Accepted Manuscript

Single versus Two Implants on Peri-implant Marginal Bone Level and Implant Failures
in Mandibular Implant Overdentures. A Systematic Review with Meta-analysis

Dina Mohamed Ahmed Elawady, BDS, MSc (Cairo), PhD Candidate, Assistant
Lecturer, Amal Fathy Kaddah, BDS, MSc, PHD (Cairo), Professor, Mohamed Talaat
khalifa, BDS MSc (Cairo), Assistant lecturer
PII: S1532-3382(17)30029-5
DOI: 10.1016/j.jebdp.2017.02.002
Reference: YMED 1174

To appear in: The Journal of Evidence-Based Dental Practice

Received Date: 6 February 2017

Revised Date: 13 February 2017
Accepted Date: 13 February 2017

Please cite this article as: Ahmed Elawady DM, Kaddah AF, Talaat khalifa M, Single versus Two
Implants on Peri-implant Marginal Bone Level and Implant Failures in Mandibular Implant Overdentures.
A Systematic Review with Meta-analysis, The Journal of Evidence-Based Dental Practice (2017), doi:
10.1016/j.jebdp.2017.02.002.

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 ACCEPTED MANUSCRIPT
Manuscript type: Systematic review with meta-analysis

Single versus Two Implants on Peri-implant Marginal Bone Level and Implant Failures in
Mandibular Implant Overdentures. A Systematic Review with Meta-analysis
Running title: Single Versus Two Implants Mandibular Overdenture

Dina Mohamed Ahmed Elawady1,*, BDS, MSc (Cairo), Amal Fathy Kaddah2 BDS, MSc, PHD (Cairo),

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Mohamed Talaat khalifa3 BDS MSc (Cairo)
1,
*PhD Candidate, Department of Removable Prosthodontics, Faculty of Oral and Dental Medicine,

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Cairo University, Egypt
Assistant Lecturer, Department of Prosthodontics, Faculty of Dentistry, Modern Science and Arts
University (MSA), Egypt

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Email: dr.dinaelawady@yahoo.com
Address: 126, zone 9 district 1 Sheikh Zayed, Giza, Egypt
Phone: 002-01023663660
Postal code: 12588
2

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Professor, Department of Removable Prosthodontics- Cairo University, Egypt
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Assistant lecturer, Department of Removable Prosthodontics, Faculty of Oral and Dental Medicine,
6th October University, Egypt
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ABSTRACT

Background: As a consensus, the two-implant supported ODs are considered as the first
choice of treatment for the edentulous mandible. In the same context, there is increased
evidence supporting the use of single implant overdenture. The aim of any design is to
preserve the remaining structures and allow the longevity of the treatment.
Objectives: To evaluate impact of single versus two implants on peri-implant marginal bone loss
(MBL) and number of implant failures in mandibular implant overdentures (MIODs).

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Methods: A literature search of electronic databases (PubMed and Cochrane) was performed up to
March 2016 and complemented by hand search. RCTs that evaluated MBL and number of implant
failures relative to single implant mandibular overdenture (MOD) were selected. The review and

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meta-analysis were performed using meta-analytic statistical package and in accordance with
PRISMA guidelines.

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Findings: Five RCTs met the inclusion criteria for systematic review and qualitative synthesis. The
observation period ranged from 12 months to 5 years in the selected RCTs. The comparison included
in the meta-analysis is; single implant versus 2 implants MODs. Pooled data revealed that single
implant MODs significantly decreased the MBL (MD: 0.27, 95% CI: 0.20, 0.34, P <0.0001, I2 = 0%)

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and number of implant failures (RR: 3.26, 95% CI: (1.18, 8.97), P = 0.02; I2 = 0%)
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Conclusions: Single implant MOD was found to be better than 2-implants MOD in terms of MBL
and number of implant failures. However, this result should be interpreted with caution due to limited
number of analyzed studies with different loading protocols and short follow-up period.
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Key words (Overdenture; Mandibular prosthesis; Dental implant; single implant; two
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implants)
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Abbreviation

MBL marginal bone loss

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RD Risk difference
MD Mean difference
OD Overdenture
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RCT Randomized Clinical Trial

MIOD Mandibular implant overdenture
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MOD mandibular overdenture

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Introduction

Edentulous patients experience problems with their complete dentures. This is mainly due to

lack of retention, stability and decreased chewing ability as their most common complaints.

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These problems are more frequently encountered with the lower denture.1 With advent of

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dental implants used to retain and/or support removable prostheses, the functional

deficiencies associated with conventional dentures are greatly improved.1

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Guidelines to assist with the selection of the optimal implant number for retaining and/or

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supporting mandibular implant overdentures (MIODs) are controversial and lacking in
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literature. The McGill consensus held in Montreal, Quebec, Canada on May 2002 was in

favor of 2-implant supported ODs as the first choice of treatment for the edentulous mandible
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regardless the type of the attachment system applied. Sadowsky suggested increased implant

number for mandibular OD when sensitive jaw anatomy, increased occlusal forces, or high
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retention needs are present or when reduced implant length (<8 mm) or implant width
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(<3.5mm) are employed.2 In conclusion of their systematic reviews and consensus statements,
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Klemetti3 and Gotfredsen et al.4 stated that patients’ satisfaction, function of the prosthesis and

implant survival are not dependent on the number of implants or type of attachment.
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Roccuzzo et al.5 concluded that bone loss, and complication incidences are not related to the
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number of implants supporting mandibular overdenture and recommended the need for well-

conducted research to identify the prognostic factors for long-term success. In the same

context, there is increased evidence supporting the use of single implant overdenture in case

of financial limitation and frail elderly patients with comparable success rate, survival rate

and functional improvement to that provided by 2-implant MOD.6

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The multitude of prosthodontic designs available merits further investigation. The eventual

aim of any design is to enhance biomechanical stress distribution, preserve the remaining

structures and allow the longevity of the treatment.

Therefore, the aim of the present review is to systematically evaluate the impact of single

versus two implants on peri-implant marginal bone loss (MBL) and number of implant

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failures in mandibular implant overdentures (MIODs).

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Method of research

The current systematic review was conducted and reported in strict accordance with

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(PRISMA) guidelines for reporting systematic reviews and meta-analyses.7

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The focused PICO question formulated to summarize the objective of the study was: for
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completely edentulous patients rehabilitated with MIOD; what is impact of single versus two

implants on peri-implant MBL and number of implant failures?

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To answer this question, a comparison was included in the meta-analysis: 1) Single implant
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versus 2-implants MODs.

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The protocol of the present systematic review was registered at PROSPERO International

prospective register of systematic reviews, registration number is: CRD42016036603.

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Inclusion criteria
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Studies were selected if they met the following inclusion criteria: 1) Reports in English up to
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March 2016; 2) Randomized controlled trials comparing single versus two implants MOD 3)

Studies including at least 10 subjects; 4) Publications of at least one-year follow-up period.

Exclusion criteria:

Studies were excluded if they: 1) compared implant overdentures to complete dentures or to

fixed prosthesis; 2) were non-randomized, retrospective, cross sectional and case series

studies; 4) did not clearly define the opposing arch 5) did not clearly define the peri-implant
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marginal bone loss and /or implant failures.

Search Strategy

A comprehensive literature search of the following database was done: PubMed and the

Cochrane database to identify relevant articles. The search was conducted up to March 2016

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and included the following key words (overdenture, dental implants, single implant, two

implants). Two authors (Elawady D and Khalifa M) performed the search independently,

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screened the titles and abstracts for relevance. Then, three authors (Elawady D, Khalifa M

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and Kaddah A) screened the full text of the selected relevant RCTs based on inclusion criteria

and any disagreement was solved by consensus and in case of missing data, the

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corresponding authors were contacted for clarification.
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Bibliographies of eligible RCTs were scrutinized for further useful publications. In addition

a manual search of the following journals was conducted: Clinical Implant Dentistry and
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Related Research, Clinical Oral Implants Research, European Journal of Oral Implantology,
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Implant Dentistry, Journal of Clinical Periodontology, Journal of Dental Research, Journal

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of Oral and Maxillofacial Implants, Journal of Periodontology, and The International

Journal of Periodontics & Restorative Dentistry, Egyptian Dental Journal, Journal of

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Advanced Prosthodontics and Journal of Prosthodontic Research. Moreover, online

databases providing information about clinical trials in progress were checked

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(www.clinicaltrials.gov; www.centerwatch.com/clinicaltrials; www.clinicalconnection.com).

Data Collection

A data extraction form was used by each author (Khalifa M and Elawady D) to collect the

following study information: 1) title; 2) authors 3) year of publication; 4) number of subjects

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and number of subjects per group; 5) subjects analyzed 6) age of subject (mean); 7) number

of implants placed and number of implants placed per subject; 8) implant system and type 9)

loading protocols; 10) the type of attachment used; 11) the follow-up period (months); 12)

number of patients with failed implants and 13) peri-implant MBL.

Quality assessment:

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Elawady D, Kaddah A and Khalifa M assessed individually the risk of bias of selected

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randomized controlled studies according to endorsements of Cochrane collaboration’s tool.8

The risk of bias was classified as either “Low risk of bias,” “High risk of bias,” or “Unclear

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risk of bias” in each domain of assessment, according to guidelines from the Cochrane

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Handbook, (Cochrane Handbook for Systematic Reviews of Interventions).
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If there was a disagreement in any phase of the study, it was solved by discussion to reach a

consensus.
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Data Synthesis
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The meta-analysis was conducted using the software program; Review Manager (RevMan,
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Version 5.3 Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014)

to pool individual outcomes and produce the forest plots. A fixed-effects model was used due
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to the absence of a statistically significant heterogeneity (I2 = 0%). Heterogeneity was assessed

using I2 measurement.
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Continuous data was summarized using mean difference (MD) and 95% confidence interval

(CI). For the dichotomous data, risk ratio (RR) and 95% confidence interval (CI) were used

to present effect measures. The pooled effect was significant if P was <0.05. In addition,

subgroup analysis was performed for variables, which might affect the outcome.

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RESULTS

The initial electronic literature search identified 300 titles and an additional 2 studies were

identified through hand search. After the removal of duplicate studies 207 records were

screened, out of which 192 records were excluded after review of abstracts and key words.

From 15 full-text publications evaluated for eligibility, 10 publications were excluded

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because they failed to meet the inclusion criteria.

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From the 10 excluded articles9-18; 6 articles 9,10,12-14,17
were excluded as they were not

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comparing single implant MOD with two implants MOD (only single implant MOD was
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investigated), another three articles were not RCTs and one article compared single

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implant MOD to complete denture 15
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6, 19-22
Thus, five full text randomized clinical trials. were selected and considered eligible for

inclusion as shown in the flow chart (Fig. 1). Characteristics of included studies are shown in
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Table 1. Excluded articles and reason of extraction are shown in table (2)
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In case of long term RCTs, only last results were reported. Kronstrom et al.19corresponding to
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Kronstrom et al.23 Bryant et al.20 corresponding to Walton et al.24

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Characteristics of included studies

The selected five studies6,19-22 were RCTs and were published between 2014 and 2016. The
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observation period ranged from 12 months to 5 years. A total of 190 participants received 258
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implants. The number of participants available at the end of follow–up period was 130

participants. All of the studies were conducted in a university setting; two studies in

Egypt21,22 two studies in Canada19,20 and one in Germany6. Two studies reported delayed

loading protocol21,22 while the other three studies6,19,20 followed an early/immediate loading

protocol. In early loading protocol, the dentures were inserted 42 days after implant

placement20 whereas in immediate loading protocol the denture were inserted at time of

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surgical implant placement19. In one study,6 soft liner material was used in the first 6 weeks

after surgery, and the authors described it as a progressive or an early loading protocol.

Data on the peri-implant marginal bone level changes was reported in three studies6,21,22

whereas the number of implant failures was extracted from all of the included studies.6,19-22

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The assessment of marginal bone level changes around implants in included studies was

based on digital radiographic techniques.6,19-22 Tavakolizadeh et al.6 used a standardized

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intraoral long cone radiographic technique and a digital sliding gauge for the bone level

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evaluation. Whereas, Elawady et al.22 used digital panoramic radiographs and analysis was

performed using the Digora software system. In the last study Talawy et al.21 , cone beam CT

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was used and image analysis was done using OnDemand3D, CD Viewer. In the three
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included studies, the measurements were limited to the vertical extent of marginal bone

resorption6,19-22 except in one study22 bone density was also measured.

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Three studies6,21,22 used criteria published by Albrektsson et al.25 to determine the implant
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success rate and the other two studies19,20 did not report the success criteria used for the
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evaluation.

Tavakolizadeh et al.6 placed 30 implants in 20 participants who received either single or 2-

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implant retained ODs. A provisional/early loading protocol was followed and the dentures
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were delivered with a soft liner material for the first 6 weeks after surgery. Radiographic
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marginal bone resorption values of 0.6±0.67 mm and 0.6±0.51 mm were reported in single

and 2-implant OD groups respectively over a follow-up period of 12 month. No implant

failures were revealed for either group. The authors that single implant overdenture could be a

viable treatment alternative for the management of completely edentulous patients but warned

in interpreting the results because of the small follow-up period.

On the other hand, Talawy et al.21 found a decreased rate of MBL of 0.96±0.32 mm in single

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implant OD compared to 1.21±0.41 mm in 2-implant group in a population of 18 participants

followed up to a period of 24 months when a delayed loading protocol was used. Further, the

authors reported the failure of four implants in two patients in 2-implant OD group.

Similarly, Elawady et al.22 followed a delayed loading protocol and evaluated the peri-

implant MBL and number of implant failures in single and 2-implant ODs in a population of

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28 patients, followed for up to 12 months. The authors reported mean MBL values of

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0.53±0.1mm and 0.807±0.1 mm for both groups respectively and no implant failures in either

group. However, The authors recommended the need for more studies with a longer follow-

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up period to confirm the results.

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Kronstrom et al.19 compared the number of implant failures between single and 2-implant
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ODs. The dentures were immediately delivered after surgery, and implants were followed up

for a period of 36 months. Three implants failed in 3 patients in single implant overdenture
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group compared to 7 implants in 6 patients in 2-implant OD. However, when an early loading

protocol was followed, Bryant et al.20 found no implant failures in either the single or 2-
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implant OD group in a population of 62 participants followed up for a period of 60 months.

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Methodologic Quality
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By using Cochrane tool for critical appraisal of randomized control studies, the five included
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randomized clinical trial were evaluated for the risk of bias. Seven categories were used to
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evaluate the quality of each selected study; random sequence generation, allocation

concealment, blinding of participants and personnel, blinding of outcome assessment

incomplete outcome data, selective reporting, other bias. For each included study, each

category was rated either to provide high, low or an unclear risk of bias. Results of quality

evaluation are summarized in (table 3). Two studies6,19 were rated to provide a high risk of

bias, two studies21,22 provided an unclear risk of bias and one study20 showed a low risk of

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bias. The overall quality of the included studies was rated to provide an unclear risk of bias.

Randomization was performed differently in the selected studies6,19-22 through the use of

sealed opaque envelopes,22 a predefined randomization table,20 random generated number,21

random sampling system.19 Nonetheless, one study6 did not report the randomization method.

Allocation concealment was performed in three studies19,20,22 and was considered unclear in

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the other two studies. 6,21 Strategies to minimize potential source of detection bias were not

described in two of the included studies6,22 but three19,20,21 where the use of masked outcome

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assessors was reported. Data reporting in two of studies6,19 was incomplete. However,

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Selective reporting was not detected in any study.

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Meta-analysis
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A meta-analysis was performed for the studies having same comparison groups and same

outcomes. The results of the meta-analysis showed that there is a significant difference in the
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peri-implant marginal bone loss (MD: 0.27, 95% CI: 0.20, 0.34, P <0.0001, I2 = 0%) (Fig. 2)
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and on number of implant failures (RR: 3.26, 95% CI: (1.18, 8.97), P = 0.02; I2 = 0%) (Fig.
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3) when the single and 2-implant ODs were compared favoring single implant group.

Subgroup analyses
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The possible source of heterogeneity and its influence on the evaluated outcomes in the
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included studies was assessed by subgroup analyses. A comparison was made based on
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loading protocol between two different groups; a conventional and an immediate/early

loading protocol.

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With regard to the peri implant marginal bone loss, the subgroup analysis demonstrated no

significant difference between the immediately loaded single and 2-implant ODs (MD:

0.0001, 95% CI: -0.52, 0.52, P = 1). However, the difference was significant when a delayed

loading protocol was followed (MD: 0.28, 95% CI: 0.20, 0.35, P < 0.0001; I2 = 0%).

However, the overall effect of all studies showed a significant difference between single and

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2-implant ODs in the peri-implant marginal bone loss (MD: 0.27, 95% CI: 0.20, 0.34, P

<0.0001, I2 = 0%) (Fig. 2) favoring single implant group

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When the implant failure rate was considered, the overall effect of all studies showed a

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significant difference in number of implant failures (RR: 3.26, 95% CI: (1.18, 8.97), P = 0.02;

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I2 = 0%) (Fig. 3) when the single and 2-implants ODs were compared favoring single implant
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group, However in sub group analysis neither immediate (RR: 2.75, 95% CI: 0.97,

7.8; P = 0.06) nor delayed loading protocols (RR: 6.11, 95% CI: 0.33, 111.7; P = 0.22)
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showed a significant difference .

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Discussion
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This systematic review and meta-analysis followed the recent guidelines of PRISMA7 and

the Cochrane collaboration methods8 to evaluate the best available evidence as regards to the
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impact of single implant versus two implants MIOD on the marginal bone level changes and
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the number of the implant failures in completely edentulous patients rehabilitated with
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mandibular implant overdentures opposed by conventional maxillary denture.

This review presented a focused PICO question related to mandibular IODs. This ensured

the homogeneity of the studies including a unified single clinical parameter to be

investigated. Only RCTs with restricted minimum follow-up period of 24 months were

included. Three independent authors reviewed the included studies to assess their conformity

with the inclusion criteria. The aim with all of this was to provide reliable evidence-based

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conclusions related to the overall treatment outcome. The review was supplemented with

meta-analysis to increase the validity of the findings. Limitations of this review should also

be acknowledged and include the limited number of studies included with small sample size

and different follow-up periods, also publication bias could not be assessed due to the limited

number of studies included in meta-analysis, another limitation is that the unpublished ‘grey

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literature were not searched.

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Comparative analysis of marginal bone loss among the included studies should be performed

with caution due to the lack of the standardization in methods used for the evaluation.

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However, the inclusion of the number of implant failures as one of the outcome measures

enabled better understanding and evaluation of the findings.

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The overall treatment effect of the five studies that compared single implant with two implant

ODs demonstrated significant difference in number of implant failures (P = 0.02) and

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marginal bone loss (P <0.00001) between the two groups. Single IODs showed reduced
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incidence of implant failures and less MBL compared to the 2-implant MODs. On contrary to
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the common belief that with a single IOD there is increased axial and lateral forces generated

on implant/abutment complex, low stress values were reported in abutments and bone around
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single implants.26 In the case of single IOD, the denture can rotate freely and the overdenture

stability is dependent to a large extent on mucosal support from the alveolar ridge27. With the
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increase in supporting effect in the case of increased implant number, more loading forces
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will be applied on implant/abutment complex and less on the mucosal area. The forces will be

distributed through fulcrum line passing through the implants resulting in increased

stress/strain values in the bone around the implants.26

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In accordance, Tavakolizadeh et al.6, Kronstrom et al.19, Bryant et al. 20
have reported

comparable success rate, survival rate and functional improvement of single implant ODs to

that provided by 2-implant MODs.

On the other hand, Talawy et al.21 have shown better survival rate, reduced marginal bone

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resorption and functional improvement of single IODs compared to 2-implant MODs. The

authors concluded that single implant ODs present a promising treatment alternative to the 2-

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implant ODs while considering the limitation of the study including the small sample size and

limited follow-up period of 2 years. Similarly, Elawady et al.22 reported that single implant

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ODs can provide better bone remodeling and less crestal bone resorption than 2-implants

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ODs. AN
Differences in the findings between the studies can be attributed to variation in the study

designs including the differences in the evaluation methods and the different parameters
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evaluated. Moreover, the accuracy of measurement of peri-implant marginal bone height is

always compromised. Distortion of buccal and lingual bone margins may result in
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overestimation of bone heights. The degree of overestimation is influenced by the

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buccolingual position of the fixture. Strict parallelism between fixture axes and film plane is

essential to obtain valid results using single films. In the present review, the assessment of
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marginal bone level changes around implants in the included studies was performed using
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different radiographic techniques. Elawady et al.22 used digital panoramic radiographs which
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is controversial when the precession of the measurement is considered in the anterior area.

Furthermore, the bone measurements in the five included studies6,19-22 were limited to the

vertical extent of marginal bone resorption.

It is relevant that all studies included in this review, comparing single and 2-implants

overdentures used either an immediate/early or a delayed loading protocol. In the

studies6,21,22 comparing the peri-implant bone loss; one study6 used an immediate loading

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protocol while the other two studies21,22 used a delayed protocol. Out of the five6,19-22

studies that evaluated the implant failures in single versus 2-implants ODs, three

studies6,19,20 used an immediate/early loading protocol and two studies21,22 used a delayed

approach. Therefore, a subgroup analysis was performed to assess the possible source of

heterogeneity on the evaluated outcomes.

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The results of the subgroup analysis of the two studies that compared the marginal bone loss

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between single and 2-implants ODs showed significant difference (P<0.00001) when a

delayed loading protocol was used. However, no significant difference (P=1.00) was found

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when an immediate/early loading protocol was employed. Lack of significant differences in

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the case of immediate/early loading protocol may be attributed to the fact that only one study
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with immediate/early loading protocol was analyzed. Therefore, prospective, controlled

comparative studies on the outcome between single and two implants MOD using immediate
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loading protocol are still lacking in the literature.

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On the other hand, the analysis of the five studies that compared the implant failure rate
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showed no significant difference, between the single and the 2-implants MODs for the

immediate (P=0.06) and delayed (P=0.22) loading approaches.

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Scrutinization of different loading protocols in the included studies reveals perplexity and
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lack of consistency among the multiple definitions usually offered for the same protocol. The
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precise loading time and the manner of load application with different loading protocols are

either ambiguous or loosely defined. Bryant, et al.20 used an early loading protocol and

inserted the dentures 42 days after implant placement. On the other hand, Tavakolizadeh et

al.6 used a soft liner material in the first 6 weeks after surgery, and described it as a

progressive or an early loading protocol. For the delayed loading protocol Elawady et al.22

inserted the dentures 2 months after removing the healing abutments whereas Talawy et al.21

inserted the dentures 3 months postoperatively. Further, the follow-up period of studies
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comparing single and two implant ODs was short and ranged from 12 to 60 months. Hence,

comparative studies with similar designs and longer follow-up periods are still required.

Further, worth to mention that all the studies were performed in university settings, which are

reported to have a bearing on the results.6,19-22

Based on the findings of this review and considering its limitations; single implant ODs were

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found to be better than the 2-implant ODs in terms of peri-implant MBL and implant failure

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rate. However, this result should be interpreted with caution. This is mainly due to limited

number of analyzed studies, and the different study designs including different loading

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protocols, different follow-up periods and different techniques used for the evaluation of

clinical outcomes.

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Conclusions

Based on the findings of this meta-analysis; single implant was found to be better than 2-
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implants MOD in terms of MBL and number of implant failures. However, this result should
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be interpreted with caution due to limited number of analyzed studies with different loading
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protocols and short follow-up period.

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Conflict of interests

The authors declare that they have no conflict of interests.

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Funding

This research did not receive any specific grant from funding agencies in the public,

commercial, or not-for-profit sectors.

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Authors’ contributions

Elawady D and Khalifa M, Kaddah A designed the study, gathered the information, and

wrote the first draft of the manuscript.

Elawady D and Kaddah A reviewed and edited the final draft of manuscript. All authors read

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and approved the final manuscript.

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Availability of supporting data

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"The data set(s) supporting the results of this article is (are) included within the article (and

its additional file(s)"

Acknowledgement
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The authors would like to acknowledge Cairo University for the unlimited access of its
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electronic library during the entire preparation process of the manuscript.

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8 Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane
Collaboration’s tool for assessing risk of bias in randomised trials. BMJ
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2011;343:d5928

9 Cordioli, G.; Majzoub, Z.; Castagna, S.: Mandibular overdentures anchored to single
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implants: a five-year prospective study. J Prosthet Dent 1997, 78,159-165.

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10 Liddelow, G.; Henry, P.: The immediately loaded single implant-retained mandibular
overdenture: a 36-month prospective study. Int J Prosthodont.2010, 23, 13-17.

11 Gonda, T.; Maeda, Y.; Walton, J.N.; MacEntee, M.I: Fracture incidence in mandibular
overdentures retained by one or two implants: J Prosthet Dent. 2010,103,178-181

12 Harder, S.; Wolfart, S.; Egert, S.; kern, M.: Three-year clinical outcome of single
implant retained mandibular overdenture: a five-year prospective study. J of
dentistry. 2011,39,656-661

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13 Alsabeeha, N.H.; Swain, M.V.; Payne, A.G.: Clinical performance and material
properties of single-implant overdenture attachment systems. Int J Prosthodont.
2011,24,247-254

14 Chenga, T.; Suna, G.; Huoa, J.; XiaojiHea, Wangb, Y.: Patient satisfaction and
masticatory efficiency of single implant-retained mandibular overdentures using the
stud and magnetic attachments Journal of dentistry. 2012, 40, 1018 – 1023

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15 Grover, M.; Vaidyanathan, A.K.; Veeravalli, P.T.: OHRQoL, masticatory performance
and crestal bone loss with single-implant, magnet-retained mandibular overdentures
with conventional and shortened dental arch. Clin. Oral Impl. Res. 2014 , 25, 580–

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16 Liu, J.; Pan, S.; Dong, J.; Mo, Z.; Fan, Y.; Feng, H.: Influence of implant number on the

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biomechanical behavior of mandibular implant-retained / supported overdentures.
Journal of dentistry. 2013,41,241-248

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17 El-Sheikh, A.M.; Shihabuddin, O.F.; Ghoraba, S.M.F.: Clinical Study Two Versus Three
Narrow-Diameter Implants with Locator Attachments Supporting Mandibular
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Overdentures: A Two-Year Prospective Study. International Journal of dentistry.
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18 Uludag, B.; Polat, S.: Retention Characteristics of Different Attachment Systems of

Mandibular Overdentures Retained by Two or Three Implants .Int J Oral Maxillofac
Implants. 2012, 27,1509–1513
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19 Kronstrom M, Davis B, Loney R, Gerrow J, Hollender L. A Prospective Randomized

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Study on the Immediate Loading of Mandibular Overdentures Supported by One or

Two Implants; A 3 Year Follow-Up Report. Clin Implant Dent Relat Res 2014;16:323-
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20 Bryant S, Walton J, MacEntee M. A 5-y randomized trial to compare 1 or 2 implants for

implant overdentures. J Dent Res 2014 ; 94:36-43.
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21 Talawy DBE, Ali SM. A two-year randomized clinical trial of one versus two implants
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23 Kronstrom M, Davis B, Loney R, Gerrow J, Hollender L. A prospective randomized

study on the immediate loading of mandibular overdentures supported by one or
two implants: a 12-month follow-up report. Int J Oral & Maxillofac Implants 2010;25:
181–188

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24 Walton JN, Glick N, Macentee MI. A randomized clinical trial comparing patient
satisfaction and prosthetic outcomes with mandibular overdentures retained by one
or two implants. Int J Prosthodont 2009;22:331-339.

25 Albrektsson T, Zarb G, Worthington P, Eriksson A. The long-term efficacy of currently

used dental implants: a review and proposed criteria of success. Int J Oral &
Maxillofac Implants 1986;1:11-25.

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26 Liu J, Pan S, Dong J, Mo Z, Fan Y, Feng H. Influence of implant number on the
biomechanical behaviour of mandibular implant-retained/supported overdentures: a
three-dimensional finite element analysis. J Dent 2013;41:241-249.

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27 Maeda Y, Horisaka M, Yagi K. Biomechanical rationale for a single implant retained
mandibular overdenture: an in vitro study. Clin Oral Implants Res 2008;19:271-275.

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28 Sewerin IP. Errors in radiographic assessment of marginal bone height around
osseointegrated implants. Eur J Oral Sci 1990;98:428-433.

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Table 1 Characteristics of included studies

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(month)
follow-up

(Mean)
Age

(days)
time
Loading

system
Implant

type
Implant

attachment
Type of

Number

group
Subjects per

subject
Implants per
per group
Total Implant

analyzed
Subject

Mean ±SD*
MBL1(mm)
failed implants
subjects with
Number of
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Authors

of
TiUnite
17 1 17 11 NR 3

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Groovy
Kronstrom 53.3 Immediate Nobel
36 (0) implant 36
et al 201419 Biocare Ball
plasma
19 2 38 8 NR 6
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oxidized

43 1 43 29 NR 0
Solid
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67 Early Strauma Screw,

Bryant, et 60 86
(42) -nn SLA Ball 0
al 2014 20
surface 43 2 86 33 NR
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Immediate
provision
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Tavakoliza 0.6±
-al/early 10 1 10 10 0
deh et al Implanti 0.67
12 59 loading NR Ball 20
2015 6 -um
(42) 0.6±
10 2 20 10 0
0.51
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Blasted 10 1 10 10 0.96 0
Talawy et Delayed Dentaur- Locat
24 55.4 ,etched 20
al 201521 (90) um or
tapered 10 2 20 8 1.21 2
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0.53±
Solid 14 1 14 14 0
0.1
Elawady et Delayed screw, Locat
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12 50 Dentis 28 0.807
al 2016 22 (90) SLA or
surface 14 2 28 14 ± 0
0.1
*standard deviation

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Table 2 Excluded articles

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Excluded Articles Reason of exclusion

Cordioli, et al 19979 Single Implant MOD only is investigated

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(not compared to 2-implants MOD)
Liddelow, et al 201010 Single implant MOD only is investigated (not
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compared to 2-implants MOD)
Gonda, et al 201011 Not RCT

Harder, et al 201112
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Single Implant MOD only is investigated

(not compared to 2-implants MOD)
Alsabeeha, et al 201113 Single Implant MOD only is investigated
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(not compared to 2-implants MOD)

Cheng, et al 201214 Single Implant MOD only is investigated
(not compared to 2-implants MOD)
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Grover, et al 201315 Single implant MOD is compared to

complete denture
Liu, et al 201316 Not RCT
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El-Sheikh, et al 201317 Single Implant MOD only is investigated

(not compared to 2-implants MOD)
Uludag, et al 201418 Not RCT
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Table 3 Risk of bias

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Study ID Random Allocation Blinding of Blinding of Incomplete Selective Other bias

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sequence concealment participant outcome outcome reporting
generation assessment data
Kronstrom Low Low Low Low High Low Unclear
et al 2014 19

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Bryant, et al Low Low Low Low Low
Low Low
201420
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Tavakolizad Unclear High Unclear Low Unclear
Low Unclear
-eh et al
20156
Talawy et al Low Unclear Low Low Low Unclear
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2015 21 Low

Elawady et low Unclear Low Unclear Low Unclear

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Low
al 201622
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Captions to figures

Figure 1

Flow chart of identification, screening, assessing eligibility and inclusion of articles.

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Figure 2

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Forest plot of comparison between single and 2- implants ODs regarding peri-implant

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marginal bone loss

Figure 3

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Forest plot of comparison between single and 2- implants ODs regarding implant

failure.
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