Corina Marilena Cristache

Ligia Adriana Stanca

Muntianu
Mihai Burlibasa
Andreea Cristiana Didilescu

Authors affiliations:
Corina Marilena Cristache, Concordia Dent Clinic,
Bucharest, Romania
Ligia Adriana Stanca Muntianu, Removable
Prosthodontics, Faculty of Dental Medicine,
University of Medicine and Pharmacy Carol
Davila, Bucharest, Romania
Corina Marilena Cristache, Mihai Burlibasa,
Implantology, FMAM, University of Medicine and
Pharmacy Carol Davila, Bucharest, Romania
Andreea Cristiana Didilescu, Department of
Anatomy, Faculty of Medicine and Pharmacy,
Dunarea de Jos University, Galati, Romania
Andreea Cristiana Didilescu, Department of
Embryology, Faculty of Dental Medicine,
University of Medicine and Pharmacy Carol
Davila, Bucharest, Romania
Corresponding author:
Andreea Cristiana Didilescu
8, Blvd Eroilor Sanitari, 050474, Bucharest,
Romania
Tel.: +40 722536798
Fax: +40 21 3131298
e-mail: Andreea.Didilescu@gmail.com

Five-year clinical trial using three

attachment systems for implant
overdentures

Key words: complications, costs, locator, magnet, prosthetic maintenance, retentive anchor
Abstract
Objective: The objective is to compare, in a prospective randomized clinical trial, three types of
attachment systems for mandibular implant overdenture, focusing on costs, maintenance
requirements and complications from baseline to the end of 5-year follow-up period.
Materials and Methods: Sixty-nine fully mandibular and fully/partially maxillary edentulous
patients received two screw-type Straumann implants, in the mandibular canine region. New
overdentures with three types of attachment systems were inserted according to an early-loading
protocol: Group B (balls, divided into Subgroup B.1 retentive anchor with gold matrix and
Subgroup B.2 retentive anchor with titanium matrix) (n = 23), Group M (magnets) (n = 23) and
Group L (locator) (n = 23).
Results: The highest maintenance event number (195) was observed in Group B vs. 31 in Group L
and 15 in Group M. Significantly more complications were recorded in Subgroup B.1 than in
Subgroup B.2, Group M and Group L (P < 0.05). Group M registered the highest prosthetic success
(82.6%) in the 5 years, followed by Group L (78.2%). Subgroup B.1 had the lowest success rate
(50%). The magnet group recorded statistically significant higher costs, comparing with the other
two groups (P < 0.05).
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.

Date:
Accepted 30 October 2012
To cite this article:
Cristache CM, Muntianu LAS, Burlibasa M, Didilescu AC.
Five-year clinical trial using three attachment systems for
implant overdentures.
Clin. Oral Impl. Res. 00, 2012, 18
doi: 10.1111/clr.12086

2012 John Wiley & Sons A/S.

In case of the edentulous patients, the success of the denture therapy depends upon the
biomechanical prodigy of support, stability
and retention (Jacobson & Krol 1983b,c). The
mandibular denture generally presents the
major problem with regard to retention due
to a movable floor of the mouth, which
causes difficulty in establishing a lingual
border seal. Denture stability is minimised
by lack of ideal ridge height and conformation (Jacobson & Krol 1983a). Due to resorption, the remaining anatomic regions of the
mandible are not usually essential in providing dental support (Jacobson & Krol 1983c).
Problems regarding integrating dentures
are observed with a higher incidence for
mandibular than for maxillary dentures
(Mericske-Stern 1998). To overcome these
drawbacks, over the past 35 years, clinicians
have been restoring aesthetics and function in
edentulous patients with implant overdentures

using different retention systems and nowadays the cost-effectiveness and the simplicity of treatment become the main issues for
the choice of treatment (Zitzmann et al.
2006). The role of the attachment type is
very important (Kimoto et al. 2009): a rigid
connection between implants and denture
induces stress with potential implant failure
(Menicucci et al. 2006), especially when
hinge movements around the fulcrum line
occurs. Moreover, splinting implants by
means of a bar-clip construction is more
expensive, time-consuming, involves more
complications (Gotfredsen & Holm 2000)
and offers no marked differences in patient
satisfaction when compared with non-splinting attachments (Cune et al. 2010). Due to
these facts, resilient and magnetic attachment for implant overdentures, allowing
several types of movements, are extensively
used. The magnetic anchor is a non-rigid,

Cristache et al
Different retentions for implant mandibular overdenture

dynamic anchor. The retentive unit permits

rotary movement of the denture in one or
more directions and/or vertical translational
movements. The magnetic attachment denture has a low resistance to lateral forces,
and the subsequent immediate loss of retention is associated with a lower level of
implant moment loading, thereby protecting
the implant against unfavourable lateral
forces (Heckmann et al. 2001). The desire
to use the magnetic retention is related to
the simplicity involving minimal time at
the chairside and in the laboratory. Two
different types of alloys were used for the
manufacture of small dental magnets:
cobalt-samarium magnets introduced in the
sixties and an alloy based on iron neodymium boron in the eighties, both with
high attractive forces but with a low corrosion resistance (Walmsley 2005). Nowadays,
to increase corrosion resistance, the magnets
are encapsulated in stainless steel, titanium
or palladium by using laser-welded coatings
(Haruta et al. 2011).
As resilient anchors, balls (retentive anchors)
are considered the simplest and less costly type
of attachments for clinical application (Cakarer
et al. 2011).
The self-aligning locator system has dual
retention: through both external and internal
mating surfaces, is resilient, retentive and
durable, and has some built-in angulation
compensation (Cakarer et al. 2011). The locator system has been widely used in the past
three to 4 years, but there is a need of longterm prospective clinical studies to compare
this system with other attachment systems
(Alsabeeha et al. 2011), particularly with
regard to the treatments success, as well as
clinical and prosthetic complications.
Although the recommended number of
implant is established (Feine et al. 2002), no
scientific data to support the use of one
attachment system against another are available for the edentulous mandible, due to the
fact that functional demands of edentulous
patients are highly variable and the choice of
treatment is strongly influenced by adaptive
capacity, socio-cultural background and also
by financial means (Fitzpatrick 2006).
Therefore, the aim of this study was to compare three types of unsplinted attachment
systems, focusing on costs, maintenance requirements and complications, in a prospective clinical trial: retentive anchors (balls, Straumann,
Basel, Switzerland), magnets (Titanmagnetics
Steco system-technick, Hamburg, Germany) and
locator (Zest Anchors, Inc., Escondido, CA,
USA), for implant overdenture in the edentulous
mandible. No differences between the attach-

2 |

Clin. Oral Impl. Res. 0, 2012 / 18

ment systems regarding costs and maintenance

requirements defined the null hypothesis formulated in the present study.

hygiene status) was performed before any

treatment procedure.
Surgical procedure

Materials and methods

The study was conducted from September 2004
to March 2012 according to the CONSORT
guidelines for improving the quality of clinical
trials (Altman et al. 2001; Moher et al. 2003;
Schulz et al. 2010) (Data S1). The use of human
subjects in this study was reviewed and
approved by the Romanian Ministry of Health
and written informed consent was obtained
from all participants.
Sixty-nine fully mandibular edentulous
patients (age ranging between 42 and 84 years)
were recruited from the University Hospital of
Dentistry and nine private practices in Bucharest and the surrounding areas (ClinicalTrials.
gov Identifier: NCT01034930). Their maxillary status was as follows: 12 (17.4%) with
fixed bridges; 3 (4.3%) with natural teeth; 46
(66.7%) with removable complete dentures
and 8 (11.6%) with removable partial dentures.
The patients were selected based on all the following criteria: complains about the stability
of the existing mandibular denture satisfactory from a technical point of view; patients
included in Class I to III (American College of
Prosthodontists Classification of Complete
Edentulism) (McGarry et al. 2004); acceptance
of a mandibular overdenture retained by two
endosseous implants; agreement for a 5-year
follow-up period.
Exclusion criteria comprised: insufficient
bone volume (height and width) for inserting
of at least a 10-mm implant (diameter 4.1)
(due to extensive residual ridge resorption,
patients in Class IV American College of
Prosthodontists Classification of Complete Edentulism, were excluded); Angle class II relationship; physical condition that will affect
the minimal invasive surgical procedure or
constitute a hindrance for a 5-year follow-up
(e.g. immunosuppressive therapy, elderly
patients in poor physical condition); history of
radio-/chemotherapy in the head and neck
region; history of pre-prosthetic surgery
(including bone graft procedures) or previous
oral implants.
Selected patients were informed about the
three different treatment options and about
the benefit of treatment with an overdenture
retained by two endosseous implants (Feine
et al. 2002).
The medical status and dental history of
all patients were checked and an oral and
radiographic examination (including oral

Each patient received two screw-type Straumann (Switzerland) standard soft tissue level
implants 4.1 mm diameter, with sandblasted
large-grit acid-etched (SLA) surface in the
canine region of the mandible with an interconnecting line approaching parallelism with
the terminal mandibular hinge axis (Naert
et al. 1998). The implant lengths were 10 or
12 mm. The choice of implant length was
dictated by the preoperative radiographic
assessment of bone height in the canine
region and drilling distance, with the principal concern of achieving primary stability.
Bone height in the canine region was
assessed on orthopantomograms. Jaw bone
quality was rated during the dental implant
surgery, by the tactile resistance during drilling. The same surgeon for all the cases
performed the implant surgery, allowing an
objective evaluation.
Both clinical and radiographic evaluation
permitted a classification according to the
Lekholm & Zarb (1985) index.
The implants were inserted under local
anaesthesia in a one-stage non-submerged
procedure according to a strict protocol (Weingart & ten Bruggenkate 2000).

Prosthodontic procedure

The mandibular denture was adjusted by

selective grinding at the implant location, Protefix (Queisser Pharma, Hamburg, Germany).
Adhesive cushions were provided and patients
received oral hygiene instructions. One, two
and 4 weeks after the surgical procedure,
patients were recalled for follow-up visits. At
the third follow-up visit, the manufacturing of a
new maxillary denture (for the full maxillary
edentulous patients) and a new mandibular
overdenture with metal reinforcement were
initiated. For the maxillary dentate patients,
correct maxillary fixed rehabilitation was
performed prior to implant surgery at the mandible.
After 6-week healing period, implants were
loaded using an early-loading protocol (Aparicio et al. 2003; Morton 2008; Lethaus et al.
2011). A dental assistant, not involved in this
research project randomly assigned the
patients to one of the three main groups
(Table 1, Fig 1ag):
1. Group B (n = 23) received retentive
anchors (Straumann); it was randomly
divided into two subgroups (B.1: with
gold matrix and B.2: with titanium
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

Group

No. of patients

Patrix

Matrix

B, Subgroup B.1

12

Retentive anchor abutment,

height 3.4 mm, titanium

Gold matrix Elitor

B, Subgroup B.2

11

23

23

matrix), based on characteristics of the

overdenture attachment.
2. Group M (n = 23) received magnets
(Titanmagnetics Steco system-technick.
3. Group L (n = 23) received locator (Zest
Anchors, Inc).
The random assigning was done using 69
sequentially numbered opaque sealed envelopes (SNOSE) according to the protocol
proposed by Doig & Simpson (2005), regardless of the state of the opposing maxilla.
The prosthetic procedure was performed by
experienced prosthodontists, according to the
recommendations of the manufacturer (Straumann Dental Implant System) for retentive
anchors, magnets and the locator system.
Occlusion was assessed both on the articulator and intra-orally to secure a balanced
occlusion in centric relation without anterior
tooth contact (Naert et al. 2004b; Vercruyssen et al. 2010).
Patients were scheduled for follow-up visits
at 1-week post-prosthesis insertion and every
6-month post-abutment insertion. At each
follow-up visit, patient received oral hygiene
care and written oral hygiene instructions.
Outcome measurements

Data collection was performed by two independent researchers (without knowledge of

the prosthodontist) at baseline assessment
(1 week after insertion of the implant overdenture) (T0), 6 months (T) and annually (T1
T5).
Prosthetic maintenance and complications
(related to implant components, structure of
the prosthesis and adjustments of the prosthesis including soft tissue problems) were
assessed from baseline until T5, according to
the number of scheduled (planned and routine
procedures) and unscheduled visits (solicited
by the patients). All the events were prospectively documented using evidence-based criteria from baseline to 5 years and the
prosthodontic success was assessed with the
aid of the six-field table analysis proposed by
2012 John Wiley & Sons A/S.

Manufacturer for Straumann

Straumann, Basel,
Switzerland

Denture
titanmagnetics

Varied retention (four

lamellae functioning
like a spring)
Spring with a defined
extraction force: 7001100 g
Not specified by the
manufacturer

Straumann, Basel,
Switzerland
Steco system-technick,
Hamburg, Germany

Denture cap titanium

with nylon retention

Pink light retention

1360 g

Zest Anchors, Inc.,

Escondido, CA, USA

Titanium matrix
Titanmagnetics insert,
height 3.25 mm,
titanium housing
Locator abutment 3 mm,
titanium alloy

Retentive force indicated

by the manufacturer

Payne et al. (2001). According to this analysis,

the criteria are defined as follows:

because of either loss of implants or irreparable mechanical breakdown.

Success no evidence of retreatment except

for accepted maintenance (includes patrix
activation/repair/replacement, matrix activation/repair/replacement and asymptomatic periimplant/interabutment mucosal
enlargement not requiring excision). There
is a limit of two replacements of either patrix or matrix in the first year and five
replacements in 5 years, and one reline of
the overdenture base in 5 years.
Survival patient cannot be examined
directly, but the patient or another clinician
confirms no evidence of retreatment except
that described for a successful outcome.
Unknown (lost to follow-up) patient
cannot be traced; surviving or successful
implant overdenture removed to allow
to provision of a new overdenture, for
example, conversion to another overdenture design with additional implants or a
fixed implant prosthesis using the same
or additional implants.
Deceased patient died during the study
period regardless of whether successful or
surviving criteria were experienced and
recorded before death.
Retreatment (repair) Treatment of
implant overdenture and/or mucosa where
marginal integrity and associated patrices/
matrices are maintained irrespective of
modifications as long as it continues as an
implant overdenture. This includes more
than two replacements of either patrix or
matrix in the first year or more than five
replacements in the first 5 years. It also
includes replacement of worn or fractured
overdenture teeth/fractured overdentures,
relining of overdenture more than once in
5 years or excision of patrix-associated
mucosal enlargement as a result of infringement on the shoulder/undersurface of the
patrix.
Retreatment (replace) part or all of implant
overdenture is no longer serviceable

The two subgroups of Group B were analysed separately.

Cost analysis

Costs for each type of attachment were calculated according to all the procedures and complications at first year (T1) and fifth year (T5)
and were subdivided into direct and indirect
costs, being estimated based on the minimal
clinical charges for the procedures by the surgeon, prosthodontist and dental hygienist.
The direct costs included costs of dental laboratory, costs of materials (implants and components), pharmaceuticals, radiography and
charges for the procedures by the clinician
and the dental laboratory. The indirect costs
included the patients time and out-of-pocket
expenses (Penrod & Takanashi 2003).
In our calculation, the direct costs were
considered. Aftercare was defined as care and
maintenance provided during the evaluation
period, including check ups and cleaning.
Costs of complications (components, prosthodontist and dental laboratory fees) were
considered separately.
The costs of dental implants and components are from the Romanian Straumann representative February 2009. Costs of the
prosthetic complications per patient were
calculated in the following manner: total costs
of complications per group/subgroup divided
by n (i.e. number of patients in the group/
subgroup) = costs of prosthetic complications
per patient in the respective group/subgroup.
Assessment of implant failure

This was performed according to previously

established criteria (Albrektsson et al. 1986).
Statistical analysis

Data were expressed as mean values, standard deviations (SD), ranges, medians and
percentages, as appropriate. The Levene test
was used to verify the homogeneity of vari-

3 |

Clin. Oral Impl. Res. 0, 2012 / 18

Cristache et al
Different retentions for implant mandibular overdenture

(a)

man, the last one, a heavy smoker lost both

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 021, median 1)
maintenance events in the 5-year period was
recorded for the entire cohort of patients
(n = 69). Table 2 shows the number of maintenance events for each group per year.

(b)

(c)

Baseline group analysis

(e)

(d)

The summary of the main findings per group

is shown in Table 3.
Occurrence of complications

(g)

(f)

Fig. 1. Implant overdenture attachment systems: (a) Group B Retentive anchor abutments; (b) Subgroup B.1 Gold
matrix with variable retention; (c) Subgroup B.2 Titanium matrix with defined retention; (d) Group M Magnet abutments; (e) Group M Magnet denture insert; (f) Group L Locator abutments; (g) Group L Locator denture insert.

ance. Associations were tested using Pearson

Chi-squared test and Fishers exact test.
Analysis of variance was used to test for significant differences between means, and the
Scheffe post hoc test analysed the effects
through multiple comparisons. Non-parametric KruskalWallis and MannWhitney U
(Wilcoxon)-tests were performed to compare
the medians between the groups/subgroups
considered. All tests of significance were
two-tailed. StataIC 11 statistical software
(StataCorp LP, College Station, TX, USA,
version 2009) was used for data analysis. A
P-value < 0.05 was considered statistically
significant.

Results
The results confirmed group homogeneity.
There was no statistical difference between
groups for age, bone height in the canine
region and interimplant distance (P > 0.05,
one-way ANOVA test). No association was
recorded between any group and bone quality, bone quantity, gender or implant length
(P > 0.05, Pearson Chi-squared and Fishers
exact tests). No significant difference was
recorded between groups in terms of period
of edentulism (P > 0.05, KruskalWallis test).
Out of the 138 implants placed, four were
lost in three patients (two women and one

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
screw was stuck inside the implant. The broken piece was removed with the aid of a
service set sent by Straumann. A new abutment 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, KruskalWallis and MannWhitney
U-tests). The number of maintenance events
was 241 in 5 years, with the following distribution: 195 were observed in Group B (184 in
Subgroup B.1 and 11 in Subgroup B.2), 31 in
Group L and 15 in Group M. All the patients
belonging to Subgroup B.1 required matrix
activation at 6 months up to 1 year. Among
them, four patients needed matrix replacement (eight prosthetic components for two
implants) (Table 4). No statistical significant
differences were recorded between Subgroup
B.2, Group L and Group M (P > 0.05, Kruskal
Wallis and MannWhitney U-tests).
Prosthodontic success

In our study, Group M registered the highest

prosthetic success (82.60%) in 5 years,
followed by Group L (78.26%). Subgroup B.1
had the lowest success rate (50%) (Table 5).
Cost analysis

Table 2. The distribution of maintenance events per year

Group

Year 1

Year 2

Year 3

Year 4

Year 5

31
7
8
7

26
0
0
0

35
1
0
0

48
0
6
11

44
3
1
13

B
B1
B2
M
L

4 |

Clin. Oral Impl. Res. 0, 2012 / 18

The subgroups B.1 and B.2 recorded differences

in cost of prosthetic components at the same
surgical, prosthodontic and dental laboratory
fee (B.1 = 1594 Euro/patient and B.2 = 1670
Euro/patient).
Subgroup B.1 registered more expensive
first-year aftercare and complications per
2012 John Wiley & Sons A/S.

Cristache et al
Different retentions for implant mandibular overdenture

Table 3. Baseline clinical characteristics of the study groups

Groups

B
(n = 23)

Age (years)
Mean (SD)
57.8 (8.8)
Median
58
Range
[4276]
Bone height in canine region (mm)
Mean (SD)
25.3 (5.6)
Median
24
Range
[1644]
Bone quality*
N (%)
Type I
4 (17.39)
Type II
13 (56.52)
Type III
6 (26.09)
Type IV
0
Bone quantity*
N (%)
Class A
1 (4.35)
Class B
7 (30.43)
Class C
8 (34.78)
Class D
7 (30.43)
Interimplant distance (mm)
Mean (SD)
20.1 (7.3)
Median
21
Range
[738]
*

M
(n = 23)

L
(N = 23)

63.4 (9.5)
64
[4784]

64 (9.6)
65
[4780]

26.2 (4.9)
25
[1836]

24.2 (3.7)
24
[18.530.8]

1 (4.35)
19 (82.61)
3 (13.04)
0

4 (17.39)
14 (60.87)
5 (21.74)
0

0
11 (47.83)
9 (39.13)
3 (13.04)

0
13 (56.52)
5 (21.74)
5 (21.74)

20.3 (5.8)
22
[431]

20.1 (4.9)
19.1
[11.634]

Lekholm & Zarb (1985).

Table 4. Prosthodontic and soft tissue complications during 5 years of functioning

No. of events
Group B
B.1
Patrix-related (implant abutment) maintenance
Fracture of the abutment screw
0
Loosening of the abutment screw
1
Matrix-related (overdenture component) maintenance
Activation of matrix
144
Exchange of rubber ring
18
Exchange of stainless steel spring
0
Exchange of the matrix
8
Replacement male locator
0
Overdenture-related maintenance
Relining overdenture
4
Fracture of the overdenture
0
Fracture of teeth
2
New overdenture
2
Soft tissue-related complications
Mucositis, soreness
3
Ulcer decubitus
1
Hyperplasia
1

B.2

Group M

Group L

0
2

1
3

0
0

0
0
0
0
0

0
0
0
0
0

0
0
0
0
22

2
0
1
1

3
1
1
1

1
0
0
1

1
2
2

2
1
2

2
1
4

Table 5. Six-field table analysis of prosthodontic success after 5 years of functioning according to
Payne et al. (2001)
Group B
N (%)
B.1
N (%)
Success
Surviving
Deceased
Unknown
Retreatment (repair)
Retreatment (replace)
2012 John Wiley & Sons A/S.

14
6
0
0
0
9
6

(56.5)
(50)

(39.1)
(50)
0

B.2
N (%)

Group M
N (%)

Group L
N (%)

8 (72.7)
0
0
0

19 (82.6)
0
0
0

18 (78.3)
0
0
0

3 (27.3)
0

4 (17.4)
0

5(21.7)
0

patient comparing with the other groups/subgroup (60 EUR vs. 40 EUR) due to the higher
number of maintenance events.
The costs per patient/group/subgroup are
shown in Table 6. The magnet group recorded
statistically significant higher costs comparing with the other two groups, whilst no
statistical
significant
differences
were
observed between Group B and Group L, after
the 5-year evaluation (KruskalWallis and
MannWhitney U-tests). The complication
costs for Subgroup B.1 vs. B.2 during years two
to five were 309.5 Euro/patient and 3.63 Euro/
patient, respectively.

Discussion
The use, in our clinical study, of two implants
as attachment for overdentures is based on the
clearly demonstrated success (Mericske-Stern
& Zarb 1993; Naert et al. 1999, 2004a) of using
fewer (generally two) implants and in accordance with the proposed standard clinical
treatment protocol for edentulous elderly
patients in daily practice (Feine et al. 2002).
The implant survival rate of 97.1% after
5 years, including loss of implants during the
osseointegration period (early failure) is comparable with the studies of Buser et al. (1999)
(96.2%), Ferrigno et al. (2002) (95.9%) and
Lethaus et al. (2011) (96.7%), with the use of
the same implant system and the same surface treatment.
The 6-week loading protocol performed in
this study is considered an early-loading protocol. The absence of implant failures after
loading is in agreement with other studies
(Payne et al. 2002; Roccuzzo & Wilson 2002).
In the light of our findings, the overall number of prosthetic and soft tissue complications
were relatively low compared with other studies (Mackie et al. 2011). Most of the maintenance requirements were easy to handle:
screwing loosening abutments or activation of
the matrix to improve retention (Subgroup
B.1). Considerably more prosthetic maintenance requirements were registered in subgroup B.1, similar to the findings of Walton
et al. (2009), but different from Watson et al.
findings (Watson et al. 2002). The type of gold
matrix used in the present study consisted of
four lamellae functioning like a spring. All the
patients needed at least one activation of the
gold alloy matrix per year (i.e. 100% activation
per year). This result is different from Waltons findings who reported, in a 3-year study,
only 73% need of matrix activation (Walton
2003). Four patients needed fully replacement
of the gold matrices due to impossibility of

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Clin. Oral Impl. Res. 0, 2012 / 18

Cristache et al
Different retentions for implant mandibular overdenture

Table 6. Computed costs in EUR (Euro) per patient and per group/subgroup
Implants/components
Surgery
Dental technician
Prosthodontist
Costs at delivery
Costs at delivery per group
Aftercare and complications first year
Total costs first year
Aftercare 5 years
Costs of complications
per patient after 5 years
Total costs fifth year
Mean (SD)
Median
Range

activation with breakage of one of the four

lamellae. The high number of maintenance
events usually recorded with this old version
matrix probably led to the replacement with
elliptical gold matrix.
No patrix wear for the retentive-anchor
patients (Group B) as well as no replacement
of stainless steel springs (titanium matrix)
occurred during the 5 years of functioning, in
contrast to previous findings (Watson et al.
2002; Walton 2003). The ball attachment
wear reported in other studies could be due
to misalignment of the implants (Walton
2003).
Prosthodontic success according to the sixfield table analysis (Payne et al. 2001)
(Table 6) was 50% for Group B.1 (retentive
anchors with gold matrix), that is, similar to
Mackies findings (Mackie et al. 2011) (54% in
5 years), but higher for Group B.2 (retentive
anchor with titanium matrix, 72.7%). The previously mentioned study found a much lower
success rate for titanium matrix in 5 years
(33%).
An abutment fracture was recorded in
Group M. No similar events occurred during
the study. No such mechanical complications were described in other overdenture
studies with Straumann abutments (RentschKollar et al. 2010; Mackie et al. 2011).
No wear or corrosion of magnetic abutments was observed in 5 years of function.
Magnet abutments require lower skills for
wearing and cleaning and, especially due to
lower maintenance requirements, are recommended to be used in elderly patients with
disabilities.

Subgroup B.1

Subgroup B.2

Group M

Group L

694
350
200
350
1594
1630.34
60
1654
160
356.16

770
350
200
350
1670
40
1710
160
67.45

1118
350
200
350
2018
2018
40
2058
160
68.34

853
350
200
350
1753
1753
40
1793
160
56.30

2170.16 (183.61)
2106
19742564

1937.45 (115.89)
1890
18702237

2286.34 (224.13)
2218
22183298

2009.30 (89)
1978
19532364

The highest number of events during the

first year was registered in Subgroup B.2 and
Group M, different from previous reported
results (Mackie et al. 2011). In the present
study, the most frequent complications during
the first year were soft tissue-related and activation of gold matrix (subgroup B.1). However,
the highest number of maintenance events
occurred during the fourth and fifth year of
service for Subgroup B.1 and Group L, mainly
consisting of matrix replacement.
The cost calculation was made taking into
consideration implant and component Straumann prices (2009), for comparison reasons.
Gold matrix was last mentioned in that price
list (replaced with elliptical matrix).
From the cost calculation (Table 6), the
low initial cost for the implant treatment in
Subgroup B.1 has been noted, as opposed to
the high cost of the aftercare for the next
4 years. The lowest overall 5-year cost is
observed in Group B.2, followed in ascending
order by Group L, Subgroup B.1 and Group
M, respectively. Group M had an initially
high cost (components), but low aftercare
requirements. The highest costs represent a
hindrance in the use of magnets as attachment for implant overdentures due to the
lower income of elderly patients and to the
fact that treatment is seldom supported by
the national or private health insurances.
The fact that significant differences were
partially recorded regarding costs and maintenance requirements between the attachment
systems rejected the null hypothesis.
A limitation of the present study was the
heterogeneous maxillary status. Selection of

study participants who are all completely

edentulous in the maxilla would have allowed
for better standardization.
It can be concluded that, after 5-year followup, the three attachment systems (retentive
anchor, magnets and locator) functioned well.
The implant-retained overdenture demands
continuous aftercare, especially when ball
attachment and golden matrix are used.
The magnets had a low maintenance
requirement and high success rate, despite the
relatively increased initial costs.
Retentive anchor with titanium matrix and
locator system may be better choices from a
financial point of view taking into consideration the initial low cost of the components
and also the reduced number of complications.
The present findings do reflect that there
is variation in the maintenance of overdenture attachment systems. Because of this,
costs for maintenance of implant-retained
overdentures have considerable individual
variance and should not be universally interpreted.

Acknowledgments: The authors are

grateful to Associate Professor Dr. Roxana
Stegaroiu, Division of Oral Science for
Health Promotion, Department of Oral
Health and Welfare, Niigata University,
Japan, for useful comments and advice. This
study was supported by Grant No. 316/03
and Grant 507-207 from the ITI Foundation
for the Promotion of Oral Implantology,
Switzerland.

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Supporting Information
Additional Supporting Information may be
found in the online version of this article:
Data S1. CONSORT 2010 checklist of information to include when reporting a randomised trial*

2012 John Wiley & Sons A/S.