Biomaterial aspects: A key factor in the longevity of implant overdenture attachment systems
Identifieur interne : 000485 ( Pmc/Corpus ); précédent : 000484; suivant : 000486Biomaterial aspects: A key factor in the longevity of implant overdenture attachment systems
Auteurs : Elie E. DaouSource :
- Journal of International Society of Preventive & Community Dentistry [ 2231-0762 ] ; 2015.
Abstract
New attachment systems are released for mandibular two-implant overdentures often without evidence-based support. Biomaterial aspects are now the parameters considered when choosing the appropriate attachment. Studies regarding their properties remain scarce.
The purpose of this review was to help the clinician in selrcting the most adapted stud attachments according evidence-based dentistry.
An electronic search was conducted using specific databases (PubMed, Medline, and Elsevier libraries). Peer-reviewed articles published in English up to July 2014 were identified. Emphasis was given on the biomaterial aspects and technical complications. No hand search was added.
The electronic search generated 115 full-text papers, of which 84 papers were included in the review. The majority were clinical and
Implant overdentures long-term follow-up studies may provide useful guidelines for the clinician in selecting the type of attachment system and overdenture design. Locator attachments are more and more used, with lesser complications reported.
Url:
DOI: 10.4103/2231-0762.161752
PubMed: 26312224
PubMed Central: 4547438
Links to Exploration step
PMC:4547438Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Biomaterial aspects: A key factor in the longevity of implant overdenture attachment systems</title>
<author><name sortKey="Daou, Elie E" sort="Daou, Elie E" uniqKey="Daou E" first="Elie E." last="Daou">Elie E. Daou</name>
<affiliation><nlm:aff id="aff1">Department of Prosthodontics, School of Dentistry, Lebanese University, Beirut, Lebanon</nlm:aff>
</affiliation>
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<idno type="doi">10.4103/2231-0762.161752</idno>
<date when="2015">2015</date>
<idno type="wicri:Area/Pmc/Corpus">000485</idno>
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<sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Biomaterial aspects: A key factor in the longevity of implant overdenture attachment systems</title>
<author><name sortKey="Daou, Elie E" sort="Daou, Elie E" uniqKey="Daou E" first="Elie E." last="Daou">Elie E. Daou</name>
<affiliation><nlm:aff id="aff1">Department of Prosthodontics, School of Dentistry, Lebanese University, Beirut, Lebanon</nlm:aff>
</affiliation>
</author>
</analytic>
<series><title level="j">Journal of International Society of Preventive & Community Dentistry</title>
<idno type="ISSN">2231-0762</idno>
<idno type="eISSN">2250-1002</idno>
<imprint><date when="2015">2015</date>
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<front><div type="abstract" xml:lang="en"><sec id="st1"><title>Background:</title>
<p>New attachment systems are released for mandibular two-implant overdentures often without evidence-based support. Biomaterial aspects are now the parameters considered when choosing the appropriate attachment. Studies regarding their properties remain scarce.</p>
</sec>
<sec id="st2"><title>Purpose:</title>
<p>The purpose of this review was to help the clinician in selrcting the most adapted stud attachments according evidence-based dentistry.</p>
</sec>
<sec id="st3"><title>Materials and Methods:</title>
<p>An electronic search was conducted using specific databases (PubMed, Medline, and Elsevier libraries). Peer-reviewed articles published in English up to July 2014 were identified. Emphasis was given on the biomaterial aspects and technical complications. No hand search was added.</p>
</sec>
<sec id="st4"><title>Results:</title>
<p>The electronic search generated 115 full-text papers, of which 84 papers were included in the review. The majority were clinical and <italic>in vitro</italic>
studies. Some review articles were also considered. Papers reported survival and failures of overdenture connection systems. Emphasis was laid on attachment deformation.</p>
</sec>
<sec id="st5"><title>Conclusion:</title>
<p>Implant overdentures long-term follow-up studies may provide useful guidelines for the clinician in selecting the type of attachment system and overdenture design. Locator attachments are more and more used, with lesser complications reported.</p>
</sec>
</div>
</front>
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<pmc article-type="review-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">J Int Soc Prev Community Dent</journal-id>
<journal-id journal-id-type="iso-abbrev">J Int Soc Prev Community Dent</journal-id>
<journal-id journal-id-type="publisher-id">JISPCD</journal-id>
<journal-title-group><journal-title>Journal of International Society of Preventive & Community Dentistry</journal-title>
</journal-title-group>
<issn pub-type="ppub">2231-0762</issn>
<issn pub-type="epub">2250-1002</issn>
<publisher><publisher-name>Medknow Publications & Media Pvt Ltd</publisher-name>
<publisher-loc>India</publisher-loc>
</publisher>
</journal-meta>
<article-meta><article-id pub-id-type="pmid">26312224</article-id>
<article-id pub-id-type="pmc">4547438</article-id>
<article-id pub-id-type="publisher-id">JISPCD-5-255</article-id>
<article-id pub-id-type="doi">10.4103/2231-0762.161752</article-id>
<article-categories><subj-group subj-group-type="heading"><subject>Review Article</subject>
</subj-group>
</article-categories>
<title-group><article-title>Biomaterial aspects: A key factor in the longevity of implant overdenture attachment systems</article-title>
</title-group>
<contrib-group><contrib contrib-type="author"><name><surname>Daou</surname>
<given-names>Elie E.</given-names>
</name>
<xref ref-type="aff" rid="aff1"></xref>
<xref ref-type="corresp" rid="cor1"></xref>
</contrib>
</contrib-group>
<aff id="aff1">Department of Prosthodontics, School of Dentistry, Lebanese University, Beirut, Lebanon</aff>
<author-notes><corresp id="cor1"><bold>Corresponding author</bold>
(email: <<email xlink:href="dreliedaou@gmail.com">dreliedaou@gmail.com</email>
>) Dr. Elie E. Daou, Department of Prosthodontics, School of Dentistry, Lebanese University, Beirut, Lebanon.
</corresp>
</author-notes>
<pub-date pub-type="ppub"><season>Jul-Aug</season>
<year>2015</year>
</pub-date>
<volume>5</volume>
<issue>4</issue>
<fpage>255</fpage>
<lpage>262</lpage>
<permissions><copyright-statement>Copyright: © Journal of International Society of Preventive and Community Dentistry</copyright-statement>
<copyright-year>2015</copyright-year>
<license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-sa/3.0"><license-p>This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.</license-p>
</license>
</permissions>
<abstract><sec id="st1"><title>Background:</title>
<p>New attachment systems are released for mandibular two-implant overdentures often without evidence-based support. Biomaterial aspects are now the parameters considered when choosing the appropriate attachment. Studies regarding their properties remain scarce.</p>
</sec>
<sec id="st2"><title>Purpose:</title>
<p>The purpose of this review was to help the clinician in selrcting the most adapted stud attachments according evidence-based dentistry.</p>
</sec>
<sec id="st3"><title>Materials and Methods:</title>
<p>An electronic search was conducted using specific databases (PubMed, Medline, and Elsevier libraries). Peer-reviewed articles published in English up to July 2014 were identified. Emphasis was given on the biomaterial aspects and technical complications. No hand search was added.</p>
</sec>
<sec id="st4"><title>Results:</title>
<p>The electronic search generated 115 full-text papers, of which 84 papers were included in the review. The majority were clinical and <italic>in vitro</italic>
studies. Some review articles were also considered. Papers reported survival and failures of overdenture connection systems. Emphasis was laid on attachment deformation.</p>
</sec>
<sec id="st5"><title>Conclusion:</title>
<p>Implant overdentures long-term follow-up studies may provide useful guidelines for the clinician in selecting the type of attachment system and overdenture design. Locator attachments are more and more used, with lesser complications reported.</p>
</sec>
</abstract>
<kwd-group><kwd><italic>Biomaterial</italic>
</kwd>
<kwd><italic>overdenture</italic>
</kwd>
<kwd><italic>stud attachments</italic>
</kwd>
</kwd-group>
</article-meta>
</front>
<body><sec sec-type="intro" id="sec1-1"><title>INTRODUCTION</title>
<p>In terms of stability and retention, attachment system provides superior effectiveness for complete dentures.[<xref rid="ref1" ref-type="bibr">1</xref>
] The connection reduces the denture movement without adding stress on the implants.[<xref rid="ref2" ref-type="bibr">2</xref>
]</p>
<p>Long-term outcome may guide the clinicians’ choice of attachment.[<xref rid="ref3" ref-type="bibr">3</xref>
<xref rid="ref4" ref-type="bibr">4</xref>
] Biological and technical (mechanical) are the two types of complications encountered in implant therapy. This review will consider the biomaterial aspects. Emphasis will be given on the performance of attachments over time. The wear patterns induced are of major importance. Prosthetic maintenance (the capability to adapt or repair) is of daily clinical interest.[<xref rid="ref5" ref-type="bibr">5</xref>
<xref rid="ref6" ref-type="bibr">6</xref>
] Technical aspects are the parameters to be considered now.[<xref rid="ref7" ref-type="bibr">7</xref>
] Durable retention remains the subject to debate.[<xref rid="ref8" ref-type="bibr">8</xref>
<xref rid="ref9" ref-type="bibr">9</xref>
]</p>
<p>“Technical complications” include mechanical damage to the implant and prosthetic components. Irrespective of the anchorage system, adjustments are the most commonly reported mechanical problem.[<xref rid="ref10" ref-type="bibr">10</xref>
] Retention loss or adjustments are the most encountered problems (30% of the reported maintenance).[<xref rid="ref11" ref-type="bibr">11</xref>
] The present review will focus on technical complications of attachments.</p>
</sec>
<sec sec-type="materials|methods" id="sec1-2"><title>MATERIALS AND METHODS</title>
<p>Databases from PubMed, Medline, and Elsevier were scrutinized. The following keywords directed the search: “Complications,” “retention,” “wear,” “attachment biomaterial,” “overdenture attachments,” “attachment systems,” “implant-retained overdentures,” “implant-supported overdentures,” and “locator.” Peer-reviewed articles reporting on investigations of retention, wear, or complications of overdenture attachment systems used specifically for mandibular two-implant overdentures were identified. The search included articles published in English up to July 2014 which contained all or part of the key words in their headings. The electronic search generated 115 full-text papers. Eighty-four papers were included in the review. The majority were clinical and <italic>in vitro</italic>
studies. Some review articles were also considered. Papers reported survival and failures of overdenture connection systems. Emphasis was made on attachment deformation. No hand search was added.</p>
<p>Divers attachment systems are released often without evidence-based support for long-term maintenance or repair.[<xref rid="ref12" ref-type="bibr">12</xref>
] Failure or frequent complications sometimes urged modification or withdrawal of these attachments.[<xref rid="ref13" ref-type="bibr">13</xref>
<xref rid="ref14" ref-type="bibr">14</xref>
]</p>
<p>Industry proposes to replace the well-documented ball and bars attachments by new connector type[<xref rid="ref7" ref-type="bibr">7</xref>
] Introduced in 2001, the Locator attachment (Zest Anchors, Escondido, CA, USA) combined the best features of a ball attachment, an ERA attachment (Sterngold), and a cap attachment,[<xref rid="ref15" ref-type="bibr">15</xref>
] with its appreciated dual retention and different retention values.[<xref rid="ref16" ref-type="bibr">16</xref>
<xref rid="ref17" ref-type="bibr">17</xref>
] It is classified as a resilient universal hinge, and is indicated for limited inter-arch distance. Angle corrections of up to 40° are allowed.[<xref rid="ref18" ref-type="bibr">18</xref>
]</p>
<p>Limited <italic>in vitro</italic>
reports on the Locator retentive force are published. The dual retention (inner and outer) enhances its cross-section strength[<xref rid="ref19" ref-type="bibr">19</xref>
] by mechanical and also frictional mode.[<xref rid="ref12" ref-type="bibr">12</xref>
<xref rid="ref20" ref-type="bibr">20</xref>
] The slightly oversized nylon male insert and the smaller diameter inner ring of the female abutment produce a dimensional misfit.[<xref rid="ref12" ref-type="bibr">12</xref>
] While the central stud of the nylon male insert of the Locator attachment press fits within the inner metal ring of the female abutment, the outer margin engages the shallow undercut area present at the outer margin of the abutment simultaneously and completely.[<xref rid="ref20" ref-type="bibr">20</xref>
] The color of the patrix (replaceable nylon insert) indicates the retention value.[<xref rid="ref16" ref-type="bibr">16</xref>
] To correct implant angulation, these attachments can be made without the inner retention feature.[<xref rid="ref16" ref-type="bibr">16</xref>
] Long-term evaluation is still lacking.[<xref rid="ref4" ref-type="bibr">4</xref>
<xref rid="ref21" ref-type="bibr">21</xref>
<xref rid="ref22" ref-type="bibr">22</xref>
]</p>
<sec id="sec2-1"><title>“Adequate” retentive force</title>
<p>The connection must provide a retentive force high enough to prevent overdenture displacement.[<xref rid="ref23" ref-type="bibr">23</xref>
] Presumed retentive quality and improved levels of patient satisfaction empirically guide clinicians’ choice.[<xref rid="ref21" ref-type="bibr">21</xref>
] There are vague reports of adequate retention of an attachment system in the literature.[<xref rid="ref24" ref-type="bibr">24</xref>
] Implant manufacturers provide only little data about the retentive strength and wear of attachments.[<xref rid="ref21" ref-type="bibr">21</xref>
] For a single individual unsplinted attachment, 4 N is mentioned as the minimum retentive force,[<xref rid="ref19" ref-type="bibr">19</xref>
<xref rid="ref25" ref-type="bibr">25</xref>
] whereas this retention may vary from as low as 1 N to as high as 85 N when mandibular overdentures are retained by two or more implants.[<xref rid="ref19" ref-type="bibr">19</xref>
<xref rid="ref24" ref-type="bibr">24</xref>
<xref rid="ref26" ref-type="bibr">26</xref>
] When a rough estimate of 20 N of adequate retentive force has been proposed for a two-implant mandibular overdenture,[<xref rid="ref23" ref-type="bibr">23</xref>
] Pigozzo <italic>et al</italic>
. suggest a value of 5–7 N to stabilize the overdentures.[<xref rid="ref27" ref-type="bibr">27</xref>
] Mechanical and frictional contacts, as well as magnetic forces of attraction between the patrix and matrix can be the basis of retentive force.[<xref rid="ref14" ref-type="bibr">14</xref>
<xref rid="ref28" ref-type="bibr">28</xref>
<xref rid="ref29" ref-type="bibr">29</xref>
]</p>
</sec>
<sec id="sec2-2"><title>Connector type and retention</title>
<p>Retention and stability are significantly affected by the type of connector.[<xref rid="ref30" ref-type="bibr">30</xref>
] Studies have classified the attachment systems into high (ERA gray), medium (Locator LR white, Spheroflex ball, Hader bar and metal clip, ERA white), low (Locator LR pink), and very low (Shiner magnet, Maxi magnet, Magnedisc magnet) retention groups.[<xref rid="ref19" ref-type="bibr">19</xref>
] Significantly higher retention and stability are provided by Locator connectors[<xref rid="ref30" ref-type="bibr">30</xref>
] and Sterngold ERA,[<xref rid="ref31" ref-type="bibr">31</xref>
<xref rid="ref32" ref-type="bibr">32</xref>
] compared to Nobel Biocare ball connectors.[<xref rid="ref33" ref-type="bibr">33</xref>
] These findings were confirmed by several studies.[<xref rid="ref19" ref-type="bibr">19</xref>
<xref rid="ref33" ref-type="bibr">33</xref>
] Alsabeeha <italic>et al</italic>
. pointed that the Locator white, pink, and blue connectors demonstrated higher retentive forces than either a 7.9-mm prototype ball attachment design or the standard 2.25-mm ball attachment.[<xref rid="ref12" ref-type="bibr">12</xref>
] The greatest reported value for the peak load was for the Zest Anchor Advanced Generation (ZAAG) attachment, compared to the Nobel Biocare ball, the Zest Anchor, and the Sterngold ERA.[<xref rid="ref33" ref-type="bibr">33</xref>
] The peak load is defined as the maximum forces developed before complete separation of the attachment components from the implant abutments.[<xref rid="ref34" ref-type="bibr">34</xref>
] The ZAAG attachment exhibited significantly the highest retentive vertical and oblique forces under dislodging tensile forces applied to the housings in two directions simulating function: Vertical and oblique. The lowest vertical force corresponds to the Zest Anchor and the lowest oblique retentive force to the Nobel Biocare Standard.[<xref rid="ref35" ref-type="bibr">35</xref>
]</p>
</sec>
<sec id="sec2-3"><title>Change of retentive values over time</title>
<p>Furthermore, according to Lehmann, an attachment system must be able to maintain its retentive force during a 10-year shelf life.[<xref rid="ref25" ref-type="bibr">25</xref>
] However, evidence from past and current studies demonstrates that the wear-induced structural changes undergone by an attachment system inevitably lead to a reduction or total loss of retention. A mechanical action alone or a combination of chemical and mechanical actions will induce loss of material from the surface. This is defined as wear.[<xref rid="ref36" ref-type="bibr">36</xref>
] Components wear decrease ball attachment's retention.[<xref rid="ref8" ref-type="bibr">8</xref>
] Deterioration and deformation, along with work hardening,[<xref rid="ref37" ref-type="bibr">37</xref>
] can also lead to attachment fracture.[<xref rid="ref38" ref-type="bibr">38</xref>
] The variations in the wear patterns seen with different attachment systems still need better understanding.[<xref rid="ref24" ref-type="bibr">24</xref>
]</p>
</sec>
<sec id="sec2-4"><title>Wear simulation tests</title>
<sec id="sec3-1"><title>Related to reproduced oral environment</title>
<p>Study designs that attempted to emulate the actual oral environment tried to investigate the effect of short- and long-term simulated function on the attachment systems’ retentive force.[<xref rid="ref26" ref-type="bibr">26</xref>
<xref rid="ref34" ref-type="bibr">34</xref>
] The retentive forces were initially determined under axially directed tensile forces. Attachment systems were then submitted to cyclic loading under either axial or paraxial forces in the range of 540–10,000 cycles of repeated insertion and removal. This would represent 6 months to 9 years of clinical function, on the basis of three daily overdenture removals and insertions for hygienic purposes.[<xref rid="ref14" ref-type="bibr">14</xref>
] A common trend toward reduction[<xref rid="ref32" ref-type="bibr">32</xref>
] or total loss in retentive force was found across the majority of the attachment systems.[<xref rid="ref12" ref-type="bibr">12</xref>
]</p>
<p>Repeated insertion–removal cycles provoke gradual and continuous loss of retention of ball–socket attachments.[<xref rid="ref26" ref-type="bibr">26</xref>
] This loss can be abrupt after approximately 500 cycles[<xref rid="ref39" ref-type="bibr">39</xref>
] and may reach 80% of the initial value after 2000 cycles.[<xref rid="ref26" ref-type="bibr">26</xref>
]</p>
</sec>
<sec id="sec3-2"><title>Related to material components</title>
<p>To evaluate the effects of wear on overdenture resilient attachments, Rutkunas <italic>et al</italic>
.[<xref rid="ref40" ref-type="bibr">40</xref>
] determined the dimensional changes and surface characteristics using light microscopy and scanning electron microscopy (SEM) of ERA orange and white (EO and EW), Locator pink, white, and blue (LRP, LRW and LRB), and OP anchor (OP), respectively, after simulated 15,000 insertion–removal cycles. The sudden decrease of retentive force of ERA attachments was opposed to the retentive force fluctuation of Locator attachments throughout the wear simulation period. The dimensional changes and surface wear on the plastic rings of attachment males were less expressed than on plastic cores.[<xref rid="ref40" ref-type="bibr">40</xref>
] SEM analysis demonstrated smoother surface after wear simulation,[<xref rid="ref38" ref-type="bibr">38</xref>
] especially for ERA.[<xref rid="ref23" ref-type="bibr">23</xref>
<xref rid="ref41" ref-type="bibr">41</xref>
<xref rid="ref42" ref-type="bibr">42</xref>
] A literature review confirmed the reduction of the retentive force of the majority of attachment systems under <italic>in vitro</italic>
conditions.[<xref rid="ref12" ref-type="bibr">12</xref>
]</p>
<p>A dramatic loss of retention for ERA attachments was observed at the conclusion of wear simulation test. Upon microscopic measurement, Gamborena noticed distinct wear patterns that arise due to distortion of the plastic patrices, with the metallic matrices remaining unchanged.[<xref rid="ref43" ref-type="bibr">43</xref>
] Studies reported similar observations with four ball attachment systems,[<xref rid="ref38" ref-type="bibr">38</xref>
<xref rid="ref44" ref-type="bibr">44</xref>
] whereas some studies reported that significant and maximal amount of wear of the diameter of ball abutment was reached after 3 years of clinical use.[<xref rid="ref8" ref-type="bibr">8</xref>
] This may indicate that severe mechanical wear on both surfaces may occur after long periods of use.[<xref rid="ref8" ref-type="bibr">8</xref>
] While some studies sustained that attachment systems which possess a male and female component of different material composition exhibit smaller changes in the retention force,[<xref rid="ref43" ref-type="bibr">43</xref>
] others reported the highest wear on the ball attachments for implant-retained overdentures. when antagonist to titanium matrix.[<xref rid="ref45" ref-type="bibr">45</xref>
] Moreover, even among samples of the same attachment systems, differences in the retentive forces were evident.[<xref rid="ref23" ref-type="bibr">23</xref>
<xref rid="ref41" ref-type="bibr">41</xref>
<xref rid="ref46" ref-type="bibr">46</xref>
] To increase the wear compensation and retention force, an attachment system has to be adjustable.[<xref rid="ref43" ref-type="bibr">43</xref>
]</p>
<p>It is noteworthy that a minimal reduction in retentive force was achieved by the magnetic attachments[<xref rid="ref46" ref-type="bibr">46</xref>
<xref rid="ref47" ref-type="bibr">47</xref>
] compared to the gradual decrease of the stud attachments’ retention.[<xref rid="ref48" ref-type="bibr">48</xref>
] When tested under identical conditions, less physical deterioration was found, despite microscopic corrosion signs observed within the stainless steel magnet case.[<xref rid="ref19" ref-type="bibr">19</xref>
<xref rid="ref26" ref-type="bibr">26</xref>
]</p>
<p>In contrast, under long-term simulated function, in the case of telescopic attachments made of different alloys (titanium, gold, and cobalt-chromium), a steady increase in the retentive force has been observed. The authors explained their results by the increased mechanical adaptation of the attachment components under cyclic loading. Some variation related to the differences in the physical properties of alloys remains.[<xref rid="ref41" ref-type="bibr">41</xref>
]</p>
</sec>
<sec id="sec3-3"><title>Related to insertion–removal cycles</title>
<p>Mechanical fatigue also induced some retention loss of the attachment systems during the experiment after 15,000 fatigue cycles,[<xref rid="ref31" ref-type="bibr">31</xref>
<xref rid="ref38" ref-type="bibr">38</xref>
<xref rid="ref49" ref-type="bibr">49</xref>
] even though it was of little valuewhen compared to the initial retentive forces.[<xref rid="ref23" ref-type="bibr">23</xref>
] Multiple pulls reduced the retentive values of the Locator attachments significantly.[<xref rid="ref16" ref-type="bibr">16</xref>
<xref rid="ref50" ref-type="bibr">50</xref>
]</p>
<p>Eight hundred cycles are needed to attain relatively stable retention of overdenture attachments,[<xref rid="ref26" ref-type="bibr">26</xref>
] especially for the most retentive systems.[<xref rid="ref51" ref-type="bibr">51</xref>
] The clinician has to place and remove the overdenture multiple times before delivery,[<xref rid="ref16" ref-type="bibr">16</xref>
] although this reduction might not be noticeable to the patient but only to the examiner.[<xref rid="ref22" ref-type="bibr">22</xref>
] Nevertheless, Cakarer did not find any advantage of ball and bar designs over the Locator in terms of retention.[<xref rid="ref52" ref-type="bibr">52</xref>
] Also, the Locator root pink remained the most retentive after fatigue, compared to the ERA orange and white.[<xref rid="ref26" ref-type="bibr">26</xref>
]</p>
</sec>
<sec id="sec3-4"><title>Related to mastication</title>
<p>The wear patterns and their related attachment deformation generated by the mastication are different from those induced by insertion–removal cycles. When occlusal loads are applied, the mucosa is displaced under the denture base resulting in denture rotation around the attachments.[<xref rid="ref53" ref-type="bibr">53</xref>
] The amount of occlusal load transmitted to the attachments is a factor of their resiliency.[<xref rid="ref54" ref-type="bibr">54</xref>
<xref rid="ref55" ref-type="bibr">55</xref>
] An optimal stress distribution reduces the denture movement and, thereby, the forces on the implants.[<xref rid="ref56" ref-type="bibr">56</xref>
] Simulated mastication reduced the Locator retention to 40% of the baseline values with a non-linear descending curve. The nylon capsules were strongly damaged.[<xref rid="ref57" ref-type="bibr">57</xref>
] This demonstrates that for Locator system, maintenance needs are correlated with mastication.[<xref rid="ref57" ref-type="bibr">57</xref>
] Only minor changes were found for the ball attachment tested.[<xref rid="ref57" ref-type="bibr">57</xref>
]</p>
<p>Kleis declared that after 12 months of overdentures’ delivery, the male parts of the Locator have to be changed, as 75.5% loss of retention has been noticed. The wear affected both male parts.[<xref rid="ref22" ref-type="bibr">22</xref>
] However, the reduction in peak load-to-dislodgement for these attachments is more apparent in case of non-parallel implants.[<xref rid="ref16" ref-type="bibr">16</xref>
]</p>
<p>Length, number, implant's angulation, opposing dentition, and parafunctional habits are among the factors that may increase susceptibility to mechanical complications.[<xref rid="ref58" ref-type="bibr">58</xref>
] Excessive masticatory forces, as off-axis centric contacts, excursive contacts, and cantilevered loading, may be generated in severely resorbed mandible.[<xref rid="ref59" ref-type="bibr">59</xref>
] Occlusal forces on angulated implants may cause more strain than the screw can bear.[<xref rid="ref59" ref-type="bibr">59</xref>
<xref rid="ref60" ref-type="bibr">60</xref>
] Correct implant placement diminishes attachment systems’ maintenance.[<xref rid="ref17" ref-type="bibr">17</xref>
] To overcome the inevitable continuous resorption of the underlying residual ridge, frequent rebasing of implant-retained Overdentures (OVDs) may restore the proper occlusion and reduce possible rotation of the denture around the retentive components.[<xref rid="ref61" ref-type="bibr">61</xref>
<xref rid="ref62" ref-type="bibr">62</xref>
]</p>
</sec>
</sec>
<sec id="sec2-5"><title>Type of attachment and incidence of mechanical complications</title>
<p>Etiological failure factors have been compared in case of splinting or unsplinting attachments. No major differences in prosthetic complications have been observed for bar or ball attachments, thus both are considered as reliable connectors.[<xref rid="ref63" ref-type="bibr">63</xref>
<xref rid="ref64" ref-type="bibr">64</xref>
] Results may be contradictory. Most of them reported more prosthetic maintenance for separated attachments,[<xref rid="ref52" ref-type="bibr">52</xref>
<xref rid="ref65" ref-type="bibr">65</xref>
] whereas others found found more technical complications/repairs per patient around bar than ball attachments. Most of the separated attachments need more prosthetic maintenance;[<xref rid="ref52" ref-type="bibr">52</xref>
<xref rid="ref65" ref-type="bibr">65</xref>
] but for others, the frequency of technical complications/repairs per patient was higher around bar than ball attachments,[<xref rid="ref52" ref-type="bibr">52</xref>
<xref rid="ref66" ref-type="bibr">66</xref>
<xref rid="ref67" ref-type="bibr">67</xref>
] with an increased failure rate for the cantilevered extended bars.[<xref rid="ref68" ref-type="bibr">68</xref>
] Meanwhile, no difference was seen in the implant survival rate among splinted and unsplinted schemes.[<xref rid="ref69" ref-type="bibr">69</xref>
<xref rid="ref70" ref-type="bibr">70</xref>
]</p>
<p>Recent studies sought to compare the incidence of mechanical complications of the Locator attachments with that of the commonly used overdenture attachment systems.</p>
<p>A recent survey showed that British general dental practitioners are not familiar with the Locator attachment system and are reluctant to do implant-retained OVDs maintenance. General dentist <italic>practitioner</italic>
general practice dentists (GDPs) would like further training in this area.[<xref rid="ref71" ref-type="bibr">71</xref>
]</p>
<p>Cakarer <italic>et al</italic>
. observed less prosthodontic complications and maintenance of the oral function for the Locator system than for ball and bar attachments.[<xref rid="ref52" ref-type="bibr">52</xref>
] Mackie <italic>et al</italic>
.'s findings were in agreement with this when they compared Locator to Southern plastic and Straumann gold over a 3-year period.[<xref rid="ref72" ref-type="bibr">72</xref>
]</p>
<p>In contrast, Kleis <italic>et al</italic>
. argued that the creep response of the matrices and the hardness of the patrices provoked extensive deformation and deterioration of the Locator nylon parts, with a higher substantial need for maintenance, compared to ball attachments.[<xref rid="ref22" ref-type="bibr">22</xref>
] Differences in the dimensions or material composition, and a large variation in retentive forces have been found between different batches of the same attachment system due to the poor manufacturing quality control.[<xref rid="ref14" ref-type="bibr">14</xref>
<xref rid="ref23" ref-type="bibr">23</xref>
<xref rid="ref73" ref-type="bibr">73</xref>
]</p>
<p>Researchers concluded that implant parallelism has more impact on the complications that occur than the choice of type of attachments.[<xref rid="ref74" ref-type="bibr">74</xref>
<xref rid="ref75" ref-type="bibr">75</xref>
]</p>
<p>Any installation load greater than 0 N is recommended for the connection of ball, Locator, or magnetic attachments to a denture base. By increasing this installation load, the resultant force acting on the implant may be decreased. However, when this load surpasses 100 N, the harmful denture movement may be increased.[<xref rid="ref76" ref-type="bibr">76</xref>
]</p>
</sec>
</sec>
<sec sec-type="discussion" id="sec1-3"><title>DISCUSSION</title>
<p>Implant survival rate of mandibular overdentures is reported high regardless attachment systems. The prosthetic maintenance and complications are influenced by attachment systems. However patient satisfaction is somehow, independent of the attachment system (3). In-depth studies following standardized criteria to compare different options for mandibular Implant overdentures (IOVD) treatment remain scarce.[<xref rid="ref3" ref-type="bibr">3</xref>
<xref rid="ref5" ref-type="bibr">5</xref>
<xref rid="ref6" ref-type="bibr">6</xref>
] In particular, similar clinical protocols are still insufficient to allow the calculation of an overall complication incidence for Implant Overdentures IOVDs.[<xref rid="ref77" ref-type="bibr">77</xref>
] New accurate measurement devices only permit comparisons of attachments that work on similar bases.[<xref rid="ref61" ref-type="bibr">61</xref>
<xref rid="ref78" ref-type="bibr">78</xref>
]</p>
<p>A limitation of this literature review is that it includes studies with non-declared sample size, or measurement methods. Other studies are <italic>in vitro</italic>
experiments, whereas non-randomized controlled studies are lacking. Well-structured clinical prospective studies remain essential, in addition to well-designed <italic>in vitro</italic>
studies. The accuracy of parameters applied to the model, including geometry, constraints, and mechanical properties, determines the value of the finite element analysis experiment.[<xref rid="ref79" ref-type="bibr">79</xref>
] Masticatory loading submits the prosthesis to a hardly reproducible scheme of three-dimensional movements. The clinical wear can be influenced by saliva,[<xref rid="ref14" ref-type="bibr">14</xref>
<xref rid="ref34" ref-type="bibr">34</xref>
] denture cleansers,[<xref rid="ref18" ref-type="bibr">18</xref>
<xref rid="ref80" ref-type="bibr">80</xref>
] or food particles.[<xref rid="ref21" ref-type="bibr">21</xref>
] As a result, it is hard to reproduce the oral environment <italic>in vitro</italic>
. Factors should be investigated separately under well-controlled conditions, in order to limit the influence of confounding variables.[<xref rid="ref12" ref-type="bibr">12</xref>
] Interpretation of results must be carefully done. Some questions remain unanswered. Evidence-based studies do not allow us to select the most effective implant–OVD connection.</p>
<p>Equal atraumatic distribution of forces between mechanical and biological supporting structures, and minimal complications are the ultimate goals when placing any connector.[<xref rid="ref19" ref-type="bibr">19</xref>
] The amount of retention desired and the specific clinical situation guide the clinician in selecting an appropriate attachment. Still, it may be based only on empirical evidence.[<xref rid="ref33" ref-type="bibr">33</xref>
] Ability to maintain retention values under simulated function remains questionable.[<xref rid="ref26" ref-type="bibr">26</xref>
<xref rid="ref43" ref-type="bibr">43</xref>
] The retention measurement values provided by the manufacturer at treatment beginning and after function would help to respond to individual needs of patients.[<xref rid="ref81" ref-type="bibr">81</xref>
] Scientific evidence related to the material's clinical performance, objective oral function, and patients’ appreciation of the treatment should guide the clinician in making the ultimate choice of a specified attachment. The initial and maintenance costs have also to be considered.[<xref rid="ref82" ref-type="bibr">82</xref>
] An annual follow-up would be necessary after Locator system placement.[<xref rid="ref22" ref-type="bibr">22</xref>
] Adequate aftercare may be difficult or impossible when treating aging patients.[<xref rid="ref83" ref-type="bibr">83</xref>
]</p>
<p>In the author's opinion and based on the presented data, the Locator attachment system is an easy-to-use connector, with less post-insertion complications. No special practical training is needed. The patient satisfaction reported is quite high. No major post-insertion reparation expenses are charged on the patient.</p>
</sec>
<sec sec-type="conclusion" id="sec1-4"><title>CONCLUSION</title>
<p>The choice of implant location and retentive attachments in implant-retained overdentures is based on clinician's preference, expert opinion, and empirical information. Clinical publications comparing the maintenance of attachment devices remain scarce. Long-term, well-designed studies are needed. Protocols variations preclude the proper analysis of certain complications. Careful post-insertion maintenance of the prosthesis, attachment system, and mucosa is mandatory. Out-of-pocket treatment and post-treatment expenses should be less and the treatment should not be time consuming.</p>
<sec id="sec2-6"><title>Financial support and sponsorship</title>
<p>Nil.</p>
</sec>
<sec id="sec2-7"><title>Conflicts of interest</title>
<p>There are no conflicts of interest.</p>
</sec>
</sec>
</body>
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