medicina
Article
Clinical Peri-Implant Parameters and Marginal Bone Loss for
Early Mandibular Implant Overdentures: A Follow-Up of
60 Months
Abdulaziz A. AlHelal 1, *, Abdulaziz A. Alzaid 2,3 , Saad H. Almujel 1 , Mohammed Alsaloum 2,3 ,
Khalid K. Alanazi 4 , Ramzi O. Althubaitiy 5 and Khulud A. Al-Aali 6
Citation: AlHelal, A.A.; Alzaid, A.A.;
Almujel, S.H.; Alsaloum, M.; Alanazi,
K.K.; Althubaitiy, R.O.; Al-Aali, K.A.
Clinical Peri-Implant Parameters and
Marginal Bone Loss for Early
Mandibular Implant Overdentures: A
Follow-Up of 60 Months. Medicina
2024, 60, 588. https://doi.org/
10.3390/medicina60040588
Academic Editor: Bruno Chrcanovic
Received: 28 February 2024
Revised: 25 March 2024
Accepted: 25 March 2024
Published: 31 March 2024
Copyright: © 2024 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Medicina 2024, 60, 588. https://doi.org/10.3390/medicina60040588
1 Department of Prosthetic Dental Sciences, College of Dentistry, King Saud University,
P.O. Box 21069, Riyadh 11475, Saudi Arabia; salmujel@ksu.edu.sa
2 Restorative and Prosthetic Dental Science Department, College of Dentistry, King Saud Bin Abdulaziz
University for Health Sciences, Riyadh 11426, Saudi Arabia; zaidab@ksau-hs.edu.sa (A.A.A.);
saloumm@ksau-hs.edu.sa (M.A.)
3 King Abdullah International Medical Research Center, Riyadh 11426, Saudi Arabia
4 Conservative Dental Science Department, College of Dentistry, Prince Sattam Bin Abdulaziz University,
Al-Kharj 11942, Saudi Arabia; kk.alanazi@psau.edu.sa
5 Department of Prosthodontics, College of Dentistry, Prince Sattam Bin Abdulaziz University,
Al-Kharj 11942, Saudi Arabia; r.althubaitiy@psau.edu.sa
6 Department of Clinical Dental Sciences, College of Dentistry, Princess Nourah Bint Abdulrahman University,
P.O. Box 84428, Riyadh 11671, Saudi Arabia; kaalaali@pnu.edu.sa
* Correspondence: abalhelal@ksu.edu.sa; Tel.: +966-013477303
Abstract: Background and Objectives: Despite the identified benefits of early implant loading, studies
have questioned its advantages compared to delayed loading in edentulous patients. This study
aimed to evaluate clinical peri-implant parameters and marginal bone loss around early placed and
loaded mandibular implant overdentures with a 60-month follow-up. Materials and Methods: In this
prospective cohort study, 43 patients were enrolled to receive 86 early loading sub-crestal dental
implants through prosthetic guides. Implant overdentures were supported by two isolated implant
locator attachments between two mental foramens. Clinical peri-implant parameters, including
plaque index (PI), bleeding index (BI), peri-implant pocket depth (PIPD), and marginal bone loss
(MBL) were evaluated using standardized techniques at 1, 12, 24, 36, 48, and 60 months follow-up.
At 60 months, complications associated with implant overdentures (IOD’s) were noted. The mean
comparison of peri-implant clinical parameters was performed through ANOVA test. A p-value of
≤0.05 was taken as significant. Results: Out of the total 43 enrolled patients, 8 patients were lost
during follow-up; as a result, 35 patients completed the 5 years follow-up. The mean values of PI,
BI, and PIPD increased with no statistical difference (p > 0.05). For marginal bone loss, an increase
in the mean values was noted at different time intervals with statistical differences (p < 0.001). The
most common complications noted were loosening of the abutment, occlusal adjustment, retentive
locator loosening and replacement, and relining of the denture. Conclusions: Early placement of
IODs failed to prevent bone loss over time and was associated with complications, predominantly
consisting of abutment loosening, occlusal adjustments, broken retentive locator components, relining,
and rebasing.
Keywords: dental implant; overdenture; implant loading; edentulous mandible; peri-implantitis
1. Introduction
Conventional complete dentures (CD) have been used as the preferred prosthetic
replacement option for edentulous patients. However, utilizing CD is not without problems
such as poor stability and retention, reduced chewing efficiency, speech difficulties, and
bone resorption. To overcome such challenges, dental implants have gained widespread
https://www.mdpi.com/journal/medicina
Medicina 2024, 60, 588 2 of 11

popularity as an excellent option for replacing missing teeth, primarily due to their high
success rates and positive patient satisfaction levels [1]. According to the York and McGill
consensus, conventional dentures are deemed inadequate for prosthodontic treatment of
the edentulous mandible [2]. Substantial evidence overwhelmingly supports the notion
that implant overdentures (IOD) are now considered the optimal choice for restoring the
edentulous mandible [3]. Among the array of prosthetic replacements available, the IOD
stands out as the most suitable option.
Implant overdentures, whether classified as implant-supported or implant-retained,
offer substantial advantages over conventional complete dentures by providing enhanced
stability, improved retention, and increased chewing efficiency, effectively addressing
limitations associated with traditional full arch dentures [4]. However, it is crucial to
acknowledge potential limitations, including the need for surgical procedures, financial
considerations, and the risk of complications like peri-implantitis. Additionally, not all
patients may be suitable candidates for implant therapy, considering systemic health
issues or insufficient bone volume, necessitating careful case-by-case evaluation [2]. The
placement of implant overdentures, whether early or delayed, plays a significant role in
the overall success rate of the prosthesis [3]. Different studies have shown that delayed
placement of IODs is associated with bone loss at the site of extraction, impacting the
placement of implants [5]. Furthermore, alterations in the soft tissue contour have also been
encountered in delayed placement, along with a psychological impact on the patient [6].
Early placement of implants is widely accepted for both removable and fixed pros-
thetic appliances due to higher acceptance and improved survival rates [7]. This approach
is particularly important as it reduces the period of edentulism. Completely edentulous pa-
tients experience various consequences, including masticatory problems, impaired speech,
compromised facial aesthetics, and psychological distress [8]. Primary implant stability is
crucial for the success of implant overdentures, influencing subsequent osseointegration.
Optimal stability at the time of placement minimizes micromotion and supports successful
healing. In early loaded cases, where functional loads are applied soon after implant place-
ment, achieving adequate primary stability is pivotal. Factors such as surgical technique,
implant design, and bone quality significantly impact primary stability. Emphasizing
the importance of precise planning and adherence to surgical protocols is essential for
maximizing long-term success and patient satisfaction [3].
Despite the identified benefits of early loading, studies have questioned its advantages
compared to delayed loading in edentulous patients [9]. One study reported a lower
survival rate for mandibular overdentures with a single implant when early loading was
performed [9]. Additionally, another study found that two-implant-supported overdentures
had similar survival rates regardless of early or delayed loading of the implants [10].
Esposito et al. [11] concluded that the evidence for early loading of implant overden-
tures is limited and recommended to conduct well-designed studies to generate robust
evidence. Moreover, numerous systematic reviews have highlighted the lack of long-term
treatment outcome for early loaded implant overdentures in clinical trials as a signifi-
cant limitation [12,13]. Further research is necessary to fully understand the benefits and
drawbacks of early loading in implant overdenture treatment. Nonetheless, early place-
ment of implants remains a valuable option for improving outcomes and the quality of
life for completely edentulous patients. Achieving stable implant placement represents a
cornerstone for the lasting success of dental implant rehabilitations. This principle holds
even greater significance when navigating the complexities of limited bone volume and
quality. Optimizing primary stability directly translates to superior implant outcomes in
the medium- and long-term. By prioritizing this critical step, we can ensure predictable
and enduring results, even in challenging scenarios with compromised bone tissue [14].
It is critical to evaluate early loaded implant overdenture treatment effectiveness,
patient satisfaction, performance, stability, and long-term outcomes. The working hy-
pothesis assumes that there will be no significant difference in the peri-implant clinical
parameters and marginal bone loss (MBL) for early loaded implant overdenture over a
Medicina 2024, 60, 588 3 of 11

follow-up of 60 months. This study aimed to evaluate clinical peri-implant parameters and
marginal bone loss around early placed and loaded mandibular implant overdenture over
a 60-month follow-up.

2. Materials and Methods

2.1. Study Design and Consent
The present clinical study was conducted in accordance with the declaration of
Helsinki and its modifications (2013). The trial protocol was reviewed and approved by
the Ethics Committee of Center for specialist dental practice and research center (UDCRC-
082-17). Before recruitment, the participants were informed about the nature of the study
and provided with all the relevant information. The patients were enrolled in this study
after obtaining their verbal and written consent. The sample size was calculated using the
OpenEPI sample size calculator, considering a 95% confidence interval and a test power of
80%. Based on a mean radiographic bone loss of 0.89 ± 0.74 [10], the estimated sample size
was determined to be 34 patients.

2.2. Eligibility Criteria

Inclusion criteria comprised patients with chronic displeasure and complications with
failure of existing removable partial dentures. Patients with a recent tooth extraction
(12–16 weeks) and denture complaints related to the lack of retention, stability, and support
were included. Patients with adequate complete dentures, free of deficiencies, were also
included. Exclusion criteria comprised of patients with combined endodontic–periodontics
lesions, uncontrolled Type 2 diabetes, Type V and VI bone type (Cawood and Howell classi-
fication) [15], bisphosphonates, limited mouth opening (15–20 mm), need for bone grafting,
moderate to severe xerostomia, osteoporosis, previous history of cancer or reconstruction,
chemotherapy, and radiotherapy.
Included patients had adequate bone height and volume for 4.1 × 10 or 4.1 × 12 mm
Roxolid implant (Straumann Holding, Basel, Switzerland), evaluated with digital Or-
thopantomogram (OPG) (Planmeca, OY, Helsinki, Finland). Included patients kept their
existing maxillary dentures and were provided with new mandibular IODs supported by
two implants. The patients were treated at specialist dental practices, in Riyadh, Saudi
Arabia, and the trial lasted from 2017 to 2022.

2.3. Surgical Procedures

All implants were placed using a surgical positioning and placement stent (copy of
existing denture), by a board-certified prosthodontist, trained in implant surgery. The
implants were placed using the implant surgery protocol of 16 weeks or beyond after ex-
traction. Surgery comprised of sterile procedure with local anesthesia, mid-crestal incision,
mucoperiosteal flap, osteotomy (using the protocol recommended), implant placement (in-
ter foramina) at canine location, submerged implant placement, torqued fixture (Straumann
Holding, SLActive, Basel, Switzerland) subcrestal, appropriate healing abutment, and
interrupted absorbable sutures (Vicryl, Ethicon, Johnson & Johnson, New Brunswick, NJ,
USA). Implants among patients included 4.1 × 12 mm (Straumann Holding, Basel, Switzer-
land) in 23 patients (n = 46) and 3.3 × 10 mm (Straumann Holding, Basel, Switzerland) in
12 patients (n = 24).
Existing mandibular dentures were relieved post-surgery (adjusted fitting surface)
and locator abutments (Straumann Holding, Basel, Switzerland) were torqued (35 Ncm)
at 6 weeks of healing. After the placement of the metal housing and picking up the
housing retentive cap on the locators, existing mandibular dentures were relined to pick
up the metal housing with retentive housing caps in vivo. The dentures were relined
to the appropriate acrylic surface and impression retentive housings were replaced with
final retentive housings in the IODs. The procedure was performed by a board-certified
prosthodontist. The pickup and reline were performed in occlusion with the maxillary
 metal housing with retentive housing caps in vivo. The dentures were relined to the ap-
propriate acrylic surface and impression retentive housings were replaced with final re-
Medicina 2024, 60, 588 tentive housings in the IODs. The procedure was performed by a board-certified prostho- 4 of 11
dontist. The pickup and reline were performed in occlusion with the maxillary denture.
Early implant loading refers to the placement of prosthetic components, such as dentures,
on dental implants
denture. shortly after
Early implant their
loading surgical
refers placement
to the inof
placement the jawbone.components, such as
prosthetic
dentures, on dental implants shortly after their surgical placement in the jawbone.
2.4. Measuring Clinical Peri-Implant Parameters
2.4.
AllMeasuring Clinical
implants and Peri-Implant
mandibular IODs Parameters
were evaluated for PI, BI, PIPD, and MBL at 1, 12,
24, 36, 48, All
andimplants and mandibular
60 months. IODs were
The unit of analysis evaluated
in this for PI,
study was perBI,implant,
PIPD, andthe MBL
outcome at 1, 12,
24, 36, 48, and 60 months. The unit of analysis in this study was per
was reported for each individual implant site. Each dental implant was treated as a sepa- implant, the outcome
ratewas
unitreported for each analysis.
in the statistical individual implant
Plaque site.[16],
index Each dental implant
bleeding wasand
index [17], treated as a separate
peri-implant
unitdepth
pocket in the [18]
statistical analysis.
reference Plaque
scorings are index [16], in
presented bleeding
Figure index [17], and
1. Marginal peri-implant
bone levels
pocket
around thedepth [18] reference
implants scoringswith
were monitored are presented
standardized in Figure 1. Marginal
intraoral periapicalbone levels around
radiographs
usingtheaimplants
paralleling were monitored
technique andwith standardized
intra-oral intraoral periapical
resin radiographic radiographs
digital sensor placement using a
jig for each patient. The radiographic bone levels were evaluated on the Planmeca Romexiseach
paralleling technique and intra-oral resin radiographic digital sensor placement jig for
patient.
Dental SoftwareThe 4.0
radiographic
(Planmeca©, bone levels Finland).
Helsinki, were evaluated
Imageson thecalibrated
were Planmecaand Romexis
bone lev-Dental
Software 4.0 (Planmeca©, Helsinki, Finland). Images were calibrated
els were assessed from the implant abutment junction to the crest of bone mesial and distal and bone levels
were
to the assessed
implant. from the implant
Evaluations abutmentat
were performed junction to the
1, 12, 24, 36, crest of bone
48, and mesial For
60 months. and alldistal
evaluations, a mean and standard deviation was identified. The prosthodontist evaluated all
to the implant. Evaluations were performed at 1, 12, 24, 36, 48, and 60 months. For
evaluations,and
complications a mean andrelated
failures standard deviationabutment,
to denture, was identified. The prosthodontist
and implants. The frequency evaluated
of
complications and failures related to denture, abutment, and
these complications was reported after a 60-month follow-up period. The assessment in- implants. The frequency
of these
cluded variouscomplications
parameterswas suchreported after loosening,
as abutment a 60-monthfracture,
follow-up period.
wear, Thefracture,
implant assessment
included various parameters such as abutment loosening, fracture,
occlusal adjustment, retentive cap looseness, retentive cap loss, replacement, metal hous- wear, implant fracture,
occlusal adjustment, retentive cap looseness, retentive cap loss, replacement, metal housing
ing looseness, and loss. Additionally, the occurrence of denture fractures, relines, rebases,
looseness, and loss. Additionally, the occurrence of denture fractures, relines, rebases, and
and replacements was also observed.
replacements was also observed.

Figure 1. Schematic diagram of indexes used to measure peri-implant clinical parameters.

Figure 1. Schematic diagram of indexes used to measure peri-implant clinical parameters.
2.5. Statistical Analysis
2.5. Statistical Analysis
Data were analyzed using a statistical program for social sciences (SPSS, Version 25,
DataArmonk,
IBM, were analyzed usingNormality
NY, USA). a statisticaldistribution
program forwas social scienceswith
identified (SPSS,theVersion 25,
Kolmogorov–
IBM, Armonk,
Smirnov NY,
test. USA). Normality
Two-way ANOVA was distribution
applied forwas
the identified
comparison with theBI,
of PI, Kolmogorov–
PIPD, and MBL.
Smirnov test. Two-way
The Tukey’s honestlyANOVA was difference
significant applied for(HSD)
the comparison of PI, BI, PIPD,
test was conducted and MBL.
to assess pairwise
Thedifferences
Tukey’s honestly significant
in marginal difference
bone loss (MBL) (HSD) test time
at various was intervals.
conductedAtop-value
assess of
pairwise
<0.05 was
differences
consideredin marginal bone
statistically loss (MBL) at various time intervals. A p-value of <0.05 was
significant.
considered statistically significant.
3. Results
At the beginning of the study, forty-three patients were initially included. However,
throughout the course of the study, three patients passed away, and five patients discon-
tinued their participation. As a result, the final assessment and evaluation included a
total of 35 patients, as depicted in Figure 2, encompassing all the relevant evaluations
and parameters.
 At the beginning of the study, forty-three patients were initially included. However,
throughout the course of the study, three patients passed away, and five patients discon-
tinued their participation. As a result, the final assessment and evaluation included a total
of 35 patients, as depicted in Figure 2, encompassing all the relevant evaluations and pa-
Medicina 2024, 60, 588 5 of 11
rameters.

Figure
Figure 2. Flow
2. Flow diagram
diagram of study
of study methodology.
methodology.

Table
Table 1 presents
1 presents thethe general
general characteristics
characteristics of the
of the included
included study
study patients.
patients. TheThe mean
mean
ageage
of of
thethe participants
participants was
was 63.7
63.7 ± 6.1.
± 6.1. TheThe gender
gender distribution
distribution waswas as follows:
as follows: 23 23 males
males
and 12 females. The mean age of denture wearing was 3.8 ± 1.6. The
and 12 females. The mean age of denture wearing was 3.8 ± 1.6. The peri-implant param- peri-implant
parameters,
eters, includingincluding plaquebleeding
plaque index, index, bleeding index,
index, and and peri-implant
peri-implant pocket pocket
depth, depth, were
were as-
assessed at various time intervals: 1 month, 12 months, 24 months, 36 months,
sessed at various time intervals: 1 month, 12 months, 24 months, 36 months, 48 months, 48 months,
andand
60 60 months.
months. A comparison
A comparison waswas
mademade between
between these
these characteristics
characteristics andand
thethe baseline
baseline
values (controls).
values (controls).
Table
Table 1. General
1. General characteristics
characteristics of patients
of patients included
included (n =(n35).
= 35).

Characteristics
Characteristics Mean Mean SDSD
Age Age 63.7 63.7 6.1 6.1
Gender
Gender (M/F)(M/F) 23/12 23/12
Age Age of denture
of denture wearing
wearing 3.8 3.8 1.6 1.6
SD,SD,
standard deviation.
standard deviation.

In relation to the
In relation PI, PI,
to the a notable decrease
a notable in the
decrease mean
in the value
mean waswas
value observed from
observed baseline
from baseline
(1.1(1.1
1 ±10.5) to 36
± 0.5) to months
36 months(0.89(0.89
± 0.6). For the
± 0.6). For36the
months and 60
36 months months
and evaluations,
60 months PI
evaluations,
PI increased from 0.89 ± 0.6 to 1.54 ± 0.6, respectively. Interestingly, PI did not show
significant change throughout the follow-up duration from 1 month to 60 months (p > 0.05).
There was an increase in the BI from baseline (0.84 ± 0.6) to 60 months (1.07 ± 0.7) follow-up,
but the difference was not statistically significant (p > 0.05). There was a gradual increase
in PIPD from baseline (3.08 ± 1.3) to 60 months (4.34 ± 1.0) follow-up, the difference was
statistically significant (p < 0.05), as shown in Table 2.
Medicina 2024, 60, 588 6 of 11

Table 2. Peri-implant soft tissue parameters from baseline (control) to 5 years function (two-way
ANOVA test).

Baseline
Soft Tissue 12 Months 24 Months 36 Months 48 Months 60 Months
(1 Month) p-Value
Parameters (Mean + SD) (Mean + SD) (Mean + SD) (Mean + SD) (Mean + SD)
(Mean + SD)
PI 1.1 1 ± 0.5 1.3 ± 0.6 0.94 ± 0.4 0.89 ± 0.6 1.36 ± 0.5 1.54 ± 0.6 >0.05 (0.065)
BI 0.84 ± 0.6 0.65 ± 0.6 0.68 ± 0.5 0.72 ± 0.4 1.05 ± 0.5 1.07 ± 0.7 >0.05 (0.366)
PIPD 3.08 ± 1.3 2.50 ± 0.9 2.78 ± 0.7 3.40 ± 1.1 3.36 ± 1.0 4.34 ± 1.0 <0.05 (0.004)
PI: plaque index, BI: bleeding index, PIPD: peri-implant pocket depth.

The marginal bone loss (MBL) at each time interval was compared with the baseline
(control). MBL at baseline was (−0.5 ± 0.3), which significantly increased at 48 months
(1.7 ± 0.6) and 60 months (2.3 ± 1.0) follow-up. Overall, MBL significantly increased
(p < 0.01) from baseline to 60 months follow-up (Table 3).

Table 3. Peri-implant bone levels from baseline (control) to 5 years function using ANOVA test.

Baseline
Clinical 12 Months 24 Months 36 Months 48 Months 60 Months
(1 Month) p-Value
Parameters (Mean + SD) (Mean + SD) (Mean + SD) (Mean + SD) (Mean + SD)
(Mean + SD)
MBL −0.5 ± 0.3 0.50 ± 0.3 1.3 ± 0.4 1.40 ± 0.5 1.7 ± 0.6 a 2.3 ± 1.0 a * <0.001
MBL: marginal bone loss, * ANOVA, superscripted alphabet a denotes significant difference from baseline.

The Table 4 summarizes the findings from the Tukey’s Honestly Significant Differ-
ence (HSD) test. Statistically significant differences were observed between 1 month and
12 months, 36 months and 48 months, 48 months and 60 months, as well as 1 month
and 60 months. These results suggest distinct patterns of MBL changes over time, where
significant alterations in marginal bone levels occurred during the 5-year study period.

Table 4. Comparison of marginal bone loss over time, post-hoc analysis (Tukey’s test).

Comparison Mean Difference (MBL) p-Value

1 month vs. 12 months 0.50 0.003 *
12 months vs. 24 months 0.10 0.312
24 months vs. 36 months 0.10 0.998
36 months vs. 48 months 0.30 0.033 *
48 months vs. 60 months 0.60 0.016 *
1 month vs. 60 months 2.80 0.001 *
* Statistical significance MBL: marginal bone loss.

Various prosthetic complications were observed over a 5-year period. Concerning

abutment-related complications, 21 implants experienced abutment loosening, while wear
was observed in 14 abutments and occlusal adjustments were performed in 23 cases. There
were no reported cases of abutment or implant fractures. Additionally, complications
related to retention elements were noted during follow-up visits. In 13 cases, the metal
housing used for retention became loose. The retentive locator component was reported as
broken in 20 cases and loose in 33 cases. Replacement of the retentive locator component
was required in 33 cases. Furthermore, complications associated with the IODs were also
observed. Sixteen cases required a reline, and four cases required rebasing. Fractures of
the IODs were observed in five cases, and new dentures were used to replace five IODs, as
presented in Table 5.
Medicina 2024, 60, 588 7 of 11

Table 5. Prosthetic complication frequency among IODs over 5 years.

Frequency and Percentage

Types of Complications
(n = 86 Implants)
Abutment (A)
A. Loosening 21 (24.42%)
A. Wear 14 (16.28%)
A. Fracture -
Implant fracture
Occlusal adjustment 23 (26.74%)
Retention Element
Metal housing loose 13 (15.12%)
Retentive locator broken 20 (23.26%)
Retentive locator loose 33 (38.37%)
Replacement of retentive locator 33 (38.37%)
Denture (n = 35 IOD)
Reline 16 (18.60%)
Rebase 4 (4.65%)
Fracture 5 (5.81%)
IOD replacement 5 (5.81%)

4. Discussion
Implant-supported overdentures have gained popularity as an effective treatment option,
particularly in cases where conventional complete dentures have shown limitations [19,20].
The present study aimed to investigate peri-implant parameters and prosthetic complica-
tions of IODs over a 5-year follow-up. It was hypothesized that no significant difference in
the peri-implant clinical parameters and MBL will be present for early loaded IOD over a
5-year follow up. The hypothesis was partly rejected as MBL significantly increased from
baseline to 60 months; however, PI, BI, and PIPD showed comparable outcomes.
Implant-supported prostheses have been widely embraced by patients, particularly in
cases where traditional complete dentures have proven inadequate [19]. Implant overden-
tures provide various advantages over conventional dentures such as improved stability
and retention, significant improvement in chewing efficiency, preservation of bone health
by overcoming bone loss, and greater aesthetic outcomes. Moreover, patients tend to
maintain their oral hygiene at acceptable levels as compared to patients with conventional
dentures [13].
In the present study, PI, BI, PIPD, and MBL were assessed around early loaded
IODs. The mean values of PI, BI, and PIPD increased from baseline to 5 years; however,
the difference was not significant. Such results correlate with a study by Maryod et al.,
where they reported higher values of BI, PI, and PIPD in patients with early loading
implants as compared to delayed loading [21]. However, one of the limitations of this
study was the shorter duration of follow-up of the patients. Similarly, another systematic
review evaluating the long-term clinical outcomes of different loading protocols of IODs
reported, that although PI and PIPD values of immediate loading protocols were greater
than conventional loading protocols, early loading protocols are well established and
are worthy of consideration in clinical practices [22]. Favorable PI, BI, and PIPD reflects
good oral hygiene, healthy peri-implant tissues, and decreased risk of complications
associated with early loaded implant overdentures. This indicates that the osseointegration
process has occurred successfully, ensuring a solid foundation for the prosthetic restoration.
Biologically, early loading allows for functional stimulation of the implant, which promotes
Medicina 2024, 60, 588 8 of 11

better bone remodeling and preserves bone density. It also helps to distribute occlusal
forces, reducing the risk of implant-related complications in the long term [23].
Early loading of implant overdentures is clinically preferred as it enables patients to
regain their functional and aesthetic aspects earlier as compared to delayed loading. More-
over, biologically speaking, early loading mitigates the risk of bone loss [23]. One study
has reported that early loading of implants reduces the micromotions of implants [24].
However, according to Zhu et al., early loading of implant overdentures has been associ-
ated with a higher risk of implant failure due to its micromotions [25]. The variability of
these results is primarily due to variability of prosthodontic and peri-implant outcomes
measured in different studies.
One of the vital indicators of success rates of overdentures are the levels of marginal
bone around implants [22]. Based on the findings of the current study, there was a sig-
nificant increase in the mean MBL from baseline to 60-month follow-up period (from
−0.5 ± 0.3 to 2.3 ± 1.0). Despite this observed bone loss over time, it remained within
an acceptable range. It is worth noting that early bone loss of 1.5 mm within the first
two years of implant placement is generally considered acceptable [26]. On the contrary,
a systematic review conducted by Sanda et al., comparing immediate and conventional
loading implants, concluded that no significant difference in bone loss was reported [27].
By contrast, Pardal et al., characterized MBL as a risk factor for early implant loss when
comparing early and delayed placement protocols [28].
In the present study, we chose subcrestal surgical technique and implant placement
and implants were submerged below the level of crestal bone [29]. A study by Pellicer-
Chover concluded that crestal and subcrestal dental implant placement techniques are used
in IODs; however, it did not show any effect [30]. Moreover, de Siqueira and colleagues
evaluated the impact of different types of dental implants over a period of 5 years on crestal
bone levels [31]. They found no difference in marginal bone levels between subcrestal
and crestal implant placement; however, subcrestal positioning resulted in higher levels of
bone. A systematic review and meta-analysis concluded that subcrestal implant placement
resulted in fewer changes in terms of MBL as compared to crestal placement [32]. A
study by Degidi et al. concluded that subcrestal implant placement provided favorable
outcomes in bone preservation as compared to crestal implant placement [33]. Other than
the placement of dental implants, mucosal thickness also plays a vital role in the impact of
bone loss around the dental implant [34].
The implant overdentures when placed in the oral cavity are subjected to an array
of insults of which masticatory forces are the most significant cause of insult. Due to
such masticatory forces, various post-operative complications can be encountered in IODs
in terms of abutments, retentive components, and dentures [22,27]. In our study, we
found loosening of the abutment, occlusal adjustment of the abutment, retentive locator
loosening, replacement of retentive locator, and relining of the dentures as common com-
plications. Similar and other complications have been reported by Ulku and colleagues,
where abutment loosening, loss of retention, mucositis, and fracture of abutment were
reported [35]. Other than the complications, patients with IODs reported suffering from
immediate post-operative symptoms such as pain, swelling, bleeding, pain on chewing,
and discomfort [36].
Implant-supported overdentures are a beneficial treatment option for completely
edentulous patients, especially in situations where conventional complete dentures have
failed [35,37]. Therefore, according to the results of our study, IODs must be given consid-
eration in clinical practice. In order to retain and stabilize IOD’s, precision attachments are
recommended over the implant abutments [34]. A wide range of attachment systems are
employed in implant overdentures (IODs). The present study adopted the isolated locator
type of attachment system. The ball-based attachment systems are also recommended
due to their cost-effectiveness and ease of maintenance; however, for better function, the
implant angulation should be given consideration [37]. Additionally, bar-based attachment
systems provide optimal retention and implant splinting, but the cost and prosthetic tech-
Medicina 2024, 60, 588 9 of 11

nique sensitivity are their major drawbacks encountered in clinical practice [38]. Magnetic
attachment systems are rarely used as corrosion and loss of magnetism significantly reduces
its long-term utilization in IODs [39].
This study had some inherent shortcomings such as the use of one type of attachment
system. The evaluation of different types of attachment systems can increase the scope
of future similar studies. Secondly, the accuracy and reliability of measuring PI, BI, MBL,
and PIPD may vary between different observers. Moreover, a follow-up period longer
than 60 months can provide a comprehensive understanding of the stability and potential
long-term challenges with IODs. The present study employed the use of bleeding index
for dental implants instead of bleeding on probing (BOP). The bleeding index may not
accurately reflect the specific condition of the peri-implant tissues. The bleeding index
is a more general measure of gingival health and may not be sensitive enough to detect
localized inflammation or pathology around dental implants. BOP, on the other hand,
is a more specific and direct measure of inflammation at the implant site, providing a
more accurate assessment of peri-implant health. A notable restraint of the study is the
absence of explicit consideration and evaluation of the influence of keratinized gingival
tissue on marginal bone loss (MBL). Given the recent findings suggesting a relationship
between the presence of keratinized tissue, MBL, and depth of fixture insertion [32], the
study missed an opportunity to explore this important parameter. The role of keratinized
gingiva in peri-implant health is significant, impacting inflammation levels and potentially
affecting MBL outcomes. The lack of data on this specific aspect limits the comprehensive
understanding of factors contributing to MBL in the studied population. Therefore, future
research could benefit from incorporating detailed assessments of keratinized gingival
tissue and its potential correlations with MBL, providing a more comprehensive perspective
on peri-implant tissue health [40].
Despite the limitations of the study, the study had notable strengths. The longitudinal
design was employed, enabling the assessment of clinical peri-implant parameters span-
ning a 5-year timeframe. This approach revealed satisfactory values for PI, BI, MBL, and
PIPD. However, it is important to note that IODs with early implants exhibited moderate
prosthetic complications, emphasizing the necessity for diligent maintenance in the treat-
ment phase for patients utilizing IODs. In the future, conducting studies with larger sample
sizes, involving multiple centers, extending follow-up periods, and performing compara-
tive analyses would significantly contribute to enhancing the evidence base, improving
patient care, and optimizing treatment outcomes in the field of implant prosthesis.

5. Conclusions
Early placement of IODs failed to prevent bone loss over time and were associated
with complications, predominantly consisting of abutment loosening, occlusal adjustments,
broken retentive locator components, relining, and rebasing.

Author Contributions: Conceptualization, A.A.A. (Abdulaziz A. AlHelal), A.A.A. (Abdulaziz A.

Alzaid), S.H.A., R.O.A. and K.A.A.-A.; methodology, A.A.A. (Abdulaziz A. AlHelal), A.A.A. (Abdu-
laziz A. Alzaid), S.H.A., M.A., K.K.A., R.O.A. and K.A.A.-A.; formal analysis, A.A.A. (Abdulaziz A.
AlHelal), A.A.A. (Abdulaziz A. Alzaid), S.H.A., M.A. and K.K.A.; writing—original draft preparation,
A.A.A. (Abdulaziz A. AlHelal), M.A., K.K.A., R.O.A. and K.A.A.-A. writing—review and editing,
A.A.A. (Abdulaziz A. Alzaid), S.H.A., M.A., R.O.A. and K.A.A.-A.; manuscript writing, A.A.A.
(Abdulaziz A. AlHelal) and K.A.A.-A. All authors have read and agreed to the published version of
the manuscript.
Funding: Princess Nourah bint Abdulrahman University Researchers Supporting Project number
PNURSP2024R6, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia.
Institutional Review Board Statement: The study protocol was reviewed by the ethics and re-
view committee of center for specialist dental practice and clinical research, Riyadh, Saudi Arabia
(UDCRC-082-17).
Informed Consent Statement: Informed consent was obtained from all participants.
Medicina 2024, 60, 588 10 of 11

Data Availability Statement: The data are available on contact from the corresponding author.
Conflicts of Interest: The author declares no conflicts of interest.

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