ASSESSMENT OF BALL VERSUS LOCATOR ATTACHMENT

FOR IMMEDIATELY LOADED TWO TRABECULAR IMPLANTS

SUPPORTED MANDIBULAR OVER DENTURE- ONE YEAR
RANDOMIZED CLINICAL TRIAL

Mona Galal Abo El- Ezz* and Lamiaa Farouk Zaki Mohamed**

ABSTRACT
Aim: This in vivo study was performed to evaluate Ball versus locator attachment for
immediately loaded two Trabecular Implants supported mandibular over denture.

Material and methods: From the outpatient clinic of the Ain-Shams University Faculty of
Dentistry, eighteen patients with a completely edentulous mandible were selected. The patients
initially received treatment with a full denture, and subsequently, two Trabecular implants were
placed in the mandible at the canine region using a surgical guide. On the day of implant insertion,
eighteen implants supported by an overdenture were loaded immediately based on the patient’s
measurements. Patients were splitted into two equal groups at random: Group A: (the control
group): Using a ball attachment, two Trabecular metal implants were loaded in the canine region
on the day of implant implantation. Group B: Using a locator attachment, two Trabecular Metal
implants were loaded in the canine region on the same day of implant placement. This was the test
group. The changes in bone height around the implants in both the vertical and horizontal planes
were assessed radiographically , CBCT scanning was used to do the radiographic examination.
At the time of overdenture implantation (T0), six months (T1), and twelve months (T2) after
insertion, the health of the peri-implant tissue was assessed for clinical assessment at T0,T1 and
T2 the modified Plaque and Bleeding Indices were utilized to evaluate the Plaque Index (PI) and
Bleeding scores (BI). Pocket depth (PD) was determined by measuring the distance between the tip
of the plastic periodontal probe and the marginal boundary of the peri-implant mucosa. Resonant
frequency analysis was used to evaluate implant stability. Using the Osstell device instrument, the
resonance frequencies were determined.

Results: There was no significant difference in the vertical bone loss between attachments
at T6. In contrast to Locator attachments, ball attachments at T12 showed a significant higher
vertical bone loss. There was a significant variation in the horizontal bone loss for both attachments

* Lecturer of Prosthodontics, Faculty of Dentistry, Modern University of Technology and Information

** Lecturer of Prosthodontics, Faculty of Dentistry, Ain Shams University
(2) E.D.J. Vol. 70, No. 4 Mona Galal Abo El- Ezz and Lamiaa Farouk Zaki Mohamed

between time intervals. For both attachments, horizontal bone loss significantly increased from
T6 to T12. Across all time intervals, Ball attachments showed a significant greater horizontal bone
loss than Locator attachments. There was no significant difference in the plaque index between
the T0 and T12 groups. But at T6, the ball attachment plaque index was substantially greater than
the Locator attachments. The bleeding index did not significantly differ across the groups for T0,
but the bleeding index for ball attachment at T12 was substantially higher than the bleeding index
for Locator attachments. There was no significant difference in implant stability at T0. Locator
attachments demonstrated significant higher implant stability at T6 and T12 compared to ball
attachments.

Conclusion :within the limitations of this in vivo study ,locator attachment used to retain
two trabecular metal dental implant supported immediately loaded mandibular overdenture was
associated with reduced vertical and horizontal bone loss around the implant and also reduced peri
-implant tissue inflammation and higher implant stability than ball attachment, trabecular metal
dental implants (Tantalum) show less decrease in crestal bone height and enhanced implant
stability in comparison to other implant types.

Keywords

INTRODUCTION Ball-socket connectors have gained a lot of

popularity as a simple and cost-effective means
Many studies have shown the clinical advantages
of maintaining implant overdentures in place,
of overdentures retained with two implants in terms
especially for people with narrow jaw anatomy.
of patient satisfaction, stability, and retention.
Over the last ten years, locator attachments have
(1) These prostheses accommodate phonetic and
become more and more common. These attachments
esthetic variables. (2) The McGill Consensus
are robust, (7) self-aligning, available in a variety
Statement on Over Dentures states that the two-
of colors, and have dual retention. When there is
implant over denture should be the minimal standard
insufficient inter arch space for denture insertion of
of care for treating the edentulous mandible. (3)
ball attachments, a number of problems may occur.
These prostheses are substantially less Over contoured prostheses, broken teeth adjacent
expensive to construct and easier to clean . (4) to the attachments, an excessive occlusal vertical
The over dentures can be secured to the implants dimension, denture base fracture , attachment
using splinted attachments like bars or unsplinted separation from the denture, and general patient dis
attachments like locators, ball anchors, double satisfaction are some examples of these problems.
crowns, and magnets. (5) In some situations, (8) locater attachments can be
Unsplinted anchorage attachments have been a useful option in place of ball attachments due of
suggested with implant-retained over dentures their low profile.
because of their ease of cleaning, reduced sensitivity The current implant surface treatment appears to
to techniques, easier space requirements within promote osteoblastic activity at the implant surface
prostheses, and more cost-effective incentives. and hence enhance implant-bone contact, resulting
The amount of tongue space available for bar in lower peri-implant bone loss, even if it does
constructions can also be reduced by using these not considerably increase the surface area or bone
attachments with a pointed jaw. (6) ingrowth inside the implant. Much of the original
ASSESSMENT OF BALL VERSUS LOCATOR ATTACHMENT FOR IMMEDIATELY LOADED TWO TRABECULAR (3)

Osseo-integration theory by Branmarke is still valid Immediate occlusal loading of implants has
in spite of this. The development of PTTM (Porous several advantages it provides to dentists. These
Trabecular Tantalum Metal) technology aimed to benefits include lowering the need for a removable
create a three-dimensional scaffold to support bone provisional prosthesis, providing psychological
ingrowth surrounding dental implants. The center support to patients awaiting tooth extraction,
area of the end-osseous titanium multi-threaded self- improving bone healing (14, 15), making it easier
tapping dental implant was coated with the PTTM to shape soft tissues, and eliminating the risk of
substance. Greater mechanical properties, a porous premature implant exposure a problem that is often
structure that resembles real bone, and exceptional associated with wearing a removable denture during
biocompatibility set PTTM-enhanced titanium the healing process (16).
dental implants apart from the competition.In theory,
A decrease of crestal bone height surrounding
these advantages surpass those of other implant
the implants in all aspects (buccal, lingual, mesial
designs, particularly improved osseointegration or
and distal) was found throughout all time intervals
osseoincorporation. (9)
during follow up periods in pervious clinical
Titanium dental implants are extensively used, researches , this bone reduction might be due to
nevertheless, case studies have indicated that surgical trauma, bone osteotomy and healing
modern dental implant surface treatment may process. Also it might be considered an immediate
advance. For example, patients with diabetes, bone reaction after insertion of the prosthesis which
(10,11) osteoporosis, irradiated bone, (12,13) or attributed to the healing and reorganization following
extensive tobacco use may benefit from this type trauma to the bone and periosteum combined with
of advanced implant surface treatment if they have
remodeling due to functional stresses following
poor tissue recovery.
prosthesis connection .Crestal bone loss could also
PTTM has shown satisfactory healing of grafted be explained by the finding that forces applied on
tissues when there is a lack of either in freshly implants are distributed on the crestal bone rather
transplanted bone or in the residual bone structure than along the entire implant/bone interface.
that needs concurrent bone augmentation. The
The selection of cone beam computered
increased surface area and improved functioning
tomography (CBCT) for measurement of the
of the PTTM collar may result in faster and more
peri-implant bone height loss, during the follow-
durable Osseo-integration in subjects with Type 3
up period, was due to the fact that it is a precise
or Type 4 bone or those with systemic problems that
and fast method which can be used to assess with
limit wound healing
high resolution digital images representing the
When implants are immediately loaded with trabecular structure in detail, allowing a three-
overdentures, the biomechanical effects of the dimensional reconstruction of the bone structure
implant’s design and attachment method on the to be achieved. Moreover, it has a significantly
surrounding bone become increasingly significant. reduced radiation exposure to the patient, is devoid
A shorter healing period may be required in the of superimpositions and has a high resolution level
majority of dental implant situations.. It is well with accurate linear measurements Compared to
known that porous materials for PTTM implants, conventional or multislice CT (17) . Compared to
which resemble trabecular bone in both structure conventional panorama or multislice CT, CBCT
and rigidity, work incredibly well to bond prosthetic has a number of advantages, such as faster scanning
implants to the skeletal system. times, and lower costs.(18, 19)
(4) E.D.J. Vol. 70, No. 4 Mona Galal Abo El- Ezz and Lamiaa Farouk Zaki Mohamed

Accordingly this study aimed to investigate suffering from metabolic disorders, hematologic
crestal bone height loss and clinical parameters illness patients, Patients will receive chemotherapy
around two trabecular dental implant supporting or radiation treatment. Changes that could impact
immediately loaded mandibular over denture in both implant therapy include smoking, corticosteroid
locator and ball attachment through one year follow therapy, and diabetic mellitus. The Clinical Research
up period , the null hypothesis for this research Ethics Committee of the Faculty authorized the
that there will be no significant differences in both research protocol, and all participants were provided
radiographic and clinical finding between the two with comprehensive written information on the
attachments . surgical and prosthetic procedures prior to obtaining
a written consent.
MATERIALS AND METHODS:
Patient grouping:
Assessing and choosing patients:
The patients were received treatment with a
Eighteen completely edentulous patients with a full denture, and subsequently, two Trabecular
maladaptive history of wearing mandibular dentures implants were placed in the mandible at the canine
were selected from the prosthodontic department’s region using a surgical guide. On the day of implant
outpatient clinic at Ain Shams University. A power insertion, eighteen implants supported by an
analysis was performed using computer software overdenture were immediately loaded based on the
(G* Power) to determine the appropriate sample patient’s measurements.
size based on the findings of a prior study (20), in
which the authors found a significant difference in Patients were splitted into two equal groups at
vertical bone loss between two attachments used random using simple random method with random
to retain mandibular 2-implant overdentures using numbers created in excel sheet:
a similar study design. - Using the independent Group A: (the control group): Using a ball
samples t-test, the sample size calculation results in attachment, two Trabecular metal implants were
a total of 18 patients (9 samples/group). loaded in the canine region immediately on the
same day of implant implantation.
The sample size calculation details are as follows:
1. Size of effect: 1.24 mm 2. Alpha (α) equals.050 Group B: Using a locator attachment, two
3. Power (β) is equal to.80. Trabecular Metal implants were loaded in the canine
region on the same day of implant placement. This
Patients who fulfilled the following criteria
was the test group.
were allowed to participate in the study: total
absence of teeth in maxillary and mandibular Clinical practices:
arch. Maxillomandibular connection in Class I
All patients were given new maxillary and
systematically free Inter-arch space that is available.
mandibular dentures and instructed to wear them for
sufficient bone volume to receive implants (at least
at least two months before implant surgery in order
10 mm long and 3.75 mm in diameter), Patients with
to maximize neuromuscular adaptation to the new
radiographic bone density ranging from 850–1250
dentures. Both the lingalized idea of occlusion and
Hounsfield units (D2) were included in the study.
acrylic resin teeth(Vita-pan acrylic teeth, Vita Ban
The standards for exclusion: Patients with poor Sackingen- Germany) were utilized. A metal radio-
dental practices or poor oral hygiene patients who opaque marker was positioned at the anticipated
are hysterical smokers or alcoholics. Individuals implant locations on a clear acrylic duplicate of
ASSESSMENT OF BALL VERSUS LOCATOR ATTACHMENT FOR IMMEDIATELY LOADED TWO TRABECULAR (5)

the mandibular denture, which was intended to the pick-up procedures, a rubber dam sheet was cut
serve as a radiography template. CBCT radiograph into small squares, punctured in the middle, and then
were employed for the preoperative assessment of placed over the attachment’s neck. Subsequently, the
implant locations in order to measure the optimum male attachment’s component was fitted with the
implant length and measure bone height, width, metal housings that contained nylon liners. (fig 2)
length and dentistry.
Direct pick-up of the attachments was done
The radiological template was then converted using a chairside hard relining material (GC Hard
into a surgical template by attaching metal tubes to Denture Liner, GC America INC. ALSIP, IL 60803
the recommended implant placements. U.S.A.). (fig 3)

Surgical techniques: The patients were told to eat a soft diet, not take
out their dentures while eating for a week, and rinse
Before the procedure, the patients were
their mouths three times a day for fourteen days
instructed to maintain good oral hygiene, rinse their
mouths three times a day with Antiseptol—a 0.12% with mouthwash containing 0.12% chlorhexidine.
chlorhexidine mouth wash—from Kahira Pharm. Two weeks later, the sutures were removed. (fig 4)
& Chem. Ind. Co., St. Victoria SQ. Shoubra-Cairo,
Egypt, and take an oral antibiotic—Augmentin 1
gm—from GlaxoSmithKline Ltd., 980 Great West
Road, Brentford, TW8 9GS, United Kingdom—two
days prior to the procedure. The surgical stent was
inserted intraorally and properly seated in place
after inferior alveolar nerve block anesthesia was
administered using 4% articaine (Ubistesin forte,
3M ESPE AG_Germany).
Two implants (Trabecular Metal Dental Implant,
Zimmer, Germany) were placed in each patient’s
canine region of the mandible with minimal flap Fig. (1) Trabecular Metal Dental Implant were placed in
reflection and no vestibular extension to minimize patient’s canine region
postoperative swelling. (fig 1) For group I patients
were received mandibular over denture retained
to the implant by ball attachments (control
group) and group II patients received mandibular
over denture retained to the implant by locator
attachment (test group) for both groups abutments
were linked immediately following surgery and the
mucoperiosteal flap was carefully modified to wrap
the healing abutments using interrupted sutures.
The same day, matrices for both groups were picked
up using cold-cure acrylic.
For both groups the denture’s fitting surface had Fig (2): Rubber dam sheet was cut into small squares, punctured
enough relief created in it to make room for the in the middle, and then placed over the locator
attachments. To seal off the undercut areas during attachment’s neck
(6) E.D.J. Vol. 70, No. 4 Mona Galal Abo El- Ezz and Lamiaa Farouk Zaki Mohamed

Fig 3: Matrices for ball (A) and locator (B) attachments were picked up using cold-cure acrylic.

Fig. (4): Ball attachments (a) and locator attachments (b) intraoral after 2 weeks surgery

Radiographic results (primary outcomes): was measured between two reference positions. The
The changes in bone height around the implants in implant platform was the first point. On the other
both the vertical and horizontal planes were assessed hand, the first bone implant contact is the second at
radiographically. At time of implant insertion, six T0, T6 and T12 time interval by subtracting readings
and twelve months following the implantation of at T6 from reading at T0 to obtain the amount of
the overdenture, CBCT scanning was used to do bone loss after 6 months and T12 from T6 to obtain
the radiographic examination. The i-CAT imaging amount of bone loss after one year follow up period.
system was used to do CBCT scanning. While the labial and lingual bone height changes
were assessed using cross sectional images, the
The patients were made to sit while their heads
bone height at the mesial and distal aspects of the
were immobilized with the use of chin cups to aid
implants was measured from the panoramic view.
in mandibular stabilization and head bands to keep
(Fig 5.)
the heads steady against the head rest. Following
the manufacturer’s recommendations, vertical and The measurement of horizontal bone loss was
horizontal alignment beams were used to make the done between two reference points; the surface of
mid-sagittal plane perpendicular to the horizontal the implant was the first point. On the other hand, the
plane. In the vertical plane, the height of the bone alveolar crest’s greatest level is the second. While
ASSESSMENT OF BALL VERSUS LOCATOR ATTACHMENT FOR IMMEDIATELY LOADED TWO TRABECULAR (7)

the mean. The average of the patient’s left and

right implant readings was subjected to statistical
analysis.

Statistical analysis
The SPSS® software version 22 (SPSS Inc.) was
used to analyze the data. The Freidman test was used
to compare the plaque and bleeding indices across
time periods, and the Wilcoxon signed ranks test
was used for multiple comparison. The Repeated
Measures ANOVA test was used to compare Pocket
Fig. (5): CBCT used to measure the height of the bone between depth and implant stability across time intervals,
two reference positions.
and the Bonferroni test was used for multiple
comparison. The paired t test was used to compare
the labial and lingual bone alterations were assessed
the amount of vertical and horizontal bone loss over
using cross sectional images, the horizontal bone
different time periods. Using the Mann Whitney
loss at the mesial and distal aspects of the implants
test, the bleeding and plaque indices between the
was measured from the panoramic view.
groups were compared. Using the independent
Clinical results (secondary outcomes): samples t-test, groups’ differences in pocket depth,
implant stability, and vertical and horizontal bone
At the time of overdenture implantation (T0),
loss were compared. A significance level of p <.05.
six months (T1), and twelve months (T2) after
insertion, the health of the peri-implant tissue was
RESULTS
assessed. clinical assessment. The Modified Plaque
and Bleeding Indices (21) were utilized to evaluate Plaque and bleeding indices
the Plaque Index (PI) and Bleeding scores (BI).
Outcomes Indexes of bleeding and plaque (Table
Pocket depth (PD) was determined by measuring the
1) compares the bleeding and plaque indices for
distance between the tip of the plastic periodontal
various attachments and time intervals. The plaque
probe (Kerr, Rastatt, Germany) and the marginal
index varied significantly between time intervals
boundary of the peri-implant mucosa (22).
for both attachments. Plaque indices showed a
Resonant frequency analysis was used to considerable increase over time (p<.001 for ball
evaluate implant stability. Using the Osstell attachment and =.002 for Locator attachment,
device instrument, the resonance frequencies according to the Friedman test). Table 1 and (Fig.
were determined, and the results were reported in 6) offer many comparisons between each of the two
terms of ISQ (implant stability quotient in kHz). time intervals. Between each of the two observation
Using a mounting tool, the SmartPeg was screwed intervals, there was a significant difference for both
into the implant fixture’s internal threads. Without attachments (Wilcoxon signed ranks test, p<.05.
being physically attached to the SmartPeg, the There was no significant difference in the plaque
measurement probe magnetically stimulated it. The index between the T0 and T12 groups. But at T6,
ISQ scale starts at 1:100. The implant is more stable the ball attachment plaque index was substantially
the higher the ISQ score. Three measurements were greater than the Locator attachments (Mann
made, and a statistical analysis was conducted on Whiteny test, p=.017).
(8) E.D.J. Vol. 70, No. 4 Mona Galal Abo El- Ezz and Lamiaa Farouk Zaki Mohamed

The bleeding index varied significantly between was a significant difference for both attachments
time intervals for both attachments. According to the (Wilcoxon signed ranks test, p<.05. The bleeding
Friedman test, the bleeding indices rose significantly index did not significantly differ across the groups
over time (p<.001 for ball attachment and =.001 for for T0. But according to the Mann-Whiteny test
Locator attachment). Table 1 and (Fig. 7) offer many (p=.009 at T6 and.011 at T12), the bleeding index
comparisons between each of the two time intervals. for ball attachment at T12 was substantially higher
Between each of the two observation intervals, there than the bleeding index for Locator attachments.
Table 1. Comparison of plaque and bleeding indices between attachments and time intervals

T0 T6 T12 Freidman
M (min-max) M (min-max) M (min-max) P value

Plaque index

Ball attachment 0.00 a 1.00 b 2.00 c <.001*

(0.00-1.00) (1.00-2.00) (1.00-3.00)

Locator attachments 1.00 a 1.00 b 1.00 c .002*

(0.00-1.00) (0.00-1.00) (1.00-2.00)

Mann Whitney (P value) .439 .017* .136

Bleeding index

Ball attachment .00 a 1.00 b 2.00 c <.001*

(0.00-1.00) (1.00-2.00) (1.00-3.00)

Locator attachments .00 a .00 b 1.00 c .001*

(0.00-0.00) (0.00-1.00) (1.00-1.00)

Mann Whitney (P value) .146 .009* .011*

*
P is significant for independent samples -t-test At 5%. T0 is the prosthesis insertion time; T6 is the prosthesis insertion
after six months; and T12 is the prosthesis insertion after twelve months. Similar numbers revealed no significant change,
whereas different letters in the same raw indicate a significant difference across observation periods (Wilcoxon sign ranks
test, p<.05).

Fig. (6): A comparison of the plaque index for both groups Fig. (7) : A comparison of the bleeding index between the two
across observation times was displayed in the Fig groups’ observation times was displayed in the Fig
boxplot graphic. boxplot chart.
ASSESSMENT OF BALL VERSUS LOCATOR ATTACHMENT FOR IMMEDIATELY LOADED TWO TRABECULAR (9)

Examining implant stability and probing depth: roni test, p<.05. The probing depth did not signifi-
cantly differ across the groups for any observation.
Table 2 compares implant stability and probing
There was a notable variation in implant stability
depth across attachments and time intervals. The
between time intervals for ball attachment alone.
probing depth varied significantly between time
intervals for both attachments. Over time, the On the other hand, there was no significant
probing depth rose significantly (Repeated measures difference in Locator attachment between
observations. Implant stability for ball attachments
ANOVA, p<.001 for both attachments).
dramatically declined over time (Repeated measures
Table 2 and (Fig. 8). offer a multiple comparison ANOVA, p<.001). Table 2 and (Fig. 9) offer a
between each of the two time intervals. Between multiple comparison between each of the two
each of the two observation intervals, there was a time intervals. There was a statistically significant
significant difference for both attachments (Bonfer- difference in Ball attachments between each of

Table 2. Comparison of pocket depth and implant stability quotient between attachments and time intervals

T0 T6 T12 Repeated measures

X±SD X±SD X±SD ANOVA P value
Pocket depth
Ball attachment .13±.02 a 1.63±.24b 2.37±.20 c <.001*
Locator attachments .15±.02a 1.75±.04 b 2.45±.02c <.001*
Independent samples -t-test (P value) .201 .175 .403
Implant stability quotient
Ball attachment 74.21±.80 a 68.72±.75 b 67.62±.87 c <.001*
Locator attachments 74.98±.50 a 74.85±1.70 a 74.45±1.83 a .225
Independent samples -t-test (P value) .25 <.001* <.001*
*
P is significant for independent samples -t-test At 5%, T0 represents the period of prosthesis insertion; T6 denotes the
6-month mark; and T12 denotes the 12-month mark. A significant difference between observation times is indicated by
different letters in the same data (Paired samples t test, p<.05), whereas comparable numbers indicate no significant
difference.

Fig (8) Bar chart showed a comparison of probing depth Fig (9) Bar chart showed a comparison of implant stability
between observation times for both groups quotient between observation times for both groups
(10) E.D.J. Vol. 70, No. 4 Mona Galal Abo El- Ezz and Lamiaa Farouk Zaki Mohamed

the two observation times (Bonferroni test, p<.05. t-test, p<.001). There was no significant difference
Between groups, there was no significant difference in the vertical bone loss between attachments at T6.
in implant stability at T0. Locator attachments In contrast to Locator attachments, ball attachments
demonstrated significant higher implant stability at T12 showed a significant higher vertical bone
at T6 and T12 compared to ball attachments loss (independent samples, p=.004). There was a
(independent samples t-test, p<.001).
significant variation in the horizontal bone loss for
Vertical and Horizontal bone loss both attachments between time intervals (Fig 11) . For
both attachments, horizontal bone loss significantly
Comparison of vertical and horizontal bone loss
between attachments and time intervals is presented increased from T6 to T12 (paired samples t-test,
in table 3 (Fig.10) . For both attachments, the amount p<.001). Across all time intervals, Ball attachments
of bone lost vertically varied significantly over time. showed a significant greater horizontal bone loss
For both attachments, vertical bone loss increased than Locator attachments (independent samples,
considerably between T6 and T12 (paired samples p=.007 for T6 and.002 for T12).

Table (3). Comparison of vertical and horizontal bone losses between attachments and time intervals

T0 T6 T12 Paired samples t-test

X±SD X±SD X±SD P value
Vertical bone loss
Ball attachment - .55±.07 a 1.21±.15 a <.001*
Locator attachments - .53±.06a .97±.14 a <.001*
Independent samples -t-test - .55 .004*
P value
Horizontal bone loss
Ball attachment - .56±.07 a 1.23±.15 a <.001*
Locator attachments - .46±.05 a 1.00±.09 a <.001*
Independent samples -t-test - .007* .002*
P value

*P is significant at 5%. T0 represents the period of prosthesis insertion; T6 denotes the 6-month mark; and T12 denotes the
12-month mark. A significant difference between observation times is indicated by different letters in the same data (Paired
samples t test, p<.05), whereas comparable numbers indicate no significant difference.

Fig (10) bar chart showed a comparison of Vertical bone loss Fig (11) bar chart showed a comparison of Horizontal bone loss
between observation times for both groups between observation times for both groups
ASSESSMENT OF BALL VERSUS LOCATOR ATTACHMENT FOR IMMEDIATELY LOADED TWO TRABECULAR (11)

DISCUSSION stimulation that promotes osteogenesis and

In this study selection of cone beam computered increases bone density. Early on the bone-implant
tomography (CBCT) for measurement of the peri- interface, mechanical stress application has been
implant bone height loss, during the follow-up demonstrated to favorably impact the early stages
period, was due to the fact that it is a precise and of bone regeneration.(31, 32)
fast method which can be used to assess with high A multitude of prosthetic components and
resolution digital images representing the trabecular attachment systems can impact the general health
structure in detail, allowing a three-dimensional of the tissues surrounding dental implants. With
reconstruction of the bone structure to be achieved. the ball attachment, the study found a 1.21 mm
Moreover, it has a significantly reduced radiation vertical bone loss; with the locater attachment, the
exposure to the patient, is devoid of superimpositions loss was 0.97 mm. The horizontal bone loss was
and has a high resolution level with accurate linear also measured with the ball attachment at 1.23 mm
measurements Compared to conventional panorama and the locator attachment at 1.00 mm. According
or multislice CT. (17) to Albrektsson et al. (33), annual resorption
In an attempt to reduce the amount of time, following abutment connection must be less than
money, and surgeries required for treatment, 1.5 mm. These measurements meet their success
immediate loading was urged. (23, 24). Many clinical requirements. Because the masticatory stress
investigations have documented high success rates exerted on the posterior portions of the overdenture
for the immediate loading (25,26) of different implant- creates an adverse torque on the abutments, it may
supported restorations. In the event that the inclusion be a factor in bone loss. Two implants operate as
and exclusion criteria are met, the survival rates will a fulcrum with two lever arms when supporting a
resemble those of early or traditional loading was mandibular overdenture; one arm extends from the
the same which has been verified by the findings of fulcrum to the denture’s distal extension, while the
multiple systematic reviews. (27, 28) other arm extends anteriorly to the incisal edge.
In this Research annual bone resorption In contrast to the ball attachment, the implant
following abutment connection was less than 1.5 supporting the locator attachment had reduced
mm, Although these results are in line with some marginal bone loss surrounding it. This is explained
previous systematic reviews, the studies did not by the denture rotating around the two attachments
reveal a statistically significant difference in the having different matrix patrix relationships. (34) In
rates of marginal bone loss around immediately group II, the locator attachment was utilized. The
loaded implants and delayed loading of implant . locator’s supra-radicular design moved the fulcrum
(24)
, which can be explained that the initial healing point closer to the fixture, which decreased torque
process of implants used for immediately loaded and lever arm and permitted less crestal bone
mandibular overdentures can be influenced by the resorption. (35) A locator attachment’s special design,
degree of mobility of the restoration, the manner in which offers 0.2 mm of vertical resilience and 8
which the abutment is linked, and early contact to degrees of hinging in all directions, contributes
oral germs.(29,30) to its advantages. The attachment can move both
The absence of second-stage surgery in the vertically and along the hinge axis thanks to this
immediate loading procedure and the early design. Furthermore, the locator has the ability to
mechanical strain may be the reason of this. evenly disperse stresses throughout the long axis of
Overdentures are thought to provide mechanical the implant. (36)
(12) E.D.J. Vol. 70, No. 4 Mona Galal Abo El- Ezz and Lamiaa Farouk Zaki Mohamed

The results of this study showed that, in compar- necessity to activate and deactivate the matrix
ison to other implant types, trabecular metal dental component to ensure appropriate retention.( 43)
implants (Tantalum) show a less significant loss in
Moreover, the locator attachment is less likely
crestal bone height. The greater functional surface
to cause denture base fracture than other attachment
area of contact between the implant and the bone
systems, making it appropriate for usage in situations
that trabecular metal dental implants (Tantalum)
where there is restricted inter-arch space. The pocket
give makes sense in light of this. According to the
depths in both groups increased significantly over
study, because it provides a larger area for osseoin-
time (44, 45). The growth of soft tissues surrounding
tegration, changing the implant surface may have an
the implant and the gradual vertical bone resorption
effect on osseointegration success. (37)
surrounding it may be the causes of this increase in
Studies on histology have shown that bone pocket depths. (41, 42).
ingrowth can occur with pores as small as 100 μm,
The findings of this study on pocket depth for
but the development of osteons requires pores larger
ball and locator attachments showed no statistically
than 150 μm in a porous substance. For vascularized
significant changes. On the other hand, less peri-
bone ingrowth to occur, pores bigger than around
implant tissue alterations were seen in locator
300 μm are required. (38) This may account for the
attachments. Similar results were observed by
little decrease in detectable bone loss that was seen
Shady et al. as well. (46)
in individuals undergoing rehabilitation using a
trabecular metal dental implant (Tantalum). Only for ball attachment, there was a
considerable variation in the Implant Stability
On the other hand, ball attachments cause
Quotient (ISQ) values, indicating a significant
greater bending moments, which exacerbate the
variation in implant stability over different times.
peri-implant bone loss that is seen.(39) This study
The continuous remodeling of the bone that occurs
found that there was a significant variation in the
following loading is the cause of the decline in ISQ
bleeding and plaque indices throughout different
values, since it results in a decrease in the anchoring
time periods. In both groups, plaque scores showed
between the implant and the bone. (47) Furthermore,
a notable increase over time. Similar increases in
increased micromovements and slight bone loss
plaque ratings were also observed in earlier research
may arise from the study’s initial loading of non-
for ball and locator attachments. (40, 41 ). This is
splinted implants, which could compromise the
because the durability of these attachments permits
stability of the devices. (48).
denture motions, food particle accumulation, and
plaque accumulation. Furthermore, patients’ oral After a year, the locator attachment in this
hygiene habits may be impacted by a decline in investigation proved to have greater implant
consciousness brought on by age. (42) stability than the ball attachment. According to the
study’s findings, there might be a difference because
Compared to balls, locators showed significantly
of the ball attachment’s higher rate of vertical bone
lower plaque scores after a year of follow-
loss than with the locator attachment.
up. Comparing overdentures supported by ball
attachments versus those supported by locator In this study the biocompatible material tantalum
attachments, numerous clinical trials have shown has exceptional corrosion resistance, according
that overdentures supported by ball attachments to this research, the porous tantalum trabecular
had greater problems and required more frequent metal (PTTM) assures stable implantation and
maintenance. This is explained by the regular has remarkable osteointegration properties.(49)
ASSESSMENT OF BALL VERSUS LOCATOR ATTACHMENT FOR IMMEDIATELY LOADED TWO TRABECULAR (13)

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