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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 13  |  Issue : 1  |  Page : 1-10

Clinical and radiographic evaluation of implant-supported removable partial overdenture in the lower Kennedy class IV cases


Prosthodontics Department, Faculty of Dentistry, Tanta University, Tanta, Egypt

Date of Web Publication26-Jul-2016

Correspondence Address:
Wesam M El-Rashedy
Prosthodontics Department, Faculty of Dentistry, Tanta University, Tanta
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-8574.186940

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  Abstract 

Introduction
The objective of the present study was to evaluate the effect of implant-supported partial overdenture design in restoring mandibular long class IV Kennedy's classification on the supporting structure, both clinically and radiographically.
Materials and methods
Ten partially edentulous patients with lower six anterior teeth missing were selected. Their ages ranged from 40 to 50 years. Each patient received two dental implants placed in the lower edentulous span at the canine area bilaterally. Ball-and-socket attachment (polycarbonate housing with rubber O-ring) was used between the implant and the overlay removable partial denture for retention. Periodic evaluation was carried out for every patient before denture insertion and then after 3, 6, and 9 months. As regards the clinical evaluation, the probing depth, gingival level, and attachment level around the implants were recorded. The radiographic evaluation included the use of specially developed software for measuring the alveolar bone density in gray scales and the bone height in pixels for the implants and the residual alveolar ridges.
Results
All implants were highly successfully osseointegrated at the end of this study. There was a statistically nonsignificant increase in the clinical parameters (probing depth, gingival level, and attachment level) around the dental implants throughout the 9-month follow-up period after denture insertion. Radiographically, there was a nonsignificant increase in bone loss, but a significant increase in bone density around the dental implants and the alveolar ridge throughout the follow-up period.
Conclusion
From the previous results, it was found that the concept of immediate loaded dental implant was efficient to be used successfully in the mandibular long Kennedy class IV to retain the partial overdenture.

Keywords: clinical follow-up, implant-supported denture, Kennedy class IV


How to cite this article:
El-Rashedy WM, Shakal EA, El Gendy MN, Saudi HI. Clinical and radiographic evaluation of implant-supported removable partial overdenture in the lower Kennedy class IV cases. Tanta Dent J 2016;13:1-10

How to cite this URL:
El-Rashedy WM, Shakal EA, El Gendy MN, Saudi HI. Clinical and radiographic evaluation of implant-supported removable partial overdenture in the lower Kennedy class IV cases. Tanta Dent J [serial online] 2016 [cited 2017 Aug 20];13:1-10. Available from: http://www.tmj.eg.net/text.asp?2016/13/1/1/186940


  Introduction Top


Dentofacial problems have known definitive effects on patients' satisfaction with their dentition, as it affects esthetics, performance, and oral functions, including chewing, speech, oral comfort, general performance, smiling, and appearance. It also has significant effects on patients' emotions and confidence, and hence patients face difficulties in accepting tooth loss [1].

Dental professionals need an accurate perception of how patients feel about their teeth and the impact of this on their daily living.

Loss of anterior teeth is a compelling reason for prosthodontic treatment. Kennedy class IV partial edentulism is a frequent result of traumatic accidents, certain congenital anomalies, or periodontal diseases [2].

Partially edentulous cases with long anterior edentulous area represent a challenging problem facing prosthodontists. Restoring such cases requires both esthetic and biomechanical consideration, and thus many options of replacement are available.

Traditionally, the choice was between removable or fixed prosthesis. Their selection depends on the size and length of edentulous ridge, quality of bone, condition of the abutment teeth, and patient's desires.

One of the most important indications for the use of overdenture is for providing support for long anterior denture bases, although restores most oral functions such as mastication, phonation, and esthetics. The use of metal clasps in this design often compromises esthetics, especially when abutment teeth for clasps are anterior [3] teeth.

Today, with the predictability of dental implant, the options of tooth replacement range from removable to fixed implant-supported prosthesis.

Implantology is a fast-growing area in dentistry. The use of implants to replace missing teeth either in partial or complete edentulism has become popular, widely acceptable, and it has undoubtedly been one of the most significant scientific treatment modalities in dentistry over the past 30 years.

Many studies have revealed good long-term success rate as high as 95% when edentulous mandibles are treated with implant-supported prosthesis [4]. However, it cannot easily be performed for all patients. Dental implant success depends primary on the patient selection. The preoperative evaluation includes the exclusion of pathology, identification of critical anatomical structures that may interfere with implant placement in the proposed site, and the evaluation of the quality and quantity of the remaining bone [5].

The time period suggested for insertion of prosthesis in the anterior zone of the mandible (a site that provided predictable results with immediate loading of implant in a one-stage protocol) was between 2 days and 2 weeks after surgery, allowing a shorter implant-to-restoration timeline [6].

This process includes patients' comfort and less anxiety as well as less expense and more convenience for both the patient and the clinician.

Aim of the study

The objective of this present study was to evaluate the effect of implant-supported partial overdenture design in restoring the mandibular long class IV Kennedy's classification on the supporting structure, both clinically and radiographically.


  Materials and Methods Top


Ten partially edentulous patients were selected for this study from the outpatients clinic of Prosthodontic Department, Faculty of Dentistry, Tanta University, and their ages ranged from 40 to 50 years. They had the lower six anterior teeth missing (long class IV Kennedy classification). The visual examination of the oral structure of each patient was carried out for the mucosa covering the mandibular edentulous area to inspect for any sign of infection, inflammation, the presence of swelling, ulcers, and remaining root, and the condition of maxillary natural teeth and its occlusion. The tongue also was carefully examined to detect its size, shape, and any abnormal lesions.

Digital examination of the mucosa covering was carried out by applying finger pressure to detect the presence of any flabby tissues, sharp ridges, areas of tenderness or extremely thin mucosa, and mandibular tori or bony prominences.

The bone height of the alveolar ridge should be enough to receive the implant length and permit at least 2 mm distance from the vital structure, and the labiolingual width should be enough to allow the insertion of implant, leaving 1 mm space on the labial side and 1 mm space on the lingual side at the prospective implant site. The patients with sufficient intermaxillary space and opposing arch who were either dentulous or partially edentulous were restored with fixed prosthesis with normal occlusion (angle class I maxillomandibular relationship).

The ridge mapping process helps in the selection of implant diameter and was performed as follows.

Anesthesia was induced in the area under investigation, and the thickness of the soft tissue was measured by puncturing it using a small size endodontic file or periodontal probe vertically and horizontally until it touched the bone. The information was transferred to the cast, which was sectioned at the area in which the implant will be placed (canine area bilaterally). The points on the cast (ridge mapping) were connected [7] to determine the width of the bone and the thickness of the mucosa [Figure 1].
Figure 1: Ridge mapping to determine the width of the bone and the thickness of the mucosa (red color).

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Construction of the metallic removable partial denture

Maxillary and mandibular preliminary impressions were made with irreversible hydrocolloid alginate (Zhermack, Badia Palestine, RO, Italy) impression material using modified stock trays. The impressions were poured in dental stone (Moldano stone W; Heraeus Kulzer, Germany) to produce the diagnostic casts. An acrylic resin (Acrostone Co., Egypt) special tray with spacer covering the edentulous area and the teeth was constructed on the primary cast of the lower arch. Secondary impression was made in the special tray that was loaded with rubber base impression material, and then inserted in the patient's mouth and maintained until the material hardened. The impression was poured in dental stone to produce the master cast. Duplication of the master cast using agar-agar (Plastergel Duplicating Gel; Metrodent, West Yorkshire, UK) duplicate material was made to produce the refractory cast, which was made from an investment (Wirovest special Investment Material; Bego Bremer Goldschlägerei Wilh, Germany) material, on which the wax pattern of the metal framework was made.

The refractory cast with the wax pattern and attached sprue was invested in a casting ring, burned-out, and then casted in cobalt–chromium alloy. The canine regions bilaterally were free from the metal to avoid the interference with the implant and housing during RPD insertion. The metallic framework was finished and polished, and then tried in the patient's mouth for testing adaptation, patient's comfort, and relation with the opposing natural teeth [Figure 2], and then the acrylic artificial teeth were set.
Figure 2: Trial of the metal framework in the patient's mouth.

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The metallic removable partial denture was flasked, packed, and processed into heat-cured acrylic resin material and then finished and polished. After partial denture delivery, occlusion, esthetics, speech, and patient's comfort were checked.

Implant placement

Each patient received one-piece ball-type Dentium implant system of 13 mm length and 3 mm diameter with polycarbonate housing (denture socket) with rubber O-ring in the lower edentulous span at the canine area bilaterally using flapless implant surgery [Figure 3].
Figure 3: Placement of one-piece ball-type dental implants at the canine area bilaterally using the flapless surgical technique.

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Immediate loading of the metallic removable partial overdenture

The time period suggested for insertion of prosthesis according to immediate loading protocol was between 2 days and 2 weeks after surgery [6].

The overdenture with attachment was inserted in the patient's mouth after 1 week from implant insertion for all patients in this study using the following method. An indelible pencil was used to mark on each ball-top. The metallic RPD was seated in the patient's mouth to determine where the denture needs to be relieved, holes were made in the fitting surface of the metallic RPD at the marked locations using a laboratory bur [Figure 4]. Two metal housings with rubber O-ring were placed above the two implants, making sure that they were securely seated [Figure 5].
Figure 4: Holes were made in the denture at the premarked locations using a laboratory bur.

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Figure 5: Two metal housings were placed on the implants and ensured that they were firmly seated.

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Pickup of the housing (chair-side pickup procedures)

The holes in the fitting surface of the metallic RPD base were filled with self-cured acrylic resin, and then the metallic RPD was placed over the housing (socket) in the patient's mouth. The patient was instructed to bite gently on the metallic removable partial overdenture to confirm the correct position, until the acrylic resin showed complete seating.

The removable partial overdenture was removed and checked to assure that the housing was in its fitting surface. Excess acrylic resin was trimmed away and the denture was polished [Figure 6]. The removable partial overdenture was reinserted and tried in the patient's mouth for occlusion.
Figure 6: The finished metallic denture with polycarbonate housing (denture socket) and rubber O-ring.

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All patients were followed up at 3, 6, and 9 months for evaluation clinically and radiographically.

The criteria evaluated clinically were [8] the probing depths, gingival level, and attachment level of the dental implant.

Radiographic evaluation

Standardized periapical radiographs were taken using the extension cone parallel technique with a film holder for measuring the alveolar bone density in gray scales and the bone height in pixels for the implants and the residual alveolar ridges [9] [Figure 7].
Figure 7: Periapical radiographs for measuring the bone height in pixels and bone density in gray level.

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All clinical and radiographic data were tabulated and statistically analyzed for each patient. The statistical presentation and analysis of the present study were conducted using SPSS V.16 (Chicago, USA), and the data were presented as mean and SD. The analysis of variance test was used to assess the effect of time in each group using the quantitative data.


  Results Top


Clinical evaluation

There was no statistically significant increase in the probing depth, the gingival level, or in the attachment level of dental implant at different follow-up periods ([Table 1],[Table 2],[Table 3]).
Table 1: Mean value and SD of the probing depth of dental implant at different follow-up periods

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Table 2: Mean value and SD of the gingival level of dental implant at different follow-up periods

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Table 3: Mean value and SD of the clinical attachment level of the dental implant at different follow-up periods

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Radiographic evaluation

Bone height in pixels for the right and left implants at the mesial and distal sides

[Table 4] shows the bone height expressed in pixels for the right implant at the mesial and distal sides at different follow-up periods.
Table 4: Mean value and SD of the bone height in pixels for the right implant at the mesial and distal sides at different follow-up periods

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The mean value of the bone loss significantly increased after 3 months, and then it nonsignificantly increased after 6 and 9 months for the right implant at the mesial and distal sides.

Bone height in pixels for the left implant at the mesial and distal sides

[Table 5] shows the bone height expressed in pixels for the left implant at the mesial and distal sides at different follow-up periods.
Table 5: Mean value and SD of the bone height in pixels for the left implant at the mesial and distal sides at different follow-up periods

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The mean value of the bone loss significantly increased after 3 months, and then it nonsignificantly increased after 6 and 9 months for the left implant at the mesial and distal sides.

Bone density in gray level for the right and left implants at the mesial and distal sides

[Table 6] shows the bone density expressed in gray level for the right implant at the mesial and distal sides at different follow-up periods.
Table 6: Mean value and SD of the bone density in gray level for the right implant at the mesial and distal sides at different follow-up periods bone density of right implant

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The mean value insignificantly decreased after 3 months, and then it significantly increased after 6 and 9 months for the right implant at the mesial and distal sides.

Bone density in gray level for the left implant at the mesial and distal sides

[Table 7] shows the bone density expressed in gray level for the left implant at the mesial and distal sides at different follow-up periods.
Table 7: Mean value and SD of the bone density in gray level for the left implant at the mesial and distal sides at different follow-up periods bone density of left implant

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The mean value insignificantly decreased after 3 months, and then it significantly increased after 6 and 9 months for the left implant at the mesial and distal sides.

Bone density in gray level for the alveolar bone ridge

[Table 8] shows the bone density expressed in gray level for the alveolar bone ridge at the midpoint between the two implants at different follow-up periods.
Table 8: Mean value and SD of the bone density in gray level for the alveolar bone ridge at different follow-up periods

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The mean value of the bone density nonsignificantly decreased after 4 months, and then it significantly increased after 6 and 9 months for the alveolar bone ridge at the midpoint between the two implants.


  Discussion Top


Management of long-span anterior edentulous area (Kennedy class IV) is considered a prosthodontic challenge, which is usually concomitant with many problems related to the length of the span, esthetics, and other biomechanical considerations. Traditionally, the missing teeth are replaced between the fixed and removable partial dentures and may exhibit many problems such as stability and retention of the denture, especially in the lower jaw.

Thus, the implant-supported removable partial overdenture is the treatment of choice, especially in patients with mandibular denture retention problem in long [5] edentulous saddle.

In this study, 10 partially edentulous patients with missing lower six anterior teeth (long Kennedy class IV) were selected. Their age ranging from 40 to 50 years that eliminate its effect on biting force and bone metabolism and to avoid variation in bone density in aged individuals [10].

The selected patients were free from any systemic diseases that affect bone metabolism or any endocrine dysfunction or nutritional disturbances that could complicate the implant treatment [11].

Patients with bad habits such as bruxism, clenching, tongue thrusting, or abnormal ridge relationship (Angle's II and III) were excluded to avoid any abnormal excessive force that may lead to ridge resorption or implant bone loss [12]. Co-operation and interest of the selected patients were important in this study to accept and withstand long follow-up period.

Sufficient interarch distance was important to provide enough space for attachment placement. In addition, sufficient buccolingual width and length of the alveolar ridge was important to permit sufficient thickness of bone around the implant [13].

The opposing arch in all selected patients was either dentulous or partially edentulous, restored with fixed prosthesis to standardize the effect of opposing [14] occlusion and their effect on the force transmission. Bone loss in the mandible after extraction of teeth is much greater than that in the maxilla. Thus, Naert et al. [15] made the restoration of the long-span edentulous area with the implant-supported overdenture as the treatment of choice.

The lower jaw was selected in this study because it has fewer amount of tissue support and has optimal cortical bone for implant to be installed compared with trabecular bone present in the maxilla. Penarrocha et al. [16] showed more bone loss for fixtures implanted at the maxilla compared with mandibular fixtures. Moreover, Koczorowski and Surdacka [17] showed that the bone loss was greater in the maxilla than in the mandible, and so the mandibular implant demonstrated a higher fixture survival rate compared with the maxillary one [18].

In the present study, preoperative panoramic radiographs were taken for every patient, as it was considered the most commonly used radiographic technique for preoperative planning of implant-supported overdentures. The panoramic radiographs were taken to detect the position of the mandibular canal and mental foramen, and to evaluate the bone height in the area in which the implant will be placed. It has several advantages as it is a quick, simple, of low-dose, and is a low-cost presurgical diagnostic tool [19].

The height, width, and contour of the ridge can be visually assessed and clinically palpated. The presence of concavities or depression (particularly on the labial aspect) is usually readily detected. However, accurate assessment of the underlying bone width is difficult, especially when the overlying tissue is fibrous. Therefore, clinical techniques such as ridge mapping may help and give a better indication of the bone profile compared with simple palpation [20].

In this study, the removable partial overdenture constructed for every patient has simple design, with no clasps or posterior extension of the base, to avoid the effect of unnecessary components on the gingival health of the remaining natural teeth. This is considered the advantage of implant-supported prosthesis [21].

The use of a removable prosthesis permits the patient to remove the restoration at night to reduce nocturnal parafunctional forces and reduce the stresses on the implant, as well as prevent food impaction beneath the denture, which can be removed by the patient to clean it and reinserted again without dentist's help [22].

A combination of cobalt–chromium and acrylic resin was used during fabrication of the denture base – that is, for restoration of facial contour with acrylic resin. The metal framework provides the strongest attachment of the acrylic resin denture base to the RPD and allows easiest relining of the denture base, if necessary. Moreover, the metal in the lingual surface is self-cleansable and prevents food impaction [23] and bad odors.

In this study, two fixtures were implanted in the mandibular intraforaminal area (in the canine area bilaterally). The bone in this area has thick dense cortical plates and dense trabecular bone that help in increasing the primary stability needed for the success of osseointegration in immediate loading. Moreover, these areas are free from any significant anatomical structures [18].

Drilling was performed with a low-speed, high-torque motor system using sharp drills with sufficient continuous cooling during bone preparation to avoid overheating of [24] bone and thermal trauma.

Dentium implant system, one-piece (Ball type) implant with polycarbonate housing with rubber O-ring attachment, was used for this study. The implants were of pure titanium with special design of the thread form and with sandblast with large grit and acid-etched surface, which give maximum bone to implant contact, resulting in successful osseointegration.

The minimum length accepted with mandibular immediate-loading dental implant is 10 mm [25].

Implant of this study was 13 mm in length and 3 mm in diameter for all selected patients.

The fixture implant design with a microroughness body develops higher mechanical retention, good force distribution, minimizes micromotion of the implant, and maximizes the implant bone surface contact and gives high initial stability that can be achieved easily with a tapered implant design [26].

The flapless implant surgical technique was chosen for this study to preserve maximum amount of blood supply to the bone, because reflection of flap will compromise a part of blood supply to bone, which comes from soft tissue. Moreover, this technique was accepted by the patients as the procedure was less time consuming, had minimal bleeding, did not require sutures, was less complicated, and had minimal postoperative pain and swelling [27].

In the present study, the one-piece implant design was used to eliminate the need for placing healing collars and makes it possible to avoid manipulation of the soft tissue portion after initial healing. The implant–abutment junction in a two-piece implant design constitutes a structural weakness that may complicate the procedure [28].

Implant-supported overdenture with ball O-ring attachment may be considered to be a reliable method in the treatment of partial edentulous patients [29].

Ball O-ring attachment provides better stability and retention and minimizes partial denture movement. It reduces pressure and is simple to use, saves time, and is a very convenient treatment modality for the patients [30].

An intraoral direct method was used to attach the metal housing (female part) of the implant to the fitting surface of the denture, that the patient occlusion aided to obtain the proper position and seating of the prosthesis and prevent any dimensional changes [31].

Oral hygiene instructions were given to all patients early in their treatment and reinforced during the subsequent appointments so as to decrease the possibility of plaque accumulation and tissue inflammation around the implants, thus further potentiating the success of the prosthetic rehabilitation and osseointegration of the implants.

In the present study, some clinical and radiographic evaluations were chosen to evaluate the condition of peri-implant tissues.

Evaluation of tissue health around both implants was carried out using clinical parameters, including pocket depth, gingival level, and attachment level. They were assessed because these are the most commonly used parameters and most definitive criteria to evaluate the damaging effect of partial denture on the peri-implant tissue health [32],[33].

Radiographic evaluation of marginal bone levels proved to be one of the most valuable means to clarify implant success [34].

The long cone paralleling technique with XCP device was used in this study as it maintains fixed film-object distance, insures the same position each time and eliminates any superimposition of the adjacent structure, and facilitates serial radiographic comparisons [35].

Gray level assessment has been established as a sensitive technique for the assessment of peri-implant bone density.

In addition, the digital gray level technique increases possibilities for an early and accurate diagnosis of peri-implant changes [36].

Measuring the bone density changes is one of the most sensitive techniques reflecting the microscopic changes occurring within the bone. The more the osteoclastic activity, the more the bone loss and the less the mean gray level values. In contrast, the more the osteoblastic activity, the more the bone formation and the more the mean gray level values. Moreover, the gray level values can detect bone decalcification before actual changes in the bone form, giving an early sensitive alarm about future bone loss before it occurs [37].

The results in this study showed that all 20 fixtures in 10 patients were successfully osseointegrated throughout the follow-up period at 3, 6, and 9 months. There were no mobility and no pain. Radiographically, the fixtures were surrounded by normal bone tissue in intimate contact with their surfaces, and there were no radiolucent areas.

The clinical results of this study revealed that the patients showed a slight nonsignificant increase in pocket depth, gingival recession, and attachment level at all observation periods. This is in agreement with the findings of Fahmy et al. [14], who reported that the presence of an intraoral appliance produced alteration in the ecological condition of the supporting tissues in terms of some tissue changes.

There was a nonsignificant increase in probing depth around the implants throughout the follow-up period. These results are in agreement with the findings of Naert et al. [15], who found that an increase in probing depth in successful implants after 1-year follow-up period should not be more than 2 mm in good oral hygiene. These results also are in agreement with those of Geihan and Amal [38], who found that the pocket depth around the dental implants was 2.4 mm and the attachment level not more than 0.28 mm after 2 years.

The nonsignificant increase in the gingival recession around the implants after its insertion may be interpreted as a gingival shrinkage during healing after surgery. Abu Elross [39] suggested that the increase in the gingival recession with time may be aggravated by the movement of the denture base during function, which may exert pumping action of the gingival margin.

These changes were accepted as it could be considered as a biologic response to the insertion of the partial denture in the patient's mouth with regard to microflora and the stresses transmitted to the investing structures[14].

Radiographic evaluation of marginal bone loss around the implant mesially and distally revealed more loss during the first 3 months, which could be due to the trauma associated with surgical procedure, bone removal during drilling, detachment of the marginal periosteum, high bone remodeling rate during the stage of osseointegration, and future changes was happened after the implant conjunction with the overdenture then subjected to functional loading through the metal framework partial denture. This is in agreement with the findings of Habeab [40], who suggested that the impaired remodeling during the healing phase can be a causative factor for initial bone loss to implants during the first year of function loading.

The results in this study are in agreement with those of Elmahdy et al. [30], who showed a significant bone loss during the first 3 months after insertion of an immediate loaded implant with O-ring attachment, and then showed a nonsignificant marginal bone loss after 1-year follow-up period, which could be attributed to the stable peri-implant conditions and maintenance of oral hygiene.

Naert and colleagues [41],[42] showed that the bone loss never exceeded 2.2 mm even after 15 years. They found that the mean bone loss around the implant was 1.7 mm for patients without periodontal disease and 2.2 mm for patients with it. This is in agreement with the studies of Mohamed and Ibrahim [43], who found that the radiographic bone loss around fixtures in the lower jaw was 0.8 mm for the first year and less than 0.1 mm for the following years. This resorption was slightly less than that in the implant-supported fixed prosthesis. Rasouli Ghahroudi et al. [44] stated that the value of bone loss following 1 year of implantation should not exceed 1.5 mm, with a mean annual rate of 0.1 mm in the following years.

In this study, bone density around the dental implants from the mesial and distal sides showed a nonsignificant decrease during the first follow-up period after 3 months from implant insertion, which was attributed to several factors such as implant placement procedure, detachment of marginal periosteum, and physiological resorption of the edentulous region after implant placement. Thereafter, it started increasing after 3- and 9-month follow-up. The alveolar bone surrounding the implant undergoes certain changes in the course of functional loading, which is known as bone remodeling, in which the bone responds positively to the applied loads by building additional support through the arrangement of its trabecular pattern and heavy lamina dura [45].

The bone density of the alveolar ridge area between the two implants was increased after 3 months from implant insertion, which could be attributed to the fact that the partial overdenture derives its support mainly from the dental implants, and so the amount of load falling on the edentulous area might have been capable of producing positive changes in bone density by the action of physiological stimulation and massaging. The results of Elmahdy et al. [30] are in agreement with the results of Yang et al. [45].

An increase was observed in peri-implant bone density around one-piece immediate loaded ball-attachment implant-retained overdenture. This increase in bone density denotes a favorable bone reaction, which was a positive response of bone to increased stress with an increase in density and trabecular arrangement pattern.

The increase in the bone density of the alveolar ridge could be attributed to the fact that denture saddles tend to function like a mechanical lever. Interforaminally positioned implants can, depending on the attachment characteristics, develop considerable moment loads, which are transferred from implant into the bone. In function, the denture base permitted vertical movements by the virtue of the resilient attachment system, thus delivering physiological normal stimulation of the peri-implant bone that is under loading [30].

This result proved that the density of alveolar bone controlled by the mechanical environment of strain, which is clearly observed in the reduction of bone density after tooth loss where the region is not loaded properly. Theoretically speaking, increase in alveolar bone height and density means that the bone reacts favorably to the applied force.

From the results of this study, the restoring of the long class IV Kennedy classification with lower six anterior teeth missing with immediate loaded implant-supported partial overdenture showed a high success in implant osseointegration, slight clinically nonsignificant changes in soft tissue around the implants, slight radiographic nonsignificant increase in bone loss, and a significant increase in bone density around the implants and the residual alveolar ridges.

The implant-supported partial overdentures of this study are well accepted by the patients because of its simple design, absence of posterior extension or clasps, ease of removal and replacement, and ease of cleaning compared with fixed restoration. As it covers a limited area of tissues, it is hygienic and well tolerated by the tongue.

Success of osseointegrated implants has been validated for more than 30 years as a viable alternative to fixed or removable prosthetic restorations. An increasing number of well-controlled studies have demonstrated that osseointegrated oral implants are a predictable therapy for the replacement of missing teeth [44].


  Conclusion Top


From this study, the following conclusions could be drawn: the use of implant in long class IV Kennedy classification cases is considered an accepted treatment modality. Flapless implant surgical technique is easy, valuable, simple method and is very useful for placement of one-piece implant type. The concept of immediate loaded dental implant was efficient to be used successfully in the anterior mandible to retain the partial overdenture. Radiographic evaluation show a lack of pathological change and less amount of bone loss resulted, which indicated successful implant osseointegration. According to the clinical results, based on the clinical parameters used in this study, the findings revealed healthy peri-implant conditions throughout the study period. The implant-supported partial overdenture of this study is well accepted by the patients in comparison with the conventional partial denture as it covers a limited area of tissues without posterior extension and without clasps. On comparing with fixed restoration, the implant-supported partial overdentures of this study can be easily removed and replaced, and so it is hygienic and can be easily cleaned.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Figures

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