Corina Marilena Cristache Five-year clinical trial using three

Ligia Adriana Stanca

Muntianu
attachment systems for implant
Mihai Burlibasa overdentures
Andreea Cristiana Didilescu

Authors’ affiliations: Key words: complications, costs, locator, magnet, prosthetic maintenance, retentive anchor
Corina Marilena Cristache, Concordia Dent Clinic,
Bucharest, Romania
Ligia Adriana Stanca Muntianu, Removable Abstract
Prosthodontics, Faculty of Dental Medicine, Objective: The objective is to compare, in a prospective randomized clinical trial, three types of
University of Medicine and Pharmacy “Carol
attachment systems for mandibular implant overdenture, focusing on costs, maintenance
Davila”, Bucharest, Romania
Corina Marilena Cristache, Mihai Burlibasa, requirements and complications from baseline to the end of 5-year follow-up period.
Implantology, FMAM, University of Medicine and Materials and Methods: Sixty-nine fully mandibular and fully/partially maxillary edentulous
Pharmacy “Carol Davila”, Bucharest, Romania
patients received two screw-type Straumann implants, in the mandibular canine region. New
Andreea Cristiana Didilescu, Department of
Anatomy, Faculty of Medicine and Pharmacy, overdentures with three types of attachment systems were inserted according to an early-loading
“Dunarea de Jos” University, Galati, Romania protocol: Group B (balls, divided into Subgroup B.1 – retentive anchor with gold matrix and
Andreea Cristiana Didilescu, Department of
Embryology, Faculty of Dental Medicine, Subgroup B.2 – retentive anchor with titanium matrix) (n = 23), Group M (magnets) (n = 23) and
University of Medicine and Pharmacy “Carol Group L (locator) (n = 23).
Davila”, Bucharest, Romania Results: The highest maintenance event number (195) was observed in Group B vs. 31 in Group L
Corresponding author: and 15 in Group M. Significantly more complications were recorded in Subgroup B.1 than in
Andreea Cristiana Didilescu Subgroup B.2, Group M and Group L (P < 0.05). Group M registered the highest prosthetic success
8, Blvd Eroilor Sanitari, 050474, Bucharest, (82.6%) in the 5 years, followed by Group L (78.2%). Subgroup B.1 had the lowest success rate
Romania
Tel.: +40 722536798 (50%). The magnet group recorded statistically significant higher costs, comparing with the other
Fax: +40 21 3131298 two groups (P < 0.05).
e-mail: [email protected]
Conclusions: The three attachment systems functioned well after 5 years. The magnets had a low
maintenance requirement and high success rate, despite the relatively increased initial costs.
Retentive anchor with titanium matrix and locator may be a better choice from a financial point of
view, taking into consideration the initial low cost of the components and also the reduced
number of complications.

In case of the edentulous patients, the suc- using different retention systems and nowa-
cess of the denture therapy depends upon the days the cost-effectiveness and the simplic-
biomechanical prodigy of support, stability ity of treatment become the main issues for
and retention (Jacobson & Krol 1983b,c). The the choice of treatment (Zitzmann et al.
mandibular denture generally presents the 2006). The role of the attachment type is
major problem with regard to retention due very important (Kimoto et al. 2009): a rigid
to a movable floor of the mouth, which connection between implants and denture
causes difficulty in establishing a lingual induces stress with potential implant failure
border seal. Denture stability is minimised (Menicucci et al. 2006), especially when
by lack of ideal ridge height and conforma- hinge movements around the fulcrum line
tion (Jacobson & Krol 1983a). Due to resorp- occurs. Moreover, splinting implants by
tion, the remaining anatomic regions of the means of a bar-clip construction is more
mandible are not usually essential in provid- expensive, time-consuming, involves more
ing dental support (Jacobson & Krol 1983c). complications (Gotfredsen & Holm 2000)
Problems regarding integrating dentures and offers no marked differences in patient
Date: are observed with a higher incidence for satisfaction when compared with non-splint-
Accepted 30 October 2012
mandibular than for maxillary dentures ing attachments (Cune et al. 2010). Due to
To cite this article: (Mericske-Stern 1998). To overcome these these facts, resilient and magnetic attach-
Cristache CM, Muntianu LAS, Burlibasa M, Didilescu AC.
Five-year clinical trial using three attachment systems for drawbacks, over the past 35 years, clinicians ment for implant overdentures, allowing
implant overdentures.
have been restoring aesthetics and function in several types of movements, are extensively
Clin. Oral Impl. Res. 25, 2014, e171–e178
doi: 10.1111/clr.12086 edentulous patients with implant overdentures used. The magnetic anchor is a non-rigid,

© 2012 John Wiley & Sons A/S. e171

Cristache et al
Different retentions for implant mandibular overdenture

dynamic anchor. The retentive unit permits ment systems regarding costs and maintenance hygiene status) was performed before any
rotary movement of the denture in one or requirements defined the null hypothesis for- treatment procedure.
more directions and/or vertical translational mulated in the present study.
movements. The magnetic attachment den- Surgical procedure
ture has a low resistance to lateral forces, Each patient received two screw-type Strau-
Materials and methods mann (Switzerland) standard soft tissue level
and the subsequent immediate loss of reten-
tion is associated with a lower level of implants 4.1 mm diameter, with sandblasted
The study was conducted from September 2004 large-grit acid-etched (SLA) surface in the
implant moment loading, thereby protecting
to March 2012 according to the CONSORT canine region of the mandible with an inter-
the implant against unfavourable lateral
guidelines for improving the quality of clinical connecting line approaching parallelism with
forces (Heckmann et al. 2001). The desire
trials (Altman et al. 2001; Moher et al. 2003; the terminal mandibular hinge axis (Naert
to use the magnetic retention is related to
Schulz et al. 2010) (Data S1). The use of human et al. 1998). The implant lengths were 10 or
the simplicity involving minimal time at
subjects in this study was reviewed and 12 mm. The choice of implant length was
the chairside and in the laboratory. Two
approved by the Romanian Ministry of Health dictated by the preoperative radiographic
different types of alloys were used for the
and written informed consent was obtained assessment of bone height in the canine
manufacture of small dental magnets:
from all participants. region and drilling distance, with the princi-
cobalt-samarium magnets introduced in the
Sixty-nine fully mandibular edentulous pal concern of achieving primary stability.
sixties and an alloy based on iron – neo-
patients (age ranging between 42 and 84 years) Bone height in the canine region was
dymium – boron in the eighties, both with
were recruited from the University Hospital of assessed on orthopantomograms. Jaw bone
high attractive forces but with a low corro-
Dentistry and nine private practices in Bucha- quality was rated during the dental implant
sion resistance (Walmsley 2005). Nowadays,
rest and the surrounding areas (ClinicalTri- surgery, by the tactile resistance during dril-
to increase corrosion resistance, the magnets
als.gov Identifier: NCT01034930). Their ling. The same surgeon for all the cases
are encapsulated in stainless steel, titanium
maxillary status was as follows: 12 (17.4%) performed the implant surgery, allowing an
or palladium by using laser-welded coatings
with fixed bridges; 3 (4.3%) with natural teeth; objective evaluation.
(Haruta et al. 2011).
46 (66.7%) with removable complete dentures Both clinical and radiographic evaluation
As resilient anchors, balls (retentive anchors)
and 8 (11.6%) with removable partial dentures. permitted a classification according to the
are considered the simplest and less costly type
The patients were selected based on all the fol- Lekholm & Zarb (1985) index.
of attachments for clinical application (Cakarer
lowing criteria: complains about the stability The implants were inserted under local
et al. 2011).
of the existing mandibular denture satisfac- anaesthesia in a one-stage non-submerged
The self-aligning locator system has dual
tory from a technical point of view; patients procedure according to a strict protocol (Wein-
retention: through both external and internal
included in Class I to III (American College of gart & ten Bruggenkate 2000).
mating surfaces, is resilient, retentive and
Prosthodontists Classification of Complete
durable, and has some built-in angulation
Edentulism) (McGarry et al. 2004); acceptance
compensation (Cakarer et al. 2011). The loca-
of a mandibular overdenture retained by two Prosthodontic procedure
tor system has been widely used in the past The mandibular denture was adjusted by
endosseous implants; agreement for a 5-year
three to 4 years, but there is a need of long- selective grinding at the implant location, Pro-
follow-up period.
term prospective clinical studies to compare tefix® (Queisser Pharma, Hamburg, Germany).
Exclusion criteria comprised: insufficient
this system with other attachment systems Adhesive cushions were provided and patients
bone volume (height and width) for inserting
(Alsabeeha et al. 2011), particularly with received oral hygiene instructions. One, two
of at least a 10-mm implant (diameter 4.1)
regard to the treatment’s success, as well as and 4 weeks after the surgical procedure,
(due to extensive residual ridge resorption,
clinical and prosthetic complications. patients were recalled for follow-up visits. At
patients in Class IV – American College of
Although the recommended number of the third follow-up visit, the manufacturing of a
Prosthodontists Classification of Complete E-
implant is established (Feine et al. 2002), no new maxillary denture (for the full maxillary
dentulism, were excluded); Angle class II rela-
scientific data to support the use of one edentulous patients) and a new mandibular
tionship; physical condition that will affect
attachment system against another are avail- overdenture with metal reinforcement were
the minimal invasive surgical procedure or
able for the edentulous mandible, due to the initiated. For the maxillary dentate patients,
constitute a hindrance for a 5-year follow-up
fact that functional demands of edentulous correct maxillary fixed rehabilitation was
(e.g. immunosuppressive therapy, elderly
patients are highly variable and the choice of performed prior to implant surgery at the man-
patients in poor physical condition); history of
treatment is strongly influenced by adaptive dible.
radio-/chemotherapy in the head and neck
capacity, socio-cultural background and also After 6-week healing period, implants were
region; history of pre-prosthetic surgery
by financial means (Fitzpatrick 2006). loaded using an early-loading protocol (Apari-
(including bone graft procedures) or previous
Therefore, the aim of this study was to com- cio et al. 2003; Morton 2008; Lethaus et al.
oral implants.
pare three types of unsplinted attachment 2011). A dental assistant, not involved in this
Selected patients were informed about the
systems, focusing on costs, maintenance require- research project randomly assigned the
three different treatment options and about
ments and complications, in a prospective clini- patients to one of the three main groups
the benefit of treatment with an overdenture
cal trial: retentive anchors (balls, Straumann, (Table 1, Fig 1a–g):
retained by two endosseous implants (Feine
Basel, Switzerland), magnets (Titanmagnetics®
et al. 2002). 1. Group B – (n = 23) received retentive
Steco system-technick, Hamburg, Germany) and
The medical status and dental history of
locator® (Zest Anchors, Inc., Escondido, CA, anchors (Straumann); it was randomly
all patients were checked and an oral and divided into two subgroups (B.1: with
USA), for implant overdenture in the edentulous
radiographic examination (including oral gold matrix and B.2: with titanium
mandible. No differences between the attach-

e172 | Clin. Oral Impl. Res. 25, 2014 / 171–178 © 2012 John Wiley & Sons A/S.
 Cristache et al
Different retentions for implant mandibular overdenture

Table 1. Groups/subgroups divided upon characteristics of overdenture attachments

Retentive force indicated
Group No. of patients Patrix Matrix by the manufacturer Manufacturer for Straumann
B, Subgroup B.1 12 Retentive anchor abutment, Gold matrix – Elitor Varied retention (four Straumann, Basel,
height 3.4 mm, titanium lamellae functioning Switzerland
like a spring)
B, Subgroup B.2 11 Titanium matrix Spring with a defined Straumann, Basel,
extraction force: 700–1100 g Switzerland
M 23 Titanmagnetics insert, Denture Not specified by the Steco system-technick,
height 3.25 mm, titanmagnetics manufacturer Hamburg, Germany
titanium housing
L 23 Locator abutment 3 mm, Denture cap titanium Pink light retention Zest Anchors, Inc.,
titanium alloy with nylon retention 1360 g Escondido, CA, USA

matrix), based on characteristics of the Payne et al. (2001). According to this analysis, because of either loss of implants or irrep-
overdenture attachment. the criteria are defined as follows: arable mechanical breakdown.
2. Group M – (n = 23) received magnets
Success – no evidence of retreatment except The two subgroups of Group B were analy-
(Titanmagnetics® Steco system-technick.
for accepted maintenance (includes patrix sed separately.
3. Group L – (n = 23) received locator (Zest
activation/repair/replacement, matrix acti-
Anchors, Inc).
vation/repair/replacement and asymptom- Cost analysis
The random assigning was done using 69 atic periimplant/interabutment mucosal Costs for each type of attachment were calcu-
sequentially numbered opaque sealed enve- enlargement not requiring excision). There lated according to all the procedures and com-
lopes (SNOSE) according to the protocol is a limit of two replacements of either pa- plications at first year (T1) and fifth year (T5)
proposed by Doig & Simpson (2005), regard- trix or matrix in the first year and five and were subdivided into direct and indirect
less of the state of the opposing maxilla. replacements in 5 years, and one reline of costs, being estimated based on the minimal
The prosthetic procedure was performed by the overdenture base in 5 years. clinical charges for the procedures by the sur-
experienced prosthodontists, according to the Survival – patient cannot be examined geon, prosthodontist and dental hygienist.
recommendations of the manufacturer (Strau- directly, but the patient or another clinician The direct costs included costs of dental labo-
mann Dental Implant System) for retentive confirms no evidence of retreatment except ratory, costs of materials (implants and com-
anchors, magnets and the locator system. that described for a successful outcome. ponents), pharmaceuticals, radiography and
Occlusion was assessed both on the articula- Unknown (lost to follow-up) – patient charges for the procedures by the clinician
tor and intra-orally to secure a balanced cannot be traced; surviving or successful and the dental laboratory. The indirect costs
occlusion in centric relation without anterior implant overdenture removed to allow — included the patient’s time and out-of-pocket
tooth contact (Naert et al. 2004b; Vercruys- to provision of a new overdenture, for expenses (Penrod & Takanashi 2003).
sen et al. 2010). example, conversion to another overden- In our calculation, the direct costs were
Patients were scheduled for follow-up visits ture design with additional implants or a considered. Aftercare was defined as care and
at 1-week post-prosthesis insertion and every fixed implant prosthesis using the same maintenance provided during the evaluation
6-month post-abutment insertion. At each or additional implants. period, including check ups and cleaning.
follow-up visit, patient received oral hygiene Deceased – patient died during the study Costs of complications (components, prostho-
care and written oral hygiene instructions. period regardless of whether successful or dontist and dental laboratory fees) were
surviving criteria were experienced and considered separately.
Outcome measurements recorded before death. The costs of dental implants and compo-
Data collection was performed by two inde- Retreatment (repair) – Treatment of nents are from the Romanian Straumann rep-
pendent researchers (without knowledge of implant overdenture and/or mucosa where resentative – February 2009. Costs of the
the prosthodontist) at baseline assessment marginal integrity and associated patrices/ prosthetic complications per patient were
(1 week after insertion of the implant over- matrices are maintained irrespective of calculated in the following manner: total costs
denture) (T0), 6 months (T) and annually (T1– modifications as long as it continues as an of complications per group/subgroup divided
T5). implant overdenture. This includes more by n (i.e. number of patients in the group/
Prosthetic maintenance and complications than two replacements of either patrix or subgroup) = costs of prosthetic complications
(related to implant components, structure of matrix in the first year or more than five per patient in the respective group/subgroup.
the prosthesis and adjustments of the prosthe- replacements in the first 5 years. It also
sis including soft tissue problems) were includes replacement of worn or fractured Assessment of implant failure
assessed from baseline until T5, according to overdenture teeth/fractured overdentures, This was performed according to previously
the number of scheduled (planned and routine relining of overdenture more than once in established criteria (Albrektsson et al. 1986).
procedures) and unscheduled visits (solicited 5 years or excision of patrix-associated
by the patients). All the events were prospec- mucosal enlargement as a result of infringe- Statistical analysis
tively documented using evidence-based crite- ment on the shoulder/undersurface of the Data were expressed as mean values, stan-
ria from baseline to 5 years and the patrix. dard deviations (SD), ranges, medians and
prosthodontic success was assessed with the Retreatment (replace) – part or all of implant percentages, as appropriate. The Levene test
aid of the six-field table analysis proposed by overdenture is no longer serviceable was used to verify the homogeneity of vari-

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Cristache et al
Different retentions for implant mandibular overdenture

man, the last one, a heavy smoker lost both

(a) (b)
implants), leading to 97.1% survival rate
during the healing phase (before loading). The
four failed implants (length of 12 mm) were
replaced and healed uneventfully. All patients
could be treated as previously planned with
mandibular two implants overdenture. No
patient dropped out from the study. A mean
number of 3.49  5.64 (range 0–21, median 1)
(c)
maintenance events in the 5-year period was
recorded for the entire cohort of patients
(n = 69). Table 2 shows the number of main-
tenance events for each group per year.

Baseline group analysis

(d) (e)
The summary of the main findings per group
is shown in Table 3.

Occurrence of complications
A mechanical complication occurred in one
patient of Group M, during the fourth year of
the evaluation period: the screw of one of the
abutments was fractured and a part of the
(f) (g) screw was stuck inside the implant. The bro-
ken piece was removed with the aid of a
service set sent by Straumann. A new abut-
ment was inserted and, due to the fracture, a
new denture had to be made.
Significantly more complications were
recorded in Subgroup B.1 than in Subgroup
B.2, Group M and Group L, respectively
(P < 0.05, Kruskal–Wallis and Mann–Whitney
U-tests). The number of maintenance events
Fig. 1. Implant overdenture attachment systems: (a) Group B – Retentive anchor abutments; (b) Subgroup B.1 – Gold was 241 in 5 years, with the following distri-
matrix with variable retention; (c) Subgroup B.2 – Titanium matrix with defined retention; (d) Group M – Magnet abut- bution: 195 were observed in Group B (184 in
ments; (e) Group M – Magnet denture insert; (f) Group L – Locator abutments; (g) Group L – Locator denture insert.
Subgroup B.1 and 11 in Subgroup B.2), 31 in
Group L and 15 in Group M. All the patients
ance. Associations were tested using Pearson Results belonging to Subgroup B.1 required matrix
Chi-squared test and Fisher’s exact test.
activation at 6 months up to 1 year. Among
Analysis of variance was used to test for sig- The results confirmed group homogeneity. them, four patients needed matrix replace-
nificant differences between means, and the There was no statistical difference between ment (eight prosthetic components for two
Scheffe post hoc test analysed the effects groups for age, bone height in the canine implants) (Table 4). No statistical significant
through multiple comparisons. Non-paramet- region and interimplant distance (P > 0.05, differences were recorded between Subgroup
ric Kruskal–Wallis and Mann–Whitney U one-way ANOVA test). No association was B.2, Group L and Group M (P > 0.05, Kruskal
(Wilcoxon)-tests were performed to compare recorded between any group and bone qual- –Wallis and Mann–Whitney U-tests).
the medians between the groups/subgroups ity, bone quantity, gender or implant length
considered. All tests of significance were (P > 0.05, Pearson Chi-squared and Fisher’s
Prosthodontic success
two-tailed. StataIC 11 statistical software exact tests). No significant difference was
In our study, Group M registered the highest
(StataCorp LP, College Station, TX, USA, recorded between groups in terms of period
prosthetic success (82.60%) in 5 years,
version 2009) was used for data analysis. A of edentulism (P > 0.05, Kruskal–Wallis test).
followed by Group L (78.26%). Subgroup B.1
P-value < 0.05 was considered statistically Out of the 138 implants placed, four were
had the lowest success rate (50%) (Table 5).
significant. lost in three patients (two women and one
Cost analysis
Table 2. The distribution of maintenance events per year The subgroups B.1 and B.2 recorded differences
Group Year 1 Year 2 Year 3 Year 4 Year 5 in cost of prosthetic components at the same
surgical, prosthodontic and dental laboratory
B
B1 31 26 35 48 44 fee (B.1 = 1594 Euro/patient and B.2 = 1670
B2 7 0 1 0 3 Euro/patient).
M 8 0 0 6 1 Subgroup B.1 registered more expensive
L 7 0 0 11 13
first-year aftercare and complications per

e174 | Clin. Oral Impl. Res. 25, 2014 / 171–178 © 2012 John Wiley & Sons A/S.
 Cristache et al
Different retentions for implant mandibular overdenture

Table 3. Baseline clinical characteristics of the study groups patient comparing with the other groups/sub-
B M L group (60 EUR vs. 40 EUR) due to the higher
Groups (n = 23) (n = 23) (N = 23) number of maintenance events.
Age (years) The costs per patient/group/subgroup are
Mean (SD) 57.8 (8.8) 63.4 (9.5) 64 (9.6) shown in Table 6. The magnet group recorded
Median 58 64 65
statistically significant higher costs compar-
Range [42–76] [47–84] [47–80]
Bone height in canine region (mm) ing with the other two groups, whilst no
Mean (SD) 25.3 (5.6) 26.2 (4.9) 24.2 (3.7) statistical significant differences were
Median 24 25 24 observed between Group B and Group L, after
Range [16–44] [18–36] [18.5–30.8]
Bone quality*
the 5-year evaluation (Kruskal–Wallis and
N (%) Mann–Whitney U-tests). The complication
Type I 4 (17.39) 1 (4.35) 4 (17.39) costs for Subgroup B.1 vs. B.2 during years two
Type II 13 (56.52) 19 (82.61) 14 (60.87)
to five were 309.5 Euro/patient and 3.63 Euro/
Type III 6 (26.09) 3 (13.04) 5 (21.74)
Type IV 0 0 0 patient, respectively.
Bone quantity*
N (%)
Class A 1 (4.35) 0 0
Class B 7 (30.43) 11 (47.83) 13 (56.52)
Discussion
Class C 8 (34.78) 9 (39.13) 5 (21.74)
Class D 7 (30.43) 3 (13.04) 5 (21.74) The use, in our clinical study, of two implants
Interimplant distance (mm) as attachment for overdentures is based on the
Mean (SD) 20.1 (7.3) 20.3 (5.8) 20.1 (4.9)
Median 21 22 19.1 clearly demonstrated success (Mericske-Stern
Range [7–38] [4–31] [11.6–34] & Zarb 1993; Naert et al. 1999, 2004a) of using
* fewer (generally two) implants and in accor-
Lekholm & Zarb (1985).
dance with the proposed standard clinical
treatment protocol for edentulous elderly
patients in daily practice (Feine et al. 2002).
Table 4. Prosthodontic and soft tissue complications during 5 years of functioning
The implant survival rate of 97.1% after
No. of events
5 years, including loss of implants during the
Group B osseointegration period (early failure) is com-
parable with the studies of Buser et al. (1999)
B.1 B.2 Group M Group L
(96.2%), Ferrigno et al. (2002) (95.9%) and
Patrix-related (implant abutment) maintenance Lethaus et al. (2011) (96.7%), with the use of
Fracture of the abutment screw 0 0 1 0
the same implant system and the same sur-
Loosening of the abutment screw 1 2 3 0
Matrix-related (overdenture component) maintenance face treatment.
Activation of matrix 144 0 0 0 The 6-week loading protocol performed in
Exchange of rubber ring 18 0 0 0 this study is considered an early-loading pro-
Exchange of stainless steel spring 0 0 0 0
Exchange of the matrix 8 0 0 0 tocol. The absence of implant failures after
Replacement male locator 0 0 0 22 loading is in agreement with other studies
Overdenture-related maintenance (Payne et al. 2002; Roccuzzo & Wilson 2002).
Relining overdenture 4 2 3 1
In the light of our findings, the overall num-
Fracture of the overdenture 0 0 1 0
Fracture of teeth 2 1 1 0 ber of prosthetic and soft tissue complications
New overdenture 2 1 1 1 were relatively low compared with other stud-
Soft tissue-related complications ies (Mackie et al. 2011). Most of the mainte-
Mucositis, soreness 3 1 2 2
Ulcer decubitus 1 2 1 1
nance requirements were easy to handle:
Hyperplasia 1 2 2 4 screwing loosening abutments or activation of
the matrix to improve retention (Subgroup
B.1). Considerably more prosthetic mainte-
Table 5. Six-field table analysis of prosthodontic success after 5 years of functioning according to nance requirements were registered in sub-
Payne et al. (2001) group B.1, similar to the findings of Walton
Group B et al. (2009), but different from Watson et al.
N (%)
findings (Watson et al. 2002). The type of gold
B.1 B.2 Group M Group L matrix used in the present study consisted of
N (%) N (%) N (%) N (%) four lamellae functioning like a spring. All the
14 (56.5) patients needed at least one activation of the
Success 6 (50) 8 (72.7) 19 (82.6) 18 (78.3) gold alloy matrix per year (i.e. 100% activation
Surviving 0 0 0 0
per year). This result is different from Wal-
Deceased 0 0 0 0
Unknown 0 0 0 0 ton’s findings who reported, in a 3-year study,
9 (39.1) only 73% need of matrix activation (Walton
Retreatment (repair) 6 (50) 3 (27.3) 4 (17.4) 5(21.7) 2003). Four patients needed fully replacement
Retreatment (replace) 0 0 0 0
of the gold matrices due to impossibility of

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Cristache et al
Different retentions for implant mandibular overdenture

Table 6. Computed costs in EUR (Euro) per patient and per group/subgroup
Subgroup B.1 Subgroup B.2 Group M Group L
Implants/components 694 770 1118 853
Surgery 350 350 350 350
Dental technician 200 200 200 200
Prosthodontist 350 350 350 350
Costs at delivery 1594 1670 2018 1753
Costs at delivery per group 1630.34 2018 1753
Aftercare and complications first year 60 40 40 40
Total costs first year 1654 1710 2058 1793
Aftercare 5 years 160 160 160 160
Costs of complications 356.16 67.45 68.34 56.30
per patient after 5 years
Total costs fifth year
Mean (SD) 2170.16 (183.61) 1937.45 (115.89) 2286.34 (224.13) 2009.30 (89)
Median 2106 1890 2218 1978
Range 1974–2564 1870–2237 2218–3298 1953–2364

activation with breakage of one of the four The highest number of events during the study participants who are all completely
lamellae. The high number of maintenance first year was registered in Subgroup B.2 and edentulous in the maxilla would have allowed
events usually recorded with this old version Group M, different from previous reported for better standardization.
matrix probably led to the replacement with results (Mackie et al. 2011). In the present It can be concluded that, after 5-year follow-
elliptical gold matrix. study, the most frequent complications during up, the three attachment systems (retentive
No patrix wear for the retentive-anchor the first year were soft tissue-related and acti- anchor, magnets and locator) functioned well.
patients (Group B) as well as no replacement vation of gold matrix (subgroup B.1). However, The implant-retained overdenture demands
of stainless steel springs (titanium matrix) the highest number of maintenance events continuous aftercare, especially when ball
occurred during the 5 years of functioning, in occurred during the fourth and fifth year of attachment and golden matrix are used.
contrast to previous findings (Watson et al. service for Subgroup B.1 and Group L, mainly The magnets had a low maintenance
2002; Walton 2003). The ball attachment consisting of matrix replacement. requirement and high success rate, despite the
wear reported in other studies could be due The cost calculation was made taking into relatively increased initial costs.
to misalignment of the implants (Walton consideration implant and component Strau- Retentive anchor with titanium matrix and
2003). mann prices (2009), for comparison reasons. locator system may be better choices from a
Prosthodontic success according to the six- Gold matrix was last mentioned in that price financial point of view taking into consider-
field table analysis (Payne et al. 2001) list (replaced with elliptical matrix). ation the initial low cost of the components
(Table 6) was 50% for Group B.1 (retentive From the cost calculation (Table 6), the and also the reduced number of complica-
anchors with gold matrix), that is, similar to low initial cost for the implant treatment in tions.
Mackie’s findings (Mackie et al. 2011) (54% in Subgroup B.1 has been noted, as opposed to The present findings do reflect that there
5 years), but higher for Group B.2 (retentive the high cost of the aftercare for the next is variation in the maintenance of overden-
anchor with titanium matrix, 72.7%). The pre- 4 years. The lowest overall 5-year cost is ture attachment systems. Because of this,
viously mentioned study found a much lower observed in Group B.2, followed in ascending costs for maintenance of implant-retained
success rate for titanium matrix in 5 years order by Group L, Subgroup B.1 and Group overdentures have considerable individual
(33%). M, respectively. Group M had an initially variance and should not be universally inter-
An abutment fracture was recorded in high cost (components), but low aftercare preted.
Group M. No similar events occurred during requirements. The highest costs represent a
the study. No such mechanical complica- hindrance in the use of magnets as attach-
tions were described in other overdenture ment for implant overdentures due to the Acknowledgments: The authors are
studies with Straumann abutments (Rentsch- lower income of elderly patients and to the grateful to Associate Professor Dr. Roxana
Kollar et al. 2010; Mackie et al. 2011). fact that treatment is seldom supported by Stegaroiu, Division of Oral Science for
No wear or corrosion of magnetic abut- the national or private health insurances. Health Promotion, Department of Oral
ments was observed in 5 years of function. The fact that significant differences were Health and Welfare, Niigata University,
Magnet abutments require lower skills for partially recorded regarding costs and mainte- Japan, for useful comments and advice. This
wearing and cleaning and, especially due to nance requirements between the attachment study was supported by Grant No. 316/03
lower maintenance requirements, are recom- systems rejected the null hypothesis. and Grant 507-207 from the ITI Foundation
mended to be used in elderly patients with A limitation of the present study was the for the Promotion of Oral Implantology,
disabilities. heterogeneous maxillary status. Selection of Switzerland.

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