Strength comparison of four techniques

to secure implant at tachment housings

to complete dentures
Karla B. Domingo, DMD,a John O. Burgess, DDS,b Mark S.
Litaker, PhD,c and Michael S. McCracken, DDS, PhDd
University of Alabama at Birmingham School of Dentistry,
Birmingham, Ala
Statement of problem. Implant overdentures become thinner and weaker after direct transfer of implant attachment
housings. While much has been published on denture repair, these data do not directly apply to implant overdentures
because the introduction of a metal housing changes the character of the repair. It is desirable to make a strong repair
to avoid prosthesis fracture.
Purpose. The purpose of this study was to compare the flexural strengths of 4 different methods for chairside direct
transfer of implant attachment housings.
Material and methods. Eighty 11.5 9.1 39 mm heat-polymerized acrylic resin blocks were processed, assessed for
porosities, and polished. An 8.5 mm diameter hole was drilled to a depth of 5 mm in the center of each block. Attachment housings were set into the bases with 4 different repair materials: autopolymerized acrylic resin (APAR), lightpolymerized acrylic resin (LPAR), autopolymerized acrylic resin with silanated attachment housings (APSAH), and
light-polymerized acrylic resin with silanated attachment housings (LPSAH). Blocks were immersed in water for 30
days in an incubator. A 3-point bend test was done in a universal testing machine, and load to fracture was recorded
(MPa). Results were compared with 2-way ANOVA (=.05).
Results. APSAH had the highest mean flexural strength at fracture (863.1 87 MPa) as compared to APAR (678.4
72.4 MPa), LPAR (550.9 119.3 MPa), and LPSAH (543.2 100.8 MPa). A comparison among the 4 groups showed
that there were significant differences in maximum flexural strength (P<.001). The mean maximum strength of autopolymerized acrylic resin groups was significantly higher than light-polymerized acrylic resin groups. Silanation
increased strength significantly compared to nonsilanated groups.
Conclusions. The flexural strength of autopolymerized acrylic resin with silanated attachment housings was significantly higher than autopolymerized acrylic resin alone, light-polymerized acrylic resin alone, or light-polymerized
acrylic resin with silanated attachment housings. Autopolymerized acrylic resin produced stronger constructs than
light-polymerized materials. (J Prosthet Dent 2013;110:8-13)

Clinical Implications

The data suggest clinicians should use autopolymerized acrylic

resin for chairside attachment transfer. Strength can also be
improved if the housings are silanated.
Patients who received implantsupported dentures often report improved function and satisfaction,1-4 as
well as an increased occlusal force.5-7
However, there are disadvantages as-

sociated with implant overdentures.

Because of the increased forces and
thinning of acrylic resin bases brought
by accommodation of implant components, failure of overdentures due

to fracture is observed clinically.8-10

A variety of materials have been
used in dental practice to repair fractured dentures. These include autopolymerized acrylic resin and light-po-

Resident, Implant Training Program, Department of Prosthodontics.

Professor, Department of Biomaterials.
c
Associate Professor, Director of Biostatistics, Department of Clinical and Community Sciences.
d
Professor, Department of Clinical and Community Sciences.
a

The Journal of Prosthetic Dentistry

Domingo et al

July 2013
lymerized acrylic resins.11 Dar-Odeh
et al12 evaluated autopolymerized and
light-polymerized acrylic resin as denture repair materials and found that
the specimens repaired with autopolymerized acrylic resin had greater
modulus of rupture values than those
repaired with light-polymerized acrylic resin. This was supported by Vojdani et al13 who showed that dentures
repaired with autopolymerized acrylic
resin had a higher (60.3MPa) transverse strength than those repaired
with light-polymerized acrylic resin
(51.3MPa). However, the use of lightpolymerized acrylic resin was considered a suitable material for denture
repair by some authors.14 It is important to note that the bond strength of
light-polymerized acrylic resin to traditional PMMA denture materials is
different than bond strengths of that
material to similar light-polymerized
denture base materials.15
To improve the bond strength of
repairs, chemical pretreatments of
acrylic resins using methyl methacrylate or organic solvents may be used.11
Inadequate bonding between the attachment housing and the repair material serves as a point of weakness
in the construct, where fracture lines
may start. Thus, the successful repair
of implant overdentures depends on
the phenomenon of adhesion, not
only between the denture base resin
and the repair material, but also adhesion between the attachment housing and the repair material.13
Silanes are commonly used to promote adhesion, especially between dissimilar materials, such as acrylic resin
and metal.16 To ensure durable retention-free bonding to resins, metals can
be coated with a silane adhesive layer
using a modern dental-adhesive bonding technology (Rocatec; 3M ESPE).
May et al17 reported that when titanium
was airborne-particle abraded and pretreated with a silane material, the shear
bond strength between titanium and
heat-polymerized PMMA based resin
was increased by 60%. This was further
supported by another study18 which
demonstrated 68% greater bond-

Domingo et al

ing strengths in the silanated housing

groups. This confirmed that the use
of 110 m alumina airborne particle
abrasive and the Rocatec material as
a pretreatment of grade 2 titanium
to increase its shear bond strength to
PMMA based resin. These data may
have clinical implications.
It is important for clinicians to
use reliable techniques when inserting implant attachments into a denture base. The null hypothesis in this
study was that there is no difference
in the flexural load to failure of acrylic
resin blocks after direct transfer of attachment housings using 4 distinct
methods: autopolymerized acrylic
resin, light-polymerized acrylic resin,
autopolymerized acrylic resin with
silanated attachment housings, and
light-polymerized acrylic resin with silanated attachment housings.

MATERIAL AND METHODS

A metal bar was cut into 4 pieces
measuring 13 10 41 mm to serve
as metal patterns for the production
of the denture blocks. These metal
patterns were invested in conventional denture investment flasks with
a silicone-gypsum mold technique to
facilitate removal of the metal patterns from the flask. The metal patterns were invested in a high-viscosity
silicone impression material (Sil-Tech;
Ivoclar Vivadent Inc, Amherst, NY)
supported by gypsum laboratory
plaster material (Lab Plaster White;
Whip Mix Corp, Louisville, Ky). Heatpolymerized denture base resin (Lucitone 199; Dentsply Trubyte, York, Pa)
was proportioned and mixed following the manufacturers instructions.
The acrylic resin was packed in the
flask and polymerized in a water tank
at 77C for 9 hours to make 80 specimens. These blocks were trimmed to
11.5 9.1 39.5mm, measured with
a digital vernier caliper (Electronic
digital caliper; Zhangjiagang Yongfa Hardware Tools Co, Ltd, Jiangsu
China), and assessed for porosities.
Blocks were progressively finished in a
rotational polishing device (No: 233-

0-1997; Buehler Ltd, Evanston, Ill) to

a final surface of 1200 grit abrasive
paper (BuehlerMet Abrasive Disks;
Buehler Ltd) This left the blocks with
a final dimension of 11 (0.5) 8
(0.5) 38 (0.5)mm.
Titanium housings (BioHorizons,
Birmingham, Ala) used in this study
had a dimension of 5 mm in diameter 3.2 mm in height. These were
made of anodized Ti-6Al-4V alloy.
The manufacturer recommended that
at least 1.5mm of clearance be created around the housing for maximum
retention in the denture base. An 8.5
(0.5) mm diameter 5 (0.5) mm
depth hole was drilled at the center
of each denture block using a drill
press (Rockwell Intl, Pittsburgh, Pa).
Attachment housings were set in the
denture blocks as described below using 4 different repair materials: autopolymerized acrylic resin (Acraweld;
Henry Schein, Melville, NY) for Group
APAR; light-polymerized acrylic resin
(Triad Gel; Dentsply Trubyte) for
Group LPAR; autopolymerized acrylic
resin (Acraweld; Henry Schein) with
silanated attachment housings for
Group APSAH; and light-polymerized
acrylic resin (Triad Gel; Dentsply Trubyte) with silanated attachment housings for Group LPSAH. Twenty specimens were randomized to each of the
4 groups using a randomly-permuted
blocks assignment scheme. Power
analysis suggested that 20 specimens
per group would differentiate differences of 20 percent between groups,
a clinically useful amount.
For APAR, the following protocol
was used. After cleaning and drying
of the drilled PMMA surface, liquid methyl methacrylate monomer
was brushed on the exposed surface
for 180 seconds. Autopolymerized
acrylic resin was applied using the
sprinkle-on technique.19 Once the
acrylic resin filled three-quarters of
the hole, the denture block was inverted and placed over the titanium
housing which was seating passively
on a glass slab, simulating clinical direct attachment transfer. The denture
block was pressed against a glass slab

10

Volume 110 Issue 1

onds. The direct transfer was accomplished using autopolymerized or lightpolymerized acrylic resin and with the
same protocol as previously described.
Once polymerized, the repaired surface
was repolished. All specimens were immersed in 37.6C distilled water for
30 days for saturation in a 37C incubation chamber (Queue Systems Inc,
Parkersburg, WV).
Final dimensions were recorded
with a digital vernier caliper (500-19620 Digital Caliper; Mitutoyo USA,
Aurora, Ill). The flexural strength of
the repaired denture blocks with the
attachment housings was measured
with a 3-point bending test in a universal testing machine (Instron model
5565; Instron Industrial Products,
Grove City, Pa). The 3-point bending
test was set to have a span of 30 mm,
and a 5000 N load cell was used at
a crosshead speed of 5 mm/min until failure occurred. Flexural strength
values were computed by the instrument software after inputting measurements of the test blocks into the
instrument. The force to failure was
recorded in newtons (N) and strength
was expressed in megapascals (MPa).
Calculations of the mean and standard deviations were done.
Data analysis used a 2 2 factorial

The Journal of Prosthetic Dentistry

design, with factors defined by type

of repair material (light-polymerized
or autopolymerized) and silanation
(silanated or not). Results were analyzed with 2-way analysis of variance
(ANOVA) implemented with statistical software (SAS, Release 9.2.; SAS
Institute Inc, Cary, NC). F-tests for the
main effects of type of repair material
and silanation and for the 2-factor interaction were conducted. Post hoc
testing used the Tukey-Kramer test
(=.05).

RESULTS
The mean flexural strength values
at failure per group were as follows:
autopolymerized acrylic resin was
678.4 72.4 MPa, light-polymerized
acrylic resin was 550.9 119.3 MPa,
autopolymerized acrylic resin with
silanated attachment housing was
863.1 87 MPa, and light-polymerized acrylic resin with silanated attachment housing was 543.2 100.8MPa
(Fig. 1). Two-way ANOVA showed significant interaction (P<.001), indicating that the effect of silanation is not
consistent across repair material type,
but instead is dependent on which
type of repair material is used. Thus,
the effects of silanation and repair

1000

Mean Flexural Strength (MPa)

for 10 minutes under finger pressure.

Using the sprinkle-on technique,
additional autopolymerized acrylic
resin was placed on the repaired side
to fill any voids. Once polymerized,
the repaired surface with the attachment housing was repolished.
For LPAR, the following protocol
was used. Triad bonding agent (Triad
Bonding Agent; Dentsply Trubyte)
was applied after cleaning and drying
of the drilled area. It was left to settle
for 2 minutes and then polymerized
for another 2 minutes in the polymerization unit (Triad 2000; Dentsply
Trubyte). Flowable resin (Triad Gel;
Dentsply Trubyte) was subsequently
used to fill three-quarters of the hole,
and the denture block was inverted
to transfer the titanium housing. The
denture block was pressed against a
glass slab and the resin was polymerized for 4 minutes while inverted, using a light-polymerization unit with
1200 mW/cm2 intensity (Elipar S10
LED Curing Light; 3M ESPE, St Paul,
Minn). Additional flowable resin
was added around the housing to fill
any voids and was polymerized for 4
minutes with the same light-polymerization unit. An oxygen barrier (Air
Barrier Coating; Dentsply Trubyte)
was applied on the light-polymerized
acrylic resin to prevent inhibition of
polymerization by oxygen, and each
block underwent final polymerization
in the Triad unit for another 8 minutes. The repaired surface was then
repolished.
For APSAH and LPSAH groups,
attachment housings were silanated
according to the manufacturers instructions. With the Rocatec system
the titanium housings were airborne
particle abraded with silica-modified
30 m aluminum oxide (Rocatec
Soft) under a pressure of 0.28 MPa.
This was done to ensure an adequately high level of energy to create the triboplasma. The surface was abraded
at right angles from a distance of 1 cm
for 15 seconds all around the titanium
housing. It was then lined with silane
using a microtip applicator (RelyX
Ceramic Primer; 3M ESPE) for 15 sec-

900
800
700
600
500
400
300
200
100
0

APAR

LPAR

APSAH

LPSAH

1 Mean flexural strength of tested groups: autopolymerizing

acrylic resin (APAR), light-polymerizing acrylic resin (LPAR), autopolymerizing acrylic resin with silanated attachment housings
(APSAH), and light-polymerizing acrylic resin with silanated attachment housings (LPSAH). Error bars represent standard deviation.

Domingo et al

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July 2013

Table I. Tukey-Kramer post hoc analysis of

significance among groups

Mean Flexural Strength (MPa)

1000
900

APAR

800
700

APAR

600
500
400

Nonsilanated

300

APSAH

LPSAH

<.001

<.001

<.001

<.001

.994

LPAR

<.001

APSAH

<.001

<.001

LPSAH

<.001

.994

<.001
<.001

Silanated

200

Table II. Two-Factor ANOVA Results

100
0

LPAR

Light-Polymerized

Autopolymerized

2 Mean Flexural Strength (MPa) showing interaction between 2 effects: silanation vs repair material type (Interaction P<.001). NS=nonsilanated,
S=silanated, LPAR=light-polymerized acrylic resin,
APAR=autopolymerizing acrylic resin.

Source

df

Type I SS

Mean Square

Silanation

156631

156631

16.8

<.001

Resin type

1000924

1000924

108

<.001

Silanation Resin

185266

185266

20

<.001

Error

76

706895

9301

Corrected Total

79

2049717

3 Autopolymerizing acrylic resin group fracture site was

between attachment housing and acrylic resin. (Group
APAR; 10 magnification)

material type are not additive. The interaction between the groups is presented in Figure 2. Based on the Tukey
HSD test (Table I) there was no significant difference in means between
nonsilanated and silanated for lightpolymerized acrylic resin groups, but
there was for autopolymerized acrylic
resin groups (P<.001). The results revealed that autopolymerized acrylic
resin with silanated attachment housings yielded the highest mean flexural
load values and is significantly different from other groups (P<.001), as
shown in Table I. The ANOVA results

Domingo et al

4 Light-polymerizing acrylic resin group fracture site was

between light-polymerizing acrylic resin and heat-polymerizing acrylic resin. (Group LPAR; 10 magnification)

are displayed in Table II.

Figures 3-6 show the fracture site
in each of the 4 groups. As shown in
Figure 4 and Figure 6, fracture lines
in the light-polymerized acrylic resin
groups were between the denture base
material (heat-polymerized acrylic
resin) and the light-polymerized acrylic resin repair material. Thus, adhesive failure may be assumed. Adhesive
failure was also seen in the autopolymerized acrylic resin groups, only it
was between the repair material and
the housing itself (Figs. 3, 5).

Discussion
The null hypothesis was rejected,
as a significant difference was noted
among test groups. The results of this
study showed that the flexural load to
failure of denture blocks repaired with
autopolymerized acrylic resin plus the
use of a silanated attachment housing
had the highest values, compared with
using autopolymerized acrylic resin
alone, light-polymerized acrylic resin
alone and light-polymerized acrylic
resin with silanated attachment housing. Furthermore, when the mean

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Volume 110 Issue 1

5 Autopolymerizing acrylic resin group with silanated

attachment housing fracture site was between attachment housing and acrylic resin. (Group APSAH; 10
magnification)
flexural load of both autopolymerized
acrylic resin groups were compared
with the 2 light-polymerized acrylic
resin groups, autopolymerized acrylic
resin groups rendered higher flexural
load values. This is in agreement with
the studies of Dar-Odeh et al12 and
Vojdani et al13 who concluded that autopolymerized acrylic resin is stronger
than light-polymerized acrylic resin
for denture repair. Autopolymerized
acrylic resin rendered higher repair
values because it produces a greater
bond with the denture base material,
since autopolymerized acrylic resin
and heat-polymerized acrylic resin
are both PMMA acrylic resins. Materials with the same composition have
better bonding. To further support
this, Stipho et al15 demonstrated that
Triad VLP reline material produced the
greatest bond with the Triad VLP denture base resin. However, when used
with PMMA acrylic resin groups, it
produced low after-repair tensile and
shear bond strengths. This further explains that visible light polymerized
acrylic resins do not bond well with
PMMA. It is likely that in the current
study the greater flexural load values
of the autopolymerized acrylic resin
group were due to a better bond between the PMMA based acrylic resin
(autopolymerized and heat-polymerized acrylic resins) as compared with
the bond from Triad Gel.

6 Light-polymerizing acrylic resin group with silanated

attachment housing group fracture site was between
light-polymerizing and heat-polymerizing acrylic resin.
(Group LPSAH; 10 magnification)

These data show that silanation of

the attachment housing increased the
bonding of the attachment housing
with the autopolymerized acrylic resin, rendering a stronger construct. Because of the roughened, partially silica-coated surface produced when 30
m silica-modified aluminum oxide
was used on the attachment housing,
the silanation of the housing was able
to produce a better bond between the
titanium and acrylic resin. Silane is a
dual molecule, with one end bonding
with the inorganic surface (titanium
silica-coated surface) and the other
end with the organic resin.
In contrast to this finding, silanation did not produce an increase in
flexural load to failure of the denture
block repaired with light-polymerized
acrylic resin. The difference between
the mean flexural load of silanated
and nonsilanated light-polymerized
acrylic resin groups was not statistically significant. However, it cannot
be assumed that silanation did not
increase the bond between the lightpolymerized acrylic resin repair material and attachment housing since
the mode of failure was between the
light-polymerizing repair material and
the denture base. An increase in bond
strength with the silanated attachment
housing is probable, only it was not
observed since the failure occurred at
the bond between light-polymerized

The Journal of Prosthetic Dentistry

and heat-polymerized acrylic resin.

A weak bond formed between the 2
materials could have caused this failure or it is also possible that there was
an incomplete polymerization of the
light-polymerized acrylic resin since
there is only a certain depth that the
polymerization light can reach. Since
there is approximately 3 mm of heatpolymerized acrylic resin before the
light could reach the light-polymerized acrylic resin material, this might
hinder complete polymerization of
the material.
Several limitations exist in this
study. Surface roughness is an important factor in both bonding and
fracture mechanics. While the acrylic
resin blocks were finished with the
same grit abrasive paper, the exact
roughness of each specimen was not
measured. When picking up the attachment housings with acrylic resins,
the acrylic resin blocks were placed by
hand. While this is clinically relevant, it
is not easily reproduced. It was difficult
to guarantee that the housing was exactly in the center of each hole. Finally,
these specimens were tested in a static
load. It would be interesting in future
research endeavors to use a dynamic
load on the specimens.
The strength of denture base materials should be sufficient enough to
withstand masticatory forces after
direct attachment transfer to pre-

Domingo et al

13

July 2013
vent fracture. With the results of this
study, it is recommended that clinicians pretreat attachment housings
with silane prior to direct transfer with
autopolymerized acrylic resin for optimal results.

CONCLUSIONS
Within the limitations of this
study, the following conclusions were
drawn:
1. Flexural strength of autopolymerized acrylic resin with silanated
attachment housings was significantly higher than autopolymerized,
light-polymerized acrylic resin, and
light-polymerized acrylic resin with
silanated attachment housing groups.
2. Flexural strength of autopolymerized acrylic resin with and without
silanation of attachment housings
was significantly higher than the lightpolymerized acrylic resin groups.
3. Silanation produced higher
flexural strength in denture blocks repaired with autopolymerized acrylic
resin.

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Corresponding author:
Dr Michael McCracken
SDB 107
UAB School of Dentistry
1919 Seventh Ave South
Birmingham, AL 35294
E-mail: mikemc@uab.edu
Acknowledgments
This project was supported by BioHorizons,
Inc, who graciously supplied the implant attachment housings used in the trial.
Copyright 2013 by the Editorial Council for
The Journal of Prosthetic Dentistry.