Igor R.

Blum A clinical investigation of the

J. Fraser McCord
morphological changes in the posterior
mandible when implant-retained
overdentures are used

Authors affiliation: Key words: bone resorption, endosseous dental implantation, posterior mandibular
Igor R. Blum, J. Fraser McCord, Unit of residual ridges, sequential mandibular casts
Prosthodontics, Department of Dental Medicine
and Surgery, University Dental Hospital of
Manchester, Manchester, UK Abstract
Correspondence to: Objectives: The widespread use and broad acceptance of osseointegrated dental implants
Dr I. R. Blum as a means of retaining and supporting mandibular overdentures provide potentially stable
11 Austin Drive
three-dimensional reference structures, which have been used to examine the
Manchester M20 6EB
UK morphological changes of the surface contours of the mandibular ridges distal to implants.
Tel.: 44 (0)161 275 6670 Unlike traditional methods that tended to measure changes in ridge morphology and
Fax: 44 (0)161 275 7822
e-mail: i.blum@ntlworld.com quantity radiographically, this prospective study investigated the changes in the sagittal
surface contours of the posterior residual ridges over a 1-year period by an alternative, non-
radiographic method using serial casts of residual ridges of a group of patients.
Material and methods: The residual ridges of the serial casts produced were examined
using a profiling apparatus and computer software programs that allowed the orientation,
digitised recording and measurement of the sagittal surface contours of the posterior
residual ridges of mandibular casts in terms of area (cm2).
Results: Statistical analysis revealed that the detected reductive changes in the surface
contour of the posterior residual ridges following the wearing of an implant-retained
mandibular overdenture over a 1-year period were highly significant (Po0.001).
Conclusion: It is concluded that the methodology presented in this study can be used
reliably as an alternative to radiographical examination for detecting changes that occur in
the distal residual alveolar ridges of the implant containing edentulous mandible when
implant-retained overdentures are used. Thus, the method presented may be used to
contribute to a reduced exposure to ionising radiation for patients wearing implant-
retained overdentures.

Morphological changes in the jaws follow- undergo continuous resorptive changes

Date:
Accepted 6 November 2003
To cite this article:
Blum IR, McCord JF. A clinical investigation of the
morphological changes in the posterior mandible when
implant-retained overdentures are used.
Clin. Oral Impl. Res. 15, 2004; 700708
doi: 10.1111/j.1600-0501.2004.01057.x
Copyright r Blackwell Munksgaard 2004
ing the loss of teeth is a well-established
phenomenon which may lead, in time and
especially in the mandible, to severe reduc-
tion in quantity and quality of the residual
alveolar ridges. Jacobson & Krol (1983) and
Watt & MacGregor (1986) have reported on
the continuous morphological changes that
occur in the mandibular denture-bearing
area and they verified that, unlike the
retromolar pads, the residual alveolar ridges
over time. This leads inevitably to a reduc-
tion in the size of the mandibular denture-
bearing area. Furthermore, the retention
and stability of conventional complete den-
tures tend to be reduced by the consequen-
tial changes in dimension of the residual
alveolar ridges. Patients with atrophy of the
alveolar ridges (especially the mandibular)
often find denture wearing problematic and
painful. Where the provision of conven-

700

tional complete dentures although norma-
tively perceived to satisfy prosthetic norms
are not functionally acceptable to patients,
the provision of dentures retained via en-
dosseous implants can be clinically effec-
tive, provide a beneficial psychological
impact and improved quality of life. While
the usage of implant-supported fixed pros-
theses has been shown to be an effective
treatment modality (Adell et al. 1981;
Lekholm et al. 1999) an overdenture sup-
ported by two to five implants in the
interforaminal region is also considered to
be a very effective and feasible modality for
the oral rehabilitation of patients with
edentulous mandibles restoring both oral
function and facial form (Mericske-Stern
1990; Chan et al. 1995). This has led to
mandibular implant-retained overdentures
becoming a rapidly expanding, successful
and recognised treatment alternative in the
rehabilitation of mandibular edentulism. In
addition, this treatment modality is seen
as a less expensive option than the fixed
prosthesis.
Whereas the impact of implants on peri-
implant bone levels has been widely inves-
tigated bone resorption distal to implants
has been documented scarcely in the lit-
erature. Only few studies (Sennerby et al.
1988; Jacobs et al. 1992; Wright & Watson
1998; Wright et al. 2002; Kordatzkis et al.
2003), albeit using proportional area meas-
urements in terms of area indices, have
investigated the effect of the implant-
supported prosthesis on the distal man-
dibular residual ridges. However, not-
withstanding the inconclusive findings
obtained from these studies, they all em-
ployed radiographic techniques such as
lateral cephalographs and panoramic radio-
graphs. The drawbacks of such imaging
techniques are, besides superimposed resi-
dual ridges, the two-dimensional distor-
tion, possible magnification errors, the
appearance of radiographs with unidentifi-
able anatomical landmarks such as, on
occasion, the mental foramen or the man-
dibular canal (Jacobs et al. 1992). In addi-
tion, all radiographic techniques have the
Table 1. Demographic information pertaining to patients involved in the study
No. of patients Gender
F/M
16 10/6
Blum & McCord . Implant-retained mandibular overdentures and posterior mandibular resorption
disadvantage when they are used of
exposing the patient, perhaps unnecessa-
rily, to ionising radiation. No alternative
methods have, to date, been described that
could meaningfully determine the continu-
ing osseous changes in the distal denture-
bearing area of the implant containing
edentulous mandible.
This paper describes a non-radiographic
method that is sensitive enough for the
detection of morphological changes in the
sagittal surface contour of the posterior
residual ridges using serial casts of a group
of patients wearing implant-retained man-
dibular overdentures over a 1-year period.
The null hypothesis was that no morpho-
logical changes occur in the edentulous
posterior mandibular residual ridges when
implant-stabilised mandibular overdentures
are worn over a 1-year period.
Material and methods
Sixteen patients aged 3672 years who had
received at least two and not more than
four dental implants in the anterior man-
dible at the University Dental Hospital of
Manchester and for whom the restorative
stage with the provision of a mandibular
overdenture was about to be commenced
were consecutively enrolled in this pro-
spective clinical study (Table 1).
Each patient satisfied all of the following
criteria: (1) uneventful healing phase sub-
sequent to implant placement; (2) moder-
ate bone quality and moderate bone
resorption at the start of the study; (3)
healthy with no systemic or psychological
disorder; (4) edentulous individual wearing,
or about to receive, a conventional max-
illary complete denture.
Eleven patients were rehabilitated with
Frialit-2 implants and five patients re-
ceived IMZ implants (both Friadent, Man-
nheim, Germany). Each patient received
only one of the two types of dental im-
plants. Of the patients involved in this
study, two patients received stud-retained
mandibular overdentures and the remain-
Age at start of restorative phase
Mean years (range)
60 (3672)
der received (oval) bar-clip-retained man-
dibular overdentures. All patients were
interviewed at the final clinical stage of
the study with reference to denture satis-
faction and denture-wearing habits. The
study was performed between September
2000 and January 2002 following local
ethical committee approval.
The clinical and laboratory stages were
as follows: All patients had definitive im-
pressions of the mandibular arch taken
during the reconstructive phase with the
corresponding impression posts in situ.
These impressions were repeated 1-year
subsequent to the fitting of the implant-
retained overdenture using

the same (disinfected) special tray,

the same impression materials and
technique,

the same operator who treated all
patients.
The maxillary impressions were made
according to the guidelines of the British
Society for the Study of Prosthetic Dentis-
try (Winstanley et al. 1996).
All definitive impressions of the man-
dibular denture-bearing area were recorded
in two stages. The first stage consisted of
an impression of the saddles and retromolar
pads using greenstick tracing compound
(Greenstick impression compound, Kerr,
Italy) and the second stage consisted of an
impression using a medium-consistency
polyether impression material (Impre-
gums, ESPE, Seefeld, Germany), which
was used as a wash impression. Following
standard infection-control procedures as
employed at the Manchester Dental Hos-
pital each impression, with the impression
posts and laboratory implant analogues
placed back in the impression, was cast in
die stone (Moon Stone, John Winter & Co.
Ltd, Halifax, UK) and these were labelled
with randomly allocated six digit patient
hospital numbers and subsequently analy-
sed. Thus, for each patient there was a series
of two casts representing baseline and 12
months after insertion of the dentures.
Length of time edentulous
Mean years (range)
4.5 (1.56.5)
701 | Clin. Oral Impl. Res. 15, 2004 / 700708
Blum & McCord . Implant-retained mandibular overdentures and posterior mandibular resorption
The orientation and mounting of casts
On all the casts, the contours of the retro-
molar pads were identified and outlined
using a pencil. Subsequently, the midway
distance of the height of these outlined
contours was measured using a transparent
flexible ruler and these positions were
marked. Prior to the marking of the mid-
way on the retromolar pads, the heights of
the (outlined) retromolar pads on the se-
quential casts were measured five times by
using the same ruler. This was followed by
the cutting of a V-shaped notch at this
very mark bisecting the retromolar pads.
The notches in the right and left retro-
molar pads served as two posterior refer-
ence points.
A vertical line was marked, for reference
purposes, on the anterior aspect of the casts
(this was done by measuring the midline
between the two middle implant impres-
sion posts) and this position was marked in
pencil on the serial casts. The location of
this reference line was measured and found
to be identical on the sequential casts.
A perspex occlusion control plate (OCP)
indicator (PTC, Bolton, UK) had been posi-
tioned in such a way that its posterior edges
would relate and fit into the notches. The
OCP indicator was then allowed to contact
(at least one of) the impression posts lo-
cated within the implant analogues in the
anterior aspect of the mandibular cast. This
provided the anterior reference point. The
OCP indicator contacted the same corres-
ponding impression post(s) in the sequen-
tial cast of each patient; thus providing the
same reading. As a result, the same ante-
rior reference point(s) was (were) used in
the sequential cast. Subsequently, the OCP
indicator was fixed to the underlying cast
with extra hard laboratory putty (Zetalabor,
Zhermack, Italy) in a reproducible way.
The OCP indicatorcast complexes were
sequentially placed onto the platform of the
mounting jig in such a way that the vertical
reference line on the casts was in align-
ment with a predetermined reading on the
vernier scale of the mounting jig. Following
this, the OCP indicatorcast complex was
adhered to the horizontal arm of the
mounting jig using heated yellow sticky
wax (Model Cement, Dentsply, UK) pro-
ducing one immobile unit. Subsequent to
the cooling of the sticky wax, the horizon-
tal arm of the mounting jig with the OCP
indicatorcast complex attached was un-
702 | Clin. Oral Impl. Res. 15, 2004 / 700708
screwed and cautiously removed. The final
stage of the mounting procedure involved
the mixing of water and die stone powder
(Moon Stone, John Winter & Co. Ltd,
Halifax, UK) which was subsequently
placed in sufficient amount on the adjus-
table platform of the mounting jig ensuring
that the conical indentations on the surface
of the platform, which acted as locating
dimples, were covered. The mixing of die
stone was standardised by using the same
quantities of powder and water and a stand-
ardised mixing time of 55 s throughout
the study. The OCP indicatorcast com-
plex with the adhered horizontal arm was
reseated onto the platform and the horizon-
tal arm was re-attached to the jig and the
central screw was tightened. Two locating
pins on the mounting jig ensured that re-
attachment of the horizontal arm occurred
in a reproducible manner. The re-attached
OCP indicatorcast complex is illustrated
in Fig. 1.
When the die stone had set, the horizon-
tal arm and the OCP indicator were re-
moved. The series of conical indentations
in the surface of the platform ensured that
the cast could be repositioned rapidly and
reproducibly onto the platform. The pro-
cess was then repeated with the subsequent
sequential cast of the same patient so
that serial comparisons could be made.
Once the cast mounting procedures were
completed the adjustable platform was
transferred to the profiling apparatus for
analyses of the casts.
Fig. 1. Mounting jig with re-attached occlusion control plate indicatorcast complex.
Cast analysis using the profile
analysis apparatus
The profiling apparatus was capable of two-
dimensional reproduction of the surface
of a cast. This research tool has been
described in detail and used reliably in
previous studies (Boyd 1993; Hoad-Red-
dick et al. 1999), albeit looking at different
variables.
Calibration of the profiling system, both
in the horizontal and vertical planes, was
accomplished as described in previous
studies (Boyd 1993; Hoad-Reddick et al.
1999).
The mounted casts were sequentially
placed onto the platform of the profiling
apparatus.
The profiling apparatus consisted of a
rigid steel base to which was mounted
a stainless steel vertical column (Fig. 2).
Onto this was clamped a horizontal stain-
less steel arm which could be fixed to the
column by a locking screw. The arm car-
ried a vertically mounted stylus assembly
in friction-free bearings. The stylus was
formed into a tapering curve of radius
10 mm and could be moved in the Y-axis
independent of the horizontal arm position.
The stylus mass was dynamically balanced
by a system of coil springs so that, as the
stylus was caused to touch the casts
surface, further downward travel of the
assembly produced no further force increase
at the point of contact with the cast surface.
Beneath the stylus, the adjustable plat-
form was fitted reproducibly to a carriage,
 Blum & McCord . Implant-retained mandibular overdentures and posterior mandibular resorption

which was attached to a precision sliding

element. The carriage could be moved in
the horizontal direction X, by a micrometre
screw (Fig. 2). Linear displacement trans-
ducers (Hewlett-Packard, 7 DCD T-1000,
Palo Alto, CA, USA), connected to an
electrical power supply, were mechanically
linked to the moving parts of the apparatus,
namely, the stylus assembly and the slid-
ing element (Fig. 2).
Starting from the distal aspects of the
most distal impression post, each sequen-
tial cast was marked at 5 mm intervals
along the right and left ridge crests. This
resulted in 57 markings along each ridge.
Subsequently, the mounted cast was
located with the conical projections ex-
tending from its base into the conical
indentations (dimples) of the adjustable
platform of the measurement apparatus.
The fitting of the conical projections into
their corresponding dimples ensured the
identical and reproducible positioning of
Fig. 2. The profiling apparatus.
the mounted cast on the measuring appa-
ratus. This was followed by moving the
moveable base cylinder (and hence the
adjustable platform which was attached to
it), by the combined turning action of the
micrometre screw handle and transverse
turning wheel, so that the distal aspect of
the most distal impression post was di-
rectly underneath the tip of the stylus.
The stylus, when lowered down and
brought into contact with the most distal
impression post on one side of the ridge and
subsequent pressing of the foot pedal, re-
corded this point that acted as a reference
point for further recordings of the cast on
that side. The next stage was performed by
moving the adjustable platform in such
positions that a marked point on the cast
was directly underneath the tip of the
stylus, which, when brought into contact
with each marked point recorded each
point on the cast. The recording of such a Fig. 3. The recording of a marked point on the ridge surface of the cast.
point on the cast is shown in Fig. 3. By
virtue of the installation of the customised of the computer. This represented the pos- tracings (i.e. one already saved and one
software program, SPROFILE (Cash 1996) terior mandibular sagittal surface contour repeated) of the same ridge contours
on the computer linked to the profiling on one side of the ridge. An example of a to be superimposed for visual comparison.
apparatus, the (predetermined) recorded trace plot is shown in Fig. 4. This proce- The matching of the superimposed
points along the ridge crest on the cast dure was then repeated for the other side of traces confirmed the reliability of the cast
could be immediately displayed on the the ridge. The whole procedure was then analysis.
monitor screen. When several points were repeated for the sequential cast.
recorded, a graphical shape (trace plot) In order to ascertain the reliability of the Trace plot analysis
made up of the individual (digitised) crosses cast analysis, each recording of each ridge Following the importing of the saved trace
was displayed on the monitor, assigned a was repeated. The view only facility of plot images from the hard disk into a
unique file name and saved to the hard disk the SPROFILE software allowed the two dedicated computer software program

703 | Clin. Oral Impl. Res. 15, 2004 / 700708

Blum & McCord . Implant-retained mandibular overdentures and posterior mandibular resorption

Profile Plot calculated represented the total change in

5.0 the sagittal surface contours of the posterior
residual ridges over a 1-year period, in
4.0 terms of area (cm2). This difference was
also expressed as a percentage.
Y Displacement [V]

3.0
Results
2.0
Of the 16 patients who participated in this
study, one individual had experienced com-
1.0
plications, which led to the removal of
dental implants prior to the completion of
0.0
this study (i.e. before the sequential im-
0.0 1.0 2.0 3.0 4.0 5.0
pression was scheduled to be recorded).
X Displacement [V] Thus the presented study is, therefore,
Fig. 4. Example of a trace plot. based on 15 patients who were followed
up over the 1-year period. All fifteen pa-
tients reported that treatment outcome
Profile Plot
5.0 enhanced their quality of life and that
they had worn the conventional maxillary
and implant-retained mandibular dentures
4.0
at all times except while sleeping at night.
Y Displacement [V]

Repeating each trace plot analysis twice

3.0
2.0
1.0
0.0
0.0
1 1183
Fig. 5. Example of a resulting image obtained subsequent to the inter-connections of the recorded points.
(SigmaScanPro 1999), each trace plot im-
age was enlarged (magnification 450%)
by using the magnification facility of the
program. The enlargement of the trace plot
image allowed the cross-shaped mouse
pointer to be precisely positioned over
each digitised cross of the trace plot, thus,
also ensuring validity. To evaluate the
changes in the surface contours of the
posterior residual ridges that had occurred
over a 1-year period, the individual record-
ings (digitised crosses) of each trace plot
graph had to be connected and the area of
the image resulting from these inter-
connections was calculated by the software
1.0 2.0 3.0 4.0
X Displacement [V]
A B C of area of the images, in Table 2. The
CMBin x CMBin y Area
693 61594
and converted in to cm2. An example of
such an image is shown in Fig. 5.
The areas of the right and left surface
contour ridges were added up at both time
scales and this gave the total area at any
one time scale which corresponded to the
total sagittal surface contour of the poster-
ior residual ridges at the given time scale.
The total area of the sagittal surface con-
tour ridges at the baseline time scale was
then compared to the total area of the
sagittal surface contour ridges at the 12
months time scale on the sequential cast
for each patient. The latter was then sub-
tracted from the former and the difference
and processing the data using the one-way
ANOVA application of the Stata statisti-
cal software package confirmed the relia-
bility of the trace plot analysis (intraclass
correlation 0.99999; SE 0.0001 at 95%
confidence intervals 0.999981).
The findings of the analyses of this
5.0 study including the resulting quantitative
changes of the sagittal surface contours of
the residual ridges on the sequential casts
distal to the implants are set out, in terms
negative difference indicated resorptive
changes. The mean reduction in the total
sagittal surface contour areas of the residual
ridges distal to the implants, over a 1-year
period, for all individuals included in pre-
sented study equated to 5 cm2 or 20%
(standard deviation, SD 9%; range
533%).
The statistical analysis of data, using
the paired t-test carried out at the 0.05
level of significance, showed that the de-
tected changes between the baseline areas,
using serial casts of patients residual
ridges, and the 12 months time scale
were statistically significant (Po0.001).
Discussion
Despite the shift that has taken place
within the dental profession over the past
20 years regarding the usage of dental

704 | Clin. Oral Impl. Res. 15, 2004 / 700708

 Blum & McCord . Implant-retained mandibular overdentures and posterior mandibular resorption

Table 2. Summary of results of the analyses of sequential casts in terms of area (cm2)
Patient no. Type of OVD Total area (cm2) of surface contours Total area (cm2) of surface Total changes in area (cm2) of
anchorage of ridges distal to implants at contours of ridges distal to surface contours of ridges distal to
baseline (0 months) implants after 12 months implants over a 1-year period (%)
1 B 30 25 5 (17)
2 B 36 25  11 (31)
3 B 29 27 2 (7)
4 B 14 10 4 (29)
5 B 37 29 8 (22)
6 S 13 9 4 (31)
7 B 26 23 3 (12)
8 B 13 11 2 (15)
9 B 27 20 7 (26)
10 B 14 12 2 (14)
11 B 32 28 4 (13)
12 B 21 16 5 (24)
13 B 19 14 5 (26)
14 S 15 10 5 (33)
15 B 37 35 2 (5)

OVD, overdenture; B, bar-clip-retained mandibular overdenture; S, stud-retained mandibular overdenture.

implants from a peripheral position to one
of central importance, and although the
successful rehabilitation of mandibular
edentulism by means of osseointegrated
implant-supported overdentures has been
well documented (Naert et al. 1997; Jagger
et al. 2001), the impact of the implant-
retained overdenture on the distal denture-
bearing area of the implant containing
edentulous mandible has not been widely
investigated.
Based on previous reports (Jacobson &
Krol 1983; Watt & MacGregor 1986) and
the observations of the present study re-
garding the unchanging dimensions of the
retromolar pads, this investigation utilised
the retromolar pads as stable posterior re-
ference structures from which measure-
ments could be made.
Further and subsequent to the casting of
the mandibular impressions, the implant
analogues represented the same relation-
ship to the surface contours of the cast
model as the implants in the mandible
had to the residual ridges. Because of this
stable transfer, Boyd (1993) described the
use of osseointegrated implants as a stable
area from which measurements could be
made. Thus, the middle parts of the retro-
molar pads and the implants, along with
their corresponding impression posts, ap-
peared to be ideal reference structures for
providing the (three) reference points ne-
cessary for transferring the plane of the
dental casts and thus enabling accurate
transfer of the orientation and consequent
analyses of these casts.
The labelling of the serial casts with
randomly allocated patient hospital num-
bers ensured a blinding process for the
making of the serial measurements.
The risks of introducing errors
were minimised by having one operator
(I.R.B.) performing all of the clinical, la-
boratory and cast analysing stages. In addi-
tion, the clinical and laboratory stages as
well as the profiling apparatus were stan-
dardised whereby, in the case of the latter,
calibration was carried out at the beginning
of the cast-analysis procedure and it
remained unchanged throughout the
course of the study. Performing repeated
measurements assessed the reliability of
measurements.
The mean reduction of 5 cm2 or 20%
(SD 9%; range 533%) in the total sa-
gittal surface contours of the residual ridges
distal to the implants over a 1-year period
appears to be in accordance with the poster-
ior mandibular resorption data presented by
Jacobs et al. (1992) who, although measur-
ing ratios of posterior area indices which
they expressed as percentile bone loss,
reported a mean vertical posterior residual
ridge reduction of 14% (SD 20%; range
068%), after a 1-year period, in a group
of patients wearing mandibular overden-
tures that were stabilised by a bar on two
implants. However, the findings of the
presented study are in contrast to the find-
ings of Wright et al. (2002) who investi-
gated vertical changes of distal residual
ridges, by means of proportional posterior
area index measurements, and reported an
average annual posterior ridge reduction of
20 mm2 or 1.1% when implant-retained
mandibular overdentures are worn. Al-
though in the latter study, patients were
also provided with complete dentures in
the maxillary arch, the different outcomes
from the two studies may be attributable to
the fact that in the study of Wright et al.
(2002) the status of the mandibular bone at
the start of the study was such that little or
no residual mandibular ridge was present.
It is generally accepted however, that once
the denture comes to rest mostly on basal
mandibular bone, the rate of bone resorp-
tion reduces (Wright et al. 2002).
The mean reduction of 20%, in the
sagittal surface contours of the ridges distal
to the implants as observed in this investi-
gation is, however, greater than the distal
ridge resorption scores reported by Jacobs
et al. (1992) for conventional mandibular
complete dentures (mean 10%; SD
19%; range 061%) and for implant-
retained fixed prostheses (mean 4%;
SD 6%; range 020%). The increased
resorption for the implant-retained over-
denture might be explained by several fac-
tors. Although anteriorly, the transmitted
loads are directed axially to the implants
which then transmit the load further to the
bone surrounding the implants, in the
posterior areas, the transmitted loads are
taken up by the residual ridges. Indeed,
supracrestal loading favours a negative re-
modelling of the underlying bone while
load transmission to osseointegrated im-
plants rather results in a positive turn-

705 | Clin. Oral Impl. Res. 15, 2004 / 700708

Blum & McCord . Implant-retained mandibular overdentures and posterior mandibular resorption
over (van Steenberghe 1988). By virtue of
the overdenture design, free rotation during
function may result in enhanced posterior
loading (Naert et al. 1988, 1991). Conse-
quently, the overdenture may be consid-
ered as a contributor to an increased
resorption of the posterior ridge.
Several authors (Thiel et al. 1996; Burns
2000) contend that a combination syn-
drome effect with mandibular implant-
retained overdentures opposing maxillary
complete dentures occurs, whereby over-
growth of the tuberosities results in
increased stresses directed to the mandi-
bular distal extension.
Part of the observations in the presented
study may also be explained by an altered
neurophysiological control mechanism.
Rehabilitating edentulous patients with
mandibular implant-retained overdentures
improves their masticatory function (Har-
aldson et al. 1988). This, in turn, en-
courages the patients to incise anteriorly
with maximum force whereby the gener-
ated forces may in fact become magnified,
inasmuch as the passive threshold for tac-
tile function on dental implants has been
reported to be approximately 50 times that
of natural teeth (Jacobs & van Steenberghe
1993).
Whereas Marcus et al. (1996) found that
nearly 20% of conventional complete den-
ture wearers never wore their mandibular
prosthesis the findings of the present study
indicates that all patients may be found to
have worn their prescribed prostheses at
diurnal times.
Tallgren (1972) and Tallgren et al. (1980)
reported that although reduction of the
residual alveolar ridges is most rapid during
the first year of denture wear continuous
resorption, albeit slight, occurs in subse-
quent years. As the pilot sample patients
selected in this study had been edentulous
very few years on average higher than
average rates of resorption may not be all
too surprising.
The dental implants and the posterior
mandibular ridges and mucosae provide
retention, support and stability for implant
overdentures. Burns (2000) stated that the
responsibility of these functions shifts from
the mucosa to the dental implants as more
implants are used. Despite the fact that the
sample population in this study presented
with a varying number of mandibular im-
plants (minimum 2 and maximum 4),
706 | Clin. Oral Impl. Res. 15, 2004 / 700708
owing to the relatively small sample popu-
lation, no attempt has been made to corre-
late the findings of this study to the
number of implants present in the anterior
mandible.
Furthermore, the unequal proportion of
males and females in the sample popula-
tion and the small sample size did not
allow for comparison of the findings be-
tween the genders.
The greatest reductive changes detected
in the sagittal surface contours of the pos-
terior residual ridges occurred in the group
of patients whose mandibular overdentures
were stud-retained rather than bar-clip-
retained. This appears to be suggestive
that increased loads are applied to the
posterior ridge areas of individuals fitted
with stud-retained mandibular overden-
tures but, owing to the relatively small
sample population and the unequal propor-
tion of stud-retained and bar-clip-retained
prostheses in the presented study, this
observation cannot be considered as being
substantiative. Nevertheless, this observa-
tion merits further investigation.
The inter-individual variation observed
in the reduction in the total sagittal surface
contours of the posterior residual ridges is
probably of multifactorial origin and, as
such, a combination of anatomic, hormo-
nal and mechanical determinants. Given
that the majority of patients were women,
there being only six men in the presented
study, and that the age range was 3672
with a mean age of 60 years, systemic
factors including osteoporosis, corticoster-
oid treatment and possibly smoking
may also be considered as major contribu-
tory factors towards mandibular resorption.
Other factors such as strong oro-facial
muscular forces, as advocated by Tallgren
(1972), and parafunctional habits (e.g.
clenching) amongst some patients in the
sample population may also contribute to
the observed inter-individual variations.
Based on the findings of this investiga-
tion, the null hypothesis is rejected as a
difference in the posterior mandibular resi-
dual ridges following the fitting and wear-
ing of an implant-retained overdenture over
a 1-year period has been detected. In addi-
tion, it is concluded that although the
removable hinging overdenture design of-
fers advantages from a financial and failure
rate point of view, its indication in younger
patients should be cautiously evaluated in
long-term perspective concerning posterior
mandibular bone resorption. Moreover, in
line with the findings by Jacobs et al.
(1992), a strict recall schedule including
relining of the overdenture should be pro-
vided to improve the load distribution on
the denture base and to avoid enhanced
loading of the posterior mandibular ridge.
Furthermore, it is concluded that the meth-
odology described can be used reliably as an
alternative to radiographical examination
for detecting changes that occur in the
distal denture-bearing area of the implant
containing edentulous mandible when im-
plant-retained overdentures are used over a
1-year period, or possibly longer. Thus, the
method presented may be used to contri-
bute to a reduced exposure to ionising
radiation for patients wearing mandibular
implant-retained overdentures.
Resume
Lutilisation a` grande echelle et lacceptation des
implants dentaires osteontegres comme moyen de
retention et dancrage pour les prothe`ses amovibles
inferieures apportent des structures de reference
tridimensionnelle potentiellement stables qui ont
ete utilisees pour examiner les variations morpholo-
giques des contours de surface des rebords mandibu-
laires en distal des implants. Contrairement aux
methodes traditionnelles qui tendent a` mesurer les
variations dans la morphologie et les quantites radio-
graphiques de la crete, cette etude prospective a
etudie les variations dans les contours de surface
sagittaux des cretes residuelles posterieures sur une
periode dun an par une methode alternative non-
radiographique en utilisant des empreintes en serie
des rebords residuels chez un groupe de patients. Ces
rebords residuels des mode`les en serie ont ete ex-
amines en utilisant un appareil de profil et un
programme dordinateur qui permettaient lorienta-
tion, lenregistrement digital et la mesure des con-
tours de surface sagittale des rebords residuels
posterieurs des mode`les mandibulaires en terme
daires (cm2). Lanalyse statistique a revele que les
variations de diminution detectees du contour de la
surface des cretes residuelles posterieures apre`s luti-
lisation dune prothe`se mandibulaire retenue sur
implants apre`s une periode dune annee etaient tre`s
significatives (Po0.001). L methode presentee
dans cette etude peut etre utilisee de manie`re sure
comme substitut de lexamen radiographique
pour la detection des variations qui se produisent
au niveau de la crete alveolaire residuelle en
distal des implants lorsque des prothe`ses ancrees
sur implants sont utilisees. La methode presentee
peut donc etre utilisee afin de contribuer a`
une reduction de lexposition des radiations
pour les patients qui portent des prothe`ses ancrees
sur implants.
 Blum & McCord . Implant-retained mandibular overdentures and posterior mandibular resorption

Zusammenfassung
Ziele: Osseointegrierte Implantate sind als Hilfsmit-
tel fur die Fixation und Abstutzung von Unterkie-
ferhybridprothesen weit verbreitet und geniessen
eine hohe Akzeptanz. Unterlagen von solchen
Fallen liefern nun moglicherweise Daten zur
Definition einer stabilen dreidimensionalen Refer-
enzstruktur, die man benutzen kann, um
morphologische Veranderungen der Alveolarkam-
moberflache im Unterkiefer distal der Implantate
zu beschreiben. Abweichend von der bisher ublichen
Methode, die Veranderungen in der Alveolarkamm-
morphologie und -quantitat meist radiologisch
misst, versuchte man in dieser Langzeitstudie die
Veranderungen der sagittalen Oberflachen in der
Freiendregion mit einer alternativen, nichtradiolo-
gischen Methode zu untersuchen. Man vermass
wahrend einem Jahr die in kurzen Abstanden bei
einer ausgewahlten Patientengruppe hergestellten
Unterkiefermodelle im Freiendbereich auf aufgetre-
tene Veranderungen.
Material und Methode: Mit Hilfe eines Profil-
ometers und einer geeigneten Komputersoftware
untersuchte man auf den seriellen Unterkiefermo-
dellen im Freiendbereich die Alveoolarkamme. Dies
erlaubte die Ausrichtung, digitalisierte Registrierung
und Vermessung der sagittalen Oberflache in der
Freiendregion der Unterkiefermodelle, ausgedruckt
in einem Flachenmass (cm2).
Resultate: Die statistischen Auswertungen zeigten,
dass die resorptiven Veranderungen der Oberflache
in der Freiendregion nach einem Jahr Tragen
der implantatgetragenen Unterkieferhybridprothese
hochsignifikant waren (Po0.001).
Zusammenfassung: Man schliesst daraus, dass die
in dieser Arbeit vorgestellte Methode eine verlas-
sliche Alternative zu der radiologischen Untersu-
chung ist, um Veranderungen festzustellen, die in
der Freiendregion von zahnlosen Unterkiefern statt- Conclusion: Se concluye que la metodologa pre-
finden, bei denen implantatgetragene Unterkiefer- sentada en este estudio puede ser usada fiablemente
hybridprothesen eingegliedert worden waren. Somit como una alternativa al examen radiografico para
konnte diese Methode dazu beitragen, Patienten, die detectar los cambios que ocurren en las crestas
eine implantatgetragene Hybridprothese eingeglie- residuales distales de las mandbulas edentulas que
dert erhalten haben, einer geringeren Menge ioni- contienen implantes cuando se usan sobredenta-
sierender Strahlung auszusetzen. duras implanto-retenidas. De este modo, el metodo
presentado puede ser usado para contribuir a una
menor exposicion a las radiaciones ionizantes para
Resumen los pacientes que llevan sobredentaduras implanto-
retenidas.
Objetivos: El extenso uso y la amplia aceptacion de
los implantes dentales osteointegrados como medios
de retencion y soporte de sobredentaduras mandibu-
lares suministran estructuras de referencia tridimen-
sionales potencialmente estables que se han usado
para examinar los cambios morfologicos de los con-
tornos de la superficie de las crestas alveolares
distales a los implantes. Al reves que los metodos
tradicionales que tendan a medir los cambios en la
morfologa y la cantidad de cresta radiograficamente,
este estudio prospectivo investigo los cambios en el
contorno de la superficie sagital de las crestas poster-
iores residuales a lo largo de un periodo de un ano por
medio de un metodo alternativo, no radiografico
usando modelos seriados de las crestas residuales
de un grupo de pacientes.
Material y metodos: Se examinaron las crestas
residuales de los modelos seriados tomados usando
un aparato de perfilado y programas de ordenador
que permitan la orientacion, digitalizacion y medi-
cion de los contornos de la superficie sagital de las
crestas residuales posteriores de los moldes mandi-
bulares en terminos de area (cm2).
Resultados: El analisis estadstico revelo que los
cambios reductivos en el contorno de las crestas
residuales tras el uso de una sobredentadura man-
dibular implanto-retenida a lo largo de un periodo de
un ano fueron altamente significativos (po0.001).

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