INTRODUCTION

The impending need for rehabilitation in a completely edentulous individual is high. This can
be attributed to increasing life span, awareness for dental treatment, and more importantly high
prevalence of edentulism.1 Despite the keen interest of the edentulous patient group for
rehabilitation, the associated economical constraint often made complete denture chosen form
of treatment modality.2 Although McGill consensus suggests the use of two implants in
mandibular arch3 to support an overdenture in a middle-income country like India, the
implementation of this consensus is far from reality.4 There has been a rise in the interest in
rehabilitation of completely edentulous patients by use of single implant retained overdenture
in recent years. Economical advantage, simplicity of the procedure, and the satisfactory patient-
reported outcome can be factors associated with the same.5 Studies comparing complete
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denture with single implant-retained mandibular overdenture and single implant-retained
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mandibular overdenture with 2 or more implant retained overdenture show that data is
compelling towards single implant-retained overdenture. Critical to the short-term and long-
term success of any prosthesis is the occlusal scheme implemented and maintained for single
implant retained overdenture and complete denture. The suggested occlusal scheme is bilateral
balanced occlusion with simultaneous centric and eccentric contacts.7 Although the meticulous
procedure for establishment of contact during fabrication of prosthesis due to numerous factors
such as occlusal surface material, the resiliency of underlying tissue causing micromovements
of the prosthesis, diet, habits (if any) can change the status of occlusion with time. Lack of
harmonization of occlusal contact during the functioning of the prosthesis can initiate the
development of premature occlusal contact with the use of a prosthesis over time.8 This can
create deleterious force vectors which if not eliminated can result in instability of prosthesis,
short term sequelae of this can manifest as a mucosal lesion or sore spots .9 Persistent long-
term presence of this prematurities and advanced force vectors can lead to accelerated residual
ridge resorption, settling in of denture and a further rise in the number of prematurities. In
extreme cases, it can even result in prosthesis failure, and in the case of a single implant retained
overdenture can compromise the status of osseointegrated implant.

Various methods for occlusal analysis currently in use are articulating paper, waxes, silicone
impressions and photocclusion .10 These materials are far from reality as the information they
provide is confusing, subjective, dimensionally unstable, and unable to register occlusal
contact force and time sequencing.10 With the introduction of the computerized occlusal
analysis system by Maness in 1987, occlusal contact data can be interpreted qualitatively and
quantitatively, this eliminates the associated subjectiveness of data and it also permits data
archiving. The latest version (T-Scan III) provides a dynamic visual evaluation of a patient’s

1
occlusion from initial tooth contact to maximum intercuspation.8 The system records force
distribution and allows for objective quantitative evaluation of occlusal balance by recording
timed occlusal contacts using pressure sensitive force transducer. This is a substantial tool for
functional improvement in terms of bite force and occlusal distribution.11 There has been no
study comparing the changes in maximum occlusal force and changes in the distribution of
occlusal contact after the use of conventional complete denture and single implant retained
overdenture. Hence this study has been designed. The null hypothesis states that there will be
statistically no significant difference in the number of tooth contacts, percent biting occlusal
force and percent force distribution between left and right side in centric occlusion in cases
with single implant-retained mandibular overdenture or conventional complete denture using
computerized occlusal analysis system after 48hr, 3month and 6month of insertion of the
denture.

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MATERIALS AND METHODS

I. STUDY DESIGN AND SAMPLE SIZE

The present study is an in vivo randomized controlled trial, a pilot study that was performed in
the division of Prosthodontics, Centre for Dental Education and Research, All India Institute
of Medical Sciences, New Delhi. Ethical clearance from the Institute Research Ethics
committee was obtained (Ref. Number: IECPG-654/25.11.2020). The CTRI registration
number for this trial is CTRI/ 2021/04/033054

Participants were randomly assigned to either an experimental group (Group A) or a control

group (Group B) with a 1:1 allocation as per a computer-generated randomization table (block
randomization). Random allocation was implemented by sequentially numbered opaque sealed
envelopes. The treatment plan for group A participants was rehabilitation by using a single
implant-retained mandibular overdenture opposing conventional maxillary complete denture.
The treatment plan for group B participants was rehabilitation by using conventional maxillary
and mandibular complete dentures. All participants were treated by a single operator (S⋅S.).

SAMPLE SIZE CALCULATION- Since previous clinical study results were not available
during the establishment of the study design, biometric sample size calculation could not be
done. All completely edentulous individuals, reporting to the department of the tertiary care
centre from August 2020 to December 2021, and fulfilling the inclusion and exclusion criteria
of the study were enrolled in the study These subjects were divided into two groups with 11
patients in each group. It is a concurrent parallel study design

Group A – 11 patients

Group B – 11 patients

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II. CRITERIA FOR SELECTION OF CASES
a) INCLUSION CRITERIA
1. Participants between the age of 50 and 74 years, with completely edentulous maxillary
and mandibular arches, edentulous for a minimum period of 6 months and a maximum
period of 1 year
2. Participants between the age of 50 and 74 years, with completely edentulous maxillary
and mandibular arches, edentulous for a minimum period of 6 months and a maximum
period of 1 year
3. Participants with a minimum of 10mm residual bone height without augmentation and
a width of 4.5mm in the mandibular symphyseal region.
4. Participants with class 1 jaw relationship
5. Participants who are first-time denture wearers
6. Participants who provided a positive written informed consent

b) EXCLUSION CRITERIA
1. Any history of metabolic or systemic disease affecting the integration of implant or
connective tissue health surrounding the implant.
2. Any logistic or physical reason that could affect follow-up.
3. History of radiation therapy to head and neck.
4. History of drug or alcohol abuse.
5. Heavy smokers.
6. Unrealistic expectations.
7. Insufficient primary stability of the implant.
8. History of temporomandibular disorders

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III. TREATMENT PROCEDURE
a) Group A (Experimental)- implant-retained mandibular overdenture

Complete patient history was taken, and a thorough clinical and radiographic examination was
done. The entire treatment procedure, its benefits, and complications were explained to obtain
informed consent before the procedure was started.

Preparation of radiographic template

After diagnostic impressions, the casts were prepared. Bone mapping was done to measure the
soft tissue thickness over the crest of the ridge, buccal and lingual cortical plates. The
mandibular edentulous ridge in the prospective implant sites was sectioned and soft tissue
thickness was outlined. Mock implant drilling was done, and implant analogues (Adin,
TouaregTM, Israel) were placed in the drilled sites. Impression posts were placed over the
analogues. Undercuts in the impression posts were blocked out and a template was made with
vacuum formed thermoplastic sheet (Biocryl® C, Scheu-Dental, Germany). The guide was
removed from the cast and the posts were pulled out which enabled correct angulation of the
pilot drill during implant placement. In this guide radiographic marker, gutta-percha was
placed. The patients were asked to wear this before a cone beam computed tomography
(CBCT) scan. A CBCT scan was used to determine the bone height, width, and density and
accordingly, the position and orientation of the implant concerning critical structures and to
determine the size of the implant (Adin, TouaregTM, Israel) to be placed.

Implant placement

Pre-operative antibiotic coverage of Amoxicillin 2g was given 1 hour before surgery. Local
anesthetic, lignocaine (LOX 2% Adrenaline, Neon, Mumbai, India) 1:1,00,000 concentration
was used to anesthetize the surgical site. Implant placement was done under Local anesthesia
with an open flap technique (Adin, TouaregTM, Israel). The osteotomy was initiated by using a
pilot drill of 2mm through a radiographic template from which radiographic markers were
removed to perforate the bone at a speed of 800-1000 rpm, Subsequent drills were used to
prepare the site according to the selected implant size. Copious irrigation was used at the time
of the surgical procedure. Implants were inserted manually with help of an insertion tool and
torque wrench. A minimum of 30-35 Ncm of torque was achieved during the complete insertion
of implants followed by sequential drilling. Implant (Adin, TouaregTM, Israel) was inserted into
the prepared site and then a cover screw was placed to prevent epithelial downgrowth. The flap
was approximated after thorough irrigation with vicryl suture of size 6.0 (ETHICON, US).

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Post-operative instructions and follow up

Patients were instructed to take a soft diet for 24 hours. Antibiotics and analgesics were
prescribed for 5 days. The patients were recalled at regular intervals to evaluate oral hygiene,
implant stability, and radiographic assessment.

Primary impression

Primary impressions were made with a Type 1 impression compound (DPI PINNACLE,
Mumbai, India) (figure 2). The impression compound was broken into small pieces and placed
into a hot water bath till the glass transition temperature was reached, and the compound was
kneaded and placed in the tray for recording the impression surface. After the tray was
positioned in the mouth it was held passively until the impression compound had been cooled
below the fusion temperature. Reheating and adjustments of the peripheries were done to obtain
an adequate border seal. Impression was poured using a standard technique in Type2 gypsum,
Plaster of Paris (Kaldent, Kalabhai, India), and the cast was used in the fabrication of a custom
tray.

Fabrication of custom tray

The wax spacer (Maarc spacer wax, Maharashtra, India) having a thickness of 0.5 to 1mm was
adapted to the cast and it was kept 2-3mm short of the tray borders and not covering the PPS
in the maxilla and buccal shelf in the mandible. Four tissue stops, 2×4 dimensions in the molar
and canine region, were fabricated on both sides of the arch extending from the palatal aspect
to the mucobuccal fold. The custom trays were fabricated with the auto-polymerizing acrylic
resin (RR Rapid Repair, DPI Mumbai, India) which was 2mm short of the borders of
muccobuccal fold where buccal reflection leaves the lateral wall of the alveolar ridge

Final impression

To make the final impression, borders were molded by using a green stick compound (DPI
PINNACLE, Mumbai, India). The sectional molding technique was used for the functional
molding of the borders. The spacer was removed, and relief holes were made to prepare the
tray for impression with Zinc oxide eugenol impression paste (DPI Impression paste, Mumbai,
India) (figure 3). The impression material was loaded into the tray and placed in the patient’s
mouth and held passively with gentle pressure. A completely set impression was removed from
the oral cavity and examined critically for any surface irregularities or imperfections.

Beading and boxing (Maarc beading and boxing wax, Maharashtra, India) were done to
preserve the border area of the impression in the cast and to obtain a condensed cast. Then the
impression was poured into a dental stone (type 3 gypsum Dental stone (Kalstone, Kalabhai,

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India). Temporary denture bases were made with auto-polymerizing resin (RR Rapid Repair,
DPI Mumbai, India) and the wax occlusal rim was made in modeling wax (Y-DENTS
Modelling wax, New Delhi, India)

Jaw relation

Lower rim height was adjusted anteriorly equal to the corner of the mouth and posteriorly to
2/3rd of the retromolar pad. The maxillary rim was adjusted to obtain proper lip contour and
length according to esthetics and phonetics. The occlusal plane was kept parallel to the
interpupillary line anteriorly and the camper’s line posteriorly. The vertical jaw relation was
adjusted and an interocclusal space of 2-3mm was provided. The maxillary cast was oriented
on a semi-adjustable articulator (HANAUTM wide vue articulator) using a face bow record
(HANAUTM Facebow Complete Spring bow) (figure4) Centric relation was recorded at the
established vertical dimension of occlusion, using an interocclusal wax technique to mount the
lower cast on the articulator in centric relation.

Teeth setting and try in

The form, size, and shape of the teeth (Dental Acry Rock Acrylic Teeth Set, India) selected
were based on anatomical factors and dentogenic concepts. Posterior teeth were arranged
between the distal end of the canine to the anterior part of the retromolar pad. The teeth were
arranged so that the centric occlusion coincides with the recorded centric relation. During try-
in esthetics and phonetics were evaluated. The vertical and centric relations were evaluated.
Retention and stability of trial denture bases were also confirmed(figure5). Wax protrusive
records were made at the try-in stage (figure6). The condylar guidance(H) was adjusted using
the wax protrusive record. The bennet angle(L) was adjusted according to Hanau’s formula

L= H/8 +12

Flasking and packing

Waxed-up dentures were flasked, dewaxed, and then packed in heat-polymerized acrylic resin
(Trevalon Hi, Gurgaon, India). Both the dentures were polymerized in acryliser for 9 hours at
165 degrees F using a long curing cycle. Then, the dental flask was left to cool down to room
temperature. After processing the dentures, the flask was opened, and remounting procedures
were done to eliminate the processing errors(figure7). Following this, dentures were finished,
polished, and inserted intraorally and necessary post-insertion adjustments were followed.

Second-stage surgery was performed after integration of implant Ball abutment (Adin dental
implant system ltd; Israel) with sufficient collar height according to the thickness of soft tissue
and tightened to 30 Ncm with a torque wrench. Transfer of nylon cap and metal housing was

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done by following direct technique by using a spacer. Room temperature polymerizing poly
methyl meth acrylate (RR Rapid Repair, DPI Mumbai, India) was used to pick the metal
housing with a spacer which was followed by delivery of the denture.

b) Group B- Conventional complete denture (CD)

All the procedures were the same as for implant-retained overdenture except for the implant
placement and use of the attachment.

c) Follow Up Schedule and Data Collection

After the delivery of the prosthesis, all subjects were recalled at 48hr, 3 months, and 6 months
for evaluation of the prosthesis and assessment of soft tissue. At each recall visit, T-scan (Tek
Scan 9.1, Seattle, WA, US) was done (figure7). The sensor was put intraorally by resting on
the maxillary denture’s central incisor teeth and then the recording was activated by clicking
the Record Button on the top of the T-Scan recording handle. The patient was then asked to
firmly intercuspate into the sensor using their complete denture occlusion and to firmly hold
their teeth together for 3 seconds once maximum intercuspation is reached. To capture 3
intercuspation in (multi bite position), the patient was asked to open after the first
intercuspation, and then re-intercuspate into the recording sensor firmly, once again and then
again. For each patient T- scans were taken at 48 hrs, 3 months, and 6 months of denture
delivery. At each instance number of occlusal tooth contacts, percent biting occlusal force, and
percent force distribution between the left and right side were noted.

d) Recall the patient after 48 hours

After 48 hours, occlusal contacts were adjusted by using articulating paper (Bausch, 100µ
Horseshoe Shape, New Hampshire, US). For this thin(100µ) blue articulating paper was placed
on the occlusal surface of lower teeth and the patient was asked to close the mouth with
sufficient pressure to record just the first contact area and then the prominent cusp or cusps
were observed. Lateral contacts were marked with red articulating paper for purpose of
differentiation. The position and number of contacts were verified by using T-scan (Tek Scan
9.1). The parameters collected were the number of occlusal tooth contacts, percent biting
occlusal force, and percent bilateral force distribution between the left and right sides. Occlusal
contacts were adjusted to 50 ±10 % force46, equal no of contacts appearing on both sides. All
adjustments were confirmed by T-scan and baseline readings were noted.

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e) Recall the patient after 3 months and 6 months

At recall visits of 3 months and 6 months, readings were noted again using T-scan.

f) Statistical analysis

Data were recorded on Microsoft excel spreadsheets. All the entries were double-checked for
any possible keyboard error and further analysed with a statistical software program (Stata
14.0; Stata- Corp LLC) Quantitative variables were summarized as mean and standard
deviation. Approximate normality was tested by using the Shapiro- Wilk test for quantitative
data. Data were normally distributed and for comparison of age groups and gender
independent t-test and chi-square test was used respectively. For intergroup comparison of
parameters between group A and group B at various timelines individually, an unpaired t-test
was used. For intragroup comparison (assessment of change from T1 to T3) within the
number of occlusal contacts, percent force distribution between left and right side, and
percent biting occlusal force, repeated measure ANOVA was used. For multiple pairwise
comparisons within intragroup i.e., to check which pair of the timeline is significantly
different Paired t-test was used.

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 REVIEW OF LITERATURE
The review of literature on this topic can be divided into:
1. Review of single implant-retained overdenture v/s conventional complete denture
2. Review of single implant-retained overdenture
3. Review of T-Scan and a complete denture
4. Review of T-Scan and implant-retained overdenture

1. Review of single implant-retained overdenture v/s conventional complete denture

[1] Rocha et al, (2021)25 The purpose of this randomized crossover clinical trial was to
evaluate the masticatory efficiency of wearers of bimaxillary complete dentures and wearers
of the maxillary complete denture and single implant-retained mandibular overdentures, both
with bilateral balanced occlusion and lingualized occlusion. Participants received 2 sets of
complete dentures with interchangeable teeth in the mandibular prosthesis to allow a change
in the occlusion scheme. Subsequently, 1 implant was placed in the mandibular symphysis
region, and the mandibular complete dentures were converted to overdentures. The
masticatory efficiency was measured by the sieve method for both occlusal
schemes. Repeated measures ANOVA showed no statistically significant difference in the
masticatory efficiency with the 2 occlusal schemes for conventional complete dentures
or overdentures When comparing the type of prosthesis, statistical differences were found for
masticatory efficiency with improved mastication for overdenture. They concluded that a
mandibular single implant improved the masticatory efficiency of patients with
complete dentures, but the occlusal scheme did not influence this factor

[2] Km et al, (2021)23 This prospective, randomized trial study compared ridge resorption
(RR) and patient satisfaction in single implants retained mandibular overdentures (SIMO)
with conventional complete dentures (CCD) over one year. In this study, 30 completely
edentulous participants were enrolled following inclusion and exclusion criteria, but the study
was completed by 28 participants. Rehabilitation of 14 participants was done by using SIMO
(group I) and CCD (group C) each according to the randomization chart. For both the groups,
RR was computed in millimeters from residual ridge height measured by using
orthopantogram at 6 months (T1), 9 months (T2), and 12 months (T3) at 3 anatomic
locations: maxillary posterior (L1), maxillary anterior (L2), and mandibular posterior (L3).
Patient satisfaction was evaluated by using Geriatric Oral Health Assessment Index Hindi
version (GOHAI-Hi) at 1 week and 12 months after denture delivery. At 12 months,
minimum RR was observed at L2 of group I (0.62 ±0.20 mm) and maximum RR was

10
observed at L3 of group C (1.04 ±0.15 mm). The comparison of ridge resorption between
group I and group C was statistically significant at T3 (P=.001 for L1, P=.006 for L2, and
P=.028 for L3). At T3, in group I, RR was more at L3 than in the L2 region (P=.011) and L1
region (P=.015). The statistically significant difference in GOHAI-Hi scores was observed
between group I and group C at end of 12 months (P=.003). They concluded that SIMO
causes less RR and higher patient satisfaction as compared to CCD and can be
recommended with higher predictability of success than CCD.

[3] Nogueira et al, (2017)6 conducted a study in which the single-implant mandibular
overdenture (SIMO) has been proposed as an alternative for edentulous patients who are poorly
adapted to their dentures due to low retention and stability of the conventional mandibular
complete denture (CD). This systematic review aimed to assess the comparative results of CD
and SIMO treatments using patient-reported outcome measures. A literature search was carried
out in PubMed, Scopus, and Cochrane Central databases. The search included studies published
up to July 2017. The focus question was: 'Do single-implant mandibular overdentures improve
patient-reported outcomes compared to conventional complete dentures in edentulous
patients?' Eligible studies were randomized clinical trials (RCT) and prospective studies. After
initial screening for eligibility and full-text analysis, 11 studies were included for data
extraction and quality assessment (five parallel-group RCTs, two crossover RCTs, and four
prospective studies). All studies reported marked improvement in satisfaction with the dentures
and quality of life measures after SIMO treatment, irrespective of variations in implant
treatment protocols and retention systems. They concluded that there was considerable
improvement in patient-reported outcomes following the insertion of a single implant to
retain a mandibular denture, further well-designed comparative studies are required

[4] Ismail et al, (2015)16 studied the success of symphyseal single implant-retained
overdenture with ball and magnet attachment.10 dental implants were inserted in the
mandibular midline and left unloaded for 4 months. Patients were divided into two groups the
first group received mandibular overdenture with ball and socket and the second group received
mandibular overdenture retained by magnet attachment. Follow-up was immediately after
denture insertion,6 months,12 months, and 24 months. They found that there was no significant
difference in marginal bone height change in both groups. They concluded that a single
implant-retained overdenture with ball and socket or magnet attachments was easy to
construct, require less home care and give satisfactory clinical results

[5] Assunção et al, (2010)26 Conducted a study to establish a comparison between treatment
with conventional complete dentures and implant-retained overdentures in elderly patients by

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conducting a literature review. A search of English language peer-review literature was
completed using Medline up to 2008 focusing on evidence-based research. Randomized
clinical trials (RCTs) and longitudinal prospective studies were favored in the review, using a
general hierarchical classification. Articles that did not focus exclusively on the comparison
of patient satisfaction between complete dentures and overdentures were excluded from
further evaluation. The last search was conducted in February 2008. Among the 90 articles
found in the initial search, 27 met the inclusion criteria. This included 18 RCTs and eight
prospective and one cohort study. Most of the articles stated the superiority of the
mandibular implant-retained overdenture therapy over the conventional complete
denture regarding patient satisfaction and quality of life.

2. Review of single implant-retained overdenture

[6] Singh et al, (2022)22 The present study was done to assess patient satisfaction and crestal
bone changes with one-piece and two-piece single implant-retained mandibular overdentures
(SIMOs). In this study, participants were divided into 2 groups. Group 1 (n=12) received one-
piece SIMOs; the participants in Group 2 (n=12) received two-piece SIMOs with follow-ups
done 1 month and 1 year after implant placement. Patient satisfaction and crestal bone
changes were evaluated.). At the 1-year follow-ups, group 1 had a mean crestal bone loss of
0.80± 0.49 mm and group 2 had 1.24± 0.90 mm (P=0.16). Crestal bone loss was greater in
the two-piece SIMOs group at 1-month and 1-year follow-ups, but statistically, it was
insignificant. One-piece. They concluded that SIMOs seemed to be a viable treatment
option with increased patient satisfaction on a VAS. Crestal bone loss was greater in the
patients with two-piece SIMOs during follow-up. One-piece SIMOs were comparatively
simple with less invasive procedures and needed fewer components, so a considerable
number of patients requiring implant retained dentures could be benefited.

[7] Kashyap et al, (2021)20 This study was planned to assess the symphyseal (midline) single
implant-assisted complete overdenture for patient satisfaction and masticatory performance. In
this study, 12 edentulous first-time denture wearers underwent placement of a single implant
in the mandibular symphyseal region. After 1-week, new complete dentures were fabricated
and delivered to the patients. Post 3 months, the denture was fixed with a nylon cap-ball
attachment to the anchor implant. Patients were questioned about comparison in the level of
satisfaction and complaint before loading the implant (control group) and after 1 week, 1
month, and 3 months. The implant-assisted overdenture was fabricated with the help of a

12
questionnaire. Masticatory performance was calculated with the help of a bite force measuring
device at the same time intervals. In the results, it was found that single implant anchorage of
the mandibular complete denture resulted in a significant increase (P < 0.05) in patients’
subjective satisfaction and a decrease (P < 0.05) in complaints at the end of 3 months. There
was a significant (P < 0.01) increase in bite force in implant overdenture after 3 months (5.459
kgf) as compared to that of the complete denture.

[8] Fouda et al, (2021)21 in this study author compared the changes in implant stability for
the non-submerged and submerged single-implant retained mandibular overdenture using
Cendres and Metaux Locator attachment in a 24-month follow-up. Eighty edentulous patients
in which a single implant was placed in the midline of the completely edentulous mandible
and on the day of implant installation, patients were randomized into two groups using sealed
envelopes: the non-submerged and submerged groups. After 3 months healing period,
randomization using sealed envelopes was performed and patients were randomized to
receive the Cendres and Metaux Locator attachment. The periotest readings were recorded
using the Periotest M device, every 3 months for the first year and annually in the second
year. Mann–Whitney U-test was used for comparison between study groups for independent
samples. There was no statistically significant difference between the mean periotest readings
of both groups throughout the 24-month follow-up. Both groups showed an improvement in
mean periotest readings with the submerged group tending to show greater stability at 6, 12,
and 24-month follow-ups. They concluded that the non-submerged and the submerged
healing protocols resulted in reliable periotest readings with the submerged group
showing greater improvement than the non-submerged, although this improvement is
nonsignificant when using the Cendres and Metaux attachment for a single mandibular
overdenture.

[9] Alqutaibi et al, (2017)5 conducted a study to compare prosthesis and implant failure,
patient satisfaction, prosthetic complications, and peri-implant marginal bone loss of
mandibular overdentures (IOD) retained by a single or two implants. Manual and electronic
database (PubMed and Cochrane) searches were performed to identify randomized controlled
trials, without language restriction, comparing single vs two implant-retained mandibular
overdentures. Two investigators extracted data independently. The Cochrane tool was used
for assessing the quality of included studies. Meta-analyses were performed for the included
RCTs. Six publications corresponding to four RCTs were identified. Three RCTs
(corresponding to five publications) were included, and one trial was excluded. Follow-ups in
function were 1, 3, and 5 years after loading. All included studies were at a high risk of bias.
The pooled result revealed more prosthesis failures at overdentures retained by two implants

13
at 1 year however, there were non-significant differences at 3 years. Regarding implant
failures, there were more implant losses in overdentures retained by two implants at 1 year
however, there was a non-significant difference at 3 years. After 5 years in function, meta-
analyses revealed that there were non-significant differences regarding overall prosthetic
complications when mandibular overdentures retained by a single implant were compared
with overdentures retained by two implants. They concluded that mandibular
overdentures retained by a single implant have comparable results to those retained by
two implants. However, this should be interpreted with caution as all the included
studies were considered at a high risk of bias.

[10] Ismail et al, (2015)16 studied the success of symphyseal single implant-retained
overdenture with ball and magnet attachment.10 dental implants were inserted in the
mandibular midline and left unloaded for 4 months. Patients were divided into two groups the
first group received mandibular overdenture with ball and socket and the second group received
mandibular overdenture retained by magnet attachment. Follow-up was immediately after
denture insertion,6 months,12 months, and 24 months. They found that there was no significant
difference in marginal bone height change in both groups. They concluded that a single
implant-retained overdenture with ball and socket or magnet attachments was easy to
construct, require less home care and give satisfactory clinical results

[11] El-Sheikh et al, (2012)15 studied the success of early loaded single implant-retained
overdenture in 20 edentulous patients. They used a single implant with a chemically modified
surface (SLActive, Straumann AG, Basel, Switzerland). Marginal bone loss and patient
satisfaction were measured after 3 months, 6 months, and one year after denture delivery. They
found that all implants showed less than 1 mm of marginal bone loss by the end of 1 year.
Patient satisfaction was high with an increase in function and comfort. They concluded that
early loaded chemically modified single implant-retained overdenture is a safe, reliable,
and cost-effective treatment.

[12] Alsabeeha et al, (2010)14 studied the surgical and prosthodontics outcome of mandibular
single implant-retained overdenture opposing maxillary complete denture. They used a ball
attachment system. They divided 36 patients into three groups. A single implant was placed in
the mandibular midline to support overdenture. The Control group received the southern
regular implant, one group received the southern 8 mm wide implant and large diameter ball
attachments. Another group received Neoss regular implants and locator attachments. After
one year they found that the success rate was 75% for the Southern regular implant group and

14
100% for the Southern wide implant group. At one year no significant difference in implant
stability was observed. They concluded that mandibular single-implant-retained
overdenture is a successful treatment option for edentulous patients.

[13] Walton et al, (2009)4 compared patient satisfaction and prosthetic outcomes with
mandibular overdentures retained by one or two implants. Subjects wearing conventional
complete dentures were randomized to receive either one midline or two bilateral mandibular
implants followed by a mandibular denture reline to incorporate implant retention. They
indicated on a visual analog scale satisfaction with their dentures before implants and at 2
months and 1 year after implant retention. Satisfaction outcomes between the two groups were
compared using the Wilcoxon/Mann-Whitney nonparametric rank test, while changes within
each group were analyzed using signed-rank tests. Component costs and times for surgery,
prosthodontic treatment, and maintenance were compared using nonparametric and t-tests.
Eighty-six subjects enrolled in this study and 85 completed the 1-year follow-up, at which
median satisfaction was 93 in the single-implant group and 94 in the two-implant group. Within
each group, the median improvement in satisfaction was similarly dramatic and significant.
Prosthodontic maintenance time was similar for both groups, but the single-implant group had
significantly lower component costs and lower times for surgery, postsurgical denture
maintenance, and denture reline. Five implants failed in four subjects, all in the two-implant
group and all before denture reline. They concluded that lower component costs and
treatment times, with comparable satisfaction and maintenance time over the first year,
indicate that a mandibular overdenture retained by a single midline implant may be an
alternative to the customary two-implant overdenture for maladaptive denture patients.

2. Review of computerized occlusal analysis system(T-Scan) and a complete

denture

[14] Floriana et al, (2022)9 In this study author digitally evaluated the static and dynamic
occlusion of patients treated with both conventional complete dentures (CCDs) and implant-
retained removable overdentures (IODs) correlated with two different methods of occlusal
analysis. Eleven edentulous patients were treated with bimaxillary CCDs. Later, mandibular
CCDs were replaced by IODs retained by either two or four implants. The distribution of the
occlusal contacts in static and dynamic occlusion was compared by using the digital method
(DM; T-Scan III) and the analog method (AM; articulating paper). Scores 0, 1, and 2 were
assigned for inadequate, satisfactory, and adequate distribution of the occlusal contacts,
respectively. Significant differences between CCDs and IODs were found in the right lateral

15
mandibular movement as well as in the left lateral mandibular movement). They concluded
that the digital and analog methods showed a significant agreement and moderate
correlation, irrespective of the type of complete denture. The T-Scan III digital system
seems to be a consistent and reproducible method to analyze occlusion

[15] Chaturvedi et al, (2021)13 This study compared the occlusal forces in complete dentures
fabricated by additive, subtractive and conventional techniques with different occlusal
schemes, using a computerized occlusal force analysis system [Tech-Scan III (T-Scan III)].
Three groups (Gr) were made based on techniques of fabrication of CDs: Conventional CDs
(CCD), Subtractive CDs (SCD), and Additive CDs (ACD). Each group of CDs was further
divided into three subgroups based on occlusion schemes: bilateral balanced occlusion (BBO),
lingualized occlusion (LO), and mono-plane occlusion (MO). A total of 45 CDs were made:
15 in each group with 5 CDs of each occlusal scheme. For all samples, occlusal force analysis
(percentage of occlusal force applied on the right and left sides of the arch, centralization of
forces, and percentage of maximum occlusal force) was done using a computerized occlusal
analysis system: T-Scan III. The intergroup comparison revealed statistically significant
differences (p< 0.01) in right-left side force difference, and maximum bite force in CDs
fabricated by various techniques and with different occlusion schemes. Though the effect of
the occlusion scheme was more than the technique of fabrication The maximum force
difference between the right-left side was observed in the combination of the CCD technique
and MO scheme (36.88 ± 2.82 N). Furthermore, the maximum bite force was observed for the
SCD technique (89.14 ± 6.08 N) and LO scheme (92.17 ± 3.22 N). In comparison to ACD, the
chances of the center of force out of ellipse were 2.53 times more in CCS and 0.75 times less
in SCD techniques, and in comparison, to MO, the chances of out of ellipse were 0.298 times
less in BBO and 0.396 times less in LO schemes, though these changes were not statistically
significant (p> 0.05). They concluded that the digital CDs fabricated by the subtractive
technique proved to be superior to the additive technique in terms of occlusal force
analysis on tested parameters. However, further research is needed on patients to
determine the exact superiority of one technique over the other.

[16] Ibraheem et al, (2021)24 This study aimed to evaluate the effect of mandibular complete
dentures relining using soft relining material on the distribution of various occlusal forces using
the T-Scan system. Fifty completely edentulous patients having their conventional complete
dentures earlier fabricated and utilized were selected for this study. Patients included were
controlled diabetics, characterized by having their residual alveolar ridges moderately
developed and lined with firm mucoperiosteum. Mandibular complete dentures were relined
with a soft denture liner and a T-Scan device was used for occlusal force distribution

16
measurement before denture relining and three months thereafter the relining procedure.
Comparison between occlusal forces percentages before and after denture relining revealed
that occlusal forces percentages were significantly lower after denture relining in the anterior
area, significantly higher after denture relining in the right posterior area, where it was
insignificantly higher after relining in the left posterior area. They concluded that the use of
a soft denture liner for mandibular complete denture relining significantly improved the
occlusal load distribution.

[17] Kürklüarpacay et al, (2019)8 conducted a study on 30 subjects of the age group 50-75yr
requiring complete dentures to evaluate premature contacts and occlusal forces for each tooth
in complete dentures before occlusal adjustment. The measurements were made using the T-
Scan. The occlusion was analyzed before and after frames from the T-scan “Force Movies” are
Centric Relation bite recordings. Several practice closures were made until a repeatable pattern
of contacts was seen on the video monitor and the sensor was calibrated. Each subject was
asked to bite on the sensor in a position of maximum intercuspation thus obtaining the location
of each tooth contact. Premature contacts and percentage distribution of forces per tooth were
obtained before and after occlusal adjustment. The worst occlusal balance was recorded in a
patient (F/74) by occlusal force values at right at 5.9% and left 94.1% before occlusal
adjustment. After occlusal adjustment, all patients’ percentage of occlusal balance values was
adjusted at an average of 48.8%, leaving 51.1%. The percentage distribution of forces per tooth
results showed that premature contacts had been observed at posterior teeth on either the right
or left side of occlusion. They concluded that occlusal adjustment is requested for all
complete dentures to prevent patients from muscular pain and/or temporomandibular
disorders.

[18] AfrashtehfarK et al, (2016)17 This article intends to describe the advantages and
limitations of the data acquired when using a computerized occlusal analysis as a dynamic
occlusal indicator.
A search of the literature was completed (Medline, PubMed) using the keywords occlusion,
occlusal registration, computerized occlusal analysis, and T-Scan for dental. According to the
evidence available, the computerized occlusal analysis system is the only occlusal indicator
that demonstrates the ability to provide quantifiable force and time variance in a real-time
window from the initial tooth contact into maximum intercuspation. They concluded that
the computerized occlusal analysis system is a better occlusal indicator when compared
with other non-digital convention indicator materials available.

17
[19] Bozhkova et al, (2016)19 conducted a study to evaluate the T-SCAN III system in
measuring and assessing the forces of occlusal contacts and their digital presence. Thirty
students aged 19 - 22 years were examined. Of these only one matched the study criteria: -
intact dentition; - without or with class I fillings in teeth 36 or 46; - Angle's class I jaw relation.
They used a computerized occlusal analysis system T-SCAN in the study and evaluated the
system's capabilities in registering the occlusal contacts during mastication on an occlusion
film and the occlusal forces using a digital display. The T-SCAN system provides the only
accurate way to determine and evaluate the time sequence and force of occlusal contacts by
converting the qualitative data into quantitative and displaying them digitally.

[20] Basso et al, (2015) 3 evaluated the effect of microwave disinfection protocols on the
occlusal pressure pattern of dentures. constructed for 40 patients divided into groups, Group 1
patients had the maxillary dentures submitted to microwave disinfection, once a week, for 4
weeks, and Group 2: Patients had the maxillary dentures submitted to microwave disinfection,
three times a week, for 4 weeks. Occlusal contacts were recorded on five occasions: 30 days
after denture insertion and before first disinfection (baseline or control group); 1 week after
disinfection; 2 weeks after disinfection; 3 weeks after disinfection; 4 weeks after disinfection.
Occlusal contacts were analyzed by T-Scan III. Intergroup analysis was performed using the
Mann-Whitney test and intragroup analysis using the Friedman test with a significance of 5%.
The results showed no significant difference between groups during the periods. The data on
parameters loss of denture adaptation or complaints showed that patients used their dentures
regularly for eating and expressed comfort and satisfaction
in all experimental periods. The evaluation of functional occlusion revealed that the
distribution of the occlusal contacts remained unaltered after disinfection. hence, Microwave
disinfection protocols as studied in this report did not influence occlusal contacts of the
complete dentures.

3. Review of computerized occlusal analysis system and implant-retained

overdenture

[21] Kabbua et al, (2020)11 conducted a study to evaluate occlusal pattern and chewing force
distribution in mini dental implant-retained mandibular overdentures by computerized occlusal
analysis system and to compare patient satisfaction after a 1-year function. Thirty-one patients
wearing complete dentures were included in the study. Before mini-dental implant-retained
treatment, all patients were assessed for occlusion and force distribution using a computerized
occlusal analysis system (T-Scan®), and then, all patients received two mini-dental implant-
retained mandibular overdentures. Mini-dental implants were immediately loaded using low
vertical profile attachments (Equator®). T-Scan® was used to evaluate chewing force and

18
force distribution at 1 day, 3 months, 6 months, and 12 months. The patient's satisfaction before
implant placement and after 1 year was evaluated using questionnaires. Clinical evaluation of
two mini-dental implant-retained mandibular overdentures showed a 100% success rate after 1
year. T-Scan® demonstrated that the maximum occlusal contact force increased continuously.
At 1-year follow-up, overall patient satisfaction was significantly greater than before receiving
mini-dental implant treatment (P < .001). They concluded that using computerized occlusal
analysis, mini-dental implants improve complete denture function significantly in terms
of maximum occlusal contact force, and tooth contact number without the impairment of
force distribution.

[22] Zayed et al, (2018)10 conducted a study to evaluate the effect of the digital occlusal
adjustment on the radiographic outcome and masticatory efficiency of mandibular implant-
retained overdentures. Fourteen edentulous male patients were selected, and Four implants
were inserted at the interforaminal area for all patients. After three months of osseointegration
period, all patients were recalled for denture construction and loading the implants with ball
& socket attachments. Patients were divided into two groups: Group I received their dentures
after occlusal adjustment by a selective grinding method using articulating paper only, while
group II received their dentures after an additional step of occlusal adjustment using the T-
scan III before articulating paper. Patients were recalled for follow-up at 1 week, 6 months,
and 12 months to evaluate the bone loss, bone density differences, and masticatory efficiency
using ViewGum® software. Two Trident® chewing gums of different colors were asked to
be chewed by the patients for 5, 10, 20, 30, and 50cycles. There were significant differences
in bone loss around the implants during the follow-up period which was less with dentures
that underwent occlusal digital adjustment than using articulating paper only. The bone
density from the 1-week baseline showed to be increasing in the T-scan III group (Group II)
but insignificant except at the distal and mesial surfaces of both implants at the premolar area
compared to their counterpart in the other group. Regarding the ViewGum analysis, chewing
cycles showed to be the most reliable cycles test as it was the only test producing realistic
results.

[23] Khuder et al, (2017) 12 conducted a study to compare residual ridge resorption (RRR)
of anterior and posterior maxillary and mandibular edentulous ridges, in patients treated with
mandibular implant overdentures (IOD) and compare with conventional complete dentures
(CD), and to determine at each location, the association of RRR with the occlusal forces
distribution. The anterior and posterior RRR of IOD (6 males, 17 females) and CD (12
males,11 females) were determined using baseline and follow-up dental panoramic
radiographs (DPT), (mean intervals 4±1.8 years). The bone ratios were calculated using

19
proportional area; anatomic to fixed reference areas, and the mean difference of ratios
between the intervals determined RRR. The ridge locations included anterior and posterior
maxillary and posterior mandibular arches. The T-Scan III digital occlusal system was used
to record anterior and posterior percentage occlusal force (%OF) distributions. There were
significant differences in anterior and posterior %OF between treatment groups.). Resorption
was observed in IOD compared to CD groups, with an 8.5% chance of less resorption in the
former and 7.8% in the latter location.

20
 Assessed for eligibility (n= 26)

Excluded (n=0 )
Enrollment Not meeting inclusion criteria (n= 0)
Declined to participate (n= 0 )
Other reasons (n=0)

Randomized (n= 26)

Allocated to intervention (n=13)

Received allocated intervention (n=11) Allocated to intervention (n=13 )
Did not receive allocated intervention (give Received allocated intervention (n=11 )
reasons) (n=0) Allocation Did not receive allocated intervention
(give reasons) (n=0 )
-

Lost to follow-up (give reasons) (n= 0 ) Lost to follow-up (give reasons) (n= 0 )
Discontinued intervention (give reasons) Follow-Up Discontinued intervention (give reasons) (n=0)
(n=0)

Analysed (n=11 ) Analysis Analysed (n= 11 )

Excluded from analysis (patient didn’t Excluded from analysis (patient didn’t
report) (n= 2 ) report) (n=2)

21
GROUP A (Implant retained overdenture

Placement of implant with open flap

technique

Stage two surgery after 3 months

Conventional procedure of denture

fabrication till try - in

Chair side pick up of attachment into

denture base

Delivery of implant retained mandibular

overdenture

Recall patient after 48 hours *

Same procedure repeated after 3month and

6month

Fig:2 Methodology flow chart, Group A (Implant retained overdenture)

22
GROUP B (conventional complete denture)

Primary impression and final

impression

Try in and packing of denture

lab remount,Occlusal adjustment,finishing

and polishing of denture

Delivery of denture

Recall patient after 48 hours*

Same procedure repeated after 3month

and 6month of denture delievery

Fig:3 Methodology flow chart, Group B (Conventional complete denture

23
RESULTS

This in vivo study was undertaken to evaluate the number of tooth contacts, percent biting
occlusal force, and percent force distribution between left and right side in centric occlusion
in cases with single implant-retained mandibular overdenture or conventional complete
denture using computerized occlusal analysis system after 48hr, 3month and 6month of
insertion of the denture.

A sample size of 22 was calculated, 26 patients were enrolled in the study following the
inclusion and exclusion criteria keeping in view the dropouts and clinical complications.
Patients were divided into two groups (A and B) based on a computer-generated
randomization table with 13 patients in each group. 2 patients in each group didn’t report for
further evaluations. 22 patients (11 in each group) completed the study. Group
A(experimental) consists of 11 patients (male= 10, female=1) who were rehabilitated with
single implant-retained overdenture, and Group B (control group) consists of 11 patients
(male= 9, female=2) who were rehabilitated with a conventional complete denture. The mean
age of the subjects in the experimental group was 58.45 years, in the control, the group was
59.1 years. No statistical difference was found between the age and gender of both
groups(p=0.8). The minimum period of edentulism was 6 months and the maximum period of
edentulism was 1 year (the average period of edentulism in group A was (8.12± 3.5 months)
and the average period of edentulism in group B was (7.62± 2.5 months). There was no
statistically significant difference between the period of edentulism between the two groups
(p= 0.78). Dentures were evaluated at 3 different time intervals T1 (48 hours after denture
insertion), T2(3 months after denture insertion), and T3 (6 months after denture insertion). At
each recall visit, a T scan was done and at each instance number of occlusal tooth contacts,
percent biting occlusal force, and percent force distribution between the left and right side
were noted. Data were recorded on Microsoft excel spreadsheets. All the entries were double-
checked for any possible keyboard error and further analysed with a statistical software
program (Stata 14.0; Stata- Corp LLC). Quantitative variables were summarized as mean and
standard deviation. Approximate normality was tested by using the Shapiro- Wilk test for
quantitative data. Data were normally distributed and for comparison of age groups
independent t-test was used. For intergroup comparison of parameters between group A and
group B at various timelines individually, an unpaired t-test was used. For intragroup
comparison (assessment of change from T1 to T3) within the number of occlusal contacts,

24
percent force distribution between left and right side, and percent biting occlusal force,
repeated measure ANOVA was used. For multiple pairwise comparisons within intragroup
i.e., to check which pair of the timeline is significantly different Paired t-test was used.

Comparison of age group using an independent t-test and gender using a chi-square test are
seen in Tables 1 and 2 respectively. The mean and standard deviation values of the number of
occlusal tooth contacts, percent force distribution between left and right side, and percent biting
occlusal force at different time intervals in both groups are seen in Tables 3, and 4, 5
simultaneously. Intergroup comparison between the number of occlusal tooth contacts,
percent force distribution between left and right side and percent biting occlusal force using
unpaired t-tests are seen in tables 6, 7, and 8. Intragroup comparison within groups A and B
using repeated measure ANOVA of the number of occlusal tooth contacts, percent force
distribution between left and right side and percent biting occlusal force are seen in Tables 9,
10, and 11. Multiple pairwise comparisons within intragroup using paired t-tests for the
number of occlusal tooth contacts, percent force distribution between left and right side, and
percent biting occlusal force are seen in tables 12, 13, and 14.

Results were tabulated as follows:

25
 TABLE 1: COMPARISON OF AGE BETWEEN BOTH GROUPS

Group N Mean Std. Deviation Std. Error Mean P value

A 11 58.45 10.55 3.18
.8
B 11 59.10 7.49 2.37

Table 1 represents a comparison of age between two groups using an independent t-test. The
test shows that there is no significant difference in age between both groups.

TABLE 2: COMPARISON OF GENDER BETWEEN BOTH GROUPS

Group A Group B
Gender P value
N % N %
Male 10 90.9 9 80.0
Females 1 9.1 2 20.0 .8
Total 11 100.0 11 100.0

Table 2 represents a comparison of age between two groups using the chi-square test. The test
shows that there is no significant difference in gender between both groups.

TABLE 3: NUMBER OF OCCLUSAL TOOTH CONTACTS AT DIFFERENT TIME

INTERVALS IN GROUP A AND GROUP B

Number of occlusal T1(mean ± SD) T2(mean ± SD) T3(mean ± SD)

tooth contacts
Group A 17.36 ±1.68 17.27 ±3.00 17.63 ±3.17
Group B 16.80 ±3.85 17.90 ±2.96 17.60 ±2.71

Table 3 represents the number of occlusal tooth contacts at different time intervals T1 (48 hours of
denture insertion), T2 (3 months after denture insertion), T3(6 months after denture insertion) in
group A(experimental), and group B(control)

26
TABLE 4: PERCENT FORCE DISTRIBUTION BETWEEN LEFT AND RIGHT
SIDES AT DIFFERENT TIME INTERVALS IN GROUP A AND GROUP B

Left side(in%) Right side (in %)

Timeline T1(mean ±SD) T2(mean ±SD) T3(mean ±SD) T1(mean ±SD) T2(mean ±SD) T3(mean ±SD)

Group B 51.16 ±3.55 51.80 ±0.60 52.40 ±1.13 48.84 ±3.55 48.20 ±0.60 47.60 ±1.13

For Group A

Timeline Left side (mean ±SD) Right side (mean ±SD)

T1 52.33 ±2.22 47.66 ±2.22
T2 51.63 ±1.62 48.36 ±1.62
T3 52.48 ± 1.84 47.51 ±1.84

For Group B

Timeline Left side (mean ±SD) Right side (mean ±SD)

T1 51.16 ±3.55 48.84 ±3.55
T2 51.80 ±0.60 48.36 ±1.62
T3 52.40 ±1.13 47.60 ±1.13

Table 4 represents percent force distribution between the left and right side at different time
intervals T1 (48 hours of denture insertion), T2 (3 months after denture insertion), T3(6 months after
denture insertion) in group A(experimental), and group B(control)

27
TABLE 5: PERCENT BITING OCCLUSAL FORCE AT DIFFERENT TIME
INTERVALS IN GROUP A AND GROUP B

Timeline T1 (mean ±SD) T2 (mean ±SD) T3 (mean ±SD)

Group A 99.02 ±0.68 99.05 ±0.48 99.06 ±0.55
Group B 99.16 ±1.00 99.24 ±1.07 99.26 ±0.65

Table 5 represents the percent maximum biting occlusal force at different time intervals T1 (48
hours of denture insertion), T2 (3 months after denture insertion), T3(6 months after denture insertion)
in group A(experimental), and group B(control)

TABLE 6: COMPARISON OF THE NUMBER OF OCCLUSAL TOOTH CONTACTS AT

DIFFERENT TIME INTERVALS BETWEEN GROUP A AND GROUP B (INTERGROUP
COMPARISON)

Mean SEM 95% CI

Timeline Group (Number of occlusal SD Upper Lower P value
tooth contacts)
A 17.36 1.69 .51 -2.11 3.23
T1 .66
B 16.80 3.85 1.21
A 17.27 3.00 .90 -3.35 2.10
T2 .63
B 17.90 2.96 .94
A 17.64 3.17 .96 -2.67 2.75
T3 .97
B 17.60 2.72 .86

Table 6 represents a mean change in the number of occlusal tooth contacts at different time intervals
T1 (48 hours of denture insertion), T2 (3 months after denture insertion), and T3(6 months after
denture insertion) between group A and group B. Unpaired t-test was used to compare the number of
occlusal tooth contacts at different time intervals. Statistical analysis showed there is no
significant change in the Number of occlusal contacts between groups A and B at 3 observed
time intervals.

28
TABLE 7: COMPARISON OF PERCENT FORCE DISTRIBUTION BETWEEN
LEFT AND RIGHT SIDES AT DIFFERENT TIME INTERVALS BETWEEN GROUP A
AND GROUP (INTERGROUP COMPARISON)

% Mean 95% CI
Std.
Side Timeline Group (Force P value
Deviation Upper Lower
distribution)
A 52.34 2.23 -1.51 3.86
T1 .37
B 51.16 3.56
A 51.64 1.62 -1.30 0.97
Left T2 .76
B 51.80 o.60
A 52.48 1.84 -1.33 1.49
T3 .90
B 52.40 1.13
A 47.66 2.23 -3.86 1.51
T1 .37
B 48.84 3.56
A 48.36 1.62 -.97 1.30
Right T2 .76
B 48.20 0.60
A 47.51 1.84 -1.49 1.33
T3 .90
B 47.60 1.13

Table 7 represents a mean change in percent force distribution between left and right sides at
different time intervals T1 (48 hours of denture insertion), T2 (3 months after denture insertion), and
T3(6 months after denture insertion) between group A and group B. Independent sample t-test was
used to compare the percent force distribution between left and right sides. Statistical analysis
showed there is no significant change in the percent force distribution within the left and right
sides between groups A and B at 3 observed time intervals.

29
TABLE 8: COMPARISON OF PERCENT BITING OCCLUSAL FORCE AT
DIFFERENT TIME INTERVALS BETWEEN GROUP A AND GROUP B (INTERGROUP
COMPARISON)

% Mean 95% CI
(Biting
TIMELINE Group SD P value
occlusal SEM
force) Upper Lower
A 99.02 0.69 0.21 -0.92 0.64
T1 .70
B 99.16 1.01 0.32
A 99.06 0.49 0.15 -0.94 0.56
T2 .60
B 99.25 1.07 0.34
A 99.07 0.55 0.17 -0.73 0.36
T3 .48
B 99.25 0.65 0.20

Table 8 represents a mean change in percent maximum biting occlusal force at different time
intervals T1 (48 hours of denture insertion), T2 (3 months after denture insertion), and T3(6 months
after denture insertion) between group A and group B. Independent sample t-test was used to compare
the percent maximum biting occlusal force. Statistical analysis showed there is no significant
change in the percent biting occlusal force at 3 observed time intervals

TABLE 9: INTRAGROUP COMPARISON OF THE NUMBER OF OCCLUSAL TOOTH

CONTACTS WITHIN EACH GROUP AT DIFFERENT TIME INTERVALS

Mean (number of occlusal tooth

Group Timeline SD P value
contact)
T1 17.36 1.69
A T2 17.27 3.00 .73
T3 17.64 3.17
T1 16.80 3.85
B T2 17.90 2.96 .54
T3 17.60 2.71

Table 9 represents mean change in the number of occlusal tooth contacts at different time intervals T1
(48 hours of denture insertion), T2 (3 months after denture insertion), and T3(6 months after denture
insertion) within group A and group B. Repeated measure ANOVA was used to compare the number
of occlusal tooth contacts at different time intervals. Statistical analysis showed there is no

30
significant change in the Number of occlusal contacts within groups A and B at different time
intervals.

TABLE 10: INTRAGROUP COMPARISON OF PERCENT FORCE DISTRIBUTION

BETWEEN LEFT AND RIGHT SIDES WITHIN EACH GROUP AT DIFFERENT TIME
INTERVALS

%Mean 95% CI
(Percent force
Group Timeline SD P value
distribution for
right side)
T1 47.66 2.23 46.17 49.16

A T2 48.36 1.62 47.27 49.45 .59

T3 47.52 1.84 46.28 48.75

T1 48.84 3.56 46.29 51.39

B T2 48.20 0.60 47.77 48.63 .27

T3 47.60 1.13 46.79 48.41

%Mean
(Percent force 95% CI
Group Timeline SD P value
distribution for
left side)
T1 52.34 2.23 50.83 53.83

A T2 51.64 1.62 50.55 52.72 .14

T3 52.48 1.84 51.25 53.71

T1 51.16 3.56 48.61 53.71

B T2 51.80 0.60 51.37 52.23 .27

T3 52.40 1.13 51.59 53.21

Table 10 represents a mean change in percent force distribution between the left and right side at
different time intervals T1 (48 hours of denture insertion), T2 (3 months after denture insertion), and
T3(6 months after denture insertion) within group A and group B. Repeated measure ANOVA was
used to compare the percent force distribution between left and right sides. Statistical analysis
showed there is no significant change in the percent force distribution between the left and right
sides within groups A and B at different time intervals.

31
TABLE 11: INTRAGROUP COMPARISON OF PERCENT BITING OCCLUSAL FORCE
WITHIN EACH GROUP AT DIFFERENT TIME INTERVALS BY USING REPEATED
MEASURE ANOVA

Std.
% Mean (biting occlusal
Group Timeline Deviati F P value
force)
on
T1 99.02 .69

A T2 99.06 0.49 .01 .98

T3 99.07 0.55

T1 99.16 1.01

B T2 99.25 1.07 .05 .95

T3 99.25 0.65

Table 11 represents a mean change in the percent biting occlusal force at different time intervals T1
(48 hours of denture insertion), T2 (3 months after denture insertion), and T3(6 months after denture
insertion) within group A and group B. Repeated measure ANOVA was used to compare the percent
biting occlusal force at different time intervals. Statistical analysis showed there is no
significant change in the percent biting occlusal force within groups A and B at different time
intervals.

32
TABLE 12: PAIRWISE COMPARISON OF THE NUMBER OF OCCLUSAL TOOTH
CONTACTS AT DIFFERENT TIME INTERVALS (1,2,3 MEANS T1, T2, T3
RESPECTIVELY) WITHIN GROUP A AND B

Group (I) Timeline (J) Timeline Mean Difference P value 95% Confidence Interval for
(I-J) Difference
(Number of Lower Bound Upper Bound
occlusal tooth
contacts)
2 0.09 1 -2.52 2.70
1
3 -0.27 1 -2.84 2.30
1 -0.09 1 -2.70 2.52
A 2
3 -0.36 1 -1.60 0.88
1 0.27 1 -2.30 2.84
3
2 0.36 1 -0.87 1.60
2 -1.10 .78 -3.78 1.58
1
3 -0.80 1 -3.15 1.55
1 1.10 .78 -1.58 3.78
B 2
3 0.30 1 -1.51 2.11
1 0.80 1 -1.55 3.15
3
2 -0.30 1 -2.10 1.51

Table 12 represents a pairwise comparison of the number of occlusal contacts at different

time intervals within groups A and B. Statistical analysis showed there is no significant
difference in the number of occlusal contacts within groups A and B at various pairwise
timeline comparisons.

33
TABLE 13a: PAIRWISE COMPARISON OF PERCENT FORCE DISTRIBUTION
BETWEEN LEFT AND RIGHT SIDE AT DIFFERENT TIME INTERVALS
(1,2,3 MEANS T1, T2, T3 RESPECTIVELY) WITHIN GROUP A

Group (I) Timeline (J) Timeline % Mean P value 95% Confidence Interval for

A Difference (I-J) Difference

(force Lower Bound Upper Bound
distribution)
2 0.70 1 -1.94 3.33
1
3 -0.14 1 -2.84 2.55
1 -0.70 1 -3.34 1.94
Left side 2
3 -0.84 .72 -2.79 1.10
1 0.14 1 -2.55 2.84
3
2 0.85 .72 -1.10 2.79
2 -0.70 1 -3.33 1.94
1
3 0.14 1 -2.55 2.84
Right 1 0.70 1 -1.93 3.34
2
side 3 0.84 .72 -1.10 2.79
1 -0.14 1 -2.84 2.55
3
2 -0.84 .72 -2.79 1.10

34
TABLE 13b: PAIRWISE COMPARISON OF PERCENT FORCE DISTRIBUTION
BETWEEN LEFT AND RIGHT SIDE AT DIFFERENT TIME INTERVALS
(1,2,3 MEANS T1, T2, T3 RESPECTIVELY) WITHIN GROUP B

Group (I) Timeline (J) Timeline % Mean P value 95% Confidence Interval for
B Difference (I-J) Difference
(force Lower Bound Upper Bound
distribution)
2 -0.64 1 -4.13 2.85
1
3 -1.24 1 -4.94 2.46
1 0.64 1 -2.85 4.13
Left 2
3 -0.60 .31 -1.57 0.37
1 1.24 1 -2.46 4.94
3
2 0.60 .31 -0.37 1.57
2 0.64 1 -2.85 4.13
1
3 1.24 1 -2.46 4.94
Right 1 -0.64 1 -4.12 2.85
2
side 3 0.60 .31 -0.37 1.57
1 -1.24 1 -4.94 2.46
3
2 -0.60 .31 -1.57 0.37

Table 13 represents a pairwise comparison of percent force distribution between the left and
right sides at different time intervals within groups A and B. Statistical analysis showed there
is no significant difference in percent force distribution between the left and right sides within
groups A and B at various pairwise timeline comparisons.

35
TABLE 14: PAIRWISE COMPARISON OF PERCENT BITING OCCLUSAL FORCE
AT DIFFERENT TIME INTERVALS (1,2,3 MEANS T1, T2, T3 RESPECTIVELY)
WITHIN GROUP A AND B

Group (I) factor1 (J) factor1 % Mean P value 95% Confidence Interval for
Difference (I-J) Difference
(Percent Biting Lower Bound Upper Bound
occlusal force)
2 -0.04 .89 -0.63 0.55
1
3 -0.05 .86 -0.63 0.53
1 0.04 .89 -0.55 0.63
A 2
3 -0.01 .96 -0.47 0.45
1 0.05 .86 -0.53 0.63
3
2 0.01 .96 -0.45 0.47
2 -0.08 .86 -1.10 0.94
1
3 -0.09 .78 -0.78 0.60
1 0.08 .86 -0.94 1.11
B 2
3 -0.01 .98 -0.51 0.50
1 0.09 .78 -0.60 0.78
3
2 0.01 .98 -0.50 0.51

Table 14 represents a pairwise comparison of the percent biting occlusal force at different
time intervals within groups A and B. Statistical analysis showed there is no significant
difference in the percent biting occlusal force within groups A and B at various pairwise
timeline comparisons.

36
GRAPHS

1. Number of occlusal tooth contacts at different

time intervals in both the groups (intergroup)

Number of occlusal tooth contacts - Intergroup

20
17.64 17.90 17.60
18 17.36 17.27
16.80
16

14

12

10

0
A B

T1 T2 T3

Graph 1 represents a mean change in number of occlusal tooth contacts at different time intervals T1
(48 hours of denture insertion), T2 (3 months after denture insertion), and T3(6 months after denture
insertion) between group A and group B. Graph showed there is no significant change in the
number of occlusal tooth contacts between group A and B at 3 observed time intervals.

37
2. Percent force difference for left side at different
time intervals in both the groups(intergroup)

Percent Force difference - Left Side- Intergroup

60
52.34 51.64 52.48 51.16 51.80 52.40
50

40

30

20

10

0
A B

T1 T2 T3

Graph 2 represents a mean change in percent force distribution for left side at different time
intervals T1 (48 hours of denture insertion), T2 (3 months after denture insertion), and T3(6 months
after denture insertion) between group A and group B. Graph showed there is no significant change
in the percent force distribution for left side between group A and B at 3 observed time
intervals.

38
3. Percent force difference for right side at different
time intervals in both the groups(intergroup)

Percent Force difference - Right Side- Intergroup

60

47.66 48.36 47.52 48.84 48.20 47.60

50

40

30

20

10

0
A B

T1 T2 T3

Graph 3 represents a mean change in percent force distribution for right side at different time
intervals T1 (48 hours of denture insertion), T2 (3 months after denture insertion), and T3(6 months
after denture insertion) between group A and group B. Graph showed there is no significant change
in the percent force distribution for right side between group A and B at 3 observed time
intervals

39
4. Percent biting occlusal force at different time
intervals in both the groups(intergroup)

Percent biting occlusal force - Intergroup

120

99.02 99.06 99.07 99.16 99.25 99.25

100

80

60

40

20

0
A B

T1 T2 T3

Graph 4 represents a mean change in percent maximum biting occlusal force at different time
intervals T1 (48 hours of denture insertion), T2 (3 months after denture insertion), and T3(6 months
after denture insertion) between group A and group B. Graph showed there is no significant change
in the percent biting occlusal force at 3 observed time intervals

40
5. Number of occlusal tooth contacts at different
time intervals in both the groups (intragroup)

Number of Occlusal contacts

20
17.9 17.64 17.6
18 17.36 17.27
16.8
16

14

12

10

0
48 hours 3 months 6 months

Group A Group B

Graph 5 represents an intragroup comparison of number of occlusal tooth contacts at different time
intervals T1 (48 hours of denture insertion), T2 (3 months after denture insertion), and T3(6 months
after denture insertion) within group A and group B. Graph showed there is no significant change
in the number of occlusal tooth contacts within group A and B at 3 observed time intervals.

41
6. Percent force distribution for left side at different
time intervals in both the groups(intragroup)

Percent force difference - Left Side

60
52.34 51.16 51.64 51.80 52.48 52.40
50

40

30

20

10

0
48 hours 3 months 6 months

Group A Group B

Graph 7 represents an intragroup comparison of percent force distribution for left side at different
time intervals T1 (48 hours of denture insertion), T2 (3 months after denture insertion), and T3(6
months after denture insertion) within group A and group B. Graph showed there is no significant
change in the percent force distribution for left side within group A and B at 3 observed time
intervals.

42
7. Percent force distribution for right side at
different time intervals in both the
groups(intragroup)

Percent force difference - Right Side

60

47.66 48.84 48.36 48.20 47.52 47.60

50

40

30

20

10

0
48 hours 3 months 6 months

Group A Group B

Graph 7 represents an intragroup comparison of percent force distribution for right side
at different time intervals T1 (48 hours of denture insertion), T2 (3 months after denture
insertion), and T3(6 months after denture insertion) within group A and group B. Graph
showed there is no significant change in the percent force distribution for right

side within group A and B at 3 observed time intervals.

43
8. Percent biting occlusal force at different time
intervals in both the groups(intragroup)

Maximum Occlusal biting force

120

99.02 99.163 99.0573 99.247 99.0673 99.253

100

80

60

40

20

0
48 hours 3 months 6 months

Group A Group B

Graph 8 represents an intragroup percent maximum biting occlusal force at different time intervals
T1 (48 hours of denture insertion), T2 (3 months after denture insertion), and T3(6 months after
denture insertion) within group A and group B. Graph showed there is no significant change in the
percent biting occlusal force at 3 observed time intervals

44
DISCUSSION

There are conditions where conventional complete dentures will not be successful like in
cases with highly resorbed ridges, or deficient residual ridges due to trauma or surgery. In
such cases, implant retained mandibular overdenture is advisable.20 But in certain cases,
placement of two implants may not be possible due to insufficient available bone,28 or in
situations where the patient cannot afford the cost of two implant-retained overdenture, in
such cases a single implant can be used to enhance the retention and stability of the complete
denture.4,29,30

Swarup et al. 201631 found better improvement in the OHRQoL (Oral Health-Related
Quality of Life) with the use of ball attachment as compared to the locator in single implant
retained overdenture. While in another study, the locator was found superior to the ball and
bar attachments, in the rate of prosthodontic complications and maintenance of attachment
further32. Ball attachment is often employed in single implants because its elastic retainer
allows for the slight rotation of the over-denture and passes the load to surrounding bone
tissue. Although ball attachment suits the requirement of implant mucosa-supported
overdenture by balancing the axial load and preventing perio-implant bone tissue damage, the
high maintenance cost of this attachment type has limited its application

The implants were placed in the anterior area of mandible. This region is the preferred site in
single implant-retained overdenture because of the thicker cortical bone, lowered surgery risk
by avoiding the inferior alveolar nerve and blood vessels, and, finally, a larger tissue-
supporting area to prevent overloading on implant. Although there was some concern
regarding the potential risk of mandibular fracture because of the anatomical structure there
was little difference found between the risk anticipate for overdentures retained by one
implant and those retained by two implants.

There are studies in literature on comfort28,33, masticatory efficiency29, quality of life24,

residual ridge resorption24, type of attachment14 to be used with single implant retained
overdenture. To date, there is no study comparing the changes in maximum occlusal force
and changes in the distribution of occlusal contact after the use of conventional complete
denture and single implant retained overdenture.

The CDs that provide esthetics with efficient function are considered successful. The
functional aspect is mostly affected by the occlusal parameters thus in this study we assessed
the number of occlusal tooth contacts, percent force distribution between the left and right
side and percent biting occlusal force generated in complete occlusion, this was evaluated 48
hours, 3 months, and 6 months after denture delivery. Final measurement was done after 6

45
months of denture insertion as Goiato et al. suggested that >5 months is needed to evaluate
patient adaptation and functional Capacity with new complete dentures.41

The occlusal parameters were analysed digitally using a computerized method viz. T-Scan
III. It is considered suitable, precise, and reliable for occlusal analysis. The T-Scan III system
proved to be beneficial as it is a rapid and accurate system in identifying the distribution of
the loads, regions of excessive force the uneven force’s concentration, and occlusal force
summation which would not be possible with the conventional way of occlusal assessment
like articulating paper. Although the thickness of the articulating paper may vary from 25 to
100 μm, the physiological displacement of the edentulous ridge has been reported to be larger
than 500 μm37,38. Research has indicated that compared with evaluating the occlusion of
dentures on an articulator, marking the occlusal contact points with articulating paper in the
patient’s mouth directly creates more spurious and false marks, regardless of whether the
dentures have been stabilized 40. Furthermore, it is difficult to check the occlusal status of
each pair of molars individually intraorally. Mpungose et al.39 established the low accuracy
and poor reliability of evaluating the occlusal status by visual inspection only. The false,
unclear marks lead to unnecessary grinding of the artificial teeth, decreasing the longevity of
the dentures.

Although several investigators supported the efficacy and reliability of T-Scan, the thickness
of sensor (100 microns), which is ~4 to 12 times higher than physiologic vertical tooth
movement (8–28 microns) in clinically healthy tooth, may interfere the patient biting into the
same MIP. This may result in high variation in relative bite force of each subject. To
overcome this problem, the average data of three repeated closures were used46.

Occlusal harmony is important for CDs comfort. The most accepted and reported occlusal
scheme, bilateral balanced occlusion for Conventional complete dentures was included in this
study and evaluated for both conventional complete denture and single implant-retained
mandibular overdenture.

Result of the present study in 28 patients showed there was no significant changes in number
of occlusal tooth contacts, percent force distribution between left and right side and percent
biting occlusal force between both the groups over a period of 6 months (p<0.05). Intragroup
comparison (assessment of change from T1 to T3) within group A and B for the number of
occlusal contacts, percent force distribution between left and right side, and percent biting
occlusal force showed no significant changes within both the groups (p<0.05). In multiple
pairwise comparisons within intragroup to check which pair of the timeline is significantly
different from other also shows no significant difference in all the 3 parameters at various
pairwise timeline comparisons (p<0.05).

46
There was no change in the number of occlusal tooth contacts within and in between both the
groups over a period of 6 months. After 48 hours of denture insertion there was no significant
difference between patients in both groups. It measures 17 for both conventional complete
denture and single implant retained overdenture. After 3 months and 6 months of denture
insertion also there is not much of significant difference in number of occlusal contacts between
patients in both groups with slight statistically insignificant increase from 48 hours to 6months
after denture delivery i.e., 18 in both groups. The possible reason could be as in both the
groups bilaterally balanced occlusion denture after lab remounting was given and as
documented by Neil that “When cases are mounted upon a precision instrument and
balanced, this balance will be fairly well maintained for a period of one year, at which time
the occlusion should be re-balanced.” He also proposed patients should have new dentures at
the end of the fifth year due to periodically clinical remounts leading to a severe loss of the
vertical dimension eventually35. The other possible reason could be resiliency effect of
mucosa as Heartwell and Rahn36 claimed, that the remaining discrepancies after remounting
are so negligible that the resilience of the supporting tissues accommodates for the error.
Surprisingly, the resilience of the supporting tissue in conventional complete denture
treatment is a double-edged sword. Although the resilience of tissues hinders accurate
adjustments from being carried out intraorally, this property also helps patients cope with the
minor occlusal interferences of their dentures. One of the goals of remounting is to minimize
occlusal discrepancies and make those discrepancies minor enough for the supporting tissue
to compensate.
Percent mean biting occlusal force is an important variable for masticatory function evaluation.
from the action of jaw elevator muscles modified by craniofacial biomechanics. After 48
hours of denture insertion there was no significant difference between patients in both groups. It
measures 99.16% for conventional complete denture while it measures 99.02% or single implant
retained overdenture. After 3 months and 6 months of denture insertion also there is not much of
significant difference in percent mean biting occlusal force between patients in both groups with
slight statistically insignificant increase and remain constant after 3 months in both groups. The
possible reason could be as there was only 3 months between measurements after which patient
might get adaptated to new prosthesis. Borie et al42 found that mean biting force in newton was
found to increase significantly after 1 month of use. The possible reason of high percent biting
occlusal force in both groups could be as in both the groups majorly males are present and as
explained in some studies43,44,45, masseter muscle in males have larger diameter fibers and
greater cross-sectional areas than that of females.

There was no change in the percent force distribution between left and right side within and
in between both the groups over a period of 6 months. This may be attributed to the old age

47
of participated patients and/or restricting inclusion criteria with good bone quality and high
primary implant stability. Owing to the decline of occlusal support and general health with
aging, there is a decline in occlusal force. It is also not known whether the findings would
apply to younger populations with single implant retained mandibular overdentures. It was
observed that Percent mean force distribution is higher on left side than right side in both the
groups as that was dominant chewing side in most of the patients. This is in accordance with
the results of Rismanchian et al47, who observed significantly increased bite force in the
dominant chewing side of patients using conventional dentures and implant-supported
overdentures.

The current study has a limitation of short follow-up period and small number of participants

48
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