Original Research

Impact of Implants Number and Attachment Type on the Peri‑Implant

Stresses and Retention of Palateless Implant‑Retained Overdenture

Abstract Salah A. Hegazy,

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Objectives: To evaluate the impact of implants number and attachments type on the Nesreen El Mekawy,
peri‑implant stresses and retention of maxillary palateless implant‑supported overdenture. Radwa M.K. Emera
Materials and Methods: Four edentulous maxillary educational acrylic resin models were used.
Department of Prosthodontics,
According to the implants number and type of attachment used, four groups were compared: Group I,
Faculty of Dentistry, Mansoura
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2‑locator attachments in the canine area; Group II, 2‑ OT equator attachments in the canine area; University, Mansoura, Egypt
Group III, 4‑locator attachments in the canine, second premolar area and Group IV, 4‑OT equator
attachments in the canine, second premolar area. Implants retained palateless overdenture was
constructed on each model. Four self‑protected linear strain gauges were cemented on each implant.
A digital loading device was used to apply compressive loads to measure the resulting peri‑implant
stresses. Forcemeter and Universal testing machines were used to test the retention of palateless
overdenture. Results: A significant difference between the same implant number and distribution
with different attachments was found (P = 0.003, P = 0.020), respectively. Least stresses amount
was found around the 4‑implant locator palateless overdenture, while the highest was found around
the 2‑implant OT equator palateless overdenture. Nevertheless; the result was that 2‑implant locator
palateless overdenture recorded insignificant higher retentive forces than the 4‑implant OT equator
one. Conclusions: It can be concluded that the implant-retained palateless overdenture with four
locator attachments is considered a promising treatment option regarding stress distribution. Using
locator attachments, for implant-retained palateless overdenture with either two or four implants
considering their superior retentive properties, is advantageous when compared to OT equator
attachments.

Keywords: Implants distribution, implants number, maxillary palateless overdenture

Introduction the gagging tendency.[4,5] However, this

Although studies have showed a decreasing
prevalence of individuals suffering from
complete edentulism, edentate status still
remains a common health problem.[1]
Edentulous patients usually have complaints
with their complete dentures; mainly due
to decrease in retention and stability of
their denture and insufficient chewing
efficiency.[2] To enhance the retention of
maxillary dentures, the denture base is
usually extended distally to the vibrating
line. This full coverage of the palate results
in morphological changes of the palate
that leads to disturbance of the oral motor
functions.[3] To avoid this; a palateless
denture is possibly an ideal design for a
maxillary complete denture, to increase
patient comfort, to positively enhance
decrease in the tissue surface contacts
causes lack of denture retention which
needs to be overcome.[6]
Implant‑retained maxillary overdenture
(IRMO) is an option to improve
retention. At least four implants are
required for implant‑retained palateless Address for correspondence:
overdentures.[7] However, a less number Prof. Nesreen H. El Mekawy,
of implants are preferable to minimise the 68 El‑Gomhoreya Street,
surgical invasion for the patient in addition Mansoura, Egypt.
E‑mail: nesreenelmekawy@
to the economic burden. This is done by mans.edu.eg
placement of only two implants accompanied
by reduction of mechanical stress on the
tissues around the implant to achieve a Received : 13-10-2018
Revised : 26-06-2019
longitudinally successful outcome.[4] Patients
Accepted : 21-08-2019
rehabilitated with a maxillary palateless Published : 06-08-2020
overdenture (MPO) appear to require more
maintenance visits when the prosthesis is Access this article online

patient’s sense of taste and to decrease
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For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
retained by two free‑standing implants in Website: www.ijdr.in
comparison to four implants.[8] DOI: 10.4103/ijdr.IJDR_772_18
Quick Response Code:
How to cite this article: Hegazy SA, El Mekawy N,
Emera RMK. Impact of implants number and attachment
type on the peri‑implant stresses and retention of
palateless implant‑retained overdenture. Indian J Dent
Res 2020;31:414-9.

414 © 2020 Indian Journal of Dental Research | Published by Wolters Kluwer - Medknow
 Hegazy, et al.: Implant number and attachment type of palateless overdenture
The attachment types must be taken into consideration to
reduce the transferred force,[9] over contouring or prosthesis
fracture which may occur due to inappropriate evaluation
of limited inter‑arch space.[10] Therefore, a special group
of attachments was introduced to be used within the
available limited inter‑arch space known as the low profile
attachments.[11] These attachments are known to disengage
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during excessive forces application, to avoid the harmful load
from reaching the implants and implant‑bone interface.[12]
Locator attachment is a low profile resilient attachment,
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with a universal hinge that allows free‑floating movement
between the nylon retention liner and its metal housing.
Moreover, locator attachments are presented with
different vertical heights, durability and can compensate
implants angulation.[13,14] OT equator attachment has the
minimum diameter and vertical height for the overdenture
abutments. Furthermore, it provides good retention and
stability, reduced residual ridge resorption and improves
aesthetics.[15]
Retention is a cornerstone in the removable appliances.
Patient’s satisfaction greatly depends on the prosthesis
retention. By using a cross‑over experimental design,
Burns et al.[16] found a strong patient preference for the
overdenture attachment with superior retention.
Therefore, the goal of this current in vitro research was to
compare the impact of implants number and type of two
low profile attachments on the peri‑implant stresses, and
retention of implant palateless overdenture.
Materials and Methods
Four standard educational clear acrylic resin models (Rapid
simplified, Vertex‑Dental B.V, The Netherlands) representing
an edentulous maxilla with deep palatal vault were used in
this study. Self‑cured silicone layer (Softliner®, Promedica,
GmbH, Neumünster, Germany) of 2 mm thickness was
incorporated over the residual ridge of each model to
simulate the oral mucosa. According to the number of
implants installed, and type of the low profile attachment
used, four models were constructed and classified as follow:
Group I: 2‑implants (TioLogic; Dentaurum, Ispringen,
Germany) were installed bilaterally at the region of
the canine, the locator attachments (Zest Anchors,
Escondido, California, USA) were used to retain the
palateless overdenture.
Group II: 2‑implants (TioLogic; Dentaurum, Ispringen,
Germany) were installed bilaterally at canines
region, the OT equator attachments (Rhein 83 OT
equator attachment) were used to retain the palateless
overdenture.
Group III: 4‑implants (TioLogic; Dentaurum,
Ispringen, Germany) were installed bilaterally at
canines and second premolars regions, the locator
attachments (Zest Anchors, Escondido, California,
USA) were used to retain the palateless overdenture.
Indian Journal of Dental Research | Volume 31 | Issue 3 | May-June 2020 
Group IV: 4‑implants (TioLogic; Dentaurum,
Ispringen, Germany) were installed bilaterally at
canines and second premolars regions, the OT equator
attachments (Rhein 83 OT equator attachment) were
used to retain the palateless overdenture.
The four models were drilled at the implant sites with
the aid of a surgical stent. Every implant fixture of
3.6 mm diameter and 12 mm length were wrapped by
1 mm thickness tin foil spacer before being installed
in its place in the models. The locator and OT equator
attachments abutments were inserted in the implants’
internal hex by using the insertion key and torque
wrench (30 N cm) [Figures 1 and 2].
Construction of implants palateless overdentures
Undercuts of the clear acrylic resin model were
blocked out; the acrylic resin model was duplicated
using Agar‑Agar (Gilvest, German.) to construct the
refractory casts. Palatal bead line of 0.5 – 1 mm in
width and depth was curved in the refractory cast. Cast
chrome‑cobalt frameworks were constructed to act as a
denture base.[17] Record blocks were adjusted according to
the standard measures and artificial teeth were arranged.
Flasking, packing and curing of heat cure acrylic resin
followed by finishing and polishing of the twenty palateless
(five for each group) overdentures. The female housings for
each group with the retentive male inserts corresponding
to the moderate retention, (pink color for the locator
attachment, yellow color for the OT equator attachment),
were picked up to the intaglio surface of each implant
palateless overdenture by using auto polymerized acrylic
resin.[18]
Peri‑implant stresses analysis procedures
Four self‑protected linear strain gauges (Kyowa, Japan)
with 1 mm lengths were luted to each implant at its
different surfaces. By unwrapping the fixtures from the
tin foil, the four strain gauges were glued to each implant
fixture in the cervical one‑third of the fixture using strain
gauge cement.[19] The wire of each strain gauge was coded
to be identified during measurements [Figure 3].
The OT equator and/or locator attachments were connected
to each implant fixture. The palateless overdenture enclosed
the attachments female housing was adapted to each model.
Bilateral central loading with stainless steel hexagonal bars
of a standardised 6 cm length and 5 mm diameter was
applied on every palateless overdenture; the loading point
was marked as the mid‑point of the stainless bar that was
fixed between first molar area bilaterally.
Compressive loads were applied by a digital loading
device (Lloyd instrument, Ltd, UK, lrx plus.); to measure
stress resulting around the implants for each type of
attachments. The gradual central load (0–50 Newton) was
applied on the predetermined loading point of the stainless
415
 Hegazy, et al.: Implant number and attachment type of palateless overdenture
steel bar. Measurements were collected and statistically
analysed. Thereafter; the strain gauges were removed from
the implant fixtures. Resin cement (Superbond CB; Sun
Medical, Kyoto, Japan) was used to secure implants in
their recess to simulate osseointegration.
Evaluation of retention forces
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Fixation of a metal bar with a central ring of radius (3 mm),
to the palateless overdenture palatal surface was done just
below the occlusal plane at the region of first and second
molar teeth using cold cure acrylic resin[20] [Figure 4]. The
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retention forces of palateless overdenture to the model was
measured by a universal testing machine (Lloyd LRX)
with a load cell of 5 KN. The maximum dislodging force
was recorded at the moment of complete detachment of
palateless overdenture from the model.
Statistical analysis
The data were analysed by SPSS version 20 (SPSS Inc.,
Chicago IL, USA). Repeated measures of ANOVA were
used to compare the recorded implant stress between
different attachment (locator, OT equator attachment) with
number and distribution of implants (two, four).
The significance of variables (attachment and number of the
implant) was detected by two‑factor ANOVA test. Tukey’s
a b
Figure 1: (a) Group I model with two implants connected with two Locator
attachments; (b) Group II model with two implants connected with OT
Equator two attachments
Figure 3: The strain gauge wires were marked with a code
416
post‑hoc tests were performed to detect significance
between subgroups. Student t‑test was performed to detect
the significance between the main groups. P values ≤ 0.05
are considered to be statistically significant in all tests.
Results
Comparison between stresses on different implants for the
model of 2‑implants in canine site with locator attachments
and the model of 2‑implants in the canine site with OT
equator attachments were presented in Table 1. There
was a significant difference between the same implants
number and distribution with different attachments as
P = 0.003. The highest amount of stress was found
around the surfaces of 2‑implant OT equator palateless
overdenture (114.55 ± 42.61).
Comparison between stresses on different implants for
the model of 4‑implants in canine and premolar sites with
locator attachments and model of 4‑implants in canine
and premolar sites with OT equator attachments were
revealed in Table 2. There was a significant difference
between the same implants number and distribution with
different attachments as P = 0.020. The least amount of
stress was found around the 4‑implant locator palateless
overdenture (5.83 ± 4.31).
a b
Figure 2: (a) Group III model with four implants connected with four Locator
attachments; (b) Group IV model with four implants connected with OT
Equator four attachments
Figure 4: Metal bar with a central ring fixed to the palatal surface of implant
palateless overdenture
Indian Journal of Dental Research | Volume 31 | Issue 3 | May-June 2020
 Hegazy, et al.: Implant number and attachment type of palateless overdenture
The results of a comparison of retention force for implant
palateless overdenture as a function of attachment and
implant number is shown in Table 3 and Figure 5.
The locator attachments with 4‑implants palateless
overdenture recorded the highest retention force mean
values, followed by locator attachments with 2‑implants
palateless overdenture. Then, the OT equator attachments
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with 4‑implants palateless overdenture, while, OT equator
attachments with 2‑implants palateless overdenture
recorded the lowest retention force mean values.
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One way analysis of variance ANOVA tests showed
that the difference between groups was statistically
significant (P = <0.0001). Tukey’s post‑hoc test showed
non‑significant (P > 0.05) difference between locator with
2‑implant and OT equator with 4‑implants which is a
surprising result revealed by this study.
Discussion
The OT equator attachments exhibited high‑stress values
on implants rather than locator attachments wherein
the implants’ distribution and number are the same.
Furthermore, the stresses on 4‑implants were lesser
than stresses on 2‑implants with the application of same
attachments. Although two implants may provide reasonable
Table 1: Comparison between stresses of 2‑implants with
OT equator attachments and 2‑implants with locator
attachments
2‑implants with OT 2‑implants with P locator abutment which may be for good stress absorbtion
equator attachments locator attachments
X±SD 114.55±42.61 44.63±23.99 P=0.003*
*: Statistically significant at P≤0.05
Table 2: Comparison between stresses of 4‑implants with
OT equator attachments and 4‑implants with locator
attachments
4‑implants with OT 4‑implants with P Locator attachments Four implants
equator attachments locator attachments
X±SD 15.24±14.58 5.83±4.31 P=0.020*
*: Statistically significant at P≤0.05
Table 3: Comparison of retention force results for
implant‑retained palateless overdenture as function of
attachment and implant number
X±SD Rank P
2‑implants with locator 79.73±4.87 B P<0.0001*
attachments
2‑implants with OT equator 52.56±3.87 C
attachments
4‑implants with locator 91.86±6.04 A FOUR
attachments
4‑implants with OT equator 77.77±6.25 B LOCATOR ATTACHMENTS
attachments
Different letters indicating statistical significance (Tukey’s; P<0.05)
*; significant (P<0.05)
Indian Journal of Dental Research | Volume 31 | Issue 3 | May-June 2020 
retention to the palateless overdenture, the omission of hard
palate coverage, which participates greatly in the support of
the overdenture, increased stresses on the implants. This is
in agreement with Damghmani et al.[21] who propositioned
that when maxillary conventional complete denture was
utilized (control group), nearly 37% of the stress was
transmitted to the palate. While, upon utilisation of two
implants retained overdenture with locator attachment, the
value of stresses on the palate slightly declined that in turn
increased stress on the implants.
Properly distributed 4‑independent implants assisted
maxillary overdentures were associated with great amount
of load reduction compared to other overdentures assisted
by only 2‑independent implants.[22] This stands in line
with this study result, where the stress on 2‑implants with
2‑locator attachments was higher than stress on 4‑implants
with 4‑locator attachments. In addition, this result was the
same with OT equator attachment.
In this study, the mean stress values of locator attachment
implant palateless overdenture were less than the mean
stress value recorded by OT equator attachment implants
palateless overdenture with standard implant number. This
decrease in the mean stresses was statistically significant.
This can be attributed to the matchless design of locator
attachment; the patrix (male) is the replaceable nylon
inserted on the intaglio surface of the palateless overdenture
and the matrix by virtue.[23] Furthermore, the nylon male
element grabs the outside and the inside contours of the
and transmission. The OT equator attachment implants
palateless overdenture combines the simplicity of ball
attachments, with no stress absorbed and transmitted.
Moreover, in comparison to the previous results where
the mean stress value with the locator attachments is
Locator attachments Two implants
equator attachments Four implants
equator attachments Two implants
100
80
Retention force
60
40
20
0
TWO FOUR TWO
IMPLANTS IMPLANTS IMPLANTS IMPLANTS
EQUATOR ATTACHMENTS
Figure 5: A column chart comparing retention force mean values between
implant retained palateless overdenture as function of attachment and
implant number ranked from higher to lower mean value
417
 Hegazy, et al.: Implant number and attachment type of palateless overdenture
less than that with OT equator attachment, it was found
that the mean retention values of locator attachment
implant palateless overdenture were higher than the
mean retention value recorded by OT equator attachment
implants palateless overdenture. This elevation in the
retention values was statistically significant. Again;
this may be due to the matchless design of the locator
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attachment where the nylon male element grabs the
outside and the inside contours of the locator abutment.
This characteristic feature redoubles the surface area for
retentive contact. In addition, the OT equator attachment
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has the diversity of retention levels and easy replacement
options of locator’s attachment with no double surface
area for retention and stress absorbtion and transmission.
This result is in agreement with Greenbaum[24] who
examined the retentive values of locator attachments with
initially placed pink nylon‑inserts.
It was found that locator attachments with 4‑implants
palateless overdenture recorded the highest retention force
followed by locator attachments with 2‑implants palateless
overdenture, then OT equator attachments with 4‑implants
palateless overdenture while OT equator attachments with
2‑implants palateless overdenture recorded the lowest
retention force mean. This may be due to the increased
friction between the nylon insert and the abutment. The
dual retention feature of locator attachment system and
the relatively wider surface area of the locator nylon insert
must aid in magnifying the effect of friction between
the two components, locator attachment system showed
superior retentive properties when compared to OT equator
attachments. This is in agreement with Satti[25] who
compared the locator with OT equator attachment.
Finally, an in vitro research on an acrylic resin model
rather than an in vivo research, was selected to perform the
current research as studies in the laboratory are controlled
easily, more practical and can yield further accurate
results. Therefore, the laboratory experiments could be
extra valid as the experience can be repeated under
the same circumstances, where the object under the
experimental study would be a single variable. In vitro
studies are recommended to analyse stresses within the
supporting structures in implant overdentures. Further
studies are needed to measure the effectiveness of
both attachments clinically either in the maxillary or
mandibular arches.
Conclusion
It can be concluded that the implant-retained palateless
overdenture with four locator attachments is considered a
promising treatment option related to stress distribution.
Using locator attachments for implant palateless
overdenture with either two or four implants regarding
stress distribution pattern and the superior retentive
properties is advantageous when compared to OT equator
attachments.
418
Acknowledgements
The authors would like to thank Mr. Ismail Elbakoosh
and, Mrs. Fatma Khalifa for their role in the collection and
organization of the article data.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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