Mario Roccuzzo What is the optimal number of

Francesca Bonino
Luigi Gaudioso
implants for removable reconstruc-
Marcel Zwahlen tions? A systematic review on
Henny J.A. Meijer
implant-supported overdentures

Authors affiliations:
Mario Roccuzzo, Luigi Gaudioso, Private Practice,
Torino, Italy
Department of Maxillofacial Surgery, University of
Torino, Italy
Francesca Bonino, Department of Periodontology,
Tufts University School of Dental Medicine,
Boston, MA, USA
Marcel Zwahlen, Institute of Social and Preventive
Medicine, University of Bern, Switzerland
Henny J.A. Meijer, Department of Prosthetic
Dentistry & Department of Oral and Maxillofacial
Surgery, University Medical Center Groningen,
University of Groningen, Groningen, The
Netherlands
Corresponding author:
Dr. Mario Roccuzzo
Corso Tassoni, 14, 10143 Torino, Italy
Tel.: +39 011 7714732
Fax: +39 011 7714732
e-mail: mroccuzzo@iol.it
Conflicts of interest:
The authors have not declared any potential conflicts.
Key words: dental implants, denture, edentulous mandible, edentulous maxilla, implant fail-
ure, overdenture, overlay, patient-centered outcomes, systematic review
Abstract
Objectives: The aim of this systematic review was to assess the optimal number of implants for
removable reconstructions.
Material and methods: Medline and The Cochrane Central Register of Controlled Trials were
searched and complemented by hand searching. All trials published in English to October 2011
were included, in which overdentures, supported by a various number of implants, in adult
edentulous individuals were compared. Only randomized controlled trials with at least 12 months
follow-up were selected. The outcomes of interest were implant loss, the amount of peri-implant
bone loss, the incidence of complications and the patient satisfaction.
Results: No articles were found providing information regarding the maxilla. Eleven studies on the
mandible were included for the final comparative analysis. It was possible to make a comparison
among four categories: (i) 1 vs. 2 implants; (ii) 2 implants with ball attachments vs. 4 implants with
a bar; (iii) 2 implants with a bar vs. 4 implants with a bar; (iv) 2 implants splinted with a bar vs. 2
unsplinted implants.
Conclusion: For the maxilla there are no studies, at the present time, that can be utilized to
address the question of how many implants should support an overdenture. For the mandible, it
cannot be concluded that bone loss, patient satisfaction, or number of complications is
significantly related to the number of implants supporting the overdenture. Furthermore, splinting
two implants does not seem to offer additional value. Well conducted research is needed to
identify the prognostic factors for long-term success.

As the stability of conventional complete patient would be best treated with an

Date:
Accepted 09 June 2012
To cite this article:
Roccuzzo M, Bonino F, Gaudioso L, Zwahlen M, Meijer HJA.
What is the optimal number of implants for removable
reconstructions? A systematic review on implant-supported
overdentures.
Clin. Oral Implants Res. 23(Suppl. 6), 2012, 229237
doi: 10.1111/j.1600-0501.2012.02544.x
dentures is often poor, the utilization of den-
tal implants, as a means for improving reten-
tion, has become a common and effective
procedure in the last decades. Various
authors have presented data on overdentures
(OD) supported by 18 implants. Ideally,
treatment planning should be based on the
best available evidence (Keirns & Goold
2009). In particular, as economical factors
play an essential role, it is important to be
able to justify, how many implants should be
used for support or retention of an OD in
each individual case. Several attempts were
done in the recent years to find an answer to
the question.
Burns (2000) first, tried to address the ques-
tion if a practitioner concludes that a
implant overdenture, how many implants
should be placed? He found no answer
because adequate data to address this topic
were lacking. The author concluded that the
number of implants required to provide ade-
quate mandibular implant overdenture treat-
ment outcome remained open to debate.
In the conclusions of his systematic
review, Sadowsky (2001) suggested multiple
implants for mandibular OD when sensitive
jaw anatomy, increased occlusal forces, or
high retention needs are present or when
implant length <8 mm or implant width
<3.5 mm are employed. When two implants
are used in the anterior mandible to retain an
overdenture, solitary ball attachments
appeared to be less costly, less technique

2012 John Wiley & Sons A/S 229

Roccuzzo et al
Implants & overdentures
sensitive, and more accommodating of
tapered arches. However, ball attachments
seemed to be less retentive than the bar
design. The use of immediately loaded
implants in the anterior mandible for the OD
design seemed a promising treatment con-
cept. An OD retained by two implants in the
anterior mandible appeared to demonstrate a
higher burden of maintenance during the first
year than in subsequent years. Controversy
persisted as to whether the ball or bar design
requires more maintenance. There appeared
to be no statistical difference when long-term
maintenance was compared among mandibu-
lar implant OD retained by two implants
compared with those retained by three or
more implants.
On May 2425, 2002, a symposium was
held at McGill University in Montreal, Que-
bec, Canada, during which experts presented
15 papers on the efficacy of OD for the treat-
ment of edentulous patients (Feine et al.
2002). The consensus conclusion was that
the two-implant supported OD should
become the first choice of treatment for the
edentulous mandible, even though no infor-
mation was given regarding the ideal type of
attachment.
Sadowsky (2007) searched articles to estab-
lish treatment considerations for maxillary
implant overdentures. The conclusions were
limited by the fact that he found a limited
number of articles relative to the design and
selection of the maxillary implant overden-
ture treatment modality. The final statement
was that until a stronger hierarchy of evi-
dence is available, emphasis on patient-medi-
ated considerations should direct treatment
planning decisions.
In August 2007, the Scandinavian Society
for Prosthetic Dentistry in collaboration with
the Danish Society of Oral Implantology
arranged a consensus conference. Klemetti
(2008) presented a systematic review address-
ing the following clinical question: Is there
a certain number of implants needed to
retain an overdenture? According to his
research, in the maxilla and in the mandible,
patient satisfaction or function of the pros-
thesis are not dependent on the number of
implants or type of attachment. In the man-
dible, an OD with two implants and with bar
attachment has the least number of compli-
cations. The consensus statement (Gotfred-
sen et al. 2008) concerning the mandible, was
that it was not possible to conclude that
patient satisfaction, dentures function, or
implant survival improved by increasing the
number of implants. Moreover, studies were
found indicating that a mandibular OD with
230 | Clin. Oral Implants Res. 23(Suppl. 6), 2012/229237
only one implant could increase patient satis-
faction. For the maxilla, no studies were
found that could explicitly address the ques-
tion.
The Annual Conference of the BSSPD (Brit-
ish Society for the Study of Prosthetic Den-
tistry) was held in York on 6 and 7 April
2009 (Thomason et al. 2009). At the sympo-
sium on mandibular ODs, presenters offered
a synopsis of the research available on the
efficacy of an implant-supported OD in the
edentulous mandible. The Consensus conclu-
sion was that a large body of evidence sup-
ports the proposal of a two implant-supported
mandibular overdenture as the minimum
offered to edentulous patients. No informa-
tion, however, was given regarding the type
of attachment or regarding a comparison with
multiple implants therapy.
The purpose of the systematic review by
Cehreli et al. (2010) was to evaluate the
effects of implant design and attachment type
on marginal bone loss in implant-retained/
supported ODs. Based on the meta-analysis
of the literature that identified a total of
4200 implants from 13 manufacturers, there
was no difference in marginal bone loss
around implants retaining/supporting a man-
dibular OD relative to implant type or
attachment designs.
In a systematic review on maxillary over-
dentures Slot et al. (2010) assessed the sur-
vival of implants, survival of maxillary
overdentures and the condition of hard and
soft tissues after a follow-up period of at least
1 year. A meta-analysis showed an implant
survival rate of 98.2% per year in case of six
implants and a bar anchorage. In case of four
implants and a bar anchorage, the implant
survival rate was 96.3%. In case of four
implants and a ball anchorage, the implant
survival rate was 95.2%. However, in this
study, different studies with various designs
were included, which weakens the evidence.
One of the most recent studies is by Tho-
mason et al. (2012). The study aimed to pres-
ent the current evidence and rationale to
support the McGill and York consensus
statements. The conclusion was that there is
now overwhelming evidence to support the
proposal that a two-implant OD should
become the first choice of treatment for the
edentulous mandible. No information was,
however, given regarding the various options
in attachment systems, i.e. bars, ball attach-
ment, locator and/or possible adjunctive ben-
efits with the use of additional implants. The
studies included were all comparisons where
patients received either new complete con-
ventional dentures in both the maxilla and
the mandible or implant supported mandibu-
lar OD opposed by a new conventional den-
ture in the maxilla. As a result, no data were
presented regarding the upper jaw.
The aim of this review was to determine if
there are reasons to recommend a certain
number of implants for retaining or support-
ing maxillary or mandibular OD, in terms of
implant loss, the amount of peri-implant
bone loss, the incidence of complications and
the patient satisfaction.
Material and methods
The first step in the review process was the
development of a protocol detailing all meth-
ods of the review a priori. The focused (PICO)
question for the review was: In edentulous
patients rehabilitated with maxillary and/or
mandibular implant-supported overdenture,
what is the optimal number of implants in
terms of lower incidence of biological/
mechanical/technical complications and a
higher level of patient satisfaction?
A second question came up after the initial
search and was: In patients with a mandibu-
lar 2 implant-supported OD, is there a differ-
ence between splinted and un-splinted
implants in terms of lower incidence of bio-
logical/mechanical/technical complications
and a higher level of patient satisfaction?
Criteria for including studies
To be eligible for inclusion in the review,
studies, in English only, had to be random-
ized controlled trials (RCT) of at least
12 months follow-up.
Studies were considered for inclusion if
they were:
-conducted on patients >18 years;
-fully edentulous;
-with information regarding opposing denti-
tion;
-presenting interproximal radiographic exami-
nation.
Exclusion criteria:
-comparison of implant ODs to conventional
dentures;
-comparison of implant ODs to FDP;
-comparison of implant surfaces, geometries,
characteristics;
-comparison of different prosthetic designs;
-comparison of loading protocols;
-comparison of retention systems.
Methods of the review
A MEDLINE (PubMed search form) search of
the literature was conducted up to and
2012 John Wiley & Sons A/S
 Roccuzzo et al
Implants & overdentures

including November 2011. The search was

complemented by checking references of
relevant review articles and eligible studies
for additional useful publications.
Titles and abstracts were initially screened
for possible inclusion by two independent
reviewers (F.B., L.G.) according to the follow-
ing criteria: (a) human trials; (b) implant sup-
ported OD; (c) RCTs; and (d) clinical
outcomes. Any disagreement in the choice of
studies of possible relevance was resolved by
discussion among the reviewers.
The full text of possibly relevant studies
was then screened by three independent
reviewers (M.R., F.B., L.G.) according to the
inclusion criteria. Any disagreement in the
selection was resolved by discussion among
the reviewers and if any missing data were
detected, the authors of the trials were con-
tacted whenever possible.
Statistical analysis
For the meta-analysis, the metan com-
mand in the statistical software Stata (Col-
lege Station, TX, USA) was used. For the
calculation of the proportion of total varia-
tion that is due to heterogeneity between
studies, rather than chance, the I2 statistics
was calculated (Higgins & Thompson 2002).
Values of 25%, 50% and 75% correspond to
low, moderate, and high degrees of heteroge-
neity, respectively.Because of the methodo-
logical diversity of the studies, only the
number of implants lost and the amount of
peri-implant bone loss in mm could be com-
bined in a meta-analysis. The risk difference
in the proportion of implants lost and the
mean difference in bone loss between the
compared groups were calculated and meta-
analyzed to obtain pooled estimates of risk
difference and difference in mean bone loss
with their 95% confidence intervals. If stud-
ies had reported zero implants loss, then a
Initial search
n = 3165 titles
1
Screening titles
2 n = 245 abstracts (214 excluded)
Screening abstracts
3 n = 31 full-text articles (20 excluded)
Screening full-text articles
4 n = 11 full-text articles selected
Fig. 1. Flow chart of the articles through review.
continuity correction was done (by adding 0.5 -Post load implant loss;
to the four cells in the 2 9 2 table) to calcu- -Overdenture longevity;
late the standard error of the risk difference. -Peri-implant bone loss;
This continuity correction is the default in -Peri-implant clinical parameters;
the metan command in Stata as in Rev- -Overdenture retention and stability;
Man, the software used by the Cochrane Col- -Patient satisfaction;
laboration (Deeks et al. 2010). -Surgical aftercare;
-Overdenture complications.
Results The results of the research are summa-
rized in Tables 57, according to the various
The flow of articles through the review is categories of comparison. Table 5 presents
shown in Fig. 1. From the original 3165 titles data on 1 vs. 2 implants, Table 6 presents
obtained from the search, 245 abstracts were comparative data regarding 2 implants and
selected. From these, 31 full articles were ana- ball attachment vs. 4 implants and a bar,
lyzed and 11 studies were considered eligible and Table 7 presents the comparison
for inclusion in the review (Table 1). The rea- between 2 implants and a bar vs. 4 implants
sons for study exclusion are given in Table 2. and a bar
After the initial search, another one was
carried out to answer whether there is a dif- Implant loss
ference in the outcome between ball and bar The number of implants lost after loading
attachment system in patients rehabilitated varied from 0 (Gotfredsen & Holm 2000;
with a mandibular two implant retained OD. Naert et al. 2004a; Meijer et al. 2009;
Twelve studies were included (Table 4). Walton et al. 2009; Burns et al. 2011; Stoker
et al. 2011) to 7 (Kronstrom et al. 2010).
Data extraction and outcomes Mean difference in implant loss and its 95%
The content of review articles when using confidence interval as well as the I2
different numbers of implants was the fol- statistics are reported in Fig. 2. The risk
lowing (Table 3). difference between two ball implants and

Table 1. Selected studies included in the review

Implants (I) and Follow-up
Study Year of publication Study design anchorage system Population# (months)
Wismeijer et al.* 1997 RCT 2I ball/ 2I bar/ 4I bar 34/34/36 16
Batenburg et al.** 1998 RCT 2I bar/ 4I bar 29/29 12
Wismeijer et al.* 1999 RCT 2I ball/2I bar/4I bar 32/34/36 19
Timmerman et al.* 2004 RCT 2I ball/2I bar/4I bar 32/36/35 99
Visser et al.** 2005 RCT 2I bar/4I bar 29/27 60
Stoker et al.* 2007 RCT 2I ball/2I bar/ 4I bar 32/36/35 99
Meijer et al.** 2009 RCT 2I bar/4I bar 27/23 120
Walton et al. 2009 RCT 1I ball/2I ball 42/43 12
Kronstrom et al. 2010 RCT 1I ball/2I ball 17/16 12
Stoker et al.* 2011 RCT 2I ball/2I bar/4I bar 27/33/34 99
Burns et al. 2011 RCT, crossover 2I ball/2I bar/4I bar 27 48^
#
Patients who dropped out from the study are excluded
*and **same study population
^
Each patient was rehabilitated with each anchorage system for 12 months plus an additional 12 month period with one system.

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Table 2. List of excluded studies and reasons for exclusion heterogeneity was I2 = 92.6% (P < 0.001). The
Author Year Reason for exclusion mean difference between splinted and un-
ten Bruggenkate et al. 1991 Opposing dentition & radiological parameters not reported splinted implants was 0.00 (CI 95%: 0.26;
Hooghe & Naert 1997 Not comparing different implant protocols 0.26) with low statistical heterogeneity.
Walmsley & Frame 1997 One single attachment system analyzed
Tang et al. 1997 Variable number of implants
Payne & Solomons 2000 Data extraction not possible
Discussion
Kiener et al. 2001 Retrospective study
Mau et al. 2003 Opposing dentition not reported Every patient should be offered sound advice
Yengopal 2004 Data not clearly stated
based on the best available evidence. Physi-
Schwartz-Arad et al. 2005 Single implant protocol analyzed
Rocha 2005 Opposing dentition not reported cian recommendations should always include
Visser et al. 2007 Not a prospective study the rationale, expected outcome, and alterna-
de Lange & van Gool 2007 Not a prospective study tives (Keirns & Goold 2009). This systematic
Karabuda et al. 2008 Opposing dentition and radiological parameters not reported
review aimed at identifying published infor-
MacEntee 2008 Financial costs analyzed
Strong 2009 Case report mation that allows assessing the optimal
Pieri et al. 2009 Single implant protocol analyzed number of implants for mandibular remov-
Balaguer et al. 2011 Retrospective study able reconstructions, in terms of implant loss
Ueda et al. 2011 Retrospective study
Cakarer et al. 2011 Different attachment systems analyzed and peri-implant bone loss. The question
Suzuki et al. 2012 Partial edentulous included whether there is an optimal number of
implants in mandibular implant retained or
supported overdentures has been raised for
four implants was 0.01 (CI 95%: 0.02; Bone loss several years.
0.03). The risk difference between 2 bar The amount of bone loss varied from 0.1 The first authors, who performed an RCT
implants and four implants was 0.00 (CI (Gotfredsen & Holm 2000) to 1.75 mm on the above mentioned topic, were Wismei-
95%: 0.01; 0.02). The risk difference (Stoker et al. 2011). Weighted mean differ- jer et al. (1997). They evaluated in over 100
between 1 and 2 implants was 0.00 (CI 95%: ence in bone loss and its 95% confidence patients the satisfaction by means of a ques-
0.04; 0.03). The risk difference between interval as well as the I2 statistics are tionnaire among a mandibular OD supported
splinted and unsplinted implants was 0.01 reported in Fig. 3. The difference in mean by two implants with ball attachments, two
(CI 95%: 0.04; 0.02). In all comparisons bone loss between 2 bar implants and implants with an interconnecting bar, and
statistical heterogeneity of results between four implants was 0.78 (CI 95%: 1.20; four interconnected implants. As no signifi-
studies was low to moderate. 0.36), but estimated with high statistical cant differences were found between the

Table 3. Outcome in included studies

Implants
post-load Mean marginal OD Patient
survival rate OD bone changes (SD) Gingival PD (SD) retention reported Surgical
Study (%) longevity (mm) index Bleeding index (mm) stability outcomes aftercare Complications
# # # # # # # # #
Wismeijer yes
et al.*
# # # # # # # #
Batenburg 99.9 0.7 (1.1)
et al.** 0.4 (0.8)
Wismeijer 100 #
1.3 (0.3); 1.4 (0.2) # # # # # # #

et al.* 1.1 (0.2); 1.0 (0.2)

1.4 (0.3); 1.9 (0.4);
2.3 (0.3); 1.4 (0.2)
# # # # # # # # #
Timmerman yes
et al.*
#
Visser 99.9 yes 1.6 (1.6) 0.7 (0.8) 0.9 (0.6)1.2 (0.7) 4.2 (1.3) yes yes yes
et al.** 1.2 (1.2) 0.8 (0.8) 4.0 (1.1)
# # # # # # #
Stoker yes yes yes
et al.*
#
Meijer 95/100 Yes 1.4 (1.4) 0.2 (0.1) 0.5 (0.6) 3.8 (1.3) yes yes yes
et al.** 1.0 (1.4) 0.1 (0.2) 1.0 (0.3) 3.9 (1.3)
# # # # # # #
Walton 100 yes yes
et al.
# # # #
Kronstrom 81.8 yes 0.4 (0.4) yes yes yes
et al.
# # # # # # #
Stoker 95.3/100/100 1.0 (1.0) 3.1 (1.1)
et al.* 1.0 (1.0) 3.5 (1.3)
1.7 (1.9) 3.6 (1.8)
Burns et al. # # #
0.5 (0.0) #
0.3 0.0 yes yes #
yes
0.4 (0.0) 0.1 0.0
0.4 (0.0) 0.1 0.0
#
no (detailed) information provided
*and **same study population.

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Table 4. Studies on two splinted vs. two unsplinted implants selected

mm of bone loss (mean SD)
Year of Follow-up Post-loading
Study publication Study design Population# (months) implant loss Splinted Unsplinted
***
Wismeijer et al. 1997 RCT 34/34 16
Naert et al.* 1997 RCT 12/12 36 0/240/24 0.59 0.55
Naert et al.* 1998 RCT 11/9 60 0/220/18
Wismeijer et al.*** 1999 RCT 34/32 19 0/660/64 1.1 0.24 (L) 1.3 0.27 (L)
1.0 0.2 (R 1.4 0.21 (R)
Gotfredsen & Holm 2000 RCT 11/15 60 0/110/15 0.2 0.6 0.1 0.8
Walton ** 2003 RCT 63/23 24
Naert et al.* 2004a RCT 7/9 120 0/140/18 1.15 0.9
Naert et al.* 2004b RCT 7/9 120
Timmerman et al. *** 2004 RCT 36/32 99
MacEntee et al. ** 2005 RCT 34/34 36
Stoker et al. *** 2011 RCT 33/27 99 3/660/64 0.95 0.99 1.04 1.01
Burns et al. 2011 RCT, crossover 27 48 0/54
#
Patients who dropped out from the study are excluded
*, **, ***same study population

Minimum follow-up

Mean follow-up

Each patient was rehabilitated with each anchorage system for 12 months plus an additional 12 month period with one system.

Table 5. OVD & implants: 1 vs. 2 implants

N of occlusal
Implant Loss adjustments

1 implant 2 implants
1 2 Patient
Authors Implants Loading Follow-up Preloading Postloading Preloading Postloading implant implants satisfaction D
^
Walton et al. 4288 6 weeks 12 months 0/42 0/42 5/88 0/83 4 2 VAS
(2009)
*
Kronstrom et al. 1420 Immediate 12 months 3/14 7/20 1 0 NO
(2010)
^
No significant differences in baseline and 1 year result.
*
Both groups had high failure rates. Implant number does not impact the outcome.

Table 6. OVD & implants: 2 ball vs. 4 bar

Post-loading
implant loss mm of bone loss (mean SD)

Authors Implants Loading Follow-up 2 ball 4bar 2 ball 4 bar Patient satisfaction Complications D
*
Wismeijer et al. (1997) 68144 12w 16mo Questionnaire

Wismeijer et al. (1999) 64144 12w 19mo 0/64 0/140 1.3 0.27 (L) 1.4 0.23 (L1)
1.4 0.21 (R) 2.3 0.27(L2)
1.9 0.36 (R2)
1.4 0.26 (R1)

Timmerman et al. (2004) 64140 12w 8.3y Questionnaire

Stoker et al. (2007) 64140 12w 8.3y N; type

Stoker et al. (2011) 12w 8.3y 3/64 0/136 1.04 1.01 1.73 1.93
**
Burns et al. (2011) 54108 1624w 1y Questionnaire CIP
*
No differences in patient satisfaction.

The central two implants have more bone loss; less BOP in 2 ball implants than 4 bar implants.

No differences in patient satisfaction. In 2 ball less satisfaction at 8.3 y than at 19 mo.

No differences in the number of check-ups. In 2ball more demand for simple re-adjustment.

4bar implants have more bone loss and PI than 2 ball implants.
**
More retention in 4 bar than in 2 ball. No differences in clinical implant performance (CIP scale).

three treatment modalities, it was concluded
that an OD retained by two ball attachments
was sufficient. The follow-up was limited to
16 months only.
The year later, Batenburg et al. (1998) trea-
ted 30 patients with an OD supported by two
implants and 30 patients with an OD on four
identical implants. No significant differences
were observed with regard to peri-implant
clinical data and radiographic bone loss. It
was concluded that there seemed not to be a
need to insert more than two implants to
support an OD, However, the follow-up was
1 year only.
Wismeijer et al. (1999) presented the 19-
month results, based on the same population
of the previous study, on implant loss, PI,
PD, attachment level, and bone loss. The

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Table 7. OVD & implants: 2 bar vs. 4 bar

Post-loading implant
loss mm of bone loss (mean SD)

Follow- 4 milled- 4 milled- Patient

Authors Implants Loading up 2 bar 4bar bar 2 bar 4 bar bar satisfaction Complications D
Part I
*
Wismeijer et al. 68144 12w 16mo Questionnaire
(1997)

Batenburg et al. 60120 14w 1y 0/58 0/116 0.7 1.1 0.4 0.8
(1998)

Wismeijer et al. 68144 12w 19mo 0/66 0/140 1.1 0.24 1.4 0.23
(1999) (L) (L1)
1.0 0.2 2.3 0.27
(R) (L2)
1.9 0.36
(R2)
1.4 0.26
(R1)
*
Timmerman 72140 12w 8.3y Questionnaire
et al. (2004)

Visser et al. 14w 5y 0/58 0/108 1.6 1.6 1.2 1.2 Questionnaire
(2005)

Stoker et al. 72140 12w 8.3y N; type
(2007)
Part II

Meijer et al. 14w 10y 3/58 0/92 1.4 1.4 1.0 1.4 Questionnaire N;type
(2009)
Weinlander 48208 5y 0/42 0/88 0/96 1.9 0.6 1.8 0.6 1.7 0.7 Questionnaire N;type **

et al. (2010)

Stoker et al. 12w 8.3y 0/66 0/136 0.95 0.99 1.73 1.93
(2011)

Burns et al. 54108 1624w 1y Questionnaire CIP
(2011)
*
No differences in patient satisfaction.

No significant differences in clinical and radiographic parameters.

The central 2 implants have more bone loss.

No significant differences in clinical, radiographic parameters and patient satisfaction. In Meijer et al. (2009) in 4 bar more complications.

No differences in the number of check-ups.
**
No significant differences in patient satisfaction; rigid prosthesis anchorage was associated with fewer complications.

Higher bone loss in four implants bar in contrast to Visser et al. (2005) and Mejer et al. (2009).

No differences in clinical implant performance (CIP scale).

bleeding index was significantly lower for the
two Implant Ball Attachment group than
both two Implant Single Bar and four Implant
Triple Bar groups two implants with ball
attachment are best treatment. The radio-
graphic analysis revealed that the bone loss
around the central two implants in the four
Implant Triple Bar group was significantly
higher than all the others.
The 8-year results of the same study popu-
lation (110 participants at baseline, 103 for
final examination) are presented by Timmer-
man et al. (2004). Participants completed a
questionnaire focusing on several aspects of
denture satisfaction and social functioning.
The responses showed no differences among
the three treatment groups at the 8-year eval-
uation. In the 19-month and 8-year evalua-
tions, the tests demonstrated a significant
difference in satisfaction among the 3 groups
for retention and stability of the mandibular
OD. Since the score on the item retention
and stability of the overdenture, for the par-
ticipants with an OD on two implants with
ball attachments, decreased over time (from
19 months to 8 years), the authors suggested
that a mandibular OD retained by two
implants interconnected by a single bar
might be the best treatment strategy, in the
long term.
Visser et al. (2005) presented the 5-year
results of a previous study (Batenburg
et al.1998), with the addition of a question-
naire on patient satisfaction and data on pros-
thetic and surgical aftercare. There was no
difference in clinical and radiographical state
of patients treated with an OD on two or
four implants. Patients of both groups were
equally satisfied with their OD.
Stoker et al. (2007) presented the 8-year
results of the RCT of Wismeijer et al. (1997),
on over 100 patients, regarding the aftercare
and cost-analysis with three types of mandib-
ular implant-retained OD. The three groups
showed no mutually significant differences
in the total number of check-ups, but there
was an increased demand for aftercare in the
two implants with ball attachments group for
simple readjustments, such as re-activating
the matrices. The authors concluded that an
OD with a bar on two implants was the most
efficient in the long term.
Meijer et al. (2009) reported the 10-year
data of the previously published paper of Bat-
enburg et al. (1998) and concluded that there
was no statistically significant difference
between patients treated with a two or four
implant mandibular OD with respect to: clin-
ical state of soft tissues, radiographic bone
loss, patient satisfaction and surgical and
prosthetic altercare. For reasons of cost-effec-
tiveness, a two-implant OD was advised.
Walton et al. (2009) compared, in a RCT,
satisfaction and prosthetic outcomes with
mandibular ODs retained by one or two
implants in 85 patients. The median satisfac-
tion was 93 (maximum 100) in the single-
implant group and 94 in the two-implant
group. Within each group, median improve-

234 | Clin. Oral Implants Res. 23(Suppl. 6), 2012/229237 2012 John Wiley & Sons A/S
 Roccuzzo et al
Implants & overdentures

Year of Events/N in
OD retained by a single midline implant
Author publication intervention and control RD (95% CI)
appeared to warrant consideration as an alter-
2ball vs 4bar
native to the standard 2-implant OD.
Stoker 2011 3/66 vs 0/136 0.05 (0.01, 0.10) A similar study design, comparing 1 vs. 2
Burns 2011 0/54 vs 0/108 0.00 (0.03, 0.03)
implants, was presented by Kronstrom et al.
Subtotal (I-squared = 53.0%, p = 0.145) 0.01 (0.02, 0.03)
(2010) in an immediate loading protocol on
2bar vs 4bar
36 subjects. Ten implants in nine subjects
Mejer 2009 3/54 vs 0/92 0.06 (0.01, 0.12) failed during the observation period, and
Stoker 2011 0/54 vs 0/136 0.00 (0.03, 0.03) three subjects with two implants each with-
Burns 2011 0/54 vs 0/108 0.00 (0.03, 0.03)
drew from the study, resulting in a 12-month
Subtotal (I-squared = 19.7%, p = 0.288) 0.00 (0.01, 0.02)
implant survival rate of 81.8%. Three sub-
1ball vs 2ball jects lost their only implant and one patient
Walton 2009 0/42 vs 0/81 0.00 (0.04, 0.04) lost both implants. The remaining five sub-
Kronstrom 2010 3/17 vs 7/32 0.04 (0.27, 0.19)
jects lost one of their two implants. Six of
Subtotal (I-squared = 0.0%, p = 0.723) 0.00 (0.04, 0.03)
the failures occurred during the first month
splinted vs unsplinted after placement. The 1-year examination was
Burns 2011 0/54 vs 0/54 0.00 (0.04, 0.04) carried out on 24 patients only. Immediate
Gotfredsen 2000 0/22 vs 0/30 0.00 (0.07, 0.07)
loading of one or two implants with a ball
Naert 2004 0/14 vs 0/18 0.00 (0.12, 0.12)

Stoker 2011 0/54 vs 3/66 0.05 (0.10, 0.01)

attachment produced an excessive failure
Subtotal (I-squared = 0.0%, p = 0.616) 0.01 (0.04, 0.02) rate. Nevertheless, no statistically significant
differences in failure rates between the two
groups were observed.
.2 0 .2
Stoker et al. (2011) presented further data
Favors intervention Favors control for the 8-year results of an RCT, on over 100
Fig. 2. Meta-analysis of the risk difference of implant loss when comparing two implants with ball attachment vs.
patients, regarding the aftercare and cost-
four implants with bar, two implants with bar vs. four implants with bar, and two splinted vs. unsplinted implants. analysis with three types of mandibular
implant-retained ODs. Patients with two
implants showed less marginal bone loss
Year of than those with four implants, suggesting
Author publication WMD (95% CI)
that two implants seem to be preferable for
mandibular implant-supported OD. Smoking
was found to be a risk factor for the survival
2ball vs 4bar
of dental implants with no difference among
Stoker 2011 0.69 (1.10,0.28)
the groups.
Subtotal (I-squared = .%, p = .) 0.69 (1.10, 0.28)
The most recent publication, to the best of
our knowledge, is a prospective, randomized
2bar vs 4bar clinical trial, using a crossover design, by
Mejer 2009 0.40 (0.07, 0.87) Burns et al. (2011). Thirty subjects received
Stoker 2011 0.78 (1.20, 0.36) four implants in the anterior mandible. For
Subtotal (I-squared = 92.6%, p = 0.000) 0.26 (0.57, 0.05) each subject, three different OD attachment
types were fabricated and/or fitted to the
splinted vs unsplinted
implants: 4-implant bar attachment, 2-
implant bar attachment, and two ball attach-
Gotfredsen 2000 0.10 (0.28, 0.48)
ments. Subjects received all three attachment
Stoker 2011 0.09 (0.45, 0.27)
types each for approximately 1 year. Data
Subtotal (I-squared = 0.0%, p = 0.477) 0.00 (0.26, 0.26)
were collected at baseline, and at 6 and
12 months for treatment types. The 2-ball
attachment provided equivalent or more
favorable treatment outcomes for most mea-
-.5 0 .5

Favors intervention Favors control

sured parameters relative to the 2- and 4-
implant bar attachments. The 4-implant bar
Fig. 3. Meta-analysis of the mean difference in bone loss when comparing two implants with ball attachment vs.
treatment provided greater prosthesis reten-
four implants with bar, two implants with bar vs. four implants with bar, and two splinted vs. unsplinted implants.
tion than the other treatment types in this
study, but after experience with all systems,
more than half the subjects selected the 2-
ment in satisfaction was similarly dramatic postsurgical denture maintenance, and den- ball attachment as their ideal prosthesis after
and significant. Prosthodontic maintenance ture reline. Five implants failed in four sub- the conclusion of the investigation.
time was similar for both groups, but the sin- jects, all in the two-implant group and all For this review, the meta-analysis included
gle-implant group had significantly lower before denture reline. Even though longer only implant loss and peri-implant bone loss.
component costs and lower times for surgery, observation periods were judged necessary, an For implant loss, the risk difference was close

2012 John Wiley & Sons A/S 235 | Clin. Oral Implants Res. 23(Suppl. 6), 2012/229237
Roccuzzo et al
Implants & overdentures
to zero between for all comparisons (2 ball
implants vs. 4 implants, 2 bar implants vs. 4
implants, 1 vs. 2 implants, and splinted vs.
unsplinted implants). These results suggest
that, in mandibular implant retained or sup-
ported OD, the risk of implant loss does not
vary substantially by number of implants.
For peri-implant bone loss, the weight
mean difference was 0.26 (CI 95%: 0.57;
0.05) between 2 bar implants and four
implants and 0.00 (CI 95%: 0.26; 0.26)
between splinted and unsplinted implants. In
2 bar implant supported OD mean bone loss
is less pronounced than four implants. In the
light of the small number of studies and a
high heterogeneity across studies (I2 of
92.6%), these results should be interpreted
with caution.
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