion of the prosthetic treatment and after 1, 2, 3, 4 and 5 years of functional loading. Prosthetic and surgical aftercare was scored during the evaluation period. Results: One implant was lost (group A) during the healing period. There were no signicant differences with regard to any of the studied clinical or radiographic parameters of the peri-implant tissues between the groups. None of the patients reported sensory disturbances in the lip or chin region. No differences in satisfaction were observed between the groups. With regard to aftercare, there was a tendency of a greater need of prosthetic interventions in group A, while correction of soft-tissue problems was restricted to patients of group B. Conclusion: There is no difference in clinical and radiographical state of patients treated with an overdenture on two or four implants during a 5-year evaluation period. Patients of both groups were as satised with their overdentures.

Date: Accepted 5 February 2004 To cite this article: Visser A, Raghoebar GM, Meijer HJA, Batenburg RHK, Vissink A. Mandibular overdentures supported by two or four endosseous implants. A 5-year prospective study. Clin. Oral Impl. Res. 16, 2005; 1925 doi: 10.1111/j.1600-0501.2004.01085.x

Copyright r Blackwell Munksgaard 2004

Edentulous patients often experience problems with their mandibular complete dentures. Lack of stability and retention of their mandibular denture, together with a decreased chewing ability are the main complaints of these patients (Van Waas 1990). A modern and currently frequently used treatment possibility is to place endosseous implants in the mandible to support an overdenture (Short communication 2002). This is an approach that already was

studied by Jemt and Lindqvist in the 1980s (Jemt et al. 1985) and still is of great value in the rehabilitation of edentulous patients (Batenburg et al. 1998a). The survival rate of implants, either placed as a one- or twostage procedure, applied to support a mandibular overdenture has been shown to be successful in over 96% of all cases (Batenburg et al. 1998a; Buser et al. 1999; Heydenrijk et al. 2002). The 10-year survival rates of implants to support mandibular overdentures

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Visser et al . Implant-supported mandibular overdentures

tended to be slightly higher than survival rates of endosseous implants in the mandible used to support xed full-arch bridges, xed partial dentures or single crowns (MericskeStern et al. 2001; Ferrigno et al. 2002). For general application in the edentulous mandible, a treatment concept utilising two or four implants to support a mandibular overdenture has been proposed (Batenburg et al. 1998a, 1998b). Studies prospectively comparing various implant systems and/or number of implants are still sparsely reported in the literature. Most prospective mandibular overdenture studies with a follow-up period of at least 5 years evaluated one implant system and a xed number of implants only, e.g. the studies of MericskeStern et al. (1994) and Behneke et al. (2002) with the ITI dental implant system (Straumann AG, Waldenburg, Switzerland), and Jemt et al. (1996) and Naert et al. (1998) nemark implant system with the Bra (Nobel Biocare, Gothenburg, Sweden). Although these studies conclude that both one- and two-stage implants as well as treatment concepts with either two or four implants result in a good treatment outcome regarding prosthodontic rehabilitation of the patient with problems with their mandibular dentures, there is still a need for comparing the treatment outcome of two vs. four implants in a prospective study with predened inclusion and exclusion criteria. Only randomised evaluation studies comparing two or more treatment modalities can be conclusive (AntczakBouckoms 1988; Barmes 1990). Currently, few prospective studies have been published comparing the treatment concept with two or four endosseous implants to support a mandibular overdenture, all with a rather short evaluation period (Wismeijer et al. 1997, 1999; Batenburg et al. 1998b). Therefore, the aim of this prospective comparative study was to evaluate treatment outcome (survival rate, condition of hard and soft peri-implant tissues, patient satisfaction, prosthetic and surgical aftercare) of mandibular overdentures supported by two or four implants during a 5-year evaluation period.

Table 1. Baseline characteristics of groups A and B

Group A (n 30) Mean age in years (SD, range) Gender (number of males/females) Mean edentulous period lower jaw in years (SD) Mean mandibular bone height in mm (SD) Mean bone quality (possible score 14)
SD, standard deviation.

Group B (n 30) 55.7 (12.3, 3579) 6/24 21.8 (10.5) 15.7 (2.7) 2.7

54 (8.7, 3877) 9/21 21 (9) 15.8 (2.3) 3

Material and methods

Patient selection and treatment

Sixty edentulous patients (39 women, 21 men: mean age, 54.9 years; median, 52 years; range, 3881 years) were selected.

They were all referred by their dentist or general medical practitioner to our clinic for Oral and Maxillofacial Surgery and Maxillofacial Prosthodontics. All patients were suffering from reduced stability and insufcient retention of their mandibular denture. Inclusion criteria for the clinical trial were an edentulous period of at least 2 years and severe resorption of the mandible (mandibular height in the symphysis region between 12 and 18 mm), class VVI according to the Cawood classication (Cawood & Howell 1988). Patients with a history of radiotherapy in the head and neck region or a history of preprosthetic surgery or previous implant placement were excluded. The hospital medical ethical committee approved the study. The patients were informed about the treatment options (overdenture on two or four endosseous implants) which were both appropriate in the included patients. Written informed consent was obtained from all participants. Treatment was randomly allocated by lots resulting in 30 patients (group A) to be treated with two IMZ implants (titanium plasma spread (TPS), Friedrichsfeld AG, Mannheim, Germany) and 30 patients (group B) to be treated with four IMZ implants. The baseline characteristics are summarised in Table 1 showing that there were no signicant differences between both groups at the start of the study. The implants were inserted under local anaesthesia in the interforaminal region according to the procedure described by Kirsch (1983). All implants were placed as a twostage procedure by the same oral surgeon. In group A, the implants were placed in the canine region of the mandible, about 1 cm left and right from the midline. In group B, there was an equal distance between the four implants and the most lateral implants were placed at least 5 mm medially of the mental foramen. Standard postoperative treatment was composed of analgesics and chlorhexidin 0.2% mouthrinses, but no antibiotics. The distribution of the lengths of the implants is presented in Table 2.

Table 2. Distribution of lengths of inserted IMZ implants

L (mm) 11 2 IMZ 4 IMZ 12 36 13 22 38 15 26 46 60 120 Total

Three months after implant placement, second-stage surgery (thinning of the peri-implant mucosa and placement of the abutment) was performed. Two weeks thereafter, standard prosthetic treatment was carried out: a new maxillary complete denture and a mandibular overdenture supported by an individual made round bar with no distal extensions and clip attachment. One experienced oral-maxillofacial surgeon and one experienced prosthodontist treated all patients.
Clinical analysis

The clinical analysis included a number of parameters. Loose and lost implants were scored any time after placement. For presence of plaque, the index according to Mombelli et al. (1987) was used (score 0: no detection of plaque, score 1: plaque can be detected by running a probe across the smooth marginal surface of the abutment and implant, score 2: plaque can be seen by the naked eye, score 3: abundance of plaque). The presence of calculus (score 1) or the absence of calculus (score 0) was scored. To qualify the degree of peri-implant inammation, the modied Loe and Silness index (Loe & Silness 1963) was used (score 0: normal peri-implant mucosa; score 1: mild inammation, slight change in colour, slight oedema; score 2: moderate inammation, redness, oedema and glazing; score 3: severe inammation, marked redness and oedema, ulceration). For bleeding, the bleeding index according to Mombelli et al. (1987) was used (score 0: no bleeding when using a periodontal probe, score 1: isolated bleeding spots visible, score 2: a conuent red line of blood along

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Visser et al . Implant-supported mandibular overdentures

the mucosa margin, score 3: heavy or profuse bleeding). Probing depth was measured at four sites of each implant (mesially, labially, distally, lingually) by using a periodontal probe (Merit B, Hu Friedy, Chicago, IL, USA) after removal of the bar; the distance between the marginal border of

the mucosa and the tip of the periodontal probe was scored as the probing depth.
Radiographic analysis

Standardised intraoral radiographs using the long cone technique of each implant were obtained using a beam direction device as

described by Meijer et al. (1992) (Fig. 1a). Analysis was done with a digital sliding gauge (Helios digit E 2056, Schneider & Kern, Niedernhall, Germany). Two-point measurements were made along the implant axis from a xed reference point (connection between abutment and the goldcap of the bar structure, Fig. 1b) to the level of bone (Meijer et al. 1993). Measurement was performed mesially and distally of each implant. The jawbone quality was scored according to the classication of Lekholm & Zarb (1985) (Table 1).
Patient satisfaction

The questionnaire focused on complaints and consisted of 54 items (Vervoorn et al. 1988). It was divided into six scales: (A) (B) (C) (D) (E) Nine items concerning functional problems of the lower denture; nine items concerning functional problems of the upper denture; 18 items concerning functional problems/complaints in general; three items concerning facial aesthetics; three items concerning accidental lip, cheek and tongue biting (neutral space); 12 items concerning aesthetics of the denture.

(F)

The extent of each specic complaint could be expressed on a four-point rating scale (0 no complaints, 1 little, 2 moderate, 3 severe complaints).
Data collection
Fig. 1. Intraoral radiographs. (a) The beam direction device designed by Meijer et al. (1992) was used to place the intraoral radiographs in a xed position to obtain reproducible images at all evaluation time points. (b) Example of intraoral radiograph. Measurements were done from the bone level up to a xed reference point, viz. the connection between abutment and goldcapscrew.

Pretreatment satisfaction of the patients with their dentures was scored according to the method described above. The subsequent data collection (clinical analysis,

Table 3. Mean values of plaque-index (possible score, 03), calculus-index (possible score, 01), gingival-index (possible score, 03), bleeding-index (possible score, 03) and probing depth in mm at T0 (evaluation after placement of the overdenture), T1 (evaluation 1 year after placement of the overdenture) and T5 (evaluation 5 years after placement of the overdenture) and the signicance level of the differences between the groups
T0 Group A (n 30) Mean Mean Mean Mean Mean plaque-index (SD) calculus-index (SD) gingival-index (SD) bleeding-index (SD) probing depth in mm (SD) 0.3 0.4 0.5 1.1 3.9 (0.5) (0.5) (0.9) (0.6) (1.2) Group B (n 30) 0.6 0.4 0.5 1.3 3.6 (0.8) (0.5) (0.7) (0.5) (0.8) Signicance Not Not Not Not Not sig. sig. sig. sig. sig. T1 Group A (n 29) 0.4 0.3 0.5 1 3.9 (0.8) (0.5) (0.7) (0.5) (1.3) Group B (n 29) 0.4 0.5 0.6 1.1 3.6 (0.7) (0.5) (0.8) (0.5) (0.8) Signicance Not Not Not Not Not sig. sig. sig. sig. sig. T5 Group A (n 29) 0.5 0.4 0.7 0.9 4.2 (0.7) (0.5) (0.8) (0.6) (1.3) Group B (n 27) 0.4 0.5 0.8 1.2 4 (0.7) (0.5) (0.8) (0.7) (1.1) Signicance Not Not Not Not Not sig. sig. sig. sig. sig.

Standard deviations (SDs) are given between brackets. Not sig., not signicant.

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Visser et al . Implant-supported mandibular overdentures

radiographic analysis, patient satisfaction) of all patients was performed as in the following: T0 (baseline evaluation, 6 weeks after placement of the overdenture) and 1 (T1), 2 (T2), 3 (T3), 4 (T4) and 5 (T5) years after placement of the overdenture. One independent investigator performed the measurements in all patients to prevent inter-observer differences. Prosthetic and surgical aftercare was continuously scored during the 5-year follow-up.
Statistical analysis

died because of an accident and one patient (group B) had moved. At T5 (evaluation 5 year after placement of the overdenture), two patients (group B) had died. With regard to the variables studied, no signicant differences occurred between T1, T2, T3, T4 and T5. For reasons of clarity, only the results of the 1 (T1) and 5 (T5) years follow-up are given with exception of marginal bone loss as a function of time.

No signicant differences between the groups were observed. Also no signicant change in probing depths during the evaluation period was observed. None of the patients in this study showed any sign of sensory changes in lip or chin region.
Radiographic parameters

The data were analysed using t-tests for the continuous data and MannWhitney tests for the ordinal data. The correlation was tested using Pearsons correlation tests (SPSS for Windows, version 10.0, SPSS Incorporated, Chicago, IL, USA). In all tests, a signicance level of 0.05 was chosen.

Clinical parameters

Results
All patients completed T0 (evaluation 6 weeks after placement of the overdenture). At T1 (evaluation 1 year after placement of the overdenture), one patient (group A) had

During the healing period prior to the abutment connection operation, one implant was lost in group A (implant length 11 mm) resulting in a survival rate of the implants 5 years after loading of 99.9% (cumulative survival for IMZ implants, either placed in a two- or four-implant concept). After a period of 6 months, a new IMZ implant was successfully placed; this patient was included in the study for follow-up evaluation. During the functional period, no implants were lost. The mean scores on the indices for plaque, calculus, gingiva and bleeding were very low at all evaluation periods (Table 3).

The marginal bone loss as a function of time is shown in Figs 1 and 2. The average annual bone loss over 5 years of time was 0.32 and 0.25 mm in groups A and B, respectively. No signicant differences in bone loss were observed between both groups.
Patient satisfaction

2.0 1.8 1.6 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0.0 0 1 2
years

The mean scores of the six scales of the questionnaire focusing on the complaints of the patients are listed in Table 4. Before treatment, patients from both groups were equally dissatised with regard to their lower dentures. The functional complaints had signicantly improved at the 1-year evaluation (Po0.05) and remained at this level during the 5-year follow-up. Also (facial) aesthetics and neutral space had signicantly improved at both the 1- and 5-year follow-up (Po0.05). After treatment, patients of both groups were equally satised with their overdentures.
Prosthetic and surgical aftercare

Group A Group B

Fig. 2. Marginal bone loss as a function of time after loading of the implants by the overdenture.

The overall prosthetic aftercare during the 5-year follow-up is listed in Table 5. Concerning the prosthetic aftercare, there was a tendency of a greater need of prosthetic interventions in group A, while surgical correction of soft tissues seemed merely a problem restricted to patients of group B. In the rst year after placement, hardly any interventions were needed.

Table 4. Mean score of six scales concerning the denture complaints before, and 1 and 5 years after treatment (possible range, 03)
Pretreatment T1 n T5n Group A Group B Signicance Group A Group B Signicance Group A Group B Signicance (n 30) (n 30) (n 29) (n 29) (n 29) (n 27) (A) Functional complaints about lower denture (B) Functional complaints about upper denture (C) Functional complaints in general (D) Facial aesthetics (E) Neutral space (F) Aesthetics
n

mm

2.2 0.4 1 1.1 0.6 0.4

2.2 0.5 1 0.6 0.6 0.4

Not sig. Not sig. Not Not Not Not sig. sig. sig. sig.

0.2 0.1 0.1 0.1 0.1 0.1

0.2 0.1 0.1 0.1 0.1 0.1

Not sig. Not sig. Not Not Not Not sig. sig. sig. sig.

0.3 0.2 0.1 0.4 0.2 0.1

0.3 0.1 0.1 0.3 0.3 0.1

Not sig. Not sig. Not Not Not Not sig. sig. sig. sig.

Functional complaints had signicantly improved between T0 and the other evaluation times (Po0.05). Not sig., not signicant.

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Visser et al . Implant-supported mandibular overdentures

Table 5. Prosthetic and surgical aftercare during 5 years of follow-up

Aftercare Group A Group B T0T1 (n 29) T1T5 (n 29) T0T1 (n 29) T1T5 (n 27) New bar/gold cylinders New clips/fastening loose clips Relining upper denture Relining lower denture Repair denture base/teeth Readjustment occlusion New upper denture New lower denture Gingivectomy Palatal mucosa grafts Total 0 1 0 0 1 0 0 0 0 0 2 1 19 2 1 9 3 0 0 0 0 35 0 0 0 1 1 1 0 0 0 0 3 0 14 2 1 6 1 0 0 1 5 29

T0T1 refers to the period up to 1 year and T1T5 to the subsequent period after placement of the overdenture.

Prosthetic corrections mainly consisted of placing new clips or fastening loose clips. Also repair of the denture base or elements occurred rather frequently, while there was almost no need for relining of dentures or readjustment of occlusion. Surgical interventions were only needed in patients of group B and consisted of gingivectomy (one patient) and palatal mucosa grafts (ve patients) because of peri-implant hyperplasia of the mucosa and tissue overgrowth of the implants.

Discussion
This is the rst prospective study evaluating mandibular overdentures supported by two or four endosseous implants. The 5year survival rate of IMZ implants in this prospective study is over 99%. This percentage is comparable with other prospective studies which have reported survival rates of implants supporting an overdenture ranging from 86% to 98.8% (MericskeStern et al. 1994; Jemt et al. 1996; Naert et al. 1998; Meijer et al. 2000, 2001; Behneke et al. 2002). Comparison of the clinical and radiographic parameters between these studies is difcult because of the variation in clinical and radiographic parameters used. The mean indices for plaque, calculus, gingiva and bleeding were very low at all evaluation periods for the groups. Also no differences in loss of marginal bone were observed. The scores are comparable with the studies of Meijer et al. (2000, 2001) in which the same criteria were used. The strict oral hygiene regime to which patients

were subjected provided healthy periimplant tissues. Peri-operative antimicrobial treatment was not given either during the surgical procedures for insertion of implants and abutment connection. Given the high survival rate in this study it can be doubted whether there is still a rationale for the use of these agents in this type of surgery. To our opinion insertion of implants in the edentulous mandible is a predictable treatment modality and there seems to be no need for antimicrobial agents other than a chlorhexidine mouthrinse and proper oral hygiene. There was only a need for gingivectomy and palatal mucosa grafts in patients of group B. In our opinion, this might be caused by the fact that the distance between the implants in group B was smaller than group A. Further research regarding this subject is needed before any conclusion can be drawn. With regard to marginal bone level, no signicant differences were noted in increase of bone defects between groups A and B during the evaluation period. This is in agreement with the study of Wismeijer et al. (1997, 1999). These authors showed a signicantly higher bone loss around the central implants as compared with the lateral implants. In the present study, there was no signicant difference with regard to peri-implant bone loss between any of the four implants in group B during the evaluation period. Intraoral radiographs were used in the study of Jemt et al. (1996), who reported 0.5 mm bone loss during the entire 5-year follow-up. Naert et al. (1998) reported

0.6 mm during the rst year and thereafter an average annual bone loss of less than 0.1 mm. Bone loss reported in the present study is comparable with the results of the mentioned studies. Marginal bone loss was 0.7 mm for group A and 0.4 mm for group B during the rst year. This phenomenon of up to 1 mm bone loss has been described previously (Adell et al. 1981) and is related to maturation of bone after implant placement and adaptation of bone to withstand functional forces. An annual bone loss of 0.2 mm after this period has been recognised as acceptable (Albrektsson et al. 1986). In the present study, annual bone loss was seen in all groups, but did not exceed 0.2 mm. No correlation between the radiographic and peri-implant parameters was observed. Obviously, the clinical peri-implant parameters do not always predict the results of the radiographic periimplant bone loss (Batenburg et al. 1998a, 1998b). From this study, it is concluded that there is no difference in clinical and radiographical state of patients treated with an overdenture on two or four implants (in cases of Cawood class IVVI resorption) during a 5-year evaluation period. Patients of both groups were as satised with their overdentures.

sume Re
tude comparative et prospective de Le but de cette e es te valuer la gue rison (taux de cinq anne a e de survie, condition des tissus paromplantaires mous `se et durs, satisfaction du patient, prothe et chirurgie) `ses mandibulaires sur deux ou quatre imde prothe dente avec une hauteur mandis plants. Soixante e bulaire entre douze et 18 mm ont participe. Trente te s `se es patients ont e traite avec une prothe ancre sur deux implants IMZ (groupe A) tandis que les trente te s `se e autres ont e traite avec une prothe ancre sur `tres quatre implants IMZ (groupe B). Les parame te varadiographiques et cliniques standards ont e e s `s lue six semaines apre la mise en place de la `se prothe et ensuite une, deux, trois, quatre et cinq es `s anne apre la mise en charge fonctionnelle. Le tique a e e te value durant suivi chirurgical et prothe riode. Un implant a e perdu dans le groupe te cette pe riode de gue rison. Il ny avait aucune A durant la pe rence signicative en ce qui concerne aucun des diffe `tres radiographiques et cliniques e tudie des s parame tissus paromplantaires entre les deux groupes. Au cun des patients na rapporte dennuis sensoriels au `vre ou du menton. Aucune diffe rence niveau de la le te e dans la satisfaction na e observe entre les deux groupes. En ce qui concerne le maintien, une ne cessite plus importante dintervention au niveau des `ses e tait constate dans le groupe A tandis que e prothe

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Visser et al . Implant-supported mandibular overdentures

`mes des tissus mous na du la correction des proble tre effectue que chez les patients du groupe B. e e rence radiographique ou Il ny a donc aucune diffe s `se clinique chez les patients traite avec une prothe e ancre sur deux ou quatre implants durant un suivi es. taient de cinq anne Les patients des deux groupes e `ses. autant satisfaits de leurs prothe

Zusammenfassung
Hybridprothesen im Unterkiefer getragen von 2 oder 4 enossalen Implantaten. Eine prospektive Studie u ber 5 Jahre Ziel: Das Ziel dieser prospektiven vergleichenden Studie uber 5 Jahre war, das Behandlungsresultat (Ueberlebensrate, Zustand der peri-implanta ren Hart- und Weichgewebe, Patientenzufriedenheit, prothetische und chirurgische Nachsorge) von Hybridprothesen im Unterkiefer, welche von 2 oder 4 Implantaten getragen werden, zu untersuchen. Material und Methoden: An der Studie nahmen 60 zahnlose Patienten mit einer Unterkieferhohe zwischen 12 und 18 mm teil. 30 Patienten wurden mit einer Hybridprothese getragen von 2 IMZ Implantaten versorgt (Gruppe A), und 30 Patienten erhielten eine Hybridprothese auf 4 IMZ Implantaten (Gruppe B). Standardisierte klinische und radiologische Parameter wurden 6 Wochen nach Eingliederung der Rekonstruktion und nach 1,2,3,4 und 5 Jahren funktioneller Belastung ausgewertet. Die prothetische und chirurgische Nachsorge wurde wa hrend der Beobachtungsperiode aufgezeichnet. Resultate: 1 Implantat ging wa hrend der Einheilphase verloren (Gruppe A). Es bestanden keine signikanten Unterschiede in Bezug auf die untersuchten klinischen und radiologischen Parameter der peri-implanta ren Gewebe zwischen den zwei Gruppen. Keiner der Patienten beklagte Gefuhls storungen im Bereich der Lippe oder des Kinns.

Zwischen den zwei Gruppen bestanden keine Unterschiede bezuglich Zufriedenheit. Bei der Nach sorge bestand eine Tendenz eines grosseren Bedarfs an prothetischen Interventionen in Gruppe A, wa hrend Korrekturen von Weichteilproblemen auf Patienten der Gruppe B beschra nkt waren. Schlussfolgerung: Es bestehen keine Unterschiede in den klinischen und radiologischen Befunden bei Patienten, welche fur eine Beobachtungsperiode von 5 Jahren mit Hybridprothesen auf 2 oder 4 Implantaten versorgt worden waren. Die Patienten beider Gruppen waren mit ihren Hybridprothesen zufrieden.

diferencias entre los grupos respecto a la satisfaccion. Respecto al mantenimiento, hubo una tendencia a ticas una mayor necesidad de intervenciones proste en el grupo A, mientras que las correcciones en los tejidos blandos se circunscribieron al grupo B. Conclusiones: No hay diferencias en el estado clnico co de los pacientes tratados con una y radiogra sobredentadura en 2 o 4 implantes durante un periodo n de evaluacio de 5 anos. Los pacientes de ambos grupos estaban satisfechos con sus sobredentaduras.

Resumen
Objetivo: La intencion de este estudio fue prospectivo comparativo de 5-anos fue evaluar los resultados del tratamiento (ndice de supervivencia, condiciones de los tejidos duros y blandos periimplant arios, satisfaccion del paciente, mantenimiento postquirurgico y postprotesico) de sobredentaduras mandibulares soportadas por 2 o 4 implantes. todos: Participaron 60 pacientes Material y Me ntulos con una altura mandibular entre 12 y ede 18 mm. Se trataron 30 pacientes con una sobredentadura soportada por 2 implantes IMZ (grupo A) y 30 pacientes se trataron con una sobredentadura soportada por 4 implantes IMZ (grupo B). Se evaluaron metros clnicos y radiologicos a las 6 semanas para sico y tras 1, 2, tras conclusion del tratamiento prote 3, 4 y 5 anos de carga funcional. Se tomo nota del tico y quirurgico durante el mantenimiento proste periodo de evaluacion. Resultados: Se perdio un implante (grupo A) durante el periodo de cicatrizacion. No hubo diferencias metros signicativas respecto a ninguno de los para clnicos y radiogracos estudiados de los tejidos periimplantarios entre los grupos. Ninguno de los pacientes informo sobre molestias sensoriales en el labio o la region del menton. No se observaron

References
nemark, Adell, R., Lekholm, U., Rockler, B. & Bra P.-I. (1981) A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. International Journal of Oral Surgery 10: 387416. Albrektsson, T., Zarb, G., Worthington, P. & Eriksson, A.R. (1986) The long-term efcacy of currently used dental implants: a review and proposed criteria for success. International Journal of Oral & Maxillofacial Implants 1: 1125. Antczak-Bouckoms, A. & Chalmers, T.C. (1988) The importance of design and analysis in clinical trials. Journal of Oral Implantology 14: 3642. Barmes, D.E. (1990) The state of science of patient outcome research. Journal of Oral Implantology 16: 245247. Batenburg, R.H.K., Meijer, H.J.A., Raghoebar, G.M. & Vissink, A. (1998a) Treatment concept for mandibular overdentures supported by endosseous implants. A literature review. International Journal of Oral & Maxillofacial Implants 13: 539545. Batenburg, R.H.K., Raghoebar, G.M., van Oort, R.P., Heijdenrijk, K. & Boering, G. (1998b) Mandibular overdentures supported by two or four endosteal implants. A prospective, comparative study. International Journal of Oral and Maxillofacial Surgery 27: 435439. Behneke, A., Behneke, N. & dHoedt, B. (2002) A 5-year longitudinal study of the clinical effectiveness of ITI solid-screw implants in the treatment of mandibular edentulism. International Journal of Oral & Maxillofacial Implants 17: 799810. Buser, D., Mericske-Stern, R.D. & Lang, N.P. (1999) Clinical experience with one-stage, nonsubmerged dental implants. Advances in Dental Research 13: 153161. Cawood, J.J. & Howell, R.A. (1988) A classication of edentulous jaws. International Journal of Oral and Maxillofacial Surgery 17: 232236. Ferrigno, N., Lauretti, M., Fanali, S. & Grippaudo, G. (2002) A long-term follow-up study of nonsubmerged ITI-implants in the treatment of totally edentulous jaws. Part I: ten-year life table analysis of a prospective multicenter study with 1286 implants. Clinical Oral Implants Research 13: 260273. Heydenrijk, K., Raghoebar, G.M., Meijer, H.J.A., van der Reijden, W.A., van Winkelhoff, A.J. & Stegenga, B. (2002) Two-stage IMZ implants and ITI implants inserted in a single-stage procedure. A prospective comparative study. Clinical Oral Implants Research 13: 37180. Jemt, T., Chai, J., Harnett, J., Heath, M.R., Hutton, J.E., Johns, R.B., McKenna, S., McNamara, D.C., Van Steenberghe, D., Taylor, R., Watson, R.M. & Herrmann, I. (1996) A ve-year prospective multicenter follow-up report on overdentures supported by osseointegrated implants. International Journal of Oral & Maxillofacial Implants 11: 2918. Jemt, T. & Lindqvist, J. (1985) Masticatory movements in patients treated with xed prosthesis on osseointegrated dental implants in the mandible. Swedish Dental Journal 28 (Suppl.): 143150.

24 |

Clin. Oral Impl. Res. 16, 2005 / 1925

Visser et al . Implant-supported mandibular overdentures

Kirsch, A. (1983) The two-phase implantation method using IMZ intramobile cylinder implants. Journal of Oral Implantology 11: 197 210. Lekholm, U. & Zarb, G.A. (1985) Patient selection nemark, P.-I., Zarb, G.A. and preparation. In: Bra & Albrektsson, T., eds. Tissue-integrated Prostheses: Osseointegration in Clinical Dentistry, 199209. Chicago: Quintessence. Loe, H. & Silness, J. (1963) Periodontal disease in pregnancy. II: correlation between oral hygiene and periodontal condition. Acta Odontologica Scandinavica 21: 533551. Meijer, H.J.A., Geertman, M.E., Raghoebar, G.M. & Kwakman, J.M. (2001) Implant-retained mandibular overdentures: 6-year results of a multicenter clinical trial on 3 different implant systems. Journal of Oral and Maxillofacial Surgery 59: 12601268. Meijer, H.J.A., Raghoebar, G.M., Van t Hof, M.A., Visser, A., Geertman, M.E. & Van Oort, R.P. (2000) A controlled clinical trial of implantretained mandibular overdentures; ve-years results of clinical aspects and aftercare of IMZ nemark implants. Clinical Oral implants and Bra Implants Research 11: 441447.

Meijer, H.J.A., Steen, W.H.A. & Bosman, F. (1992) Standardized radiographs of the alveolar crest around implants in the mandible. Journal of Prosthetic Dentistry 68: 318321. Meijer, H.J.A., Steen, W.H.A. & Bosman, F. (1993) A comparison of methods to assess marginal bone height around endosseous implants. Journal of Clinical Periodontology 20: 250253. Mericske-Stern, R., Aerni, D., Geering, A.H. & Buser, D. (2001) Long-term evaluation of nonsubmerged hollow cylinder implants. Clinical and radiographic results. Clinical Oral Implants Research 12: 252259. Mericske-Stern, R., Steinlin Schaffner, T., Marti, P. & Geering, A.H. (1994) Peri-implant mucosal aspects of ITI implants supporting overdentures. A ve-year longitudinal study. Clinical Oral Implants Research 5: 918. Mombelli, A., Van Oosten, M.A.C., Schurch, E. & Lang, N. (1987) The microbiota associated with successful or failing osseointegrated titanium implants. Oral Microbiology and Immunology 2: 145151. Naert, I., Gizani, S., Vuylsteke, M. & van Steenberghe, D. (1998) A 5-year randomized clinical trial on the inuence of splinted and unsplinted

oral implants in the mandibular overdenture therapy. Part I; peri-implant outcome. Clinical Oral Implants Research 9: 170177. Short communication (2002) Clinical Oral Implants Research 13: 453454. Van Waas, M.A.J. (1990) The inuence of clinical variables on patients satisfaction with complete dentures. Journal of Prosthetic Dentistry 63: 307310. Vervoorn, J.M., Duinkerke, A.S.H., Luteijn, F. & Van Der Poel, A.C.M. (1988) Assessment of denture satisfaction. Community Dentistry and Oral Epidemiology 16: 364367. Wismeijer, D., Van Waas, M.A.J., Mulder, J., Vermeeren, J.I. & Kalk, W. (1999) Clinical and radiographical results of patients treated with three treatment modalities for overdentures on implants of ITI dental implant system. A randomized controlled clinical trial. Clinical Oral Implants Research 10: 297306. Wismeijer, D., Van Waas, M.A.J., Vermeeren, J.I., Mulder, J. & Kalk, W. (1997) Patient satisfaction with implant-supported mandibular overdentures. A comparison of three treatment strategies with ITI-dental implants. International Journal of Oral & Maxillofacial Implants 26: 263267.

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