University of Groningen
Maxillary overdentures on dental implants Boven, Geessien Catharina
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Carina Boven
MAXILLARY OVERDENTURES
ISBN: 978-94-6233-963-7 Cover design: Remco Wetzels Book design: Rianne Boven Printed by: Gildeprint
Publisher: G.C. Boven, Groningen
© G.C. Boven, 2018 | All rights reserved.
No part of this publication may be reported or transmitted, in any form or by any means, without permission of the author.
Maxillary overdentures
on dental implants
Proefschrift
ter verkrijging van de graad van doctor aan de Rijksuniversiteit Groningen
op gezag van de
rector magnificus prof. dr. E. Sterken
en volgens besluit van het College voor Promoties. De openbare verdediging zal plaatsvinden op
maandag 25 juni 2018 om 16.15 uur door
Geessien Catharina Boven
geboren op 26 juli 1988Promotores
Prof. dr. H.J.A. Meijer
Prof. dr. G.M. Raghoebar Prof. dr. A. Vissink
Beoordelingscommissie
Prof. dr. M.S. Cune Prof. dr. H. De Bruyn Prof. dr. D. WismeijerParanimfen
Elise Zuiderveld, MScContents
Chapter 1
General introduction
Chapter 2
Improving masticatory performance, bite force, nutritional state and patient satisfaction with implant overdentures: a systematic review
Chapter 3
Does a large dehiscent implant surface at placement affect the 5-year treatment outcome? An assessment of implants placed to support a maxillary overdenture
Chapter 4
Four-implant maxillary overdentures on bars or locators: a 1-year randomized controlled trial
Chapter 5
Masticatory performance improves after maxillary overdenture treatment: a 1-year randomized controlled trial
Chapter 6
Costs and cost-effectiveness of maxillary four-implant overdentures on bars or locators
Chapter 7
Choices in attachment systems for the maxillary implant overdenture. Two case reports.
Chapter 8
Summary
Samenvatting
Dankwoord
Curriculum vitae
1
1
Introduction
Currently, placement of dental implants is the treatment of choice to
eliminate common problems reported by wearers of conventional complete dentures. Implants provide support, improve retention and stability of overdentures, and reduce or eliminate pain during mastication (1–3). Implants not just eliminate problems, they also clearly contribute to improvement of patient satisfaction and masticatory performance (4). The success of overdentures can be valued addressing different outcome measures and using different measuring methods. Patient satisfaction is one of these outcome measures. Many studies on patient satisfaction with implant overdentures use questionnaires to rate whether patients are satisfied or not (5–7). For this purpose, a wide variety of questionnaires is available, either validated (8–12) or non-validated (13,14). Additionally, a variety of ways of measuring function as a parameter of satisfaction is reported. Amongst others, the treatment effect of implant overdentures can be evaluated by assessing chewing efficacy, bite force, muscle activity and muscle anatomy. The assumption is made that improvement in these items also reflects greater patient satisfaction (13,15,16). The outcome of the various methods to assess patients’ appreciation with regard to overdenture treatment has not been reviewed in detail, but is eagerly awaited.
When, in a particular case, implant overdenture treatment is a good option to improve function and patient satisfaction, the amount of bone available for reliable implant placement can be limited or insufficient. With the increasing demand for implant treatment and increasing patients’ expectations to minimize morbidity, there is pressure in implant dentistry to perform rehabilitations with implants placed in challenging sites such as sites with a low bone density and/or quantity. This condition is accompanied by an increase of presence of dehiscences or fenestrations at implant placement (17–19). When placing implants with adequate primary stability but no complete coverage by bone, a bone augmentation in the same session might be a solution; such approaches are commonly applied in routine clinical practice to prevent extra surgical sessions and morbidity. This applies especially to the severely resorbed maxilla, when implants are placed to retain an overdenture. It is not well known how implants, which were placed with a dehiscence or fenestration of the implant surface,
1
perform after an intermediate-term follow-up. It is meaningful to assess the peri-implant bone changes of implants placed with large and small dehiscences after five years.
When maxillary overdenture treatment is chosen, the question
remains how many implants are needed? The amount of evidence with intermediate to long-term follow-up on this topic is limited. Based on the findings of a systematic review about how many implants are needed for overdentures (20) and the good results from a randomized controlled trial with a five year follow-up comparing six- and four-implant overdentures (21) the choice for four implants to support a maxillary overdenture seems reasonable. After determining the amount of implants, the attachment system could influence success too. Various attachment systems have been used successfully to retain implant-supported overdentures in recent years. These systems can be classified as bars and solitary attachments (balls and locators® (Zest Anchors, Inc. homepage, Escondido, CA, USA)). Which system a dental practitioner and technician prefer is predominantly based on their experience, training and clinical outcomes (22). Overdentures with a bar attachment system are a therapeutic option that offers many advantages for patients with severely resorbed edentulous ridges (21). For mandibular overdentures bars are seen as the golden standard because of their good retention capacity, low maintenance costs and simple insertion and removal of the denture (23). The relative high initial costs are a disadvantage of the bar system. Additionally, there is some evidence that solitary attachments are more easy to clean by the patient than bars and that the soft tissues and bone are healthier because of this (24–26). Solitary attachments can be used with different matrices. Attachment design and the choice of material used for the retentive part of the matrix influence the friction grip and thus the need for aftercare (27). It has been reported that for mandibular overdentures ball attachments need more aftercare then bar attachments (28,29). However, an advantage of the solitary attachment system in comparison to the bar attachment system is that when maintenance, repair or replacement is needed, this can be done quickly, the procedures are straightforward and it can mostly be done chair side (30). Repair and replacement of a bar superstructure mostly takes more time and is more complicated. Besides initially solitary attachments are less costly.
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When comparing ball and locator attachments in the mandible and maxilla, ball attachments have more prosthodontic complications than locator attachments (31). Therefore, it seems that the locator attachment system is financially more favourable than other ball attachments (32,33). No differences between ball or locator attachments for patient satisfaction and peri-implant parameters were observed after one year (34). For this reason the locator attachment system seems promising and is preferred over the ball attachment system. Locators might be more favourable than bars for financial, oral hygiene and easy handling and maintenance reasons. However, there is scant literature containing direct comparison of bars and locators for maxillary implant overdentures. More research on radiographic, clinical and patient-reported outcomes of both options is needed before an evidence-based choice can be made on which attachment system is preferred.
Besides radiographic, clinical and patient-reported outcomes, functional outcomes are a very important aspect as well. In most cases the main complaint of a patient is the disability to function. As a consequence it is important to know whether the masticatory performance of a patient with a maxillary overdenture on a locator attachment system is as good as the masticatory performance of a patient with a maxillary overdenture on a bar attachment system. A variety of methods is currently in use to measure masticatory performance. The degree of breakdown can be measured using real test foods (peanuts, carrots, etc.) (35–37) or artificial materials (e.g., Optosil® and Optocal®) (38,39). Of all these tests, the two-coloured wax mixing ability test is the best at discriminating between people with compromised masticatory performance (40) and seems the best to use to measure performance.
As well as radiographic, clinical, functional and patient-reported outcomes, the arguments to choose a specific treatment can also be based on costs and especially cost-effectiveness. The initial costs of the newer locator system are presumed to be lower. Thus, choosing the locator system could be a way to keep up with the rising health care costs in general. If costs are known of both attachment options, and especially which treatment is more cost-effective, insight can be provided into whether the more costly treatment option offers sufficient added value to the patient to outweigh additional costs. In case of similar effectiveness, it could help health care
1
insurance companies in deciding which therapies to reimburse and which not, to control expenditures.
Last but not least, it should be three-dimensionally possible to apply the chosen treatment option. For the bar and locator attachment system the applicability depends on available space. The interocclusal clearance needed for the locator attachment system is less than for the bar
attachment system. Providing information about the treatment process and the use of digital planning software when assessing available space is a good way to help the practitioner to choose between the different possibilities for treatment.
Aim of the thesis
The general aim of the research described in this thesis was to assess the performance of maxillary overdentures supported by four dental implants with regard to patient satisfaction, masticatory performance, impact of implant dehiscences at surgery, clinical and radiographic outcome, costs and choice of attachment system.
The specific aims were:
• to systematically review the literature on overdentures, in order to
assess the improvement in masticatory performance, bite force, nutritional state and patient satisfaction after overdenture
treatment (chapter 2);
• to assess the 5-year treatment outcome of implants to support a
maxillary overdenture with a large dehiscent implant surface at
placement (chapter 3);
• to assess, in a randomized controlled trial, the one year peri-implant
bone height changes, implant survival, overdenture survival, clinical scores, and patient satisfaction of maxillary four-implant
overdentures with either bar or locator attachments (chapter 4);
• to assess, in a randomized controlled trial, the change in masticatory
performance one year after maxillary four-implant overdenture
treatment with either bars or locator attachments (chapter 5);
• to perform a cost-effectiveness study on bars or locators for
maxillary four-implant overdentures (chapter 6);
• to describe, in two clinical reports, the reasons for choosing either
1
References
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13. Müller F, Duvernay E, Loup A, Vazquez L, FR H, Schimmel M. Implant-supported mandibular overdentures in very old adults: a randomized controlled trial. J Dent Res. 2013;92(12 Suppl):154S–60S.
14. Gjengedal H, Dahl L, Lavik A, Trovik TA, Berg E, Boe OE, et al. Randomized clinical trial comparing dietary intake in patients with implant-retained overdentures and conventionally relined denture. Int J Prost-hodont. 2012;25(4):340–7.
15. Van Der Bilt A, Burgers M, Van Kampen FMC, Cune MS. Mandibular implant-sup-ported overdentures and oral function. Clin Oral Implants Res. 2010;21(11):1209–13.
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16. Da Silva RJ, Issa JPM, Semprini M, Da Silva CHL, De Vasconcelos PB, Celino CA, et al. Clinical feasibility of mandibular implant overdenture retainers submitted to imme-diate load. Gerodontology. 2011;28(3):227– 32.
17. Malo P, Nobre MDA, Lopes A. Immedi-ate rehabilitation of completely edentulous arches with a four-implant prosthesis con-cept in difficult conditions: an open cohort study with a mean follow-up of 2 years. Int J Oral Maxillofac Implants. 2012;27(5):1177– 90.
18. Van den Bogaerde L, Rangert B, Wen-delhag I. Immediate/early function of Brånemark System TiUnite implants in fresh extraction sockets in maxillae and poste-rior mandibles: an 18-month prospective clinical study. Clin Implant Dent Relat Res. 2005;7 Suppl 1:S121–30.
19. Mattsson T, Gynther II, Fredholm U. Implant Treatment without Bone Grafting in Severely Resorbed Edentulous Maxillae. J Oral Maxillofac Surg. 1999;57(3):281–7. 20. Raghoebar GM, Meijer HJA, Slot W, Slater JJR, Vissink A. A systematic review of implant-supported overdentures in the edentulous maxilla, compared to the mandible: how many implants? Eur J Oral Implantol. 2014;7 Suppl 2:S191-201. 21. Slot W, Raghoebar GM, Cune MS, Vissink A, Meijer HJA. Maxillary overden-tures supported by four or six implants in the anterior region: 5-year results from a randomized controlled trial. J Clin Periodon-tol. 2016;43(12):1180–7.
22. Kern JS, Kern T, Wolfart S, Heussen N. A systematic review and meta-analysis of
removable and fixed implant-supported prostheses in edentulous jaws: Post-loading implant loss. Clin Oral Implants Res. 2016 Feb;27(2):174–95.
23. Bueno-Samper A, Hernandez-Aliaga M, Calvo-Guirado J-L. The implant-sup-ported milled bar overdenture: a literature review. Med Oral Patol Oral Cir Bucal. 2010;15(2):e375-8.
24. Cordaro L, di Torresanto VM, Petricevic N, Jornet PR, Torsello F. Single unit attach-ments improve peri-implant soft tissue conditions in mandibular overdentures sup-ported by four implants. Clin Oral Implants Res. 2013;24(5):536–42.
25. Bilhan H. An alternative method to treat a case with severe maxillary atrophy by the use of angled implants instead of compli-cated augmentation procedures: a case report. J Oral Implantol. 2008;34(1):47–51. 26. Kleis WK, Kämmerer PW, Hartmann S, Al-Nawas B, Wagner W. A comparison of three different attachment systems for mandibular two-implant overdentures: one-year report. Clin Implant Dent Relat Res. 2009;12(3):209–18.
27. Watson GK, Payne AGT, Purton DG, Thomson WM. Mandibular overdentures: comparative evaluation of prosthodontic maintenance of three different implant systems during the first year of service. Int J Prosthodont. 2002;15(3):259–66.
28. Naert IE, Hooghe M, Quirynen M, van Steenberghe D. The reliability of im-plant-retained hinging overdentures for the fully edentulous mandible. An up to 9-year longitudinal study. Clin Oral Investig. 1997;1(3):119–24.
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29. Stoker GT, Wismeijer D, van Waas MAJ. An eight-year follow-up to a randomized clinical trial of aftercare and cost-analy-sis with three types of mandibular im-plant-retained overdentures. J Dent Res. 2007;86(3):276–80.
30. Chung KH, Chung CY, Cagna DR, Cronin RJ Jr. Retention Characteristics of Attach-ment Systems for Implant Overdentures. J Prosthodont. 2004;13(4):221–6.
31. Cakarer S, Can T, Yaltirik M, Keskin C. Complications associated with the ball, bar and Locator attachments for implant-sup-ported overdentures. Med Oral Patol Oral Cir Bucal. 2011;16(7):e953-9.
32. Cristache CM, Muntianu LAS, Burliba-sa M, Didilescu AC. Five-year clinical trial using three attachment systems for implant overdentures. Clin Oral Implants Res. 2014;25(2):e171-8.
33. Mahajan N, Thakkur RK. Overdenture locator attachments for atrophic mandible. Contemp Clin Dent. 2013;4(4):509–11. 34. Krennmair G, Seemann R, Fazekas A, Ewers R, Piehslinger E. Patient preference and satisfaction with implant-supported mandibular overdentures retained with ball or locator attachments: a crossover clinical trial. Int J Oral Maxillofac Implants. 2012;27(6):1560–8.
35. Lucas PW, Luke DA. Methods for analys-ing the breakdown of food in human masti-cation. Arch Oral Biol. 1983;28(9):813–9. 36. Manly RS, Braley LC. Masticatory per-formance and efficiency. J Dent Res. 1950 Aug;29(4):448–62.
37. Pera P, Bassi F, Schierano G, Appendino P, Preti G. Implant anchored complete
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2
Improving masticatory
performance, bite force,
nutritional state and patient
satisfaction with implant
overdentures: a systematic
review.
This chapter is an edited version of the manuscript:
Boven GC, Raghoebar GM, Vissink A, Meijer HJA
Improving masticatory performance, bite force, nutritional state and patient’s satisfaction with implant overdentures: a systematic review of the literature.
2
Abstract
Background Oral function with removable dentures is improved when dental implants are used for support. A variety of methods is used to
measure change in masticatory performance, bite force, patient satisfaction and nutritional state. A systematic review describing the outcome of the various methods to assess patients’ appreciation has not been reported.
Objectives The objective is to systematically review the literature on the possible methods to measure change in masticatory performance, bite force, patient satisfaction and nutritional state of patients with removable dentures and to describe the outcome of these.
Data sourcesMedline, Embase and The Cochrane Central Register of Controlled Trials were searched (last search July 1, 2014). The search was completed by hand to identify eligible studies. Two reviewers independently assessed the articles.
Study eligibility criteria Articles should be written in English. The study design should be prospective. The outcome should be any assessment of function/satisfaction before and at least one year after treatment.
Eligible participants Fully edentulous subjects.
Interventions Any kind of root-form implant(s) to support a mandibular and/or maxillary overdenture.
Results 53 out of 920 found articles fulfilled the inclusion criteria. A variety of methods was used to measure oral function; mostly follow-up was one year. Most studies included mandibular overdentures, three studies included maxillary overdentures. Implant-supported dentures were accompanied by high patient satisfaction with regard to denture comfort, but this high satisfaction was not always accompanied by improvement in general quality of life and/or health related quality of life. Bite force improved, masseter thickness increased and muscle activity in rest decreased. Patients could chew better and eat more tough foods. No changes were seen in dietary intake, BMI and blood markers. Improvements reported after one year apparently decreased slightly with time, at least on the long run.
Conclusions Treating complete denture wearers with implants to support their denture improves their chewing efficiency, increases maximum bite force and clearly improves satisfaction. The effect on quality of life is uncertain and there is no effect on nutritional state.
2
Introduction
Missing teeth, which are not replaced with prosthesis, result in a poor quality of life comparable with the effects of cancer and renal disease on physical well-being scales (1). When patients are provided with conventional dentures (CDs), improvements are reported with regard to overall satisfaction, aesthetics, comfort and speech, while the improvement in functional outcomes is often unsatisfactory (2). Usually, the functional outcome and patient satisfaction is increased when implants are placed to retain the mandibular (3) and/or maxillary (4) denture. Many studies on patients’ appreciation of implant overdentures (IODs) use questionnaires to rate whether patients are satisfied with the current situation or not (5-7). For this purpose, a wide variety of questionnaires is available, either validated (8-12) or non-validated (13, 14). In addition, treatment effect of IODs is measured with testing chewing efficacy, bite force, muscle activity and muscle anatomy. The assumption is made that improvement in these items also reflects greater patient satisfaction (13, 15, 16).
Reviews on certain aspects of patients’ appreciation of treatment with implant-supported overdentures are available. For patient satisfaction reviews were done to assess dentist- and patient-mediated preferences (17), the efficacy of mandibular IODs from the patient’s perspective (18), a comparison between treatment with CDs and IODs in elderly patients (19), the outcome in terms of (oral health related) quality of life (QoL) (20), and to assess the association between the oral health status and health related QoL (21). For the restoration of the edentulous mandible with IODs or CDs there is an accumulating body of evidence on the effect of treatment choice. Providing edentulous patients with implant-supported complete dentures contributed to improved health related QoL. Some articles show a significant association between oral health status and health related QoL. Although mandibular IODs may be more satisfying for edentulous patients than new CDs, the magnitude of the effect is still uncertain. Even with implant treatment presenting higher patient satisfaction and improvement of quality of life, it was not possible to establish a direct comparison between studies due to differences in adopted methodologies. Better designed, long-term studies are required to further explore differences in patient acceptance to each treatment intervention (CD, IOD, fixed prosthesis) for the edentulous mandible.
2
Evidence suggests that edentulous individuals lack specific nutrients and, as a result, may be at risk for various health disorders. Some reviews about the effect of treating edentulous subjects with IODs or CDs on nutritional and physical state (22, 23) are done. The effect on the nutritional state in edentulous subjects treated with implant therapy is similar to the one obtained with conventional removable dentures. This is not an optimum nutritional state, which also depends on other factors not related to prosthodontics treatment. The authors (24, 25) suggest that mandibular prostheses supported by two implants might offer a solution to the lack of intake of healthy, hard-to-chew foods by people wearing CDs.
A lot of different questionnaires and different ways of measuring function as a parameter of satisfaction are reported. A systematic review describing the outcome of the various methods to assess patients’ appreciation has not been reported. Therefore, the aim of the present systematic review on edentulous patients treated with IODs is to assess patients’ appreciation of the situation before and after treatment after an observational period of at least one year with respect to satisfaction, chewing (patterns), bite force and nutritional state measured by various methods.
Methods
Information sources and search strategy
A thorough search of the literature was conducted and was completed on July 1, 2014. The primary database used was Medline (via PubMed). Additional databases used were Embase and The Cochrane Central Register of Controlled Trials. The search was supplemented by hand-searching (checking references of the relevant review articles and eligible studies for additional useful publications). The search strategy was a combination of MesH terms and free text words. The strategy has been depicted in table 1.
Eligibility criteria
The studies had to meet the following requirements:
• Type of participants Patients who received an implant-retained
mandibular and/or maxillary IOD replacing a CD.
• Types of intervention Placement of root-form implants to support
a removable complete overdenture in de mandible and/or maxilla replacing a conventional complete denture. There were no
2
Table 1. Search strategy developed for Medline (via PubMed) and revised appropriately for each search database
Parameter Search Strategy
Overdenture #1 "Dental Prosthesis, Implant-Supported"[Mesh] OR
"Den-ture, Overlay"[Mesh]
#2 implant overdenture* OR implant-supported* OR implant-stabilized* OR implant-retain* OR overdentur* OR removable denture* OR removable prosthesis*
Conventional Denture #3 "Denture, Complete"[Mesh]
#4 complete dentur* OR full dentur* OR conventional* OR edentulous*
Quality of life #5 "Quality of Life"[Mesh]
#6 "quality of life"
Patient
satisfaction #7"Patient satisfaction"[Mesh]
#8 satisfact* OR “ satisfied” OR comfort* #9 "Treatment Outcome"[Mesh]
Ability to chew #10 "Mastication"[Mesh]
#11 "chewing" OR "mastication" OR "masticatory"
Bite force #12 "Bite Force"[Mesh]
#13 "biting" OR "bite force"
Identifying correct type of
studies #14 "Epidemiologic Studies"[Mesh] OR "Randomized Con-trolled Trial" [Publication Type] OR "Questionnaires"[Mesh]
#15 random* OR "prospective" OR "longitudinal" OR "follow-up" OR questionnaire* OR measur* OR assess* OR survey* OR scale*
Excluding partial dentures, including partial palatal coverage
#16 partial*[tiab] NOT palatal*[tiab]
Search strategy (#1 OR #2) AND (#3 OR #4) AND (#5 OR #6 OR #7 OR #8 OR
#9 OR #10 OR #11 OR #12 OR #13) AND (#14 OR #15) NOT #16
Last run data search 1 July 2014
attachment system, and immediate or conventional loading.
• Comparison Outcomes should be a comparison between before and
at least one year after treatment for the same patient.
• Principle outcomes Principle outcome is from methods assessing
2
satisfaction (with a range of parameters); quality of life; oral health related quality of life; function (with a range of parameters); bite force; ability to chew; nutritional state; and any other parameters to measure whether the amount of initial complaints has changed.
• Study design All types of prospective studies were considered for
evaluation.
Inclusion criteria
• Publications must be reporting in English.
• Treatment of the patients has to be initially planned for an
overdenture replacing a conventional complete denture.
• Detailed information on IODs; in case of combined data for IODs
and implant-supported fixed complete dentures, extraction of data for the overdentures must be eligible.
• Measurements for the same patient must be done pre-treatment
and after 1 year or longer.
Exclusion criteria
• Less than 10 patients treated with overdentures.
• Articles describing other studies.
Validity assessment and data extraction
Initial screening of the abstracts was performed by one reviewer (GCB), based on the criteria above. Full-text documents were obtained for all articles meeting the inclusion criteria. Full text analysis was performed by two reviewers (GCB, HJAM) independently.
Methodological quality and risk of bias were assessed independently by the reviewers using specific study-design related checklists designed by the Dutch Cochrane Collaboration as described by Offringa et al. (26) for each of the obtained full text papers. Agreement was reached by a consensus discussion and if necessary, a third reviewer (GMR) was consulted.
Results
Study selection
The results of the primary search for the period until 1 July 2014 was 917 hits for the Medline search, 194 hits for the Embase search and 109 hits for the Cochrane search (Fig. 1). Using this strategy, 1220 papers were initially
2
identified, of which 276 articles appeared to be double and of which 31 were review articles and as such contained no new data. These papers were excluded.
Figure 1. Flow diagram study selection
After scanning of titles and abstracts a further 837 papers were excluded because they didn’t meet the inclusion- and exclusion criteria. This approach resulted in 76 papers to be evaluated by full-text analysis. The amount of excluded articles with reasons for exclusion is found in figure 1. Reference checking of relevant reviews and included studies revealed
2
5 additional articles that met the criteria. The remaining 53 studies were filed electronically. The data were recorded and reported in annotated form (Table 2 (which can be found at the end of this chapter)).
Results of individual studies
Of all the studies found, most studies used patient satisfaction as a parameter (Table 2). A few were (also) evaluating chewing, bite force or other types of parameters. Most studies reported on mandibular overdentures, only three studies included maxillary overdentures.
Generally an improvement in satisfaction was seen after treating patients with CDs with IODs.
Five of the seven studies on chewing reported improvement. All four studies that reported on bite force reported an increase in bite force. Chewing patterns seemed to improve, and no change in BMI and blood plasma levels was seen.
A summary of the studies and outcomes is given in table 2.
Chewing evaluation
All studies reporting on masticatory performance showed a higher increase after IOD treatment than after CD treatment. Patients were able to chew better (27, 28) needed less chewing cycles to reach the same result (15) and were able to eat more tough foods (29) after IOD treatment. One author (13) found no differences in mixing ability between patients treated with CDs or IODs.
Bite force evaluation
Two authors (13, 29) described an improvement of the average maximum bite force after IOD treatment and this improvement remained established after 10 years (15). However, the average maximum bite force obtained with IODs was still significantly lower than that of dentate subjects (16).
One-year patient satisfaction evaluation
Treating CD wearers with IODs led to obvious improvements of patient satisfaction with their oral status as seen from custom made questionnaires (3, 4, 16, 30-48), the general satisfaction scores (4, 27, 33, 40, 44,
2
questionnaire) (4, 48, 50, 51), the OHIP-20 (46, 52-54), the OHIP-EDENT (13, 55, 56), the McGills denture satisfaction questionnaire (57, 58), the self-reported denture satisfaction scale (13, 53, 59) and the patient denture complaint questionnaire (60). The improvement in satisfaction did not necessarily lead to improvement in general quality of life (32) or health related quality of life (46).
Two authors (32, 51) described improvement of psychological factors and less activity restriction for patients treated with implants to support their dentures. One author (57) described that patients are less satisfied with overdentures than with fixed bridges. However overdentures score better on ease of cleaning. The Short Form Health Survey with 36 questions (SF-36) (46), World health organization Well-being Index (WHO-Five) (46) and Brief Approach/Avoidance Coping Questionnaire (BACQ) (46) showed no difference between treatment with a CD or IOD.
Five-year patient satisfaction evaluation
As seen from the custom made questionnaires (37, 61-66), general satisfaction scores (63), verbal questions (29), the self-reported denture satisfaction score (59), OHIP-20 (59) and OHIP-14 (66) treating CD wearers with implants to support their dentures led to obvious improvements of patient satisfaction with their oral status. All authors described that improvements reached after one year are stable for the first five years. One author (66) described that the amount of satisfaction of edentulous patients differs depending on prosthetic type. Patients rehabilitated with fixed prostheses obtained a generally higher level of satisfaction than patients wearing overdentures, except for the parameter for oral hygiene (halitosis and ease of cleaning).
Ten-year patient satisfaction evaluation
The improvement reached after one year was stable for the next ten years (67-70). If the mean satisfaction score of a treatment group was low at baseline, it stayed lower after treatment than the scores of groups receiving the same treatment with a higher satisfaction score at baseline (68).
Other evaluations
2
treatment. One author (27) reported an increase in the area covered and more harmonic and efficient chewing movement were seen by another author (71). Chewing muscle thickness increased after IOD treatment (13) and muscle activity during rest decreased (16). No (positive) changes in salivary flow (13), BMI (13, 60) blood markers (13, 60, 72) were seen. No changes in dietary intake (13, 72) and energy distribution (14) were seen. However, those wearing IODs were significantly more likely to take in their nutrients through fresh, whole fruits and vegetables (72).
Synthesis of results
No outcome measures could be meaningfully combined, so no meta-analysis was carried out.
Discussion
Major findings
This review attempted to identify published articles describing the effect of IOD therapy on elements of chewing efficacy, bite force, quality of life, patient satisfaction and other found functional outcomes. The focus of this article was to describe and summarize the outcome of the studies published so far.
Treating CD wearers with implants to support their dentures led to obvious improvements of patient satisfaction with their oral status as measured by questionnaires and interviews. One author found no improvement as measured by the SF-36, BACQ and the WHO-five. A part of the explanation for this might be that the SF-36 has limited construct validity for measuring oral health conditions, as stated by Allen et al. (73). This might also be true for the other questionnaires. The improvement in satisfaction did not necessarily lead to improvement in general quality of life or health related quality of life. The questionnaire used to measure quality of life, did not really focus on oral health, so it might be that the questionnaire can’t measure the impact on the general quality of health when the quality of oral health is improved.
For the parameter of chewing it was found that patients treated with IOD’s could chew better and eat more tough foods. Although patients could eat more tough foods (such as raw fruit, vegetables, nuts, etc.), an IOD didn’t
2
seem to improve dietary intake as measured by interviews, questionnaires and blood samples. A diet is a habit and it seems that by just improving the dental situation, the dietary habit does not change. In one article (13) no improvement in chewing efficiency was found, the explanation given was that they reused the existing dentures with abraded denture teeth. Because their treatment group existed of very old adults, also age-related decline of motor coordination could have contributed to this fact. Remarkably is the loss to follow up of 56% after 12 months in the CD group, this contributes to the questionability of the results of this study.
As expected, bite force improved after IOD treatment. Because of more usage and training of the m. masseter the thickness increased. Muscle activity in rest decreased, because there was no longer a need to stabilize the loose denture.
Improvements reached after one year seemed to decrease slightly but were stable over time, at least for 10 years.
Limitations
Even though there is a large amount of articles available about patients with CDs treated with IODs, almost all of these articles are about mandibular overdentures. In this review we included only three studies on maxillary overdentures. Thus, conclusions are based mostly on data about mandibular overdentures and might not be applicable for maxillary overdentures. Next to this only a few articles have a follow-up of longer than one year. So, long-term results are based on a small amount of data. Also the methods used in the reviewed studies are various, therefore it is only partly possible to compare the results of the different studies.
Comparison with existing reviews
In literature various authors (23-25) suggested that mandibular prostheses supported by only 2 implants offer a solution to the lack of intake of healthy, hard-to-chew foods by people wearing CDs. In the articles described in this systematic review no changes in energy distribution and dietary intake were seen. This was also described in the reviews done by Thomason et al. (20) and Sánchez-Ayala et al. (22). Thomason et al. (20) described that without tailored dietary advice, prosthetic rehabilitation didn’t necessarily result in a satisfactory diet. They suggested a relationship
2
between QoL and dietary selection, which might be justifiable, because in this systematic review it is found that QoL does not always improve after rehabilitation. Naito et al. (21) did a review on the relationship between satisfaction and quality of life and found 3 articles that confirmed an
improvement in QoL after improving the oral health status and 4 that didn’t confirm it. This seemed to show that the magnitude of the improvement in QoL is uncertain. Maybe there is some improvement, but no valid data is available due to measuring methods which are not appropriate for measuring the improvement in QoL. Even though an improvement in QoL is not certain, the improvement in satisfaction is obvious. This is in line with the conclusion of Thomason et al. (20) and Assunção et al. (19). Emami et al. (18) described that an improvement in satisfaction was seen, but the magnitude was uncertain. This might be due to poor possibilities to compare the results of individual studies because of all the different measuring methods used.
Conclusions and implications
Treating complete denture wearers with implants to support their denture improves their chewing efficiency, increases maximum bite force and it clearly improves satisfaction. The effect on quality of life is uncertain. There is little research about maxillary overdentures, so the results of this systematic review are mainly related to mandibular IODs. Because the overwhelming amount of research done on mandibular overdentures with a follow-up of one year, future research should focus on long term results and more on maxillary overdentures.
2
Table 2. Char act eris tics of included s tudies. Fir st author Year Gr oup s Sample size Follo w -up in mon ths Che wing Bit e for ce Pa tien t sa tis faction Other Out comes Benzing (71) 1994 15 0, 6-41 Che wing pa tterns, mandibu -lar bor der mo vemen ts + Cune (30) 1994 A (Select ed for implan t tr ea tmen t): 132 132 Gr oup A: 0, 12 Custom made ques
-tionnair e + Boerrig ter (31) 1995 IOD , n=32 32 0, 12 Cus
tom made ques
-tionnair e ++ PPS, n=29 0, 12 “ + CD , n=29 0, 12 “ No chang e Bouma (32) 1997 IOD , n=32 32 0, 12 GAR S-D , PW SoDP , HSCL , LAS AM, cus tom made ques tionnair e
+, no effect on QoL
PPS, n=29
0, 12
“
+, no effect on QoL
CD , n=29 Raghoebar (61) 2000 IOD , n=32 32 0, 12, 60 Cus
tom made ques
-tionnair e ++ PPS, n=29 0, 12, 60 “ +
2
Table 2. (c on tinued) Fir st author Year Gr oup s Sample size Follo w -up in mon ths Che wing Bit e for ce Pa tien t sa tis faction Other Out comes CD , n=29 0, 12, 60 “ + Raghoebar (67) 2003 IOD , n=32 32 0, 12, 60, 120 Custom made ques
-tionnair e ++ PPS, n=28 0, 12, 60, 120 “ + CD , n=30 0, 12, 60, 120 “ + Boerrig ter (33) 1995 IOD , n=91 91 0, 12 Cus
tom made ques
-tionnair e, g ener al sa tis faction sc or e (0-10) +* CD , n=60 0, 12 “ Geertman (34) IOD , n=91 91 0, 12 Cus
tom made ques
-tionnair
e incl. che
w
-ing ability ques
tions +* CD , n=60 0, 12 “ Burns (35) 1995 17 0, 1 w eek, 6, 12 Cus
tom made ques
-tionnair e + Cor dioli (62) 1997 21 0, 1, 6, 18, 36, 48, 60 Cus
tom made ques
-tionnair
e
2
Table 2. (c on tinued) Fir st author Year Gr oup s Sample size Follo w -up in mon ths Che wing Bit e for ce Pa tien t sa tis faction Other Out comes Wismeijer (36) 1997 2 impl/ball, n=36 110 0, 16 Custom made ques
-tionnair e + 2 impl/bar , n=37 0, 16 “ + 4 impl/bar , n=37 0, 16 “ + Timmerman (37) 2004 2 impl/ball, n=36 110 0, 19, 100 Cus
tom made ques
-tionnair e + 2 impl/bar , n=37 0, 19, 100 “ ++ 4 impl/bar , n=37 0, 19, 100 “ ++ Garr et (28) 1998 IOD , n=62 62 0, 6, 24 Sw allo wing thr eshold ++ CD , n=40 0, 6, 24 “ + Kapur (3) 1999 IOD , n=62 62 0, 6, 24 Cus
tom made ques
-tionnair e ++ CD , n=40 0, 6, 24 “ + Per a (27) 1998 12 0, 12 Tes t f ood +
2
Table 2. (c on tinued) Fir st author Year Gr oup s Sample size Follo w -up in mon ths Che wing Bit e for ce Pa tien t sa tis faction Other Out comes Gener al sa tis faction sc or e (0-10) +** Siz e and shape of che wing cy cles + Meijer (63) 1999 IOD , n=61 61 0, 12, 60 Custom made ques
-tionnair e, g ener al sa tis faction sc or e (1-10) +* CD , n=60 0, 12, 16 “ + Meijer (68) 2003 IOD , n=61 61 (after 60 mon ths, 85) 0, 12, 60, 120 Cus
tom made ques
-tionnair e, g ener al sa tis faction sc or e (0-10) +* CD , n=60 (a fter 60 mon ths 24 patien ts elect -ed t o receiv e implan ts) 0, 12, 60, 120 “
2
Table 2. (c on tinued) Fir st author Year Gr oup s Sample size Follo w -up in mon ths Che wing Bit e for ce Pa tien t sa tis faction Other Out comes Landa (38) 2001 10 0, 12 Custom made ques
-tionnair e + Bakk e (29) 2002 12 0, 3, 12, 60 Che wing ability + ma
xi-mum bite force
+ Verbal ques tions + Electr o-m yogr aphic activity + W alt on (39) 2002 67 0, 1, 12 Cus
tom made ques
-tionnair e, g ener al sa tis faction sc or e (0-100) + MacEn tee (40) 2005 BAR, n=34 68 0, 1, 12, 24 Cus
tom made ques
-tionnair e, g ener al sa tis faction sc or e (0-100) + BALL , n=34 0, 1, 12, 24 “ +
2
Table 2. (c on tinued) Fir st author Year Gr oup s Sample size Follo w -up in mon ths Che wing Bit e for ce Pa tien t sa tis faction Other Out comes St ellingsma (51) 2003 TMI, n=20 60 0, 12 Ver voorn ques tion -nair e, g ener al sa tis -faction sc or e (0-10), GAR S-D , PW SoDP ++ AUG, n=20 0, 12 “ + SHOR T, n=20 0, 12 “ ++ Att ar d (52) 2006 35 0, 12 The self -report ed den tur e sa tis faction sc ale, OHIP -20 +Van der Bilt (74)
2006 18 0, 3, 6, 12 Ja w muscle activity No chang e, ne w un -support ed den tur e lo w er activity
Van der Bilt (15)
2010 18 0, 3, 6, 12, 120 Mas tic at or y perf ormance + Ma
xi-mum bite force
2
Table 2. (c on tinued) Fir st author Year Gr oup s Sample size Follo w -up in mon ths Che wing Bit e for ce Pa tien t sa tis faction Other Out comes Zitzmann (41) 2006 2 impl/ball, n=20 60 0, 6, 36 Custom made ques
-tionnair e + 4 impl/bar , n=20 0, 6, 36 “ + CD , n=20 0, 6, 36 “ + Liddelo w (42) 2007 28 0, 3, 12 Cus
tom made ques
-tionnair e + Liddelo w (43) 2010 35 0, 3, 12, 36 Cus
tom made ques
-tionnair e + Cooper (64) 2008 59 0, 12, 60 Cus
tom made ques
-tionnair e + Pan (57) 2008 IOD , n=128 128 0, 6, 12 McGill Den tur e sa tis -faction ins trumen t +* CD , n=128 0, 6, 12 “ Alf adda (59) IM, n= 35 35 0, 12, 60 The self -report ed den tur e sa tis faction sc ale, OHIP -20 + CON, n=42 (his toric al cohort) 60 “ + Meijer (69) 2009 2 impl, n=30 60 0, 1, 5, 12, 60, 120 Cus
tom made ques
-tionnair
e
2
Table 2. (c on tinued) Fir st author Year Gr oup s Sample size Follo w -up in mon ths Che wing Bit e for ce Pa tien t sa tis faction Other Out comes 4 impl, n=30 0, 1, 5, 12, 60, 120 “ + Meijer (70) 2009 IMZ, n=30 90 0, 12, 60, 120 Custom made ques
-tionnair e + BRA , n=30 0, 12, 60, 120 “ + ITI, n=30 0, 12, 60, 120 “ + W alt on (44) 2009 1 impl, n=42 86 0, 2, 12 Cus
tom made ques
-tionnair e, g ener al sa tis faction sc or e (0-100) + 2 impl, n=44 0, 2, 12 “ + Att ar d (53) 2010 15 0, 12 The self -report ed den tur e sa tis faction sc ale, OHIP -20 + Burns (45) 2011 30 0, 6, 12, 18, 24, 30, 36 Cus
tom made ques
-tionnair
e incl. che
w
-ing ability ques
tions + Da Silv a (16) 2011 16 0, 3, 15 ma
xi-mum bite force
2
Table 2. (c on tinued) Fir st author Year Gr oup s Sample size Follo w -up in mon ths Che wing Bit e for ce Pa tien t sa tis faction Other Out comes Custom made ques
-tionnair e + Electr o-m yogr aphic activity + Al-Zubeidi (65) 2012 106 0, 1, 12, 36, 60 Cus
tom made ques
-tionnair e + Aw ad (72) 2012 CD , n=127 128 0, 6, 12 Che wing
ability and habits ques
-tionnair e food prepa -ra tion, ability t o che w; no chang e IOD , n=128 0, 6, 12 “ + Blood plas -ma le vels - f or bo th gr oup s Butt el (49) 2012 20 0, 6, 24 Gener al sa tis faction sc or e (0-10) + Gjeng edal (14) 2013 IOD , n=30 30 0, 3, 24 Cus
tom made ques
-tionnair e, SF-36, WHO-fiv e w ell-being inde x, B AC Q , OHIP -20 ++, HR QoL no chang e RCD , n=30 0, 3, 24 “ +, HR QoL no chang e
2
Table 2. (c on tinued) Fir st author Year Gr oup s Sample size Follo w -up in mon ths Che wing Bit e for ce Pa tien t sa tis faction Other Out co mes Gjeng edal (46) Cus tom made ques -tionnair e about f ood av oidance, die tar y in tak e as -sessmen t b y telephone inter vie w s +* Guljé (50) 2012 12 0, 12 Ver voorn ques tion -nair e, o ver all sa tis fac -tion r at e (0-10) + Jabour (54) 2012 CD , n=68 85 0, 12, 24 OHIP -20 + IOD , n=85 0, 12, 24 “ ++ Kr ennmair (58) 2012 20 0, 3, 6, 12 McGill Den tur e sa tis -faction ins trumen t + Kr ons trom (55) 2012 1 impl, n=17 36 0, 12, 36 OHIP -EDENT + 2 impl, n=9 0, 12, 36 “ + Martine z - Gonz ále z (66) 2013 IOD , n=20 20 0, 12, 24, 60 OHIP -14, cus tom made ques tionnair e ++2
Table 2. (c on tinued) Fir st author Year Gr oup s Sample size Follo w -up in mon ths Che wing Bit e for ce Pa tien t sa tis faction Other Out co mes FIX, n=20 0, 12, 24, 60 “ + Jofr e (56) 2013 CD , n=15 15 0, 12 OHIP -EDENT + SDI, n=15 0, 12 “ ++ Khoo (60) 2013 43 0, 3, 6, 12 Pa tien t den tur e c om -plain t ques tionnair e Aft er ne w CD +, a fter IOD + +BMI, Serum albumin levels
No chang e Malms trom (47) 2013 50 0, 2 wk., 3, 12, 24 Cus
tom made ques
-tionnair e + Müller (13) 2013 IOD , n=16 16 0, 3, 12 Mixing abili -ty t es t No chang e CD , n=18 0, 3, 12 “ No chang e Ma xi-mum volun -tar y bit e for ce + f or IOD gr oup The self -report ed den tur e sa tis faction sc ale, OHIP -EDENT +*
2
Table 2. (c on tinued) Fir st author Year Gr oup s Sample size Follo w -up in mon ths Che wing Bit e for ce Pa tien t sa tis faction Other Out co mesBMI, Mini Nutritional Assess
-men t, Blood mark er s, Masse ter thickness, saliv a flo w.
BMI – blood mark
er , nutritional assess -men t, saliv a flo w no chang e in both group s, masse ter
thickness + for IOD group
Slot (48) 2013 4 impl, n=33 66 0, 12 Che
wing ability ques
-tionnair e, V er voorn ques tionnair e, Ov er all sa tis faction sc or e (0-10) + 6 impl, n= 33 0, 12 “ +
2
Table 2. (c on tinued) Fir st author Year Gr oup s Sample size Follo w -up in mon ths Che wing Bit e for ce Pa tien t sa tis faction Other Out co mes Slot (4) 2013 4 impl, n=25 50 0, 12 Chewing ability ques
-tionnair e, V er voorn ques tionnair e, Ov er all sa tis faction sc or e (0-10) + 6 impl, n= 25 0, 12 “ + * In c
omparison with the other tr
ea tme nt gr oup; ** The degr ee of sa tis faction w as c orr ela ted neither t o incr ease d mas tic at or y e fficiency nor t o impr ov ed or al function; +: some impr ov eme nt a fter tr ea tme nt; ++: much impr ov eme nt a fte r tr ea tme nt; -: The situa tion a fte r tr ea tmen t is w or se than be for e; Abbr evia tions GAR S-D: Gr oning en Activity R es triction Sc ale–Den tis tr y; PW SoDP: P sy chologic al W ell-be ing Sc ale f or Den tur e P atien ts; HSCL: Hopk ins S ymp tom Che ck Lis t; LAS
AM: Linear Analogue Self
-Assessmen t Me thod, One -It em V er sion; OHIP -20: or al health impact pr ofile – 20 ques tions; SF-36: short f orm 36-it em he alth sur ve y; B AC Q: brie f appr oach/ av oidance coping ques tionnair e; OHIP -EDEN T: or al health impact pr ofile – f or ede ntulous pa tien ts; OHIP -14: or al he alth impact pr ofile – 14 que stions; BMI:
body mass inde
x; CD: con ve ntional de ntur e; IOD: implan t o ver den tur e; PPS: Pr e-pr os the tic sur ger y; impl: implan ts; B
AR: bar supe
rs
tructur
e; B
ALL: ball super
structur e; TMI: tr ansmandibular implan ts; A UG: augme nt ation be for e placing implan ts; SHOR T: tr ea tme nt with f
our short implan
ts; C ON : c on ven tional loading pr ot oc ol; IM: Immedia te loading pr ot oc ol; IMZ: IMZ implan t s ys tem; BRA: Br ånemark implan t s ys te m;
ITI: ITI implan
t s
ys
tem; HR
QoL: Health r
ela
ted quality of lif
e; R CD: re lining of c on ven tional den tur e; FIX: fix ed supe rs tructur e;
SDI: Small diame
ter implan
2
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