Bone atrophy beneath implant supported overdentures

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1

Chang Yun Yang

5th, OF group12

`

Bone atrophy beneath implant supported overdentures

Master’s Thesis

Work supervisor

Doc, Rimantas Oziunas

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2 LITHUANIAN UNIVERSITY OF HEALTH SCIENCES

MEDICAL ACADEMY FACULTY OF ODONTOLOGY

ORTHOPEDIC CLINIC

Bone atrophy beneath implant supported overdentures

Master’s Thesis

The thesis was done

By student... Supervisor...

(signature) (signature)

... ...

(name surname,year,group) (degree, namesurname)

...20…. ... 20….

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3

EVALUATION TABLE OF THE MASTER’S THESIS OF THE TYPE OF SYSTEMIC REVIEW OF SCIENTIFIC

LITERATUREEvaluation: ... ...

Reviewer: ...

(scientific degree. name and surname)

Reviewing date: ...

No. MT parts MT evaluation aspects

Compliance with MT requirements and evaluation Yes Partially No 1 Summary (0.5 point)

Is summary informative and in compliance withthe

thesis content and requirements? 0.3 0.1 0

2 Are keywords in compliance with the thesis

essence? 0.2 0.1 0

3 Introduc- tion, aim and tasks (1 point)

Are the novelty, relevance and significance of the

work justified in the introduction of the thesis? 0.4 0.2 0 4 Are the problem, hypothesis, aim and tasks formed

clearly and properly? 0.4 0.2 0

5 Are the aim and tasks interrelated? 0.2 0.1 0

6 Selection criteria of the studies, search methods and strategy (3.4 points)

Is the protocol of systemic review present? 0.6 0.3 0 7

Were the eligibility criteria of articles for the

selected protocol determined (e.g., year, language, publication condition, etc.)

0.4 0.2 0

8

Are all the information sources (databases with dates of coverage, contact with study authors to identify additional studies) described and is the last search day indicated?

0.2 0.1 0

9

Is the electronic search strategy described in such a way that it could be repeated (year of search, the lastsearchday;keywordsandtheircombinations; number of found and selected articles according to the combinations of keywords)?

0.4 0.1 0

10

Is the selection process of studies (screening, eligibility, included in systemic review or, if applicable, included in the meta-analysis) described?

0.4 0.2 0

11

Is the data extraction method from the articles (types of investigations, participants, interventions, analysed factors, indexes) described?

0.4 0.2 0

12

Are all the variables (for which data were sought and any assumptions and simplifications made) listed and defined?

0.4 0.2 0

13 Are the methods, which were used to evaluate the

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4 information is to be used in data synthesis,

described?

14 Were the principal summary measures (risk ratio,

difference in means) stated? 0.4 0.2 0

15 Systemiza- tion and analysis of data (2.2 points)

Is the number of studies screened: included upon assessment for eligibility and excluded upon giving the reasons in each stage of exclusion presented?

0.6 0.3 0

16

Are the characteristics of studies presented in the included articles, according to which the data were extracted (e.g., study size, follow-up period, type of respondents) presented?

0.6 0.3 0

17

Are the evaluations of beneficial or harmful outcomes for each study presented? (a) simple summary data for each intervention group; b) effect estimates and confidence intervals)

0.4 0.2 0

18

Are the extracted and systemized data from studies presented in the tables according to individual tasks?

0.6 0.3 0

19

Discussion (1.4 points)

Are the main findings summarized and is their

relevance indicated? 0.4 0.2 0

20 Are the limitations of the performed systemic

review discussed? 0.4 0.2 0

21 Does author present the interpretation of the

results? 0.4 0.2 0

22

Conclusions (0.5 points)

Do the conclusions reflect the topic, aim and tasks

of the Master’s thesis? 0.2 0.1 0

23 Are the conclusions based on the analysed material? 0.2 0.1 0

24 Are the conclusions clear and laconic? 0.1 0.1 0

25

References (1 point)

Is the references list formed according to the

requirements? 0.4 0.2 0

26

Are the links of the references to the text correct? Are the literature sources cited correctly and precisely?

0.2 0.1 0

27 Is the scientific level of references suitable for _{Master’s thesis?} 0.2 0.1 0 28

Do the cited sources not older than 10 years old form at least 70% of sources, and the not older than 5 years – at least 40%?

0.2 0.1 0

Additional sections, which may increase the collected number of points 29 Annexes Do the presented annexes help to understand the

analysed topic? +0.2 +0.1 0

30

Practical recommen-

dations

Are the practical recommendations suggested and

are they related to the received results? +0.4 +0.2 0 31

Were additional methods of data analysis and their results used and described (sensitivity analyses, meta-regression)?

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5 *Remark: the amount of collected points may exceed 10 points.

Reviewer’scomments: 32

Was meta-analysis applied? Are the selected statistical methods indicated? Are the results of each meta-analysispresented?

+2 +1 0

General requirements, non-compliance with which reduce the number of points 33

General require- ments

Is the thesis volume sufficient (excluding annexes)?

15-20 pages (-2 points)

<15 pages (-5 points)

34 Is the thesis volume increased

artificially? -2 points -1 point

35 Does the thesis structure satisfy the _{requirements of Master’s thesis?} -1 point -2 points 36 Is the thesis written in correct language,

scientifically, logically and laconically? -0.5 point -1 points 37 Are there any grammatical, style or

computer literacy-related mistakes? -2 points -1 points 38 Is text consistent, integral, and are the

volumes of its structural parts balanced? -0.2 point -0.5 points

39 Amount of plagiarism in the thesis. >20%

(not evaluated) 40

Is the content (names of sections and sub- sections and enumeration of pages) in compliance with the thesis structure and aims?

-0.2 point -0.5 points

41

Are the names of the thesis parts in compliance with the text? Are the titles of sections and sub-sections distinguished logically and correctly?

-0.2 point -0.5 points

42 Are there explanations of the key terms

and abbreviations (if needed)? -0.2 point -0.5 points 43

Is the quality of the thesis typography (quality of printing, visual aids, binding) good?

-0.2 point -0.5 points *In total (maximum 10 points):

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6 Annex No.4

Summary

Background: As the demand for implant supported mandible overdenture is increasing, a large number of studies are ongoing nowadays. Several studies provide data that the bone atrophy might increase due to this appliance.

Aim: To analyze clinical data about the bone atrophy of implant supported overdenture to see if it can be a better alternative treatment to conventional dentures.

Material and Method: Systematic review was carried out to identify relevant studies reporting data about bone atrophy of implant supported overdenture for seeking better alternative treatment in orthopedic dentistry. This systematic review is written according to the criteria of PRISMA-P. Data from the selected articles which were in the form of randomized clinical trials seven studies) and observational studies including prospective and retrospective types (7 studies). Subsequently, continuous evaluation and determination through follow-ups analyzed atrophy and marginal bone level changes retrospectively. The data was mainly extracted from electronic databases such as ScienceDirect, ResearchGate, Wiley Online, PubMed and was restricted to publications from 2008- 2019.

Results: Based on all 14 analyzed articles with the observational periods in the range of 1-11 years, the bone atrophy value after 6months of application, the mean of ball was (0.75mm), bar (0.52), locator (0.35), magnetic (0.41), and in 1 year, the mean of the ball (0.82mm), bar (0.95), locator (0.59), magnetic (0.56). In 2 year, the mean of the ball (1.27), bar (1.04), locator (0.80).

Conclusions: Based on analyzed literature, it can be concluded that Bone loss through different attachment types shows various results, ball, bar attachment has relatively higher stress observed than the locator and magnetic attachment. Immediately loaded implants associates more marginal bone resorption, increased probing depths resulted, compared with conventional loading method. Overall, with the level of stress in the surrounding bone are influenced by the bone quality, periodontal conditions, mechanical properties, loading method, implant attachment type, implant thickness and length

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INTRODUCTION

Dental implants, which are analog equipment inserted into the jaws, increased to support various types of dental prostheses, such as fixed partial dentures, fixed complete dentures and removable full dentures, implants, etc.

Due to edentulism, patients can undergo functional impairment as well as psychological stress, speech impairment, loss of soft tissue or residual ridge. With using a conventional method, it is not sufficiently treated nor satisfied for the patients. Besides, many types of research [36,37], could find that Implant supported overdenture shows better stability, retention, satisfaction to the patient as well as better quality of patient mastication.

A high number of elderly patients can be vulnerable to become edentulous. Therefore, it is essential to prevent resorption of the alveolar ridge, mandible atrophy, residual ridge resorption, that is irreversible and chronic. Nowadays abundant studies investing outcomes compared to the conventional method and various ways of mandibular overdentures. Moreover, lately, implant supported mandible overdentures are much-accepted treatment and widely used for edentulous patients worldwide. The benefits of IMO are already commonly accepted in the specialized literature.

Generally speaking, the cause of bone loss can be various such as consequences of periodontitis, tooth extracted and left alone, misaligned teeth, infection, tumor etc. but reason for bone loss can also be made when too much pressure applied to the jaw, while implantation, too much heating in the bone, the dentist’s fault can lead to bone loss.

Atrophy of inferior alveolar process often results in problems with a lower denture due to its insufficient retention and instability of the denture, and this may cause secondary mucosal atrophy, also causing pain when patient wearing prosthesis, deformation of soft mucosa that can alter facial appearance.

As the increasing aging population in nowadays society, the demand for implant supported overdenture will increase. The goal is to treat the patient to a high level of satisfactory esthetics, excellence in functions of speech, mastication. The biggest conventional dentures default is a functional problem which is poor retention and bone resorption. For this reason, implant supported overdenture was developed to collect benefits in retention, stability. Also, numerous studies [38] have shown high rates of satisfaction and survival rate. Nowadays the survival rate and success rate

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9 of dental implants retained overdenture is greater than 95%, which is sufficient success rate. Even though a high success rate, failures emerge. It is critical to prevent late-implant bone loss in the long term of successful implant retained overdentures. It is essential to investigate the amount of bone loss, force distribution around supporting implants, attachment types resulting in a bone loss in advance

The usage of implant-supported denture is indicated in a wide variety of evaluated socioeconomic strata since it is lower cost than giving full implants in the jaw, which is minimal usage of implants for prosthodontic support. Therefore, it is significantly essential to evaluate implant supported

overdenture. To evaluate Marginal bone loss under implant supported overdenture, survival(success) rate with overdenture treatment as well as an annual bone loss with overdenture usage.

Aim: To analyze clinical data about the bone atrophy beneath implant supported overdenture

Task:

1. To collect information to assess biomechanical differentiation, between different attachments of overdentures

2. To obtain information to differentiate marginal bone resorption by different loading method.

3. To evaluate outcomes of years case history and to inspect the cause of stresses and marginal bone losses.

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1. SELECTION CRITERIA OF STUDIES. SEARCH METHODS AND

STRATEGY

1.1. Selection criteria of studies

Selection of the studies was searched from internet, and systematic review was selected with a PRISMA-P(Preferred Reporting Items for Systematic review and Meta-Analysis Protocols) criteria, hence by following criteria written under was additionally used.

Inclusion criteria including for selection were the following:

1) scientific articles of randomized clinical trials and (prospective and retrospective) observational clinical studies,

2) articles are not older than 10 years, 3) research is written in English, 4) studies performed on humans, 5) in vivo.

Furthermore, articles and studies were selected that involved following exclusion criteria such as: 1) studies in vitro,

2) studies on animals 3) author debates 4) summaries

5) systematic reviews.

6) Maxillary overdentures only

7) The sample consists of partially edentulous patients

1.2 Search methods.

All the search was investigated through electronic search, done by several web databases such as ScienceDirect, PubMed, ResearchGate and Wiley online, by the keywords such as overdenture, atrophy, mandibular overdenture, implant supported overdenture, case report overdenture. Databases were accessed through the online library of the Lithuanian University of Health Science‘s EZproxy. Primary search method was concentrated on clinical observation, influence

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11 function of Implant supported overdenture and bone atrophy occurrence on overdenture. Supervisor (Rimantas Ožiūnas) reviewed electronic databases, assisted upon finding sufficient databases.

1.3. Study selection

Main keywords that have been chosen for Electronic databases were selected in the following 4 keywords. Selected Keywords were looked upon every web database. 1) atrophy implant supported overdenture, 2) stress distribution in overdenture, 3) Retrospective Evaluation of Implant-Supported Overdentures, 4) biomechanics difference in the overdenture attachment. The researched date for all electronic databases was on 2019.03.03.

In web database PubMed, the primary keywords that have been used were ‘atrophy implant supported overdenture, it's shown 81 results. Publication dates in 5years were 11 results. Moreover, publication dates in 10years were 38 results.

Table1. PubMed database with the date of research 2019.03.03

Keywords filters Results

atrophy implant supported overdenture

Articles with no filters 81

Articles publication date in 5years

11

38

In PubMed with the second keyword, ‘stress distribution in overdenture.' The results were 128 for the total. Moreover, with using filters publication dates in 5years, 48 results and in 10years were 80 results. Since too many results were irrelevant, they were excluded by looking upon the contents. Table2. PubMed database with the date of research 2019.03.03

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12 stress distribution in

overdenture

stress distribution in overdenture

48

80

In the next research, the keywords that are used is ‘Retrospective Evaluation of Implant Supported Overdentures'. The filter was repeatedly used for checking upon publication dates within 5,10years.

Table 3. PubMed database with the date of research 2019.03.03

Retrospective Evaluation of Implant Supported

Overdentures

Access to the full text 31

Overdentures

Access to full text, In 5years, humans

6

Overdentures

Access to full text, In 10 years, humans

16

Table4. PubMed database with the date of research 2019.03.03

biomechanics difference in overdenture attachment

Access to the full text 93

Access to full text, In 5years,

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13 biomechanics difference in

overdenture attachment

Access to full text, In 10 years,

64

The articles that are searched in the Wiley database were investigated the same manual strategy as PubMed. Refining search system was different and it was accessed with relevant contents. Results are seen in tables beneath.

Table 5. Wiley online database with the date of search 2019.03.03

Publication in 10years b 170

Publication in 10years, dentistry

23

Overdentures

Publication in 10years 97

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14

Publication in 10years 49

By using keywords through ScienceDirect, databases that are included criteria were found in below tables. 1) atrophy implant supported overdenture, 2) stress distribution in overdenture, 3) Retrospective Evaluation of Implant Supported Overdentures, 4) biomechanics difference in the overdenture attachment.

Table 9. ScienceDirect database with the date of search 2019.03.03

Research articles, 84

Research articles, 5 years 32

Research articles, 10years 50

Table 10. ScienceDirect database with the date of search 2019.03.03

127

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15 Table11.ScienceDirect database with the date of search 2019.03.03

Retrospective Evaluation of Implant Supported Overdentures Research articles, 58 Retrospective Evaluation of Implant Supported Overdentures

Research articles, 5 years 26

Overdentures

Research articles, 10years 32

Table12. ScienceDirect database with the date of search 2019.03.03

84

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16 Figure1. A flowchart for the article selection.

1.4 Data extraction

Data was extracted via all the databases that were selected. Table 13 was extracted from databases by its authors, average age, the number of the total implant, attachment type, loading type, follow up interval which was different by all other articles and marginal bone loss measured in various method.

included eligibility screening identification

Records identified through databases Searching (2108):

ScienceDirect: 1128 PubMed: 641 Wiley Online: 339

Records after using at least 3 keywords in combination, with filter ‘10years’ (n=1335)

➔ Files excluded at title screening (n=912)

Records screened (n=423)

➔ Full- text articles accessed for eligibility (n=60) *46 articles exclude: Due to lack of relevant, sufficient data

Studies included in qualitative synthesis (n=14)

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17 1.5 Study variables

In this systematic analysis, the main purpose was to examine overdenture resulting bone atrophy by various reasons by not only attachment types but also loading method, number of implants to evaluate bone atrophy which was divided in to different attachment, loading system and number of total supported implants, differentiating the results from many articles to evaluate objective bone loss in implant supported overdentures.

According to the studies, success implant without a bone loss was defined as the absence of signs and symptoms such as pain, infections, dysesthesia and marginal bone loss >1.5mm, without peri-implant risk of bias in studies

1.6 Risk of bias in studies

Due to collecting databases and analyzing access, study designs are not identical, such as type of radiographs used for measuring MBLCs were varied to orthopantomogram or CBCT. In addition, loading system techniques, implant materials were not scripted in some databases. However, none misleading prognosis, bone atrophy was evaluated in variable ways

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2. Systemization and analysis of data

In Table 13, all the important data has been illustrated.

First of all, table 13 shows data from the selected articles which were in the form of randomized clinical trials 7 studies) and observational studies including prospective and retrospective types (7 studies). Subsequently, continuous evaluation and determination through follow-ups analyzed atrophy and marginal bone level changes retrospectively.

The mean age of patients was 65.5per study (ranging from 40to 72). Patients were mainly chosen by the absence of the teeth/edentulism since most elders tend to become edentulism rather than the young aged. Including a number of 2109 total implant with the mean 150 implants inserted per study (ranging from 88 to 402).

In addition, types of implants that have been used were evaluated, starting from the most common which was ball type (999), locator type (667), bar type (143), magnetic (131).

Next factor that has been estimated results, were loading method; CL (conventional loading) and IL (immediate loading). The number of participants by loading method was considerably even, more common loading method was IL (immediate loading), 6 studies used IL only, and 2 studies used IL in the combination of CL, and 5studies with CL only.

Concerning the Follow up to evaluate MBL (marginal bone loss) s, time varied with all studies. It was ranging from 2weeks to 9 years. Mean of the follow-up frequency was mostly 4times. The observation period, the mean of the first follow up was 5.8months (ranging from 2weeks to 1year). Mean of the second follow up was 9.1months (ranging from 2months to 24months). Mean of the third follow up 19.7months (ranging from 6months to 36months)

Speaking about the main variables in the systematic review that are bone atrophy. Bone atrophy. Starting with the bone atrophy, it was classified by clinical evaluation and radiographic evaluation. The clinical method was by PI (plaque scores), BI (bleeding scores), PD (probing depth), ISQ (implant stability) and GI (gingival index), PTVs (periotest values). And in radiographi6c method was evaluated by not only intraoral periapical panoramic X-ray but also CBCT, panoramic X-ray, as shown in table 13, VBL (vertical bone loss), HBLO (horizontal alveolar bone loss) was measured through the radiographic method.

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19 Finally, Table 13 illustrates the bone loss value after 6months of application, the mean of the ball was (0.75mm), bar (0.52), locator (0.35), magnetic (0.41), and in 1year, the mean of the ball (0.82mm), bar (0.95), locator (0.59), magnetic (0.56). In 2 year, the mean of the ball (1.27), bar (1.04), locator (0.80).

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20 Table 13. Clinical key factors and study variables of systematic analyses

Authors Study

design

Mean age Number

of implants Attachment type Loading type Follow up (intervals/ wk, weeks; mo, months; y, years) Measurements method

Marginal bone loss (results)

Jofre et al 2010

RCT Ball 69 bar 73

90 Ball,Bar IL 15 mo, (5, 7,

10 and 15 mo)

• GI, radiograph GI: ball = 5 mo = 0.89 ± 0.57 7 mo = 0.98 ± 0.65 10 mo = 1.30 ± 0.99 15 mo = 1.40 ± 1.02 GII: bar = 5 mo = 0.50 ± 0.53 7 mo = 0.65 ± 0.56 10 mo = 0.80 ± 0.63 15 mo = 0.84 ± 0.66 Jofre et al 2010 RCT ball 69 bar 73 90 Ball, Bar IL 2 y, (5, 10, 15 and 20 mo)

• GI, radiograph GI (ball): 5 mo = 0.90 ± 0.75 10 mo = 1.09 ± 0.91 15 mo = 1.34 ± 1.32 24 mo = 1.43 ± 1.26

GII (bar): 5 mo = 0.55 ± 0.59 10 mo = 0.76 ± 0.55 15 mo = 0.80 ± 0.58 24 mo = 0.92 ± 0.75

Elsyad et al 2011

POCS 62.9 112 Ball IL 3 y (T1—6 mo,

T2—12 mo, T3—24 mo, T4—36 mo)

• MBL: Vertical bone loos (VBLO); Horizontal bone loss (HBLO)

• PI, GI and PD (lingually, mesially, buccally,

VBLO: T0 = 0 T1 = 0.71 ± 1.0 T2 = 1.2 ± 0.96 T3 = 1.25 ± 0.64 T4 = 1.26 ± 0.64

HBLO: T0 = 0 T1 = 0.46 ± 0.35 T2 = 0.62 ± 0.42 T3 = 0.64 ± 0.49 T4 = 0.74 ± 0.57

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21

design

distally) • Periotest Maryod et al 2014 ROCS IL= 63.4 CL = 64.8 Ball IL/CL 36 mo (6, 12, 24 and 36 mo) • PI, SBI, PD • MBL IL Group: T6 = 0.73 ± 0.45 T12 = 1.03 ± 0.61 T24 = 1.29 ± 0.63 T36 = 1.17 ± 0.65 CL Group: T6 = 0.37 ± 0.18 T12 = 0.93 ± 0.52 T24 = 1.12 ± 0.51 T36 = 1.06 ± 0.49 Mangano et al

2015 POCS 71.1 231 Ball IL 2.7 y • Clinical radiographic

parameters assessed.

• RDI

1 y = 0.45 ± 0.314

Mundt et al, 2017

RCT 68.8 402 Ball IL/CL Observation

time= 2.2 ± 1.0 y

• radiographic Mean MBL = 0.5 mm

Morneburgand

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design

Pröschel 2008

Ball 8 wk, 6mo, and

regularly every 6 mo) measured using panoramic radiographs 2 y = 0.2 ± 0.3 Geckili et al 2011 ROCS 52 159 X X 5 y after prosthetic loading Clinical radiographic • absence of peri‐implant radiolucency; • MBL

Anterior mandible: Distal = 1.00 ± 0.19 Mesial = 0.96 ± 0.

Al‐Nawas et al

2011 RCT 65.8 178 Locator CL 6 and 12 mo • MBL

• PI

• SBI

• At buccal, palatal, distal and mesial sites were measured (criteria described by Mombelli)

6 mo TiZr = −0.23 ± 0.35 Ti IV = −0.23 ± 0.40 12 mo TiZr = −0.34 ± 0.54 Ti IV = −0.31 ± 0.56

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design

• RDI Quirynen et al 2014 RCT 65.8 178 Locator CL 3 y, Intervals: 12, 24 and 36 mo • MBL

• PI, SBI (Mombelli et al)

• RDI 12 mo TiZr = −0.34 ± 0.54 Ti IV = −0.31 ± 0.562 24 mo TiZr = −0.58 ± 0.60 Ti IV = −0.57 ± 0.633 36 mo TiZr = −0.78 ± 0.75 Ti IV = −0.60 ± 0.71 Muller et al 2015 RCT 72 150 Locator CL 60 mo, comparing results from 6, 12, 24, 36 mo mPI, mSBI(according to Mombelli) RDI 60 mo TiZr = −0.60 ± 0.69 Ti IV = −0.61 ± 0.83 Zweers et al 2015 ROC 69 88 Ball, Locator CL 3 y (maintenance visits with radiographs taken at 1 and • Peri‐implant conditions • PD • RDI 1 y = 3.53 ± 0.54 3 y = 3.84 ± 0.49(ball) MBL difference = 0.32 ± 0.43 1 y = 3.59 ± 0.55 3 y = 3.73 ± 0.65(locator) MBL difference = 0.14 ± 0.50

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design

3 y) M.A. Elsyad 2015 RCT 63 62.2 64 64 Magnetic locator IL IL 6months, 12months • Probing depth • implant stability, • PI, BI. PD

• Measured mesial, distal, buccal, lingual of each implant

• RDI

(magnetic)Vertical bone loss =6months 0·44 ± 0·07, 12months =0·68 ± 0·09 horizontal bone loss =6months=0·41 ± 0·07, 12months= 0·62 ± 0·07

(locator)Vertical bone loss=6months- 0·48 ± 0·20, 12months= 0·99 ± 0·34 horizontal bone loss= 6months= 0·43 ± 0·12, 12months 0·64 ± 0·18 OnurGeckiliPhD, DDS 2013 ROCS 40-54y= 18 55-63y= 21 >65y= 23 169 (2= 28) (3=23) (4=11) Ball Locator bar IL IL IL

1~2y • Panoramic radiograph Average marginal bone loss

= 2implants= 1.04 ± 0.19, 3implants=1.09 ± 0.21, 4implants= 1.08 ± 0.20

2balls=1.01 ± 0.23, 2locators= 1.07 ± 0.16, 3balls= 1.07 ± 0.17, 3 bars= 1.13 ± 0.29, 4bars= 1.08 ± 0.20

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25

design

Measurements: GI, Gingival index, MBL, Marginal bone loss, PD, Probing depth, PI, Plaque index, RDI-radiology and diagnostic imaging

Loading types: CL, Conventional loading, IL, Immediate loading TiZr= titanium zirconium implants Ti IV= titanium implants

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3. Discussion

Previous clinical table 13along with a systematic review described the bone atrophy, emphasized in what instrument used, annual bone loss in the course of time as well as the contribution of the loading system. The present study expands on these previous results by providing data from a controlled clinical study with frequent follow ups from 1 year to over 10years. It was written by systematic review and meta-analysis through many articles from variable databases, by RCT, ROC, POC studies. It was to acquire variable outcomes and attain desirable statement.

3.1 Influence of attachment type on bone atrophy

Starting to talk with the types of attachment on overdenture, according to analyzed studies, opinion that there is an influence of different types resulting in different results. Many results have a similar pattern of the results with table 13. So, the studies that had clinical trials with various attachment types have concluded that mean of the ball, and bar attachment has relatively higher stress observed than the locator and magnetic [33]. However, other studies found that Bar models attachment showed the most elevated stress relative to different types, and the lowest stress shown with magnetic attachment following by the ball, socket attachment. In some studies, the locator attachment model shows superior performance in caps, with 99% and 100% less deformation and Von Mises stress, respectively. It indicates a longer cap lifespan with more time between successive maintenance sessions. In contrary, some results found that ‘MBL around implants supporting mandibular overdentures was affected by neither the number of implants nor the attachment type; however, MBL was affected by MBF (maximal bite force)’ [22].

In the table (13) the results were found that ball, bar attachment types are relatively higher stress given that locator and magnetic types. In additional studies have shown that ball attachment shows highly stressed in comparison to the locator one, but on the other hand mucosa and cortical bone received fewer stresses under the ball, socket attachment [32].

3.2 Influence of the Loading method on the bone atrophy

In the table (13), the loading method is separated into CL, IL. Many studies have concluded that immediately loaded implants associates more marginal bone resorption, increased probing depths resulted, compared with conventional loading method, although not many clinical outcomes do not differ outstandingly between loading protocols. Also, immediately loaded implants supporting locator retained overdenture is more likely to produce more vertical bone resorption when

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27 compared to conventionally loaded implants after 1 year, and marginal bone resorption was associated with probing depth [21]. Moreover, [35], reported the oblique direction loading resulted in the highest Von Mises stresses compared to vertical loading.

3.3.Bone atrophy factors

Once implantation is given to the participant, marginal bone loss occurs annually, predominantly arising during the first year of loading. Adell et al. 1981[39], analyzed that the loss of vertical marginal bone of 1mm could be anticipated during the first year of function. The level of stress in the surrounding bone is influenced by the bone quality, periodontal conditions, mechanical properties, loading method, implant attachment type, implant thickness[35], showed that regardless of the implant diameter, marginal bone loss occurred relevant to the attachment type [36], length(Anitua et al. 2010[40]) concluded that the impact of implant diameter is more significant than that of implant length, and cortical bone thickness.

3.4 Bone evaluation through the clinical method

Soft tissue assessment had been performed at prosthesis placement after implant placement by calibrated operators. (Modified) Plaque Index (mPI) and the (modified) Sulcus Bleeding Index (mSBI), GI (gingival index), PD (probing depth), PTVs (periotest values) according to Mombelli were recorded for the lingual, buccal, mesial and distal sites of the implant [37].

3.5 Bone evaluation through radiograph

Mostly bone evaluation through radiograph was figured through panoramic radiographs with standardized settings. Orthopantomography is a reliable and efficient procedure, due to its vertical plane projection, it is well suited for vertical measurements (bone loss). Panoramic radiograph offers reliable information to assess the length and determination of implants, even though dental volumetric tomography or radiography using standardized periapical radiography are the best methods, panoramic radiographs are a good substitute for evaluation of MBL. For further accurate measurements, computer-aided panoramic radiography can be used.

This systematic review had a few limitations. First of all, study designs are not the absolutely identical type of radiographs, clinical evaluation method used for measuring MBLCs, bone atrophy varied from study to study, loading system, varying from the time of all loading system techniques. It is necessary to standardize baseline in order to implement optimal meta-analyses. The sample size

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is comparatively small since the number of databases met our inclusion criteria is limited. For the future meta-analysis, it is anticipated for more ROCs, RCTs to complement the number of subjects.

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4 Conclusion

Based on analyzed randomized clinical trials and prospective/retrospective observational clinical studies, those are not older than 10 years and with appropriate observational periods, can be concluded:

1. Bone loss by the ball, bar attachment has relatively higher stress observed than the locator and magnetic Attachment

2. Immediately loaded implants associates more marginal bone resorption, increased probing depths resulted, compared with conventional loading method

3. The level of stress in the surrounding bone is influenced by the bone quality, periodontal conditions, mechanical properties, loading method, implant attachment type, implant thickness and length

Practical Recommendation

If we rely on conclusions of clinical trials best recommendations for the implant supported overdenture are:

1. To make first of all a precise diagnosis. 2. To evaluate precisely with the clinical and radiographical method before and after implantation. 3. Inspect bone atrophy factors sufficiently (bone quality, periodontal conditions, mechanical properties, loading method, implant attachment type, implant thickness). 4. Attachment type is recommended to use locator and magnetic comparing to ball and bar attachment. 5. Conventional Loading method is recommended if patients have sufficient time to heal in the jaw, to prevent marginal bone resorption, increased probing depths and vertical bone resorption.

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35 Annex No. 1 Protocol for systematic review according to PRISMA-P

TITLE Bone atrophy beneath implant supported

overdentures INTRODUCTION

Aim - To analyze clinical data about the bone atrophy

beneath implant supported overdenture

Tasks - To collect information to assess biomechanical

differentiation, between different attachments of overdentures

-To collect data from differentiating marginal bone resorption by different loading method. -To evaluate outcomes of years case history and to inspect the cause of stresses and marginal bone losses.

METHODS

Eligibility criteria PRISMA-P

PRISMA-P(Preferred Reporting Items for Systematic review and Meta-Analysis Protocols) criteria

Inclusion criteria:

1) scientific articles of randomized clinical trials and (prospective and retrospective)

observational clinical studies,

2) articles are not older than 10 years, 3) study is written in English,

4) studies performed on humans, 5) in vivo. Exclusion criteria: 1) studies in vitro, 2) studies on animals 3) author debates 4) summaries 5) systematic reviews.

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36 6) Maxillary overdentures only

7) The sample consists of partially edentulous patients

Information sources Electronic databases: ScienceDirect, ReasearchGate, Pubmed, WileyOnline.

Keywords: implant supported overdenture, bone atrophy, loading method. Attachment types Time frame: December 2018 – April 2019

Study selection *Searching by entering the keywords in few

combinations and according chosen including criteria.

*Screening with excluding duplicates. *Eligibility according to exclusion criteria: studies in vitro, studies on animals, abstracts, case reports, author debates, summaries, systematic reviews and lack of relevant details. *Double-checking articles that were included in the systematic review by supervisor (Rimantas Ožiūnas).

Outcomes and prioritization . Assessing bone atrophy in implant supported overdenture with different clinical key factors (attachment type, loading method, evaluation of the clinical, radiographical method, bone

Bone atrophy beneath implant supported overdentures

Chang Yun Yang

Bone atrophy beneath implant supported overdentures

Bone atrophy beneath implant supported overdentures

Table of Contents

Summary

INTRODUCTION

1. SELECTION CRITERIA OF STUDIES. SEARCH METHODS AND

STRATEGY

2. Systemization and analysis of data

3. Discussion

4 Conclusion

Practical Recommendation

References