Mandibular Overdentures

Stabilized by Astra Tech Implants

with Either Ball Attachments or
Magnets: 5-Year Results

David M. Davis, BUS, PhD, FDSRCS'

Mark E. Packer, BDS, MPhii, FDSRCS''

Purpose; The purpose of this work was to report on the use of implant-stabilized
overdetitures iti the mandible using the Astra Tech implant system with either ball
attachments or magnets as the retentive mechanism. Materials and Methods: Mandibular
overdentures that used ball attachments on 2 implants were provided for 13 edentulous
patients; 12 edentulous patients were provided with mandibular overdentures with
magtiet retention, using 2 implants in 10 patients and 3 implants in 2 patients. Once they
were comfortable, the participants were placed on annual recall. Any other visits were
initiated by the patients. Detaiied records were kept for all visits. At the annual recall the
following parameters were monitored: plaque levels, mucosal health, marginal bone
levels, and the patients' assessment of the treatment. The patients were followed for 5
years. Results: There was no statistical difference between the 2 groups for mucosal
health and postinsertion maintenance. The magnet group had more abutment sutfaces
covered with plaque. Statistical analysis of the patients' subjective assessment of their
treatment showed that the magnet group was less comfortable and chewing was less
effective. Conclusion: The results indicate that both ball attachments and magnets used
on isolated Astra Tech implants in the mandible are viable treatment options. Both
attachment mechanisms provided patient satisfaction, although the ball attachments were
better in this respect than the magnets. Int j Prosthodont 1999:12:222-229,

mplant-stabilized overdentures have been shown to

provide a successful long-term outcome, particularly
when used to restore the edentulous mandible.'"^^ A
variety of implant systems has been used, including the
Brnemark system (Nobel Biocare),^'^'^'^"''^ the ITI
system (Straumann),^''''i the IMZ system (Steri-Oss),'''-''
and the Astra Tech system (Astra Tech).^"^ The success

rates for these studies are very similar, as judged by survival of the implants. In a review of 37 overdenture
studies, Batenburg et aP^ reported only 2 studies that
did not have success rates of 90% or greater.

The most widely reported attachment mechanism

is the linked bar, although ball attachments and magnets are also used. In a review by Batenburg et a l "
34 of the studies used implants linked with a bar attachment and 21 used unlinked implants. Tbe most
'Senior Lecturer and Honorary Consuitant. Department of
commonattachment used for unlinked implants is the
Prosthetic Dentistry, The Dental institute. King's Coiiege School
ball attachment,'^''''^"'^ with relatively few using
of Medicine and Dentistry, London, England.
''Lecturer. Department of Prosttietic Dentistry, The Dentai Institule,magnets.''''^ No difference has been reported among
King's College School of Medicine and Dentiitry, London. Engiand.the different attachment mechanisms for success rates
in the mandible as measured by survival of the imReprint requests: Dr David Dayis, The Dental institute. King's
College Sci^ool of Medic me and Dentistry, Caldecot Road, Londonplants.''"*'^''^ Naert and coworkers^'^" used all 3 atSES 9RW, England, UK. Fax: + 17U346-37F5.
tachments. Tbey reported tbat the bar attachment

I of ProBtliodontics

222

Davis/Packer

Astra Tech Implants with Ball or Magnet Attachments

was technically the most demanding compared to

unlinked implants. However, from a maintenance
point of view the bar was less demanding and provided better patient satisfaction with the treatment.
The purpose of this study was to report on the use
of implant-stabilized overdentures in the mandible
using either magnets or ball attachments as the retentive mechanism. This article presents the 5-year
data from this continuing prospective study.

Materials and Methods

Patients
A total of 25 edentulous patients participated in this
prospective study. All participants gave a history of
difficulty in wearing a conventional complete
mandibular denture. The complaint had been present
for a number of years and had not been resolved by
theprovisionof new dentures. Mandibular overdentures that used ball attachments on 2 implants were
provided for 13 patients (ball attachment group).
Mandibular overdentures using magnet retention
were provided for 12 patients (magnet group); 10
patients had 2 implants stabilizing their overdentures
and 2 patients had 3 implants. The ball attachment
group comprised 8 women and 5 men with a mean
age of57 years and a range of 41 to 72 years. The 12
patients in the magnet group were all women with a
mean age of 57 years and a range of 45 to 76 years.
There were 24 patients still in the study at the end of
the 5 years, as one man from the ball attachment
group died toward the end of the second year.
Implants
The Astra Tech System was used for all patients (Fig
1 ). The threaded implants and abutments are made of
commercially pure titanium. The abutment and abutment screw are constructed as a single unit. The abutment threads are within the implant to produce what
the manufacturer calls a conical seal. For this study
7 lengths of implants were available, ranging from 7.5
to 19 mm with diameters of either 3.5 or 4 mm. The
abutments were available in 6 lengths, ranging from
0 to 7.5 mm with a 45-degree taper at the top.
The ball attachment mechanism comprised a commercially pure titanium, ball-shaped attachment that
is threaded into the top of the abutment and a goldalloy cap that is incorporated into the denture base.
The magnet attachment mechanism consisted of a
stainless steel keeper coated with titanium and titanium nitride that is threaded into the abutment. The
split-pole magnet is incorporated into the denture
base and is made of neodymium-iron-boron.

12, Number , 1999

223

Fig 1 Separated componeots of the Astra Tech implant system: ball attachment, left, and magnet keeper, right.

Surgical Technique
A total of 24 patients had 4 implants placed in the
mandible between the mental foramina using standard implant protocol; one additional patient had 3
implants placed. The participants were not allowed
to wear their mandibular dentures for 2 weeks following placement of the implants. After this period,
the dentures were adjusted and relined with a provisional resilient material. The implants were left submerged for a minimum of 4 months.
At second-stage surgery 52 of the 99 implants were
activated (Table 1 . Healing abutments were placed
on the 2 implants that had been placed closest to the
canine region. When the time came to expose the implants it was found that in 2 individuals a more centrally placed implant had already perforated the mucosa. It was decided to use this implant in addition
to the more favorably placed implants. All other implants were left as "sleepers." All surgical procedures
were carried out by the same oral and maxillofacial
surgeon.
Prosthetic Technique
Once the tissues had healed the healing abutments
were replaced with definitive abutments and the patients were allocated randomly to either the ball attachment group or the magnet group. In 21 individuals new

The International Journal of Ffosthodontics

Astra Tech Implants wilh Ball or Magnet Attactiments

Table 1

Oavis/Packer

Number and Length of Implants Activated at Second-Stage Surgery

Length in mm (3.5-mm diameter)

Group

7.5

11

13

15

17

Length in mm (4.0-mm diameter)

19

7.5

11

13

15

Magnet
m = 26]
Total
(n = 52)

fi

14

10

19

The patients' views on their dentures were assessed

by asi<ing them to record as good, moderate, or poor
their subjective assessment in reiation to chewing
abiiity. Their views on this subject, reiative to their
conventionai compiete dentures, were aiso obtained
at the beginning of the study, in addition the participants were asked, "Have you had any probiems or
discomfott with your denture?" The choices for answering this question were no, yesminor, and yes
severe.

maxiiiary and mandibuiar dentures were fabricated

using standard prosthetic techniques. For 4 individuis, 3 in the baii attachment group and one in the
magnet group, it was decided that there wouid be no
advantage in making new maxiiiary and mandibuiar
dentures, and the attachments were incorporated into
the existing mandibuiar dentures, which were rebased
at the same time.
The prosthetic treatment was provided by one of
6 experienced dentai surgeons using an estabiished
protocol. Four dentai surgeons treated 2 patients
each, one treated 3 patients, and one treated 14 patients. Apart from the dental surgeon who treated 3
patients, each clinician treated an equai number of
patients with bail attachments and magnets. The first
treatment was compieted in June 1990 and the iast
in May 1992,
Upon placement of the dentures the patients were
instructed on routine denture care using a brush and
soap, Whiie the dentures were being constructed the
patients' abiiity to maintain a high level of oral hygiene around the abutments was monitored and,
where necessary, further instructions were given. The
patients were seen until they were probiem free, at
which point they were placed on annuai recali. Any
other visits were initiated by the patients when and
if they experienced probiems. Detai led records were
kept for each visit, noting the reasons for attendance
and the treatment provided, Aithough ali 24 patients
attended the recaii at the end of the fifth year, not ali
ofthem attended every annuai recaii. The number of
patients who attended ail 5 recails was 10 in the bail
attachment group and 9 in the magnet group.

Radiographic

Analysis

The bone ieveis were monitored with intraorai radiographs using the iong-cone parai iei ing technique, A
scale ioupewitha magnification of 7 X that was graduated in 0.1-mm increments was used to measure the
bone Ievei around the implants. When evaiuating the
change in the bone ieveis the distance between a reference point at the top of the implant and the marginal bone ievel was recorded for the mesiai and
distai surfaces. In addition, the distance between a
given number of threads was measured; this was
compared to the known distance for this measurement, in this way, the measurement ofthe bone ievei
could be adjusted to ai iow for any distortion. To anaiyze the marginal bone ioss at the end of each year
the distance ofthe marginai bone from the reference
point was compared with the baseiine vaiue.
Assuming that the patient had 2 implants, there were
4 vaiues for marginai bone ioss at the end of each
year. The mean bone ioss was tben calcuiated by
combining aii ofthe resuits. The baseiine radiographs
for 4 patients in the baii attachment group and 3 in
the magnet group were unfortunately iost. Therefore,
the figures for marginai bone ioss were based on 9 individuis in each group.

Baseline and Recall Visits

At these visits the state of the soft tissues around the

impiants was recorded by noting the presence or absence of erythema, edema, and bleeding on probing
ofthe mucosa. The presence or absence of piaque on
the mesiai, distai, buccai, and iinguai surfaces ofthe
abutments was recorded. This was assessed visuaiiy
and recorded as either present or absent.

The Irternalioiial lournal of Proslliodontic

17

Ball attachment

Statistical

Analysis

The results were analyzed using either the Chisquared test or the Student's t test to look for differences between the 2 groups.

224

Volume 12, Numbe

Davi^acker

Table 2

Asrra Tech Implants with Ball or Magnet Attachments

Mean Marginal Bone Loss at the End of Each Year (mm)*

Group

Ball attachment
Mean
Range
Magnet
Mean
Range

-0.2 0.4
-1.7-0 8

-0.1 0.6
-1.4-1.4

0.1 0.3
-1.4-1 6

0.1 +0.4
-3.0-1.5

0.0 0.5
-1.4-1.3

-0.3 0,6
-2.0-1.0

-0.4 0.6
-1 6-1.1

-0.3 + 0.7
-1,8-1.6

-0.2 0.7
-1.6-1.9

-0.3 + 0.8
-1.7-1.7

"Student's (test applied to raw data. P = 0.0016.

Results
Implant Components
Integration was lost in one implant 6 tnontlns after
denture insertion, while in a second patient an implant fractured toward the end of the first year. Both
ot these patients were in the magnet group. One patient in the ball attachment group fractured an implant toward the end of the fifth year. In all 3 instances
spare implants were activated, new abutments were
placed, and the patients continued in the trial.
During the 5 years it was necessary to change the
abutments in 4 patients. There were 2 patients who
were unhappy with their dentures in the region of the
attachments as they felt bulky. It was therefore decided to replace the abutments with shorter ones. In
the other 2 patients the ball attachments, which
screwed into the top of the abutments, kept unscrewing. These abutments were replaced with "allin-one" abutments of the same length (Fig 2). All-inone abutments, which were introduced during the
course of the study, are designed so that the abutment
and ball attachment are manufactured as one unit.

Fig 2

"All-in-one" ball attachment.

Mucosal Response

Marginal Bone Levels

There was no statistical difference, over the 5 years,

between the 2 groups when comparing the percentage of abutments around which the mucosa showed
signs of erythema, edema, and bleeding on probing.
The mean value for the ball attachment group was
25% 15% and 17% 9% for the magnet group
(Student's ftest, P= 0.211. There was, however, a statistically significant difference between the 2 groups
for the percentage of abutment surfaces that showed
the presence of plaque. The mean percentage value
for the ball attachment group was 20% 7% and 33%
10% for the magnet group {Student's ttest, P= 0,04).

The bone loss around the implants was greatest during the first year, after which there was very little
change (Table 2)- There was a statistical difference between the 2 groups, with the magnet group exhibiting greater marginal bone loss than the ball attachment group (P= 0.016).

-r:\':\:-r^

' 2 . Number J, 1999

Postinsertion Maintenance
The ball attachment mechanism required 56 episodes
of maintenance because of the ball attachments
unscrewing, fracturing, or wearing and the clips

225

The International lournal of Frosthodontics

Astra Tech Implants with Ball or Magnet Attachments

Diivis/Packer

Table 3 Reasons for and Frequency of Postinsettion

Care Related to Implants and Attachment Mechanisms
Total
Ball attachment group
Abutment unscrewed
Abutment changed
Ball attachment unsorewed
Ball attachment fractured
Ball attachment worn
Clip adjusted
Clip replaced
Loss of implant
Fracture of implant
Total
Magnet group
Abutment unscrewed
Abutment changed
Keeper unscrewed
Keeper fractured
Magnet replaced
Loss of implant
i Fracture of implant
Total

2
3
26
7
1
18
4
0
1
62

5
1
7
1
21
1
1
37

Table 4 Reasons for and Frequency of Postinsertion

Care Related to Mandibular Overdentures

No, of people

Total
Ball attachment group
Denture adjustment
Denture rebased
Denture fractured
Denture remade
Other problems
Total
Magnet group
Denture adjustment
Denture rebased
Denture fractured
Denture remade
Other problems
Total

2
3
9
5
1
6
3
0
1
12
5
1
3
1
11
1
1
12

Table 5 Patient Response to the Question "Have

You Had Any Problems or Discomfort with Your
Prosthesis?"*
Pretreatment
Ball attachment group
None
Yesmild
Yessevere
Magnet group
None
Yesmild
Yessevere

52 7
45 8

50
50

31 1 0
60 + 11

21
5
6
2
2
36

9
5
4
2
2
12

29
5
6
6
3
49

11
3
4
6
3
12

Table 6 Subjective Patient Assessment of

Prostheses in Relation to Chewing Ability"

Posttreatmenl mean

8
23
69

No, ot people

Pretreatrrent
Ball attachment group
Good
fi^ ode rate
Poor
fvlagnet group
Good
fi/loderate
Poor

34

9t6

Posttreatment mean

83*12
17 + 12
70 13
21 i l l
1010

Responses are expresses as a percentage of all responses for each ye

Chi-sqjared lest, P = 0.0Q5.

'Responses are expreised as a percentage of all responses for each year,

Chi-squared test, P ^ 0,005,

requiring adjustment or replacement. The magnet attachment mechanism required 29 episodes of maintenance because of keepers unscrewing or fracturing
and the magnets needing replacement (Table i). This
difference was statistically significant Chi-squared
test, P= 0.052), The major maintenance requirement
with the ball attachments was the need to retighten
them, which requiredonevisit. The major requirement
with the magnets was that they needed to be replaced,
which involvedat [east 2 visits. The total number of visits required to maintain the ball attachment mechanisms was EJO, while the magnet attachments required
55 visits. On comparing the number of visits there
was no statistical difference between the 2 groups for
the amount of postinsertion maintenance.
The mandibular overdentures required attention on
36 occasions in the ball attachment group and 49 occasions in the magnet group (Table 4). The category
"other problems" consists of prosthetic chai lenges that
were unrelated to the use of implants, for example the

need to reposition teeth to increase tongue space or the

need to reposition the anterior feeth to produce the correct lip support.
The total number of episodes of maintenance related to the implants, attachment mechanism, and
mandibular prosthesis was 98 in the ball attachment
group and 86 in the magnet group. This maintenance
required the ball attachment group to make a total of
150 visits and the magnet group to make 158 visits.
Thus, on average each patient in the ball attachment
group made 12.2 visits over the 5 years for postinsertion care, while those in the magnet group made
13.2 visits. There was no statistical difference between the 2 groups when comparing the total amount
of postinsertion care.

226

Patient Assessment

There was a statistically significant difference between

the 2 groups in response to the question "Have you

Volume 12, Numbe

Davis.'Packer

Astra Tech Implants with Ball or Magnet Attachments

bad any problems or discomfort with your prosthesis?"; the ball attachment group appeared to be more
comfortable (Chi-squared test, P= 0.005) (Table 5).
Similarly, chewing abilit>' also showed a statistical difference, with the ball attachment group rating their
ability higher iChi-squared test. P = 0.005] (Table 6).

of plaque increased, it was expected tbat there would

be a decrease in the health of the mucosa as indicated
by signs of erythema, edema, or bleeding on probing.
However, no such correlation could be found.
Marginal bone loss around implants has been highlighted as an important criterion for judging long-term
implant survival. The usual means of monitoring
bone levels is with periapical radiographs. However,
it can be difficult to obtain consistency between radiographs, particularly in individuals who have a
high levei of the floor of the mouth relative to the crest
of the ridge. This can result in radiographs that are difficult to read. Both Johns et ai'" and Wright et aP^ reported that approximately V. of the radiographs in their
Studies were unreadable or missing. Jn a prospective
study such as the present one, the fact that 7 baseiine
radiographs were missing is extremely disappointing.
Although the magnet group exhibited statistically
significantly more marginal bone loss than the ball attachment group, the figure for mean marginal bone
ioss of 0.33 mm after 5 years was less than the 0.2 mm
per year recommended by Albrektsson et al.^^ For
both groups, the marginal bone loss was greatest
during the first year, after which the bone level was
remarkably stable.
Bone Ioss around implants has usually been measured in tenths of a millimeter. However, Sewerin^"
has shown that a 1-degree change in the angulation
of the x-ray beam results in a change in the measured
bone level of 0.1 mm. Benn-' has estimated that any
measured change in marginal bone height of less
than 1 mm is likely to be an artifact. Thus, in view of
the small sample size in this study and the vvide range
of the readings (Table 2), it is quite possible that the
differences in bone loss between the 2 groups are not
real. Further studies with a larger pool of participants
would be necessary to confirm any differences. Naert
and coworkers'"* -- could find no differences in marginal bone levels among 3 groups of overdenture patients, with each group having a different attachment
mechanism.
One of the purposes of a clinical trial is to examine the efficacy of a particular treatment modality and
to make modifications in light of the experience
gained. The drawback with this is that the piece of
equipment that is being tested becomes obsolete.
This is demonstrated by the design of the ball attachment, which was changed during the course of
this trial. The screw part of the ball attachment was
the weakest link in this attachment mechanism. To
overcome this problem, Astra Tech introduced an attachment in which the ball and the abutment are
made as one unit (Fig 2). This all-in-one attachment
has replaced the separate ball attachment, which is
now no longer available. The all-in-one attachment

Discussion
Only one implant was lost during the 5 years because
offailureofosseointegration. Thefaatbat2 implants
fractured is an indication of the bending stresses to
which implants are subjected. Clantz and Nilner'^
concluded, from a biomechanical point of view, that
the prognosis for overdenture treatment in patients
with osseointegrated implants is maximized when (/J
the number of implants used to stabilize the overdenture is as great as possible, (2) the bar system has
been designed with the highest possible rigidity, and
(3) tbe overdenture itself has some functional flexibility, judged by these criteria, the use of 2 isolated implants is the least favorable situation. Although the
number of fractures is small, it does represent an implant fracture rate of 4%. It is therefore essential that
the group of people in the present study is followed
for a longer period of time to see if there is an increased
number of implant fractures. As both of the fractured
implants had a diameter of 3.5 mm, it would seem to
be a sensible precaution to use the larger 4.0-mm diameter implant when using the Astra Tech implant system for overdentures, particularly wben using only 2
implants.
The implant survival rate for the ball attachment
group was 96%, and that for the magnet group was
92%. These survival rates are very similar to those obtained in other studies.^^'^^ Thus, it would seem that
the Astra Tech System is one of a number of implant
systems that can be used successfully to stabilize
overdentures in the mandible.
Tbe abutments in the magnet group consistently
had more surfaces covered in plaque than the ball attachment group. It was felt that the number of sun^aces
covered in plaque would give an indication of the difficulty in cleaning around the implants. The magnet
keepers are wider at the top than at the base (Fig 1 ).
This leads to the creation of a space between the prosthesis and the implant. This would encourage greater
plaque accumulation, which patients could find more
difficult to remove completely.
Naert et al'"' found a similar increase in plaque
around implant-stabilized overdentures when magnets were used, compared to ball attachments and
bars. They attributed this difference to loss of motivation in the magnet group, who showed a tendency
to dissatisfaction with their magnets. As the amount

Z,.:,.,,.^ :2,Niimber, 1999

227

Ttie Internat ion,

al of Pro5thodonlics

Astra Tech Implant! with EIIII or Magnet Attachments

Davis/Packer

was used on 2 patients during the course of this

study. These 2 individuals accounted for 16 of the 33
occasions when the ball attachment required attention. Once the all-in-one ball attachments were used,
there were no further episodes of the attachments
loosening. Thus, it seems likely that the use of this
new abutment would have improved the security of
the ball attachment and therefore reduced the amount
of postinsertion care. However, further studies are
necessary to confirm this view.
The data for clip adjustment is underreported in
that at least 3 individuals made their own adjustments to maintain retention. It could be argued that
one of the advantages of the clips is that they allow
wearers to make their own adjustments, unlike failure of the magnets, which requires the individual to
return to the dental office for treatment.
The magnets do corrode and cease to function. In
the present study 3 patients required magnet replacement on one occasion, 6 on 2 occasions, and
2 patients on 3 occasions. Only one patient did not
have the magnets replaced during the 5 years of the
study. In this individual, the magnets ceased to function during the third year of the study, but because
of illness the patient was unable to return to have
them replaced. They were eventually replaced, but
outside the 5-year period covered by this paper. The
mean life of the magnets was 103 weeks, with a
range of 40 to 183 weeks.
None of the overdentures was strengthened originally. Glantz and Nilner'^ have highlighted the fact
that, from a biomechanical point of view, the prognosis for overdenture treatment s maximized when
the overdenture has some functional flexibility. The
inclusion of a cobalt-chromium alloy strengthener
conflicts with this requirement. In 2 individuals the
overdentures fractured twice within a short period of
time, and the overdentures were therefore remade
with the inclusion of a cobalt-chromium alloy
strengthener. However, it seems advisable not to do
this as a matter of routine in view of the potential for
increasing the loading onto the 2 implants.
The number of visits made for postinsertion care excludes the annual recall visits, unless they involved
an episode of maintenance. It could be argued that
annual recall visits are an essential part of implant
maintenance and so should be included in the total
number of visits irrespective of whether they resulted
in the provision of extra care. However, as the purpose of the study was to examine the amount of
maintenance required to maintain the overdentures
and implants, it was decided to exclude those annual
recall visits when no maintenance was required.

ability to chew effectively when compared to patient

denture assessment prior to the placement ol implants.
There is the suggestion that the magnet itoup was less
comfortable and chewing was less etieciive when
compared to the ball attachment group. However,
there was no direct comparison of the 2 types of attachments on the same patients. The participants were
therefore not able to compare the effectiveness of the
2 attachment mechanisms. Burns et aP' have carried
out such a study with 17 subjects using O ring and
magnet attachments. The subjects were satisfied with
both overdentures but showed a strong preference for
the O ring. It is likely that the preference for ball attachments over the magnets is related to the better retention provided by the ball attachments,^^'^^

Conclusion
The evidence indicates that both ball attachments and
magnets used on isolated Astra Tech implants in the
mandible are viable treatment options. There was no
difference between the 2 groups in either soft tissue
health around the implants or the amount of postinsertion maintenance. The magnet group had significantly more abutment surfaces with plaque on them.
Both groups exhibited marginal bone loss that was
less than 0,2 mm per year. Both attachment mechanisms provided patient satisfaction, aithough there is
the suggestion that the ball attachments were better
in this respect than the magnets.

Acknowledgment
The authors would like to thank Astra Tech for their support of
this work.

References

The use of the ball attachments and the magnets both

seemed to provide patient satisfaction and improved

The Internat an a I |ourral of Prosiliodontics

228

1.

Engquist B, BergendalT, KaiiusT, Linden U. A retrospective multicenter evaluation of osseoinlegrated implants supporting overdentLres. l n t | Orai Maxillofac Implants 1988;3:129-134.

2.

Mrricske-Stern R, Clinical evaluation ot overdenture restorations

supported by osseointegrated titanium implants: A retrospective
study, int J Oral Masillofac Implants 19O;5:375-3B3.

3.

Naert I, Quirynen M, Theuniers G, van Steenberghe D, Prosthetic

aspects of osseointegrated tixtures supporting overdentures. A 4 year report. | Prostliet Dent 1991 ;65:671-68O.

4.

Chan MFW-Y, Johnston C, Howeli RA, Cawood Jl. Prosthetic

management of the atrophie mandible using endosseous implants and oveidentures: A six year review. Br Dent J 1995;
179:329-337.

5.

Sprekermann M, ansen VK, Richter EJ, A10-year follow up study

of IMZandTPS implants in the edentulous mandible using barretained overdentures. Int J Oral Maxillofac Implants 1995;
10:231-243.

6.

|em(T, Char], Harnett J, Heath RM, Hutton JE, |ohns RB, et al.
A 5-year prospective multicenter follow-up report on overdentures supported by osseointegrated implants. Intj Oral Maxillofac
lmpiantsl996;11:29I-298.

Davis/Packer

Asir Tech Implants with Ball or Magnet Attachments

7-

Yusuf H, Raira N, Observations on 25 patienK treated wilh ball

retained overdenlures. Eyr | Prosthodont Restorative tJent 1996;
4:T8l-!83,

8.

Walmsley AD, Frame]W. Implant supported overdenturesThe

Birmingham experience, ) Dent SuppI 1997;25:43-i7,

9.

Cotfredsen K, Implant supported overdenturesThe

Copenhagen experience, J Dent SjppI 1997;25:39^2,

10,

Mencske-Stem R, Zarb CA, Overdentures: An altemative implant

methodology for edentulous patients. Int J Prosthodont
1593;6:203-208,

11.

Mericske-Stem R, Steiniin Schaftner T, Marti P, Geering AH. Periimplant mucosal aspects of ITI implants supporting overdenlures,
A five-year longitudinal study. Clin Oral Implants Res 19945:9-18,

n.

Bergendal T, Engquist B. Implant-supported ovenJentures: A longitudinal study, Int I Oral Maxillofac Implants 1998;13-.353-262,
Batenburg RHK, Meijer H|A. Raghoebar CM, Vissink A. TreatTneni
concepts for mandibular overdentures supported by endosseous
implants: A literature review. Inl J Oral Maxillofac Implants 199813J39-545.

13.

14.

Naert I, Cizani S, VuylstekeM, van Steenberghe D. A 5-vear randomized clinical trial on the intluence of splinted and unsplinted
oral implants in mandibular overdcnture therapy. Part 1 : Periimplant outcome. Clin Oral Implants Res 1998:9:170-177.

15.

Clantz P-O, Nilner K. Biomechanical aspects of overdenture

treatment, i Dent SuppI l997;35:21-24.

16.

CuneMS,dePunerC, Hoogstratenl.Ananonwideevaluativestudy
on implant-retained overdentures, J Dent Supp11997;25:13-19.

17.

Johns RB, lemt T, Heath MR, Hutton JE, McKenna S, McNamara

DC, el al. A mullicenter study ol" overdentures supported by
Brnemark implants. Inl | Oral Maxillofac Implants J992-7513-522,

1 a.

Wright PS, Watson RM, Heath MR. The effects of prefabricated

bar design on ihe success of overdentures stabilized by implants. Inll Oral Maxillofac Implants l995;10:79-87.

19.

Albrefctsson T. ZarbC, Worthington P, Eriksson AR, The long-term

efficacy of currently used dental implants: A review and proposed
criteria of success. Inl | Oral Maxillofac Implants 1986:1:11-25.

20.

Sewerin IP. Errors in radiographie assessment of marginal bone

height around osseoirtegrated implants, Scand J Den Res 199098:428-433,

21.

Benn DK. A review of the reliability of radiographie measurements in estimating alveolar bone changes. | Clin Periodontol
1990;! 7:14-21.

22.

Naert I, Quirynen M, Hooghe M, van Steenberghe D. A comparative prospective study of splinted and unsplinted Bineniark
implants in mandibular overdenlure therapy: A preliminary report. J Prosthet Dent 994:7] :4a6-492,
Burns DR, Unger JW, Elswick RK, Ciglio |A, Prospective clinical evaluation of mandibular implant ovefdentures: Part II
Patient satisfaction and preference. I Prosthet Deni I995;73364-369,
Burns DR, UngerjW, Elswick RK, 8eck DA. Prospective clinical
evaluation of mandibular implant overdentures: Part IRetention,
stability and tissue response. J Prosthet Dem 1995;73:354-363.

23.

24.

Literature Abslract-

Effect of occlusal appliances and clenching on the internally deranged TMJ

space.
Stabilization appliances (SA) and mandibular antenor repositioning appliances (MARA) have
been used for treatment ot temporomanaibular disorders (TMD). These appliances have been
assumed to reduce interarticLJlar surface compression in the temporomandibuiar jrnt fTMJ)
during closing and clenching. This study aimed to test that assumption. Inciusion cnteria tor
the 7 patients who sought treatment at a TMD clinic were anterior disc displacement (ADD)
without reduction verified by MRI, history of unilateral TMJ pain and locking during opening,
and/or difficulty in jaw opening for less than 6 months. All teeth except third moiars were required for participating in the study and the exciusion criterion was clear evidence of osseous
changes in the TMJ. The SA used in this study was a maxiliary compiete appiiance with a flat
occlusal table, which increased the vertical dimension of occlusion by 3 mm in the anterior region. The MARA was designed to hold the mandible in a straight, forward position 2 mm from
intercuspal position. Bilateral tomograms were faken of these 7 patients with ADD during comfortable closure and maximal clenching in maximum intercuspation; tomograms were aiso
taken with the 2 different types of splints in situ. The tomogram with the slice ievei nearest to
the central part of the condyle was selected. Six images tor each joint were taken, one baseline and tive exprimentai conditions with tfie SA and MARA, Outlines of the condyle and temporal fossa were automatically determined by an edge-detection protocol, and the minirrurr
joint space dimensions were automatically measured for each expenmental condition as the
outcome variable. The results showed no significant ditferences in minimum joint space dimensions between the splints (SA or MARA] or between any of the splints and maximum intercuspation. It was concluded that these appliances do not induce an increase in joint space during
closing and clenching In joints with ADD without reduction.
Kubokl T, Takenami V, Orsni MG, Maekawa K, Yamashlta A, A2uma Y, Clark GT. J Orotac Pain
1999:13:38-48 Relerences: t5. Heprints; Dr Takuo KuOoki, Department of Fixed Prosthodontios,
Okayama University Dental School, 2-5-1 Shikata-clio, Okayama 7Q0-8525. Japan, e-maii:
kubokiSder t.okayam a-u. ac. jpA W

"2,Numt)er3,l999

229

The Intemational ioun