EGYPTIAN Vol.

61, 131:138, January, 2015

DENTAL JOURNAL I.S.S.N 0070-9484

w w w. e d a - e g y p t. o r g

EFFECT OF DIFFERENT MANDIBULAR PROSTHESIS

ON ANTERIOR MAXILLARY RIDGE RESORPTION
(RETROSPECTIVE STUDY)

Ehab A.E Elsaih*

ABSTRACT
Objective: The Purpose of this study was to investigate and compare the effect of different
mandibular prosthesis; non-splinted implant overdenture (NSIOD), splinted implant overdenture
(SIOD) with bar, distal extension removable partial denture (DERPD) and conventional complete
denture (CCD) on the antagonist maxillary edentulous arch anterior bone resorption.

Materials and methods: twenty four patients were selected with maxillary edentulous arches
against different mandibular prosthesis. According to the mandibular prosthesis the patients were
grouped as follows; six patients had NSIOD, six patients had SIOD, six patients had bilateral
DERPD and six patients had CCD. Standardized digital panoramic radiographs for each patient at
prosthetic delivery and five years later were traced and compared for bone resorption ratio in the
anterior maxilla.

Results: The mean anterior maxillary bone resorption ratio (AMaxRR) results revealed that
in the NSIOD, SIOD, DERPD and CCD groups ongoing resorption of the anterior maxilla had
occurred during the 5-years evaluation period, which was significant for DERPD compared to all
groups and both SIOD and NSIOD groups compared to CCD group. However, between NSIOD and
SIOD groups the results showed insignificant difference.

Conclusions: Within the limitation of this study it could be concluded that; 1) maxillary bone
resorption continue through time especially anteriorly, 2) absence of clinical evidence that maxillary
ridge resorption is accelerated with certain types of two-implant supported mandibular overdenture
attachments; 3) for edentulous maxilla the AMaxRR showed a significantly higher in two implant
overdenture compared to CCD.

KEYWORDS: Bone resorption; Implant overdenture; Distal extension RPD.

* Lecturer of Removable Prosthodontics, Faculty of Dentistry, Mansoura University

(132) E.D.J. Vol. 61, No. 1
INTRODUCTION
Four decades since Kelly [1] described the
combination syndrome in 1972. This syndrome,
which outlines a number of specific oral changes in
patients with a maxillary complete denture against
a mandibular Kennedy class I removable partial
denture, the remaining natural anterior teeth will
often result in premature anterior occlusal contact
and cause extensive intraoral hard- and soft-tissue
damage [1-4].
The changes were (1) bone loss in the maxillary
anterior ridge, (2) overgrowth of the tuberosities, (3)
palatal papillary hyperplasia, (4) supraeruption of
mandibular anterior teeth, and (5) bone loss beneath
removable partial denture bases. Kelly [1] considered
the early bone loss in the anterior maxilla to be the
key to the other changes and noted that as resorption
of the premaxilla progressed, further tissue damage
and denture instability followed proportionately.
In completely edentulous patients the mandibular
implant retained overdentures is a common treatment
plane that could improve oral function, chewing
force and comfort for edentulous patients[5,6]. This
clinical situation was suggested to develop a risk for
severe resorption in the anterior maxilla in persons
wearing mandibular implant-retained overdentures,
which was claimed to create anterior hyper function
or combination syndrome [7-12].
In the last two decades the two implants
overdenture (IOD) is considered a conventional
treatment modality. In this treatment modality,
implants may be non-splinted implant overdenture
(NSIOD) or splinted implant overdenture (SIOD)
with bar to gain anterior retention and support via
plastic clips [13-18].
Recently some researchers reported implant
overdenture to produce anterior occlusal loading on
the anterior maxilla that may be claimed to produce
anterior maxillary resorption [12,13].
In this, research the effect of mandibular solo
Ehab A.E Elsaih
IOD, splinted IOD, distal extension removable
partial denture (DERPD) and conventional complete
denture (CCD) on the anterior maxillary resorption
of edentulous maxilla.
MATERIAL AND METHODS
For this study, standard digital panoramic
radiographs that had been made before and 5 years
after prosthodontic treatment were available of five
groups of patients that were enrolled from previous
prospective studies. The studies had been performed
by the department of removable prosthodontics,
dentistry collage, Mansoura University and
encompassed twenty four patients. Twelve of them
were treated with a mandibular overdenture using
two dental implants (Dyna® Dental Engineering,
Bergen op Zoom, Netherlands) inserted parallel
to each other intra-foraminal in the canine region
and a maxillary complete denture. Six patients had
solitary (un-splinted) implant retained overdenture
“NSIOD” (group I); six patients had (splinted)
bar implant retained overdenture “SIOD” (group
II). The other ywo groups included, six partially
edentulous patients treated with maxillary complete
denture and mandibular distal extension removable
partial denture (DERPD) (group III) and six patients
treated with a conventional complete denture (CCD)
(group IV). All selected participants in this study
were previously treated and under follow-up.
Patient selection criteria
1. Implant overdenture patients (group I and II)
The implant overdenture patients in the previous
studies had been selected on the basis of the
following inclusion criteria: edentulous maxilla
and mandible for at least 1 year, problems with
retention and stability of the mandibular denture, a
mandibular bone height between 15 and 22 mm as
measured at the mandibular symphysis region on a
lateral cephalometric radiograph, and no history of
former pre-prosthetic surgery or contraindications
EFFECT OF DIFFERENT MANDIBULAR PROSTHESIS ON ANTERIOR MAXILLARY
for a surgical procedure. The mean age at prosthesis
placement was 58.5 ± 7.5 years. None of the patients
suffered from a systemic bone disease or traumatic
injury to the maxilla in the follow-up time and all
of them were free from diseases affecting bone
resorption (i.e. diabetes).
2. Complete denture patients (group III)
Each patient had complete denture and their
mean age at prosthesis placement was 43 ± 5.5 years
3. Partial denture patients (group VI)
The mandibular arch had remaining six/eight
anterior teeth (Long distal extension cases). Each
patient had distal extension RPD and their mean age
at prosthesis placement was 43 ± 5.5 years
All patients involved in this study were selected
based on fulfilling the following clinical criteria:
• Occlusion and articulation
Occlusion was evaluated using guided
closure [19,20] and was accepted when: 1) if centric
relation (CR) coincided with centric occlusion
(CO); 2) if minor (< 0.5 mm) deviation was
observed between CR and CO and was excluded if
clear (> 0.5 mm) deviation was observed between
CR and CO. Articulation was considered acceptable
when it was fully balanced during protrusive and
lateral movements performed from CO, otherwise
it was excluded. All dentures included in this study
had semi-anatomic acrylic denture teeth arranged
for bilaterally balanced occlusion without contacts
on the anterior teeth.
• Retention and stability
maxillary complete denture was examined and
the patients were included using the following
criteria:
A) Retention; a) good resistance to vertical pull,
and sufficient resistance to lateral forces; b)
slight to moderate resistance to vertical pull,
and little resistance to lateral forces.
(133)
B) Stability; a) slight or no rocking on denture-
supporting structures when under pressure;
b) moderate rocking on supporting structures
under pressure otherwise it was excluded [19,20].
For group (IV) the mandibular denture was
checked also for stability and retention as well.
• Oral mucosa
The patient was excluded when the following
mucosal changes was noted [20,21]; ulcers, localized
hyperemia, hyperplasia, denture stomatitis and/or
flabby ridge.
Radiographic evaluation
All digital panoramic radiographs were taken in
the radiology dep., Mansoura University. Using the
same machine with exposure parameters of 57-90
KV, 5-12 mA and total filtration of 2.5 mm Al / 80
IEC-522 with cronex intensifying screen HI plus
regular speed and Kodak films X-OMAT RP pan DF
75. Standardization was assured using custom clear
acrylic stent attached to the mouth portion of the
machine. Both, the films taken immediately after
prosthesis insertion and / or implant loading (T0)
and the films taken after 5 years (T5) at recall visits
were used for this research.
Evaluations, tracing and maxillary anterior
area calculation of radiographs were performed by
experienced professional radiologist and a software
expert both was calibrated and was not aware of the
aim of the study.
Maxillary bone resorption was evaluated using a
previously described method based on proportional
area measurements [13,22]. Reference points and lines
(described below) were traced using computer
program (Autocad 14) on panoramic radiograph.
Reference points, lines and areas
The following reference points, lines and areas
(Figure 1) used for the investigation (Figure 2).
The anterior nasal spine S and the two lowermost
(134) E.D.J. Vol. 61, No. 1
bony margins of the orbit O right and O left form
the ‘central triangle’. The line o joins O right and
O left. The intersection between a line and o line,
perpendicular to o line through S, is point P. The
point R divides the distance (PO) into two-thirds and
one-third. This value was determined experimentally
so as to divide the maxilla in anterior and posterior
regions. r is a line perpendicular to o through R. u is
a line parallel to o line through S. u line and r line
meet at the point U. P’ was marked by measuring
the distance (UR) starting from S. R’ was marked
by measuring the distance (UR) starting from U.
The line i is parallel to u line connects the points R’,
P’ and R’. u line intersect and divide r lines at the
points U in both sides.
1 is the intersection of the alveolar crest with
FIG. (1) Tracing of the panoramic radiograph showing the reference points and lines.
FIG. (2) Tracing of the panoramic radiograph of NSIOD case using computer software calculating the areas of reference.
Ehab A.E Elsaih
a line extension and 2 is the intersection of the
alveolar crest with r line extension. In the anterior
region, the experimental area is outlined by the area
S12U and the reference area by the area SP’R’U.
Anatomical and reference areas on the right and left
sides were averaged, and a ratio (R) for the anterior
maxillary bone area was calculated by dividing the
anatomical bone area by the reference area.
The sizes of the anatomic reference areas were
determined using computer program (AUTOCAD®
14) on traced panoramic radiograph (Figure 2).
The change in anterior maxillary residual ridge
resorption was calculated by subtracting the ratio
at the baseline (T0) from the ratio at 5 years (T5),
and it was indicated as anterior maxillary resorption
(AMax RR).
EFFECT OF DIFFERENT MANDIBULAR PROSTHESIS ON ANTERIOR MAXILLARY (135)

Statistical analysis comparison to the other groups. The two-implant

overdenture groups were statistically different
Results were collected from a single calibrated
compared to the CCD group, but not from each.
examiner (mean of three measures). Using computer
program (SPSS® 18), the AMax RR for each group
was compared between groups in the period of TABLE (1) The means and standered deviations of
study using paired t-test at 5% level of significance. anterior maxillary bone resorption ratio
after five years of prosthetic placement.
RESULTS
Group Mean ± SD
The change in AMaxRR was calculated for
each patient by subtracting the ratio value at (T0) NSIOD 0.0851 ± 0.01039
years from the ratio value at (T5). Therefore, a SIOD 0.0952 ± 0.01251
(T0 - T5)
negative difference indicated resorption, and a DERPD 0.2205 ± 0.00855
positive difference indicated an increase in area or CCD 0.0303 ± 0.00456
apposition of bone [15].
NSIOD = Un-splinted two implant overdenture; SIOD =
Table 1 indicates that on average bone resorption Two implant bar overdenture
had occurred in the anterior maxilla in patients DRRPD = Conventional distal extension removable
from all four groups at the 5-year evaluation. While partial denture
Table 2 indicates that this bone loss in the anterior CCD = Conventional complete denture
residual ridge between base line (T0) and (T5) (T0 - T5) = anterior maxillary bone resorption ratio (at
was statistically different for the DERPD group in prosthetic placement and 5 years later).

TABLE (2) The comparison between groups on anterior maxillary bone resorption ratio after five years of
prosthetic placement.

Compared NSIOD - NSIOD - NSIOD - SIOD - SIOD - DERPD -

groups SIOD DERPD CCD DERPD CCD CCD
P 0.068 0.000a 0.000a 0.000a 0.000a 0.000a
a
P is significant (P ≤ 0.05), paired t-test at 5% level of significance.

No. of patients per group = 6.

P = Significance value; NSIOD = Un-splinted two implant overdenture; SIOD = Two implant bar overdenture; DERPD =
Conventional distal extension RPD; CCD = Conventional complete denture.

DISCUSSION occurred during the 5-years evaluation period, which

Mean reduction in the measured proportional
areas in the anterior maxilla was 0.0851 ± 0.01039
in NSIOD group I, 0.0952 ± 0.01251 in SIOD group
II, 0.2205 ± 0.00855 in DERPD group and 0.0303 ±
0.00456 in CCD group. These results revealed that
in the NSIOD, SIOD, DERPD and CCD groups
ongoing resorption of the anterior maxilla had
was significant for DERPD compared to all groups
and both SIOD and NSIOD groups compared to
CCD group. However, between NSIOD and SIOD
groups the results showed insignificant difference.
These observations for implant overdenture
groups are in line with the findings of other
authors who showed gradual maxillary ridge
(136) E.D.J. Vol. 61, No. 1
resorption in patients wearing implant-retained
overdentures [12,16,23]. However, these studies did not
include a control group, which can be considered an
omission of valuable guiding base that should not be
neglected. The present study showed that resorption
patterns were not similar between patients treated
with an implant overdenture and patients treated
with a conventional denture.
On the other hand, some studies reported more
pronounced maxillary ridge resorption in patients
wearing a conventional denture in comparison
with patients wearing an overdenture or fixed
prosthesis [14,24,25]. Their explanation was attributed
to the instability of the complete dentures, which
accordingly contributed to an unfavorable stress
distribution over the denture bearing areas.
The patients included in the present study were
selected based on balanced criteria of prosthetic
management as retention, stability, occlusion,
articulation and prosthetic after car based on regular
routine recall visits every year checking denture,
therefore a more balanced stress distribution was
assured [26,27]. Both the controlled stress distribution
and less chewing forces than the implant
overdenture [28] may contributed to the minimal
change in resorption for the CCD group of this
study.
In the present study, the A Max RR results for
implant overdenture groups may show reduction in
the maxillary residual ridge that could be compared
to other study [12]. Although the results showed
insignificant difference between NSIOD and SIOD
groups but it seems that the A Max RR for SIOD
group were slightly more, that may be attributed to
the more retention and patient satisfaction in bar
implant overdenture [17,18], although the two designs
seems comparable to each other regarding implant
and tissue loading [29]. However, Abd El-Dayem et
al. [14] studied the maxillary resorption as a whole
using a different evaluation method and found
that, the amount of antagonistic maxillary bone
Ehab A.E Elsaih
resorption was significantly high when using the
SIOD overdenture, comparing to that using mucosa
supported complete overdentures where the non-
splinted Implants had a magnetic attachment.
The DERPD group showed significant AMax RR
compared to all other groups of this study seems to
be a classical finding and even expected [1-4] due to
the high biting force of the anterior dentition [28] and
the relatively more stable clasp retained DERPD.
Generally, resorption ratios for anterior maxilla
in group I, II and VI were high but comparable
to ratios of maxillary resorption of earlier studies
and could be related to the multifactor aetiology of
bone resorption [24,25,30,31]. That does not assure the
development of combination syndrome but suggest
a possible risk factor for it in implant overdenture
groups.
According to Närhi et al. [12] The anterior part
of the maxillae is the weakest part of the upper
arch to resist stress and when using implants in the
edentulous mandible, or when lower anterior teeth
occlude anterior to the basal support, trauma is
inevitable. The anterior maxillary ridge resorption
was suggested to be a result of the posterior
mandibular ridge resorption, both conditions being
symptoms of the combination syndrome. However,
Tymstra et al. [15] found no correlation between the
posterior mandibular residual ridge resorption and
the anterior maxillary residual ridge resorption. So
their study could not confirm the suggestion that the
combination syndrome may occur in conventional
maxillary dentures opposed by an implant retained
mandibular overdenture.
Although several studies [9,14,32,33] found a higher
annual residual ridge resorption in supporting
tissues of prostheses that oppose a mandibular
implant overdenture, our study revealed otherwise
and that may be attributed to several factors. Firstly,
all patients in the present study were treated with
a balanced occlusion using monoplane teeth with
freedom of anterior contacts to avoid too much
EFFECT OF DIFFERENT MANDIBULAR PROSTHESIS ON ANTERIOR MAXILLARY
anterior pressure. This concept is compatible with
the teeth contact relation recommended for implant
retained mandibular overdentures to preserve
anterior maxillary bone [12,15,34]. In addition to special
attention to optimal denture fit during patient
selection based on balanced selection criteria.
For mandibular two implant overdenture the
prosthesis is suspended from one end to implants
and the distal extension moves tissue ward causing
distal edentulous ridge loading. After years the dis-
tal mandibular ridge resorption is claimed to cause
anterior overloading. Rutkunas et al. [35] believed
that loosening of the maxillary denture, loss of pos-
terior occlusion is sequenced by increased anterior
occlusal pressure and anterior maxillary bone loss
similar to the effects seen in “combination syn-
drome”. They also suggested that mandibular two-
implant supported overdentures can pose a certain
risk of increased maxillary ridge resorption [35].
But in our study the careful monitoring of occlusal
relation on patient selection based on balanced
criteria does not agree with that explanation, in fact
the possible logic cause of statistically significant A
max R in group I and II is the patient desire to use
anterior teeth for incising motivated by the presence
of implants.
CONCLUSIONS
Within the limitation of this study the following
conclusions might be drawn:
1. Most common complication for the maxilla
prosthetic maintenance is the need for relining
whatever the type of mandibular prosthesis
due to continuous maxillary bone resorption
especially anterior region.
2. Absence of clinical evidence that maxillary
ridge resorption is accelerated with certain
types of two-implant supported mandibular
overdenture attachments but not preclude the
need for further investigations regarding this
point.
(137)
3. For edentulous maxilla the anterior maxillary
bone resorption is higher in case of mandibular
implant supported overdenture compared to
conventional mandibular complete denture
especially bar-supported overdenture.
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