Implant-assisted complete prostheses.pdf

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Implant-assisted completeprostheses

E L H A M EM A M I , P I E R R E -LU C M I C H A U D , I M A D SA L L A L E H & J O C E L Y N E S. F E I N E

Oral health status has long been reported as an

important determinant of morbidity and mortality in

the general population (1, 15, 20, 33, 39, 51, 62, 63, 68,

72, 78, 88, 91, 101, 102, 106, 108). An eminent compo-

nent of oral health is the number of remaining teeth,

with tooth loss resulting in partial or complete edent-

ulism as its consequence. Edentulism is considered as

the nal marker of disease burden for oral health (23,

76, 77) and remains a major health problem world-

wide (16, 29, 66, 77). However, high levels of disability

can be reduced through new technologies and

health-promotion strategies. As replacing missing

teeth with conventional dentures cannot offer the

efciency of natural teeth, the therapeutic paradigm

for the treatment of edentulism has shifted from con-

ventional dentures to osseointegrated implant-

assisted prostheses (42, 52, 97). Currently, there is a

great demand for dental-implant therapy (71). Thistreatment modality has attracted the attention of

researchers, clinicians and patients because of

increased knowledge of its biological, functional,

esthetic and psychological benets, as well as low sur-

gical morbidity.

In fact, edentate patients treated with implant-

assisted complete prostheses (a new terminology

encompassing all types of complete prostheses

retained or supported by implants) have reported an

improvement over conventional prostheses in several

outcomes (18, 19, 35, 64, 113). However, when consid-

ering the rehabilitation of edentulous jaws usingimplant-assisted complete prostheses, an important

decision about prosthetic type must be made: xed or

removable?

A review of the current literature has revealed a lack

of consistency in terminology. In fact, the wide array

of terms used to describe prosthesis types may lead

to misinterpretation (89). Accordingly, Simon &

Yanase (89) have proposed using the terms implant-

supported overdenture or implant-tissue-supported

overdenturefor an implant-assisted removable pros-

thesis and implant xed complete denture for an

implant-assisted xed prosthesis. In this review, we

have attempted to summarize the existing terminol-

ogy in a way that will facilitate the use of the appro-

priate terms.

The xed prosthesis could be porcelain fused to

metal, or a zirconia or a metal acrylic restoration (64)

(previously called hybrid restoration of denture,

teeth, acrylic and metal framework, but according to

the Glossary of Prosthodontics (93) the term hybrid

should not be used (Fig. 1)). The implant-assisted

xed complete prostheses (xed dentures) are totally

supported by implants and can only be removed

by clinicians (Figs 13), whereas implant-assisted

removable prostheses (implant-overdenture) are usu-

ally supported by implants and soft tissues, but can

be supported by implants alone, depending on thesuperstructure used. They can also be removed by

the patients themselves (Fig. 4). Various terminolo-

gies have been used to differentiate these type of

prostheses: the terms implant-retained overdenture

or tissue-supported overdenture are used when a

prosthesis relies on tissue support and retentive ele-

ments, such as ball or Locator, attached to implants

(120) (Figs 4A and 5A). In these cases, the tissue sup-

port is achieved by a hinging movement around the

superstructure; the term tissue-implant-supported

overdenture denes the type of prostheses that get

their retention and anterior support from their super-structures and their posterior support from mucosal

tissues (such as an ovoid/round bar with no cantile-

ver) (Fig. 5B), whereas implant-supported overden-

tures (such as a rigid bar with a posterior bar

extension) provide retention and most of the support

(99, 120) (Fig. 6). Prostheses may also be classied by

arch, superstructure designs and splinting character-

istics, infrastructure (number and position of

implants) and prosthesis material (17, 89).

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Periodontology 2000, Vol. 66, 2014, 119131 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Printed in Singapore. All rights reserved PERIODONTOLOGY 2000


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Each prosthesis may have different long-term

patient-reported or clinical outcomes, and wise treat-

ment planning should take into account a vast array

of outcomes, such as esthetics (lip support), implant

success/survival rates, prosthetics success rate, func-

tional ability, time to retreatment, maintenance,

A B

Fig. 1. Implant-assisted xed pros-

theses.

A B


theses.

A B


theses.

A B

Fig. 4. Implant-assisted removable

prostheses. (A) Two Locators attach-

ments provide retention and ante-

rior support for the prosthesis. (B) A

long Dolder bar is used to provide

retention and most of the anterior

and posterior support for the pros-

thesis.

A B

Fig. 5. Simple attachments. (A)

Locator attachments. (B) Short Dol-

der bar attachment

Emami et al.

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complications and cost, as well as psychological and

social benets associated with choice of treatment

(119). Treatment decisions should be grounded in

evidence-based knowledge to assure quality and to

avoid negligent care. Hence, it would be useful to

review and compare the evidence available on vari-

ous treatments to assist both clinicians and patients.

The objective of this manuscript was to scope the lit-

erature on the efcacy of implant-assisted complete

prostheses in edentate jaws from the perspective of

both clinicians and patients in order to assist in the

diagnostic process and choice of treatment alterna-

tives for patients considering implant prostheses.

Therefore, the review was focused on answering the

following four questions: (i) What are the advantages

and disadvantages of xed dentures and implant-

assisted overdentures compared with conventional

dentures? (ii) What are the indications for prescribing

xed dentures? (iii) What are the indications for pre-

scribing implant-assisted overdentures? (iv) What are

the differences between xed dentures and implant-

assisted overdentures in terms of patient-reportedand clinician-measured outcomes? Finally, knowl-

edge gaps and clinical recommendations were high-

lighted.

Advantages of implant-assistedxed or removable prosthesescompared with conventionaldentures

The results of several randomized controlled trials

with short- and long-term follow-ups conrm thatmandibular and maxillary implant-assisted complete

prostheses offer biologic and functional benets to

edentate individuals and are more advantageous than

the rehabilitating effect of conventional dentures (10,

57, 69, 80, 82). These benets include a decreased

bone-resorption rate, enhanced prosthetic retention

and stability, improved masticatory efcacy and

chewing ability, and decreased soft-tissue trauma (7,

21, 34, 75, 81, 112). Several research teams worldwide

have tested the impact of implant-assisted dentures

on satisfaction and quality of life (3, 7, 9, 44, 83, 107,

110). The evidence shows that individuals with man-

dibular implant-assisted dentures are more satised

and have a better oral health-related quality of life

than do those with conventional dentures, indepen-

dently of sociodemographic factors, anatomy, num-

ber of implants and type of superstructure (7, 9, 11,

26, 32, 35, 44, 58, 75, 80, 81, 107). However, increasing

the number of implants per denture decreases the

cost efciency of treatment. This is why the mandibu-

lar two-implant overdenture has been recommended

as the minimal standard of care for edentate patients

(37, 94). A meta-analysis of eight randomized con-

trolled trials published since 2007 indicated that,

when compared with mandibular conventional com-

plete dentures, implant-supported overdentures were

rated to be more satisfactory at a clinically relevant

level (35). However, this meta-analysis questioned the

stability of the treatment effect and the magnitude of

the improvement in oral health-related quality of life.

This research question was recently addressed in afollow-up study indicating that oral health-related

quality of life will improve following delivery of con-

ventional dentures or two-implant overdentures and

that the treatment effect for both was stable over time

(48). However, the magnitude of the treatment effect

was signicantly larger for the overdenture group.

Recent effectiveness research has supported these

ndings (84). Finally, some promising results appear

to favor the use of mandibular overdentures retained

by a single midline implant, showing comparable sat-

isfaction and maintenance vs. the two-implant over-

dentures (104).Even though implant-assisted prostheses were

superior over conventional dentures for restoring

edentulous mandibles, the completely edentulous

maxilla is usually successfully restored with conven-

tional dentures because of greater retention and sta-

bility. In a crossover trial, de Albuquerque Jr et al.(26)

showed that patient satisfaction with maxillary

implant-assisted prostheses was not signicantly

higher than for new conventional maxillary prostheses.

A B

Fig. 6. Long bar attachments. (A)

Long Dolder bar on four mandibular

implants with bilateral cantilevers

and a central Locator for anterior

retention. (B) Long bar on ve maxil-

lary implants with unilateral cantile-

ver and four CEKA attachments for

retention.

Implant-assisted complete prostheses

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In general, there is limited evidence available on the

benets of maxillary implant-assisted complete pros-

theses over conventional dentures. Thus, no rm

conclusions can be made as to whether one is super-

ior to the other. However, the implant-assisted treat-

ments could be considered for dissatised patients

with advanced maxillary bone resorption, for those

who desire xed prostheses, or as a preventive

approach to bone loss (26). These treatments aremore complex than those performed in the mandible,

and treatment success relies on the meticulous

assessment of several factors such as esthetics, pho-

netics, bone and soft-tissue quality/quantity and bio-

mechanical factors (64).

Indications for implantoverdentures

A successful prosthetic treatment relies on evidence-

based comprehensive treatment planning, in whichseveral elements should be considered, such as

patient preferences and needs, anatomic constraints

and prosthetic limitations.

Based on these factors, removable implant-assisted

prostheses could be the treatment of choice for a sig-

nicant proportion of patients. In terms of patient

preference, many patients desire an implant-assisted

denture but are nancially limited. In such cases, the

presence of only one mandibular implant may make

overdenture treatment possible (104). Depending on

a patient

s chief reason for seeking implant treat-ment, an implant overdenture may be the best alter-

native. For example, a patient complaining of stability

or retention issues could potentially benet from this

treatment modality. Furthermore, additional surgery,

such as bone augmentation, may not be necessary as

a result of the use of implant overdentures and there-

fore the cost, morbidity and duration of treatment

could be reduced (28). For elderly patients who may

lack dexterity and/or have limited visual acuity, and

for patients with poor oral hygiene, the overdenture

may be preferable (13, 38, 43) because it can be

removed and is therefore easier to clean. This abilityto remove the overdenture prosthesis easily also

makes it a better option for people with acquired or

congenital oral and maxillofacial defects because it

can be easily removed by the oncologist during

check-up appointments or in the event of complica-

tions (28).

In a crossover trial it was found that patients did

not nd implant overdentures to be a second-class

treatment compared with the xed alternative (27,

38). Both were found to be equally satisfying, even

though the xed counterpart was rated as more ef-

cient for chewing. Still, half of the patients decided to

keep the removable prostheses because of easier

hygiene and the fact that it could be removed at

night. The length of time that patients were com-

pletely edentulous did not appear to affect which type

of prosthesis they preferred, even though it would be

logical to think that this might be the case. However,younger patients seemed to prefer the xed-implant

prostheses, whereas patients over 50 years of age had

a tendency to favor the removable design (38). As the

ability to clean the prosthesis was the factor that had

the greatest inuence on whether or not patients

chose the removable alternative, it has been sug-

gested that, during treatment planning, the clinician

should determine which patients consider cleanliness

as an important factor (38).

Some anatomic constrains could also hold great

importance on the treatment of choice. For example,

when the opposite arch is dentate or provided with

an implant-xed prosthesis and there is potential for

parafunctional activity, an overdenture is recom-

mended because it can be removed at night (64). For

patients presenting with moderate to severe vertical

and horizontal atrophy, a concave and prognathic

prole, inadequate lip support or phonetic problems,

the implant-assisted overdenture would be preferable

(117, 118); this would allow the construction of labial

anges to provide esthetic lip support and could

potentially improve the phonetics because of a better

seal and the possibility to add acrylic onto the lingualaspect of the teeth when needed.

There are some prosthetic limitations that must be

taken into consideration during treatment planning

for an implant-assisted prosthesis. Overdentures

require more interarch vertical space to provide the

room necessary for superstructures such as a bar, the

clips and the overlying acrylic restoration (30). It has

been suggested that at least 12 mm (Locators) to

15 mm (bar) are needed between the soft tissues and

the occlusal plane (65, 96) to use implant-overden-

tures, but depending on the system used, as much as

20 mm could be needed. For an example, when usinga bar with Locator abutments on top of it (Fig. 6),

20 mm may be needed. The possibility of using

acrylic anges also provides increased control of

esthetics by replacing lost hard and soft tissues. For

this reason, it is suggested that implant overdentures

should be used when the antero-posterior bone

resorption exceeds 10 mm (30). Overdentures are also

less sensitive to malpositioned implants, excessive

cantilevering and lateral offset of the occlusal surface

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compared with the xed designs (28, 32). Finally,

patients whose tongues cannot reach the palate (ton-

gue hypomobility) could also benet from the short-

ened distance offered by the acrylic thickness of the

overdenture, and the use of axed prosthesis in these

cases could potentially cause speech problems.

Indications for implant-xeddentures

Implant-xed dentures are often recommended for

younger edentate patients, those who psychologically

could not tolerate removable dentures and the sense

of tooth loss, those suffering from prosthesis-related

recurrent sores, and those with an excessive gag reex

(28). Also, a larger denture-bearing area is covered

with a removable prosthesis. Therefore, patients with

high muscle attachments, sensitive mandibular ridges

or tori, or knife-edge ridges may be more satised

withxed dentures (28). However, for axed denture,

a minimum of four implants is needed (12, 31, 40)

and therefore cost could be a limiting factor (65).

If there is no need to replace soft or hard tissues,

then a xed prosthesis is the best option, as there

would then be no space to accommodate acrylic

anges associated with overdentures. If only 8

10 mm of vertical space is available, the treatment of

choice is a porcelain-fused-to-metal restoration (65).

With less than 8 mm, the outcome could have poor

esthetics as a result of very short crowns, and soft/

hard tissue remodeling should be considered (65). Ifsoft or hard tissues have to be replaced vertically by

the prosthesis, axed restoration consisting of acrylic

supported by a metallic Montreal bar (Figs 1,7) could

be used instead of a porcelain-fused-to-metal pros-

thesis. The advantage of this type of denture is that it

will lower the costs and allow the use of acrylic teeth

if required, although porcelain teeth could also be

used with this type of prosthesis. The optimal vertical

space for this type of restoration is 15 mm (65). If

using a xed implant prosthesis, an intermaxillary

space of more than 15 mm could lead to esthetic

problems, such as long and/or buccallyared teeth,

black triangles and visible abutments (60, 61), and

may also cause excessive air space and additional

speech problems (28). If soft or hard tissues have to

be replaced horizontally (e.g. for lip support), the

overdenture is still the better choice (30). However,

xed dentures for the mandible produce fewer

esthetic complications because of reduced lip move-

ment and a need for lip support. Hygiene is more dif-cult with xed prosthesis and this should be

discussed with the patient. Depending on the design

of the xed prosthesis, ease of hygiene can vary

greatly (Figs 2B and 3B).

Differences between implant-xeddentures and implant-assistedoverdentures in terms of patient-reported and clinician-measured

outcomes

Patient-reported outcome

Patient satisfaction and oral health-related quality

of life

In general, studies comparing patient satisfaction

with implant overdentures and xed dentures

showed favorable outcomes for both treatments,

regardless of the characteristics of the rehabilitated

jaw (27, 79, 118). In a crossover clinical trial 20 years

ago, Feine et al. (38) compared mandibular

xed andlong-bar implant-supported overdentures using

patient-based outcomes of various aspects of the

prostheses. Almost equal numbers of study partici-

pants chose the xed and the removable dentures.

Both groups rated stability and the ability to chew

some foods as signicantly better with xed dentures

than with removable dentures (27). There was a ten-

dency for the removable denture to be chosen by

older subjects (50 + years of age), who preferred its

ease of cleaning (2). Heydecke et al. (43) used the

same design for comparing maxillaryxed overdentures

A B

Fig. 7. Montreal bars. (A) Occlusal

view (same bar as Figure 1). (B)

Front view of a second bar with

guide pins.


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with removable long-bar overdentures, both of which

were opposed by mandibular implant-supported

overdentures. Removable long-bar overdentures

received signicantly higher ratings of general satis-

faction compared with xed prostheses. In this study,

about two-thirds of the participants preferred to keep

the removable prosthesis. Heydecke et al. (45) also

examined the rate of speech errors with different

prosthetic designs. Subjects produced a signicantlyhigher percentage of correct sounds with the over-

dentures than with the xed dentures. There were no

signicant differences in error rates between the two

maxillary implant overdentures with and without pal-

atal coverage (45). Zitzmann et al. (118) compared

the patients perspective of xed and removable

implant-supported restorations in the edentulous

maxilla. No statistically signicant difference was

found between the patients denture assessments in

both groups. However, patients with removable den-

tures demonstrated greater improvement in esthetics,

taste and speech. In a 10-year follow-up of clinical

studies comparing xed dentures with implant-sup-

ported overdentures, Quirynen et al. (79) showed

that patients were highly satised with both treat-

ment types. Patients with xed dentures were slightly

more satised with chewing ability and general satis-

faction.

Although these results show a coherent pattern

of patient-based outcomes regarding xed and

removable prostheses, a recent survey by Brennan

and co-workers (13) and a clinical two-year study

by Katsoulis et al. (53) got quite different results,which suggest that we still need to investigate this

subject and identify the rationale behind these dif-

ferences. Katsoulis et al. (53) compared the oral

health-related quality of life of 41 patients with

maxillary implant overdentures with a gold bar,

computer-aided design/computer-aided manufac-

turing (CAD-CAM)-fabricated implant overdentures

with a titanium bar and CAD-CAM produced

implant-xed dentures. This study showed good

oral health quality of life for the three groups, with

a tendency for better oral health-related quality of

life in the xed group. Brennan and co-workers(13) surveyed patients who wore overdentures

(mostly in the maxilla) over a 6-year period; they

found that these patients had poorer oral health-

related quality of life and were less satised in gen-

eral, specically with chewing ability and esthetics,

compared with those wearing xed prostheses. In

this study, the xed group was less satised with

cost, clinician performance and hygiene factors,

but had signicantly lower psychological discomfort

and psychological disability compared with the

overdenture wearers.

Our review found that the prosthetic design effect

and its impact on oral health-related quality of life,

especially for the maxillary jaw, is seldom assessed.

Clinical outcomes

Implant survival ratesuccess

Implant survival and success have been widely exam-

ined in implant research on xed and removable

prostheses. Researchers have attempted to under-

stand these data by means of systematic reviews and

meta-analyses. A recent systematic review by Bryant

et al. (17) examined data from randomized clinical

trials and 5-year follow-up studies to determine the

effect of type of removable or xed prosthesis on

implant survival and success. Descriptive analysis of

at least 60-month follow-up data indicated no type-

specic differences in relation to implant survival

rate. Implant survival varied between 71.3% and

97.0% in the maxilla and between 83.0% and 100% in

the mandible. The maxillary removable and xed

prostheses had pooled 5-year implant-survival rates

of 76.6% and 87.7%, respectively. The mandibular

removable and xed prostheses had pooled implant-

survival estimates of 95.7% and 96.7%, respectively. In

a systematic review of longitudinal studies with at

least 5 years of follow-up, Berglundh et al. (8) esti-

mated the rate of implant loss for different prosthetic

designs. They found that implant loss during func-

tion was higher for overdentures (range: 5.6

5.9%)than for those supporting xed prostheses (range:

2.73.1%), with the failures located primarily in the

maxilla.

In a 6-year prospective clinical study, Tinsely et al.

(95) reported 100% survival and 100% prosthetic suc-

cess, with interval success rates of 95% in the rst 4

years; this dropped to 83% at 6 years for both the

xed and removable groups. Following a 10-year per-

iod, Schwartz-Arad et al. (87) reported a total cumu-

lative implant-survival rate of 95.4% (maxilla 83.5%,

mandible 99.5%), with an overdenture success rate of

70.4% (maxilla 41.9%, mandible 80.8%). Van Steen-berghe et al. (98) reported a 97.2% cumulative suc-

cess rate for mandibular two-implant overdentures.

In a long-term follow-up study performed by Attard

et al. (5), cumulative survival rates of over 90% for

mandibular overdentures were reported after

15 years of follow-up. Naert et al. (70), reported a

cumulative implant failure rate of 3% over 9 years in

207 consecutive patients who received mandibular

overdentures with Dolder bar attachments. Another

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retrospective study, of 495 mandibular overdentures

on two implants, reported a survival rate of 95.5%

after 20 years of loading (100).

These results indicate that both removable and

xed treatments are reliable in terms of success and

survival, but the mandibular xed prosthesis may

have greater survival than the maxillaryxed prosthe-

sis, and greater implant failures were observed for

overdentures in the maxilla (47). This dissimilaritycould be explained by differences in bone quality and

quantity, loading conditions, selection bias and the

effect of treatment planning (36). In a retrospective

study by Widbom et al. (109), a group of 27 patients

wearing maxillary overdentures retained by a long

bar attachment were followed over 5 years and

divided in two groups, according to initial treatment

planning. The cumulative implant-survival rate after

5 years was 77% in the group planned for overden-

ture treatment and 46% in the group who were

planned for treatment with a xed prosthesis, but

who received overdentures. Sadowsky (85) reviewed

maxillary implant overdenture outcomes and con-

cluded that there is a lack of solid evidence to support

guidelines on treatment planning for this modality of

treatment.

Sanna et al. (86) compared the clinical outcomes of

maxillary implants supporting plannedoverdentures

with those supportingxed prostheses. They found a

high cumulative survival rate of 99.3% when four to

six connected implants were used to support the

overdenture. In fact, different studies demonstrated

that implant survival with maxillary overdentures willincrease where bone quantity and quality are good

and loading characteristics are well evaluated (49, 74,

86, 87, 109, 114, 115).

Biologic complications

Implant-assisted treatment could result in a wide

range of biologic complications, including marginal

bone loss around implants, peri-implantitis, peri-mu-

cositis, tissue hyperplasia and residual ridge resorp-

tion (22, 116).

A limited number of studies have compared these

types of complication for implant-assisted xed/removable dentures. Berglundh et al. (8) systemati-

cally reviewed the incidence of biologic and techni-

cal complications in 51 longitudinal studies. In

general, soft-tissue complications were found to be

more prevalent in patients with overdentures than

in patients with xed prostheses. In a recent prac-

tice-based study in Italy, a 3.9-year follow-up of bio-

logic complications of 159 patients with mandibular

bar-retained overdentures showed a prevalence of

46% of biologic complications. The most common

soft-tissue complication, especially with the use of

bars, is hyperplasia, which may be avoided with

careful oral hygiene (14, 50). Shrinkage of the tissue

has been observed if a change is made to a xed

design (59).

A 10-year follow-up of 37 patients restored with

xed prostheses and overdentures revealed no dif-

ference in the marginal bone level (79). The review,by Esposito et al. (36), showed that late failures

caused by peri-implant infection are rare, in gen-

eral. According to Montes et al. (67), most failures

(88.2%) occur before loading, which may be a result

of local bone quality and quantity, instead of load-

ing factors and type of prosthesis. In his study, only

1% of the failed implants could be attributed to

peri-implantitis.

Regarding marginal bone loss, a meta-analysis of

eight observational studies on the impact of overden-

ture attachment types detected no bone loss around

mandibular implant overdentures (22). These nd-

ings agree with numerous other studies demonstrat-

ing very limited marginal bone loss with the use of

overdentures (50, 56, 98).

Concerning residual ridge resorption, Wright et al.

(111) investigated the effect on residual ridge resorp-

tion of two implant-retained mandibular overden-

tures and xed dentures on ve or six implants in the

posterior mandibular up to 7 years after insertion.

They reported that patients rehabilitated with over-

dentures had low rates of residual ridge resorption,

whereas patients with

xed prostheses showed boneapposition.

Maintenance

One important aspect of prosthetic care is long-term

maintenance. The type of prosthesis, as well as the

type of materials used, the dental or prosthetic status

of the antagonist jaw and the related loading factors

and occlusal forces, can all inuence the magnitude

of the maintenance issues (24). Clinicians may

encounter complications, such as wear or fracture of

prosthetic components, loosening and wear of reten-

tive mechanisms, as well as the need to reline and/orremake the prostheses (5, 24, 25).

Tinsely et al. (95) compared the maintenance

complications for xed dentures and implant-sup-

ported overdentures. The long-term maintenance,

including the incidence of remakes, relines and gen-

eral adjustments, was higher for implant-supported

overdentures than for xed dentures. Naert et al.

(70) reported the need for relatively low mainte-

nance care of mandibular implant overdentures


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supported by a Dolder bar over a 9-year period,

with a 23% need to reline, a 10% untightening of

the retention, 7% remakes and 7% fracture of

opposing dentures. According to the review by

Goodacre et al. (41), loosening of the overdenture

retentive mechanism was the most common after-

care need (33%), followed by need for relines (19%)

and overdenture clip/attachment fracture (16%).

A higher frequency of prosthetic complications wasalso reported for maxillary implant-supported over-

dentures than for mandibular implant-supported

overdentures (4). Katsoulis et al. (53) compared the

2-year maintenance service of 41 patients wearing

maxillary implant overdentures with a gold bar,

CAD-CAM fabricated implant overdentures with a

titanium bar or CAD-CAM produced implant-sup-

ported xed prostheses. Most complications

occurred in the rst year, independent of prosthesis

design. Direct screw xation of the superstructure,

having axed prosthesis and use of CAD-CAM tech-

nology appeared to reduce complications. They also

found a signicant difference between gold and tita-

nium bars in some complications (e.g. matrix and

bar-extension fractures were found only in the group

with the gold bar, and 65% of these patients had tis-

sue hyperplasia compared with the absence of this

complication in the titanium group). Davis and co-

workers (24) examined the dental records, over a 5-

year period, of a limited number of patients (n = 37)

who wore a mandibular xed prosthesis, which was

opposed by a mix of dental or prosthetic conditions

in the maxilla. They reported a higher maintenance

rate for implant-xed prostheses opposed by xed

prostheses compared with those opposed by natural

teeth or complete dentures. Combining these results

with other studyndings, Berglundh et al. (8) demon-

strated that the incidence of technical complications

in implant overdentures (1.9; 5-year mean) was about

3.5 times higher than for xed dentures (0.54; 5-yearmean). This higher incidence of complications was

also noted for implant components. These data indi-

cate that, although overdentures are a more econom-

ical alternative to xed prostheses, they may need

greater long-term maintenance, which would neces-

sarily increase cost.

Cost-effectiveness

Continuous increases in the cost of alternative

implant therapies have led to an expansion of cost-

effectiveness studies. Accordingly, different cost-

effectiveness assessment methods have been applied

to compare implant-assisted xed prostheses, over-

dentures and complete dentures, as well as different

types of superstructures and attachments (6, 46, 54,

55, 90, 92, 103, 105, 118, 121, 122). Attard et al. (6)

conducted an economic analysis of xed prostheses

and removable overdentures over a 15-year period.

According to their results, initial time and treatment

costs were signicantly higher for the xed group. In

fact, even taking into account long-term outcomes

Table 1. Comparison between xed and removable implant-assisted prostheses

Removable Fixed

Indications 1220 mm of vertical space 810 mm of vertical space (PFM)

15 mm of vertical space (metal-acrylic)

Patients lacking dexterity Younger patients

Oral/maxillofacial defects Psychological needs

Severe bone loss Mild/moderate bone loss

Malpositioned implants No horizontal bone loss

High nocturnal parafunction

Financially limited

Advantages Easier to clean Can be made of acrylic or porcelain

Phonetics Esthetics

Provides lip support Higher bite force

Technically easier to make Better stability/retention

Disadvantages More mucosal problems More implants required

Wear of components Accumulation of food posteriorly

More difcult and expensive to make, adjust and redo

Emami et al.

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and greater maintenance needs, mandibular implant-

assisted overdentures seem to be the best option in

terms of cost-effectiveness (6, 121).

In contrast to these results, a small study by Palmq-

vist et al. (73) indicated that clinical and laboratory-

work costs were relatively similar for 17 edentate par-

ticipants who randomly received three implant-xed

prostheses (All-in-One concept) with varying num-

bers of implants or overdentures supported by a Dol-der bar. However, these results are not in agreement

with the majority of studies, which concluded that

the implant-assisted overdentures are the most cost-

effective treatments (46, 122). Our review found that

the number of research studies in this eld is still lim-

ited, and the majority of these few studies used a

short follow-up period (46, 92) and they did not com-

pare different designs of implant-assisted overden-

tures (64).

Table 1 presents a summary of comparison of these

two modalities of treatments.

Knowledge gaps: research implications

This review reveals that there is still a need to provide

data on the differences between xed and removable

implant-assisted treatments on patient-based and

some clinical outcomes using robust research meth-

ods. These methods could include both quantitative

and qualitative approaches. Quantitative unbiased

research is hard to achieve, mainly because of the

high costs of conducting large randomized clinical tri-

als with long-term follow-up. One approach would be

to provide standard raw data, then aggregate these

data. This suggests that there is a need for an

extended collaboration of multidisciplinary teams of

oral scientists and research methodologists. Another

approach would be to encourage qualitative research

in the eld of implant dentistry. Qualitative research

may help us to gain a better understanding of the per-

ceptions of patients about differences in the types of

treatment, their decision-making process and the

extent of the burden of unsuccessful treatment.

These results could promote more judicious oral-

health care and encourage clinicians to emphasizecautious treatment planning so that patient dissatis-

faction and potential lawsuits can be avoided.

Conclusion and clinicalrecommendation

When indicated, and depending on the patients

needs, both removable and xed implant-assisted

prostheses can be highly safe, reliable and satisfactory

treatment modalities for rehabilitation of edentulous

jaws. Careful and precise treatment planning would

assist the clinician in preventing potential prosthetic

failures and is highly recommended. Clinicians

should consider patient preferences, nancial con-

straints, hygiene capacities and anatomic factors as

key elements in their decision-making process

regarding the choice of removable and xed implant-assisted prostheses.

Acknowledgments

We acknowledge Maha Masri and Nathalie Clairoux

for their assistance with the literature search. Figures

presented in this manuscript were reproduced by cour-

tesy of Drs Pierre Luc Michaud and Melanie Menassa.

Dr Emami holds a Canadian Institutes of Health

Research (CIHR) Clinician Scientists Salary Award.

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