VOLUME 44 NUMBEP 1 JANUAPY 2013 45

QUI NTESSENCE I NTERNATI ONAL

IMPLANTOLOGY
prosthesis retention and comfort gained by
the reduction of palatal coverage.
3
Such
treatment is often challenging due to inher-
ent anatomical and biomechanical prob-
lems.
4
Also, immediate implant loading is
frequently limited by reduced maxillary
bone quality and quantity, as well as varied
primary implant stability.
5

The reduction of palatal coverage gives
more room for the tongue, exposes addi-
tional palatal tissue for better appreciation
of food texture,
6
and provides greater com-
fort for complete denture wearers, espe-
cially those with hyperactive gag reexes or
maxillary tori.
7
However, the removal of the
palatal coverage reduces the area for tis-
Implant-supported maxillary overdentures
are a predictable, accepted treatment
option for the edentulous maxilla.
1,2
Patients
with conventional maxillary dentures may
seek implant treatment to obtain higher
1
Lecturer, Department of Removable Prosthodontics, Faculty of
Dentistry, Mansoura University, Mansoura, Egypt.
2
Lecturer, Department of Oral Surgery, Faculty of Dentistry,
Mansoura University, Mansoura, Egypt.
3
Lecturer, Department of Oral Medicine and Periodontology,
Faculty of Dentistry, Mansoura University, Mansoura, Egypt.
Correspondence: Dr Moustafa Abdou ELsyad, Department
of Removable Prosthodontic, Faculty of Dentistry, Mansoura
University, PO Box 35516, #68 ElGomhoria Street, ElMansoura,
Eldakahlia, Egypt. Email: M_syad@mans.edu.eg
Marginal bone loss around unsplinted mini-
implants supporting maxillary overdentures:
A preliminary comparative study between partial
and full palatal coverage
Moustafa Abdou ELsyad, BDS, MSc, PhD
1
/Nahed Ebrahim Ghoneem,
BDS, MSc, PhD
2
/Hesham El-Sharkawy, BDS, MSc, PhD
3
Objective: To evaluate and compare marginal bone loss around mini-implants supporting
maxillary overdentures with either partial or full palatal coverage. Method and Materials:
Ninotoon odontulous pationts oomplaining o rotontion probloms involving tnoir maxil-
lary dentures were randomly allocated in two groups. Group I (n = 10) received maxillary
dentures with full palatal coverage, and group II (n = 9) received maxillary dentures with
partial palatal coverage. In total, 114 mini-implants (6 per patient) were inserted using the
nonsubmerged apless surgical approach and loaded immediately with maxillary overden-
tures. Each implant was evaluated at the time of initial prosthetic loading and at 6, 12, and
24 montns tnoroator. Padiograpnio ovaluation was porormod in torms o vortioal and nori-
zontal bone loss. Implant mobility (via Periotest values) was measured using a Periotest
device, and patient satisfaction was evaluated with a visual analog scale. The cumulative
survival rate was calculated using Kaplan-Meier analysis. Results: After 2 years, the mean
vertical bone loss in groups I and II was 5.38 and 6.29 mm, respectively, while the mean
horizontal bone loss in groups I and II was 1.52 and 1.93 mm, respectively. Most bone
resorption occurred within 6 months after overdenture insertion in both groups. Group
II recorded signicant higher vertical bone loss and Periotest values than group I at all
observation times. The cumulative survival rates of the mini-implants were 78.4% and
53.8% for groups I and II, respectively. All patients were satised with their maxillary over-
dentures in terms of retention and chewing ability. Conclusion: Ponabilitation o odon-
tulous maxillae with unsplinted mini-implants supporting overdentures and in particular
with a combination of partial palatal coverage is not recommended because of excessive
marginal bone resorption and the higher failure rate of mini-implants than was expected.
(Quintessence Int 2013;44:4552)
Key words: bone loss, immediate load, maxillary, mini-implants, overdenture
46 VOLUME 44 NUMBEP 1 JANUAPY 2013
QUI NTESSENCE I NTERNATI ONAL
ELsyad et al
sue support and diminishes the retention of
the maxillary denture.
7,8
Mini-implants are biocompatible titanium
screws with ultrasmall diameters (1.8 to
2.4 mm) originally used for temporary stabi-
lization of overdentures while conventional
implants integrated into the bone.
911
In
comparison with conventional implants,
mini-implants are cost-effective,
12
have
fewer complications during apless implant
placement,
11,13
and can be used in edentu-
lous arches with minimal remaining bone in
a faciolingual dimension.
1315
Mini-implants
have the advantages of single-stage
implants, including short healing time, mini-
mal trauma,
12,16
and immediate restoration
of mastication and esthetics.
17,18

A high success rate
1113,1922
and minimal
crestal bone loss
22
have been reported with
the application of mini-implants for immedi-
ate and long-term mandibular overdenture
stabilization. However, the use of mini-
implants to permanently retain maxillary
overdentures for the edentulous patient was
not investigated. The aim of this preliminary
study was to evaluate and compare mar-
ginal bone loss around immediately loaded
mini-implants supporting maxillary overden-
tures with either partial or full palatal cover-
age.
METHOD AND MATERIALS
Patient selection
Ninotoon odontulous pationts (11 mon and 8
women) with mean age of 63.8 years (range,
59 to 73 years) and persistent retention
problems with their conventional maxillary
dentures were selected from the outpatient
clinic of the Department of Prosthodontics,
Faculty of Dentistry, Mansoura University,
Mansoura, Egypt. All patients signed an
informed consent form. The study protocol
was approved by a local ethical review
board to ensure the protection of the par-
ticipants. The selected patients were
required to have healthy mucosa, sufcient
interarch space, and Class III to V resorp-
tion in the anterior maxillary region,
23
with
remaining bone height to allow placement of
15-mm implants. Patients were excluded if
they had diabetes, were smokers, had
osteoporosis, or had undergone radiothera-
py to the head and neck region. A single
randomization was performed to allocate
the participants into one of two groups.
Group I consisted of 10 patients who
received maxillary overdentures with full
palatal coverage, and group II consisted of
9 patients who received maxillary overden-
tures with partial palatal coverage.
Surgical and prosthetic
procedure
For all patients, new maxillary and mandibu-
lar complete dentures were constructed. All
dentures were made with semianatomical
teeth (Vitapan, Vita Zahnfabrik), arranged in
bilateral balanced occlusal contact. The full
palatal coverage of maxillary denture was
maintained in group I, while the palatal part
was removed in group II.
A preoperative panoramic radiograph
was performed for each patient to locate
important anatomical landmarks and evalu-
ate implant placement sites. A total of 114
mini-implants with treated surfaces (one
piece, ball-type, 2.415 mm, MAX Thread,
Sendaxs MDI, IMTEC) were inserted, six
per patient at the lateral incisors and pre-
molar areas bilaterally. The insertion was
carried out by the same oral surgeon using
the single-stage flapless surgical
approach.
11,17
The tting surface of the max-
illary denture was marked at the proposed
implant sites and placed in the patients
mouth after drying the mucosa to transfer
the marks to the alveolar ridge. A 1.2-mm
pilot drill was used to penetrate the mucosa
and the cortical plate at marked sites. Mini-
implants were manually self-tapped with a
nger driver, and the nal seating was com-
pleted with a ratchet (Fig 1).
All prosthetic procedures were per-
formed by the same prosthodontist.
Pooossos or tno O-ring omalo nousings
were prepared in the tting surface of the
new maxillary denture. The housings were
then attached to the maxillary denture using
self-cured acrylic resin while the patient
held the dentures in centric occlusion
(Fig 2). The denture was immediately func-
tionally loaded on the same day the implants
were placed. The patients were instructed
not to eat without the dentures in place. Oral
VOLUME 44 NUMBEP 1 JANUAPY 2013 47
QUI NTESSENCE I NTERNATI ONAL
ELsyad et al
Fig 1 Intraoral view of mini-implants in place.
Fig 2 Mini-implant supported maxillary overdentures with (a) full palatal coverage (group I) and (b) partial
palatal coverage (group II).
a b
hygiene instructions were given to the
patients, and regular 3-month recall visits
for adjustments (occlusal renement and
O-ring replacement) were scheduled
throughout the study period.
Implant-related outcomes
Primarily, the peri-implant bone loss around
the mini-implants was assessed in both
groups. Mobility, patient satisfaction, and
survival rate of the mini-implants were con-
sidered secondary outcomes
Radiographic (primary) outcome. Intra-
oral radiographs were produced using the
periapical long-cone paralleling tech-
nique.
22
All radiographs were scanned at
600 dpi. Subsequently, lines and reference
points woro traood using CorolDPAW
(Corel). The ratio between implant dimen-
sions in the radiographs and actual implant
dimensions was used to detect magnica-
tion errors.
Peri-implant vertical and horizontal alve-
olar bone loss were measured (in mm) at
the mesial and distal surface of each
implant,
22,24
and the mean was subjected to
statistical analysis. The distance between
implant abutment base (A point) and rst
bono to implant oontaot (B point) indioatod
vertical bone level (Fig 3). The distance
between the marginal bone level (C point,
which represents the intersection point of a
tangent to the horizontal bone crest [CD
line] and another tangent to the crater-
snapod dooot |CB lino]) and tno implant
perpendicularly indicated horizontal bone
level. Vertical and horizontal bone loss were
calculated by subtracting bone levels at 6,
12, and 24 months after insertion from bone
levels immediately after insertion.
Clinical (secondary) outcomes. Implant
mobility was measured at the abutment
level by means of a Periotest instrument
(Periotests S, Medizintechnik Gulden).
48 VOLUME 44 NUMBEP 1 JANUAPY 2013
QUI NTESSENCE I NTERNATI ONAL
ELsyad et al
Fig 3 Traced periapical radiograph. A, abutment
base; B, frst bone to implant contact; C, marginal
bone level; D, horizontal bone crest; VBLE, vertical
bone level; HBLE, horizontal bone level.
Periotest values of 0 indicated that osseo-
integration had been achieved, while values
> 9 denoted compromised osseointegra-
tion.
25,26
Patients were given two questionnaires
that used visual analog scales (VAS) to
assess their satisfaction with their maxillary
overdentures with regard to retention and
chewing ability. The endpoints of the VAS
were 0 (totally dissatised) and 10 (excel-
lent).
To estimate the cumulative survival rate,
a Kaplan-Meier analysis was made involv-
ing the clinical parameters for success
suggested by Albrektsson et al.
27
These
include the individual implant was immo-
bile when tested clinically; absence of peri-
implant radiolucency; and absence of per-
sistent signs and symptoms such as pain,
infections, and paresthesia. An implant
was classied as a survived implant if it
was still functioning and did not need
immediate removal, but did not fulll the
success criteria.
Marginal bone and implant mobility were
assessed for each implant immediately
after overdenture insertion (T0, baseline)
and 6 (T1), 12 (T2), and 24 (T3) months
thereafter. Evaluations were performed by
one calibrated examiner.
STATISTICAL ANALYSIS
Data woro analyzod using SPSS 17.0 (BM)
and SAS 9.2 (SAS Institute). Comparison of
vertical bone loss, horizontal bone loss,
Periotest values, and VAS between obser-
vation times for each group was performed
using SAS macroprogram LD_F1 for non-
parametric longitudinal data,
28
and the
Wilooxon signod-rank tost was usod to
compare between each times. For between-
group comparisons, the nonparametric
Mann-Wnitnoy tost was usod. Tno Spoarman
rho correlation coefcient was used to
assess the relationship between vertical
and horizontal bone loss and implant mobil-
ity. A comparison of the survival rates
between the two groups was carried out by
applying the log-rank test. Differences
were considered to be statistically signi-
cant at P < .05.
RESULTS
Radiographic (primary)
outcome
Vertical and horizontal bone loss at different
observation times for both groups are pre-
sented in Table 1. At the 24-months evalua-
tion, the mean vertical bone loss was
5.38 1.65 and 6.29 2.33 mm for groups
I and II, respectively, while the mean hori-
zontal bone loss was 1.52 1.01 and
1.93 1.23 mm for groups I and II, respec-
tively. Vertical and horizontal bone loss
increased over time for both groups
(P < .001). The intragroup analysis using
Wilooxon signod-rank tost ovidonood a sig-
nicant difference (P < .002) between
observation times (T1, T2, and T3). Group II
showed higher vertical bone loss than
VOLUME 44 NUMBEP 1 JANUAPY 2013 49
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ELsyad et al
Table 1 Mean SD vertical and horizontal bone loss (mm) at different observa-
tion times for both groups
Vertical bone loss Horizontal bone loss
Group
Time Group I Group II
Mann-Whitney
test (P value) Group I Group II
Mann-Whitney
test (P value)
6 mo after
insertion (T1)
4.40 1.60 5.61 2.22 .016 0.99 0.70 1.35 1.05 .206
12 mo after
insertion (T2)
4.98 1.71 5.94 2.23 .043 1.20 0.86 1.66 1.20 .154
24 mo after
insertion (T3)
5.38 1.65 6.29 2.33 .029 1.52 1.01 1.93 1.23 .095
SD, standard deviation.
Fig 4 Red line, group I; blue line, group II.
20
18
16
14
12
10
8
6
4
2
0
-2
-4
-6
-1.881.39
-1.691.53
11.155.80
8.304.32
Observation time
M
e
a
n

S
D

P
e
r
i
o
t
e
s
t

v
a
l
u
e
s

(
m
m
)
10.774.48
14.746.56
18.007.79
13.675.28

T0 T1 T2 T3
group I for all observation times (P < .045),
while horizontal bone loss demonstrated
insignicant difference between the two
groups. Vertical bone loss was signicantly
higher than horizontal bone loss for both
groups at different observation times (Mann-
Wnitnoy tost, P < .001).
Clinical (secondary) outcomes
The Periotest values of the mini-implants for
both groups are shown in Fig 4. After 2
years, the mean Periotest values of the sur-
viving mini-implants for groups I and II were
13.67 5.28 and 18 7.79, respectively.
The mean Periotest values increased over
time for both groups (P < .001), with signi-
cant differences between observation times
(P < .001). Immediately after insertion (T0),
the Periotest values did not differ signi-
cantly between the two groups. Later, sig-
nicantly higher values were recorded in
group II than in group I at the remaining
evaluation periods (P = .047 at T1, P = .020
at T2, and P = .012 at T3). A signicant
positive correlation (P < .001) was record-
ed between Periotest values and vertical
bono loss (P
2
= 0.289) and between
Periotest values and horizontal bone loss
(P
2
= 0.452).
Booro implant stabilization, pationts
tended to be dissatised with the function of
their dentures, although they were accu-
rately made and free of defects. The mean
VAS values for denture retention were
2.5 0.84 for group I and 1.0 0.99 for
group II, while the values of chewing ability
were 2.1 0.73 for group I and 1.11 0.78
for group II. After connecting the dentures
to the mini-implants, there was a signicant
increase in satisfaction with denture reten-
tion and chewing ability (9.0 0.66 and
7.9 0.73 for group I (P = .005 and
P = .004) and 7.2 0.83 and 8.22 0.97
for group II (P = .007 and P = .005), respec-
tively. Group I recorded signicantly higher
retention than group II (P = .001), while no
50 VOLUME 44 NUMBEP 1 JANUAPY 2013
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ELsyad et al
Fig 5 Kaplan-Meier analysis of the cumulative sur-
vival rate.
100
80
60
40
20
0
Time (months)
C
u
m
u
l
a
t
i
v
e

s
u
r
v
i
v
a
l

(
%
)

0 3 6 9 12 15 18 21 24
Group I
Group II
Group I-censored
Group II-censored
signicant difference between groups was
noted for chewing ability.
Figure 5 shows Kaplan-Meier analysis of
the cumulative survival rate of mini-implants.
Of 114 mini-implants (19 patients) inserted
in both groups, 38 implants were lost after
24 months of overdenture insertion. Thirteen
mini-implants failed in group I (7 after 3
months, 3 after 6 months, 2 after 9 months,
and 1 after 12 months), resulting in 21.6%
failure rate in this group. In group II, 25 mini-
implants failed (15 after 3 months, 4 after 6
months, 3 after 9 months, and 3 after 12
months), yielding a 46.2% failure rate in this
group. Therefore, the cumulative survival
rates were 78.4% and 53.8% for groups I
and II, respectively. The mean survival and
failure rate in groups I and II was 67% and
33%, respectively. The rst premolar posi-
tion showed the highest failure rate in both
groups (14 mini-implants), followed by the
lateral incisor position (13 mini-implants)
and the second premolar position (11 mini-
implants). The survival rate of mini-implants
in group I was signicantly higher than that
of group II (log-rank test, P < .001). Implant
failures were associated with pain and
mobility with or without suppuration. The
failed implants were removed, and the
remaining implants were left in place to
retain the maxillary overdentures.
DISCUSSION
Six mini-implants were inserted in each sub-
ject to support maxillary overdentures,
instead of the traditional four implants, to
compensate for reduced implant diameter
and poor maxillary bone quality
11,29,30
and to
allow the use of open palate design for the
overdentures.
7,31
These implants were
placed in the lateral incisor and premolar
positions to stay away from maxillary sinus
location and to ensure that the antroposte-
rior spread of the implants was favorable for
good load distribution.
6
The percentage of vertical and horizontal
bone loss was high during the rst 6 months,
after which the velocity of bone resorption
tends to decrease. This nding concurred
with the results of previous reports on mini-
implants.
2022
The increased vertical bone
loss with the passage of time could be
attributed to increased mechanical stresses
that may produce fatigue microdamage and
bone resorption.
32
Such stresses may be
related to the following factors: (1) the ne
trabecular maxillary bone with absent corti-
cal plate may subject the maxilla to higher
biomechanical forces,
33
(2) the thick masti-
catory mucosa on the maxilla often neces-
sitates longer implant abutments, which
increases lever arm length,
34
(3) the immedi-
ate loading of mini-implants during the heal-
ing period could lead to greater bone over-
load, which may exceed physiologic
threshold
20
since the implants have less
mechanical anchorage, and (4) the unsplint-
ed mini-implants also show a certain degree
of disparallelism, which produces micro-
movements as a result of multiple removals
and insertions of the prosthesis.
9,35

Partial palatal coverage demonstrated
signicant bone loss around mini-implants
when compared to complete palatal cover-
age. This nding may be due to the fact
complete palatal coverage improves distri-
bution of stress between implants and adja-
cent soft tissue support areas, while the lack
of palatal coverage increases stress around
supporting implants, especially when there
are risk factors, such as compromised bone
quality and off-ridge relations, present.
7,36
In
contrast, another study
6
reported stable
marginal bone around unsplinted conven-
VOLUME 44 NUMBEP 1 JANUAPY 2013 51
QUI NTESSENCE I NTERNATI ONAL
ELsyad et al
tional implants supporting a maxillary over-
denture with partial palatal coverage.
Periotest values of mini-implants sup-
porting maxillary overdentures are higher
than values reported previously with mini-
implants supporting mandibular overden-
tures.
22
One reason might be related to the
difference in bone density between the
maxilla and mandible. Overall, the patients
were satised with their overdentures
regarding retention and chewing ability. A
similar nding was observed by de
Albuquerque et al
37
who found that patients
were equally satised with implant-support-
ed overdentures with and without palatal
coverage.
The cumulative mini-implant survival
rate with complete palatal coverage (78.4%)
was consistent with the survival rate of
another study
11
but higher than the survival
rate observed by Krennmair et al
10
(62.5%).
The difference may be a result of the mini-
implants used in the Krennmair et al study,
which had square abutments that were
designed to support xed provisional res-
torations but were used for removable xa-
tion. The higher failure rate of mini-implants
at the lateral incisor and rst premolar
regions may be because of resorptive pat-
terns causing maxillary implants to be
angled facially at these regions.
38
In addi-
tion, the replacement teeth were usually
anterior and inferior to the residual ridge,
thereby producing destructive cantilever
forces.
39,40

The present study included a small
sample size. Although useful information
was found in this study, this limitation should
be acknowledged. A larger sample size
and long-term follow-up would undoubtedly
provide more insight regarding the perfor-
mance of mini-implants used to support
maxillary overdentures.
CONCLUSION
Witnin tno limits o tnis proliminary study,
rehabilitation of the edentulous maxilla with
unsplinted mini-implants supporting over-
dentures, and in particular with a combina-
tion of partial palatal coverage, is not
recommended because of excessive mar-
ginal bone resorption and a higher-than-
expected mini-implant failure rate.
ACKNOWLEDGMENT
The study was self-funded by the authors, who would
like to thank Dr Osama Askar, Department of Removable
Prosthodontics, Faculty of Dentistry, Mansoura
University, Mansoura, Egypt, for providing 25% of the
implants used.
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