The notion of implant-supported overdentures
Identifieur interne : 002F68 ( Istex/Corpus ); précédent : 002F67; suivant : 002F69The notion of implant-supported overdentures
Auteurs : Adrianne Scmitt ; George A. ZarbSource :
- The Journal of Prosthetic Dentistry [ 0022-3913 ] ; 1998.
English descriptors
- KwdEn :
- Abutment, Clip assembly, Complete dentures, Dent, Dent assoc, Dental implants, Dentistry, Denture, Edentulous, Edentulous condition, Edentulous predicament, Effective treatment options, First patients, Fracture, High levels, Implant, Implant prosthodontics, Implant systems, Maintenance requirements, Maladaptive, Mandibular, Mandibular implants, Mandibular overdentures, Mandibular prostheses, Optimization, Optimization phase, Optimization procedures, Oral maxillofac implants, Osseointegrated, Osseointegrated implants, Osseointegration, Overdenture, Overdenture design, Overdenture group, Overdentures, Parafunctional activity, Preprosthetic surgery, Prosthesis, Prosthet dent, Prosthetic, Prosthetic dentistry, Prosthetic dentistry schmitt, Prosthetic dentistry table, Prosthetic design, Prosthetic problems, Prosthodontic, Prosthodontic treatment, Removable, Removable overdentures, Removable prostheses, Retentive units, Schmitt, Specific therapy options, Success criteria, Treatment outcome measures, Unfavorable location, Years years, Zarb.
- Teeft :
- Abutment, Clip assembly, Complete dentures, Dent, Dent assoc, Dental implants, Dentistry, Denture, Edentulous, Edentulous condition, Edentulous predicament, Effective treatment options, First patients, Fracture, High levels, Implant, Implant prosthodontics, Implant systems, Maintenance requirements, Maladaptive, Mandibular, Mandibular implants, Mandibular overdentures, Mandibular prostheses, Optimization, Optimization phase, Optimization procedures, Oral maxillofac implants, Osseointegrated, Osseointegrated implants, Osseointegration, Overdenture, Overdenture design, Overdenture group, Overdentures, Parafunctional activity, Preprosthetic surgery, Prosthesis, Prosthet dent, Prosthetic, Prosthetic dentistry, Prosthetic dentistry schmitt, Prosthetic dentistry table, Prosthetic design, Prosthetic problems, Prosthodontic, Prosthodontic treatment, Removable, Removable overdentures, Removable prostheses, Retentive units, Schmitt, Specific therapy options, Success criteria, Treatment outcome measures, Unfavorable location, Years years, Zarb.
Abstract
Abstract: This article presents a brief review of the methods and techniques to manage the maladaptive edentulous patient. A discussion of the inclusion and exclusion criteria and treatment outcome measures associated with published prospective osseointegrated implant studies are included and specific therapy options are suggested. It is concluded that there is a need for less invasive, less expensive, less complex, and equally effective treatment options such as the implant-supported overdenture for the maladaptive edentulous patient. (J Prosthet Dent 1998;79:60-5.)
Url:
DOI: 10.1016/S0022-3913(98)70195-7
Links to Exploration step
ISTEX:60F97D6E08C1B3F8B0B8251F1E7F518B618ADF7BLe document en format XML
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A discussion of the inclusion and exclusion criteria and treatment outcome measures associated with published prospective osseointegrated implant studies are included and specific therapy options are suggested. It is concluded that there is a need for less invasive, less expensive, less complex, and equally effective treatment options such as the implant-supported overdenture for the maladaptive edentulous patient. 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(J Prosthet Dent 1998;79:60-5.)</abstract><qualityIndicators><refBibsNative>true</refBibsNative><abstractWordCount>79</abstractWordCount><abstractCharCount>573</abstractCharCount><keywordCount>0</keywordCount><score>7.09</score><pdfWordCount>4142</pdfWordCount><pdfCharCount>26674</pdfCharCount><pdfVersion>1.3</pdfVersion><pdfPageCount>6</pdfPageCount><pdfPageSize>612 x 792 pts (letter)</pdfPageSize></qualityIndicators><title>The notion of implant-supported overdentures</title><pmid><json:string>9474543</json:string></pmid><pii><json:string>S0022-3913(98)70195-7</json:string></pii><genre><json:string>research-article</json:string></genre><host><title>The Journal of Prosthetic Dentistry</title><language><json:string>unknown</json:string></language><publicationDate>1998</publicationDate><issn><json:string>0022-3913</json:string></issn><pii><json:string>S0022-3913(05)X7048-2</json:string></pii><volume>79</volume><issue>1</issue><pages><first>60</first><last>65</last></pages><genre><json:string>journal</json:string></genre></host><namedEntities><unitex><date><json:string>1979</json:string><json:string>1997</json:string><json:string>1986</json:string><json:string>1982</json:string><json:string>1998</json:string><json:string>1994</json:string><json:string>1989</json:string><json:string>1980s</json:string></date><geogName></geogName><orgName><json:string>University of Toronto</json:string><json:string>Department of Prosthodontics</json:string><json:string>Academy of Prosthodontics</json:string><json:string>Nobel Biocare</json:string><json:string>Faculty of Dentistry</json:string><json:string>University of Toronto</json:string><json:string>Ontario Ministry of Health</json:string></orgName><orgName_funder><json:string>Nobel Biocare</json:string><json:string>Faculty of Dentistry</json:string><json:string>University of Toronto</json:string><json:string>Ontario Ministry of Health</json:string></orgName_funder><orgName_provider></orgName_provider><persName><json:string>I. 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A discussion of the inclusion and exclusion criteria and treatment outcome measures associated with published prospective osseointegrated implant studies are included and specific therapy options are suggested. It is concluded that there is a need for less invasive, less expensive, less complex, and equally effective treatment options such as the implant-supported overdenture for the maladaptive edentulous patient. (J Prosthet Dent 1998;79:60-5.)</p></abstract></profileDesc><revisionDesc><change when="1998">Published</change></revisionDesc></teiHeader></istex:fulltextTEI><json:item><extension>txt</extension><original>false</original><mimetype>text/plain</mimetype><uri>https://api.istex.fr/document/60F97D6E08C1B3F8B0B8251F1E7F518B618ADF7B/fulltext/txt</uri></json:item></fulltext><metadata><istex:metadataXml wicri:clean="Elsevier doc found" wicri:toSee="Elsevier, no converted or simple article"><istex:xmlDeclaration>version="1.0" encoding="utf-8"</istex:xmlDeclaration><istex:docType PUBLIC="-//ES//DTD journal article DTD version 5.0.1//EN//XML" URI="art501.dtd" name="istex:docType"></istex:docType><istex:document><article docsubtype="fla" xml:lang="en"><item-info><jid>YMPR</jid><aid>86942</aid><ce:pii>S0022-3913(98)70195-7</ce:pii><ce:doi>10.1016/S0022-3913(98)70195-7</ce:doi><ce:copyright type="other" year="1998">Editorial Council of The Journal of Prosthetic Dentistry.</ce:copyright></item-info><ce:floats><ce:table id="tab2" colsep="0" rowsep="0" frame="topbot"><ce:label>Table II</ce:label><ce:caption><ce:simple-para>Prosthodontic treatment and implant survival outcome</ce:simple-para></ce:caption><tgroup cols="2"><colspec colname="col1" colsep="0"></colspec><colspec colname="col2" colsep="0"></colspec><tbody><row rowsep="1"><entry colsep="1"><ce:bold>Study 1 (fixed)</ce:bold></entry><entry><ce:bold>Study 2 (overdenture)</ce:bold></entry></row><row rowsep="1"><entry colsep="1">• 2 patients (3 arches) could not be reached for recall appointments after the fourth year of the study. 16 implants were therefore unaccounted for.</entry><entry>• 2 patients (2 arches) could not be reached for recall appointments, 1 patient after his second and the other after her sixth year in the study. 5 implants were therefore unaccounted for.</entry></row><row rowsep="1"><entry colsep="1">• 2 patients (2 arches) died (after 10 and 11 years of function) with 8 of the 10 originally placed implants still in function.</entry><entry>• 6 patients (6 arches) died with 14 of the 14 originally placed implants still in function after an average of 5.5 years.</entry></row><row rowsep="1"><entry colsep="1">• 1 patient (1 arch) lost all 5 of his mandibular implants at different times after a period of 3 to 6 years of function.</entry><entry>• 37 patients (39 arches) meet success criteria and are wearing 39 implant-supported removable prostheses. Of the originally placed 132 implants placed in all 45 patients, a total of 5 implants failed to osseointegrate (3.8%), 3 by stage 2 surgery and 2 implants failed after 2 and 3 years in the study. 3 implants were not used because of their unfavorable location as abutments. They were left in situ as so-called “sleeper” abutments.</entry></row><row><entry colsep="1">• 40 patients (40 arches) meet success criteria and are wearing 38 implant-supported fixed prostheses. Of the 259 implants placed in all 45 patients, a total of 32 implants failed to osseointegrated (12.4%), 21 by stage 2 surgery, and 11 after varying periods of loading. 6 implants were not used because of their unfavorable location as abutments. They were left in situ as so-called “sleeper” abutments.</entry><entry>• 35 removable overdenture prostheses are retained through bar and clip assembly, 2 by means of magnets and 2 with a custom framework.</entry></row></tbody></tgroup></ce:table></ce:floats><head><ce:article-footnote><ce:label>☆</ce:label><ce:note-para>This study was made possible by grants from the Ontario Ministry of Health, the Faculty of Dentistry, University of Toronto, and a staff support grant from Nobel Biocare.</ce:note-para></ce:article-footnote><ce:article-footnote><ce:label>☆☆</ce:label><ce:note-para><ce:sup>a</ce:sup>Assistant Professor, Department of Prosthodontics.</ce:note-para></ce:article-footnote><ce:article-footnote><ce:label>★</ce:label><ce:note-para><ce:sup>b</ce:sup>Professor and Head, Department of Prosthodontics.</ce:note-para></ce:article-footnote><ce:article-footnote><ce:label>★★</ce:label><ce:note-para>Reprint requests to: Dr. Adrianne Schmitt, Department of Prosthodontics, Faculty of Dentistry, University of Toronto, 124 Edward St., Toronto, Ontario, M5G 1G6, CANADA</ce:note-para></ce:article-footnote><ce:article-footnote><ce:label>♢</ce:label><ce:note-para><ce:bold>10/1/86942</ce:bold></ce:note-para></ce:article-footnote><ce:title>The notion of implant-supported overdentures</ce:title><ce:presented>Presented at the annual meeting of the Academy of Prosthodontics, Halifax, Nova Scotia, Canada, May 1997.</ce:presented><ce:author-group><ce:author><ce:given-name>Adrianne</ce:given-name><ce:surname>Scmitt</ce:surname><ce:degrees>MSc, DDS<ce:sup>a</ce:sup></ce:degrees></ce:author><ce:author><ce:given-name>George A.</ce:given-name><ce:surname>Zarb</ce:surname><ce:degrees>BChD, DDS, MS,.MS, FRCD(C)<ce:sup>b</ce:sup></ce:degrees></ce:author><ce:affiliation><ce:textfn>Faculty of Dentistry, University of Toronto Toronto, Ontario, Canada</ce:textfn></ce:affiliation></ce:author-group><ce:abstract><ce:section-title>Abstract</ce:section-title><ce:abstract-sec><ce:simple-para>This article presents a brief review of the methods and techniques to manage the maladaptive edentulous patient. A discussion of the inclusion and exclusion criteria and treatment outcome measures associated with published prospective osseointegrated implant studies are included and specific therapy options are suggested. It is concluded that there is a need for less invasive, less expensive, less complex, and equally effective treatment options such as the implant-supported overdenture for the maladaptive edentulous patient. (J Prosthet Dent 1998;79:60-5.)</ce:simple-para></ce:abstract-sec></ce:abstract></head><body><ce:sections><ce:para>For many years, traditional complete denture designs have been modified to gain additional support and stability from a few retained and suitably prepared natural teeth. Numerous publications attest to the effectiveness of such tooth-supported complete dentures or overdentures as a mitigating alternative to complete dentures.</ce:para><ce:para>During the same time period that techniques for producing tooth-supported overdentures were being perfected, P. I. Brånemark was developing the science of osseointegration.<ce:cross-ref refid="bib1"><ce:sup>1</ce:sup></ce:cross-ref> Brånemark's original prosthodontic protocol described a screw-retained full-arch fixed prosthesis. This clinical objective produced a prosthesis that was literally attached to the person, while remaining electively removable. The argument was made that, if the prosthesis were inseparable from the patient, it would be perceived as part of the patient and would therefore be the best solution to the problem of unsatisfactory adaptation to the complete denture experience. The biotechnological achievement of osseointegration was justifiably heralded as a major therapeutic breakthrough for edentulous people.<ce:cross-ref refid="bib2"><ce:sup>2</ce:sup></ce:cross-ref></ce:para><ce:para>The prosthodontic community quickly embraced this initiative and sought to use the concept in an abbreviated manner. They sought just enough adjunctive retention and support to solve a patient's demonstrated or reported maladaptive response by prescribing a removable (by the patient) implant-supported overdenture. A corollary in the field of ophthalmology may be cited. Wearing corrective lenses is a minimal solution to most problems of reductions in visual acuity. Though surgical solutions exist, it is not necessarily true that a shift to an almost total surgical solution for all visual problems is either logical, feasible, or financially prudent.</ce:para><ce:para>It should be emphasized that the initial thrust of osseointegration was predictability of the surgical protocol. In fact, the prosthodontic protocol and application did not follow a similar vigorous development and was not necessarily executed by prosthodontists experienced in the management of the edentulous condition. Thus surgeons provided a foundation and the dentists resorted to a “knee-jerk” response of basic fixed prosthodontic method. The original approach was to solve patients' denture wearing problems (conveniently referred to as maladaptation) by making a full-arch acrylic resin or porcelain veneered superstructure attached with screws to five or six osseointegrated implants. This design did solve the denture wearing problem, but for many patients was clearly an overengineered solution.</ce:para><ce:para>Prosthodontists had previously developed an ingenious repertoire of methods and techniques to manage the edentulous condition. Experience and observation had taught them that the vast majority of their patients' early years of denture wearing were without major problems. However, the risk of time-dependent adverse changes in the edentulous milieu led to a reduction in certain patients' ongoing ability to wear their dentures comfortably. They became maladaptive with respect to wearing their dentures, and prosthodontists realized that, for the majority of such patients, it was the evolving lack of denture stability that accounted for their patients' unhappy situation.</ce:para><ce:para>Once established that osseointegration is a predictably successful treatment, it was a natural progression to the notion of using osseointegrated implants to support overdentures. The feasibility of implant-supported overdentures was first tested at the University of Toronto in the early 1980s as a provisionalization procedure during the variable time interval between stage II surgery and insertion of the finished fixed implant-supported prosthesis.<ce:cross-ref refid="bib3"><ce:sup>3</ce:sup></ce:cross-ref> Patients' responses to the occasional prolonged wearing of their provisional implant-supported overdentures indicated that their maladaptive problems had been resolved, and that the common denominator of successful resolutions of problems lie in the achievement of adequate denture retention and stability to provide patients with the capacity to readapt to their complete dentures. Early observations led to the next study to test the efficacy and effectiveness of implant-supported overdentures. The objective of this article is to report the outcome of patients treated with implant-supported and retained overdentures and to compare this outcome with that on a comparable group of patients treated with implant-supported full-arch fixed prostheses.</ce:para><ce:section><ce:section-title>Materials and Methods</ce:section-title><ce:para>The study population was comprised of 96 consecutively treated patients who had been referred to the Prosthodontic Department at the University of Toronto because of their inability to wear their complete dentures. The first patients who were to receive the fixed prosthesis (study 1) entered into the study in 1979 and the first patients who were to receive the overdentures were entered into the study (study 2) in 1982. There were 40 women and 10 men in each group of patients; however, there was some crossover between the two patient groups so the actual number of patients treated was 96 (Table I).<ce:cross-refs refid="bib4 bib5"><ce:sup>4,5</ce:sup></ce:cross-refs><ce:display><ce:table colsep="0" rowsep="0" frame="topbot"><ce:label>Table I</ce:label><ce:caption><ce:simple-para>Study population</ce:simple-para></ce:caption><tgroup cols="5"><colspec colname="col1" colsep="0"></colspec><colspec colname="col2" colsep="0"></colspec><colspec colname="col3" colsep="0"></colspec><colspec colname="col4" colsep="0"></colspec><colspec colname="col5" colsep="0"></colspec><tbody><row rowsep="1"><entry colsep="1"></entry><entry namest="col2" nameend="col3" colsep="1"><ce:bold>Study 1 (fixed)</ce:bold></entry><entry namest="col4" nameend="col5"><ce:bold>Study 2 (overdenture)</ce:bold></entry></row><row rowsep="1"><entry colsep="1">Patients</entry><entry colsep="1">50 (40F 10M)</entry><entry colsep="1"></entry><entry colsep="1">50 (40F 10M)</entry><entry></entry></row><row rowsep="1"><entry colsep="1"></entry><entry colsep="1"></entry><entry colsep="1"></entry><entry colsep="1">4 of these patients transferred from study 1</entry><entry></entry></row><row rowsep="1"><entry namest="col1" nameend="col5" align="center"><ce:bold>Phase one – Prosthesis optimization</ce:bold></entry></row><row rowsep="1"><entry colsep="1">Patients</entry><entry colsep="1">46 (36F 10M)</entry><entry colsep="1">4 (4F)</entry><entry colsep="1">45 (36F 9M)</entry><entry>5 (4F 1M)</entry></row><row rowsep="1"><entry colsep="1">Status</entry><entry colsep="1">Problems persisted</entry><entry colsep="1">Improvements/reluctance regarding surgery</entry><entry colsep="1">Problems persisted</entry><entry>Improvements/reluctance regarding surgery</entry></row><row rowsep="1"><entry namest="col1" nameend="col5" align="center"><ce:bold>Phase two – Treatment</ce:bold></entry></row><row rowsep="1"><entry colsep="1">Patients</entry><entry colsep="1">45 (36F 9M)</entry><entry colsep="1">4 (4F)</entry><entry colsep="1">45 (36F 9M)</entry><entry>5 (4F 1M)</entry></row><row rowsep="1"><entry colsep="1">Arches</entry><entry colsep="1">46 (4mx 42md)</entry><entry colsep="1">4 (4md)</entry><entry colsep="1">47 (5mx 42md)</entry><entry>5 (5md)</entry></row><row rowsep="1"><entry colsep="1">Implants</entry><entry colsep="1">259 (26mx 233md)</entry><entry colsep="1">0</entry><entry colsep="1">132 (17mx 115md)</entry><entry>0</entry></row><row rowsep="1"><entry colsep="1">Treatment</entry><entry colsep="1">Implant-supported fixed prosthesis</entry><entry colsep="1">Continued optimization</entry><entry colsep="1">Implant-supported overdentures</entry><entry>Continued optimization</entry></row><row rowsep="1"><entry colsep="1"></entry><entry colsep="1"><ce:sup>*</ce:sup>1 patient (M)</entry><entry colsep="1"><ce:sup>*</ce:sup>3 patients (F)</entry><entry colsep="1"></entry><entry></entry></row><row rowsep="1"><entry colsep="1"></entry><entry colsep="1">2 arches transferred to study 2</entry><entry colsep="1">3 arches later entered study 2</entry><entry colsep="1"></entry><entry></entry></row><row rowsep="1"><entry namest="col1" nameend="col5" align="center"><ce:bold>Phase three – Follow-up</ce:bold></entry></row><row rowsep="1"><entry colsep="1">Annual recalls: 13 to 17 years</entry><entry colsep="1"></entry><entry colsep="1"></entry><entry colsep="1">Annual recalls: 4 to 15 years</entry><entry></entry></row><row><entry namest="col1" nameend="col5"></entry></row></tbody></tgroup><ce:legend><ce:simple-para>Clinical and radiographic success criteria (Smith and Zarb) applied to patients treated with implant-supported prostheses.</ce:simple-para><ce:simple-para><ce:italic>F</ce:italic> = Females; <ce:italic>M</ce:italic> = males; <ce:italic>mx</ce:italic> = maxillary; <ce:italic>md</ce:italic> = mandibular</ce:simple-para></ce:legend></ce:table></ce:display>Patients for whom fixed prostheses were prescribed had an average age of 50.4 years, while those with removable prostheses had an average age of 59.7 years at the time of treatment.</ce:para><ce:para>All but three patients were completely edentulous in both arches. All the patients were diagnosed maladaptive with respect to their prostheses for one or more of the following reasons: severe morphologic compromise of their denture-bearing area, high levels of parafunctional activity, apparent lack of oromuscular control and/or a hyperactive gag reflex. Some patients were included because they simply could not adapt to wearing their complete dentures.</ce:para><ce:para>The same exclusion criteria were applied to all patients. Patients who were not medically stable and were therefore unable to undergo a minor oral surgical procedure, and those who had a known history of substance abuse were not included. Also excluded were patients who had unrealistic expectations of the esthetic results. Because an integral part of the study was the surgical placement of titanium implants, those patients with insufficient bony dimensions in the proposed host bone sites to accommodate the implants could not be included.</ce:para><ce:para>In accordance with the University of Toronto institutional review process, the informed consent of all the subjects who participated in the experimental investigation was obtained after the nature of the procedures and possible discomforts and risks had been fully explained. The study was designed to be prospective and longitudinal and to deal with consecutively treated patients. An initial phase was included to optimize the existing prostheses by adjustments, occlusal corrections, relines, or the making of new dentures.<ce:cross-refs refid="bib4 bib5"><ce:sup>4,5</ce:sup></ce:cross-refs> If the patient did not report significant improvement after this phase, the patient entered the second phase–the treatment phase of the study.</ce:para><ce:para>Four of the 50 patients in study 1 noted a sufficient degree of improvement in the comfort and function of their prostheses, and they declined preprosthetic surgery at that time. One of the 50 patients was transferred to study 2 because his congenital anatomic deficits (Treacher-Collins syndrome) made it necessary to restore his dentition with removable rather than fixed prostheses. Five of the 50 patients in study 2 (removable prostheses) experienced enough improvement with their optimized prostheses to warrant a decision on their part to postpone preprosthetic surgery indefinitely.</ce:para><ce:para>In the surgical treatment phase, 45 of the remaining 49 patients in study 1 had 4 to 8 implants placed into the individual arches for a total of 259 implants. This represented 46 treated arches (4 maxillae and 42 mandibles). The other 4 patients continued with optimization procedures and monitoring; eventually 3 of these 4 patients entered the overdenture part of the study. The fourth patient continues with traditional complete dentures.</ce:para><ce:para>For study 2, 45 of the 50 patients had a total of 132 implants inserted into 47 arches (5 maxillae and 42 mandibles). The number of implants placed comprised 2 to 4 implants per arch with one exception. The patient with Treacher-Collins syndrome had 5 and 6 implants placed in the mandible and maxilla, respectively. Those patients who did not undergo preprosthetic surgery continued with traditional complete dentures. The routine prosthetic design prescribed for study 2 was an implant-supported prosthesis that simulated the stress distribution pattern, which exists in a bilateral distal extension Class I removable partial denture. The distal extension areas of the implant-supported overdentures were tissue-supported; therefore there was a degree of mobility of the prostheses in this area.</ce:para><ce:para>The protocol for the follow-up phase of the study consisted of annual recalls where both the implants and the prostheses were evaluated. The criteria used for determining successful osseointegration of the implants were those proposed by Albrektsson et al.<ce:cross-ref refid="bib6"><ce:sup>6</ce:sup></ce:cross-ref> in 1986 and subsequently refined by Smith and Zarb<ce:cross-ref refid="bib7"><ce:sup>7</ce:sup></ce:cross-ref> in 1989. These criteria were designed specifically to define successful outcomes rather than mere implant survival. The fixed prostheses patients in study 1 have now been monitored for 13 to 17 years; the removable prostheses group, study 2, for 4 to 15 years. Both fixed prostheses and overdentures were removed, so that individual implants could be tested for mobility and radiographed with a special holder to ensure that the x-ray films were perpendicular to the long-axis of the implant. The customary periodontal indices were noted for the fixed group for the first 10 years, and for the overdenture group for the first 2 years. After years of monitoring the soft tissue and bony responses and finding that there was no correlation between loss of osseointegration and levels of plaque or gingival index or any other periodontal index, the decision was made to stop recording these indices. Details of these data for study 1 patients have been previously published.<ce:cross-ref refid="bib16"><ce:sup>16</ce:sup></ce:cross-ref></ce:para><ce:para>At recall appointments, the prostheses for all patients were assessed for retention, support, stability, and occlusion. Patients in both studies were also asked for their subjective evaluation of their dentures as related to comfort, chewing efficiency, esthetics, articulation, soreness, and food trapping. These questions were also posed to each patient as he or she entered the study and again at the end of the optimization phase. The answers were recorded on a simple good, fair and poor scale.</ce:para></ce:section><ce:section><ce:section-title>Results</ce:section-title><ce:para>Implant outcomes for both parts of the study are summarized in Table II.
<ce:float-anchor refid="tab2"></ce:float-anchor>Of the 259 implants inserted for the patients in the fixed prosthesis group, 21 had not integrated by stage II surgery and 11 failed after stage II surgery. Of the latter 11 implants removed after stage II surgery, only 5 were true late losses. A subsequent review of clinical notes and sequential films revealed that the other 6 implants were indeed not integrated from the time of the second surgery on. These 6 implants should therefore have been considered as failures to integrate rather than late losses or losses after loading. Another 6 implants were left covered and were not used due to their position or angulation. In the overdenture group, 132 implants were placed, 3 failed to integrate and 2 failed after a period of loading. Three implants were not used as abutments and were left covered–again due to incorrect surgical placement.</ce:para><ce:para>Prosthodontic results for both groups are outlined in <ce:cross-ref refid="tab2">Table II</ce:cross-ref>. Of the 45 patients originally prescribed fixed implant-supported prostheses, 38 were known to be wearing their prosthesis successfully (after the 1997 recall assessment). High levels of parafunctional activity leading to gold screw fractures made it necessary for two patients to have their fixed prosthesis replaced by removable overdentures. Two patients moved and have been lost to the study since their 4-year recall; 2 patients died after 10 and 11 years of successful and monitored treatment; and 1 patient has reverted to traditional complete dentures 6 years after prosthesis insertion when his five implants failed. Of the 4 patients who originally opted for continuation of optimization procedures, 3 patients have entered the overdenture portion of the study and 1 patient continues with traditional dentures.</ce:para><ce:para>Of those patients prescribed removable overdentures, 39 arches treated in 37 patients continue to wear their prostheses successfully. Thirty-five of the overdentures were supported and retained by means of a bar and clip assembly, 2 with magnets and 2 with custom fittings. Two patients could not be reached, 1 after 2 years, the other after 6 years. Six patients have died after an average loading period of 5.5 years. The 5 patients who did not choose preprosthetic surgery continue with regular optimization therapy.</ce:para><ce:para>The small number of maxillary overdentures compared with the larger number of mandibular overdentures prevents making conclusive observations about inherent differences in arch-specific responses at the level of tissue response and patient reported concerns. The relevance of such observations in larger patient samples, such as that recently published by Watson et al.,<ce:cross-ref refid="bib8"><ce:sup>8</ce:sup></ce:cross-ref> is undermined by the variations in prosthetic design and in opposing dentition.</ce:para><ce:para>Complications of both the biologic and prosthetic variety were encountered in both studies. The incidence of implant failure has been noted in Table III.
<ce:display><ce:table colsep="0" rowsep="0" frame="topbot"><ce:label>Table III</ce:label><tgroup cols="5"><colspec colname="col1" colsep="0"></colspec><colspec colname="col2" colsep="0"></colspec><colspec colname="col3" colsep="0"></colspec><colspec colname="col4" colsep="0"></colspec><colspec colname="col5" colsep="0"></colspec><tbody><row rowsep="1"><entry colsep="1"></entry><entry namest="col2" nameend="col3" align="center" colsep="1"><ce:bold>Study 1 (fixed)</ce:bold></entry><entry namest="col4" nameend="col5" align="center"><ce:bold>Study 2 (overdentures)</ce:bold></entry></row><row rowsep="1"><entry colsep="1"></entry><entry align="right" colsep="1"><ce:bold>0-9 years</ce:bold></entry><entry align="right" colsep="1"><ce:bold>9-17 years</ce:bold></entry><entry align="right" colsep="1"><ce:bold>0-3 years</ce:bold></entry><entry align="right"><ce:bold>3-15 years</ce:bold></entry></row><row rowsep="1"><entry colsep="1">Damaged abutment screw</entry><entry align="right" colsep="1">3</entry><entry align="right" colsep="1">0</entry><entry align="right" colsep="1">0</entry><entry align="right">0</entry></row><row rowsep="1"><entry colsep="1">Implant fracture</entry><entry align="right" colsep="1">0</entry><entry align="right" colsep="1">0</entry><entry align="right" colsep="1">0</entry><entry align="right">0</entry></row><row rowsep="1"><entry colsep="1">Abutment screw fracture</entry><entry align="right" colsep="1">9</entry><entry align="right" colsep="1">13</entry><entry align="right" colsep="1">0</entry><entry align="right">0</entry></row><row rowsep="1"><entry colsep="1">Gold screw fracture</entry><entry align="right" colsep="1">53<ce:sup>*</ce:sup></entry><entry align="right" colsep="1">17</entry><entry align="right" colsep="1">4</entry><entry align="right">0</entry></row><row rowsep="1"><entry colsep="1">Framework fracture</entry><entry align="right" colsep="1">13</entry><entry align="right" colsep="1">3</entry><entry align="right" colsep="1">n/a</entry><entry align="right">n/a</entry></row><row rowsep="1"><entry colsep="1">Bar fracture</entry><entry align="right" colsep="1">n/a</entry><entry align="right" colsep="1">n/a</entry><entry align="right" colsep="1">2</entry><entry align="right">0</entry></row><row rowsep="1"><entry colsep="1">Bar and clip assembly fracture</entry><entry align="right" colsep="1">n/a</entry><entry align="right" colsep="1">n/a</entry><entry align="right" colsep="1">2</entry><entry align="right">4</entry></row><row rowsep="1"><entry colsep="1">Magnet keeper screw fracture</entry><entry align="right" colsep="1">n/a</entry><entry align="right" colsep="1">n/a</entry><entry align="right" colsep="1">5</entry><entry align="right">3</entry></row><row><entry namest="col1" nameend="col5"></entry></row></tbody></tgroup><ce:legend><ce:simple-para><ce:sup>*</ce:sup>Accounted for in 2 patients and related to incorrect prosthetic design. Subsequent design rectified the problem.</ce:simple-para></ce:legend></ce:table></ce:display>In the hardware category of complication, after the initial adjustment period, the removable overdenture problems required less time and expense to remedy than did those for the fixed prostheses.<ce:cross-ref refid="bib9"><ce:sup>9</ce:sup></ce:cross-ref></ce:para></ce:section><ce:section><ce:section-title>Discussion</ce:section-title><ce:para>Throughout the 13- to 17-year period of monitoring of patients for whom implant-supported fixed prostheses were prescribed, the edentulous predicament of 44 of the 45 patients was resolved with relatively few associated problems and complications.<ce:cross-ref refid="bib4"><ce:sup>4</ce:sup></ce:cross-ref> The overall assessment to date supports the notion that implant-retained and supported overdentures can predictably provide the necessary prosthesis stability to resolve patients' denture wearing problems.<ce:cross-ref refid="bib5"><ce:sup>5</ce:sup></ce:cross-ref> It must be emphasized that we did not rely solely on implant survival data to determine treatment outcome, but combined the success criteria for osseointegrated implants as outlined by Smith and Zarb,<ce:cross-ref refid="bib7"><ce:sup>7</ce:sup></ce:cross-ref> with clinically recorded observations of soft tissue health, needs for servicing prostheses or prosthodontic components, and patient responses to questions concerning the comfort and function of their prostheses. The combined observations and subjective evaluations indicated a complete resolution of the patients' presenting prosthetic problems.</ce:para><ce:para>It appears that, if a patient has the bone quality and quantity to be a candidate for the number of implants to support a fixed prosthesis, that patient could also be a candidate for an implant-supported overdenture supported by fewer implants. In such a situation, the decision to prescribe a fixed or removable treatment for the patient should be based on considerations of patient and dentist preferences in terms of retention and ease of hygiene, as well as esthetic, psychologic, and financial concerns.</ce:para><ce:para>Recognizing the logistical difficulties encountered in designing true randomized clinical trials for multistage clinical interventions, we did not propose to design one for this study. An interesting attempt at circumventing some of these difficulties was demonstrated by Feine et al.<ce:cross-refs refid="bib10 bib11"><ce:sup>10,11</ce:sup></ce:cross-refs> In their study, the same four or five mandibular implants were used to support two types of fully implant-supported prostheses with escalating levels of retention. One prosthesis type was retained by clips, the other was screwed to place. Irrespective of the patient's quantifiable perceptions of the two types of prosthetic designs, it could be argued that the traditional and, in fact, desirable test of an overdenture design that is implant tissue supported was not addressed. As a result, this otherwise elegant study only partially dealt with the real issues in decision-making with implant prosthodontics.</ce:para><ce:para>The overdenture design used in our study depends on both implant and gingival support. Therefore the prosthodontic procedures used are more demanding than those for the fixed prosthodontic design. Obviously, the prosthodontist using the overdenture technique, a technique that is essentially a complete denture with additional implant-provided mechanical retention, must know the principles of, and be skilled in, the construction of complete dentures.</ce:para><ce:para>The objective was not to study the various retentive mechanisms themselves, but rather to make use of an existing clinical/laboratory protocol that had previously been proven successful with tooth-supported overdentures. Dolder and Durrer<ce:cross-ref refid="bib12"><ce:sup>12</ce:sup></ce:cross-ref> already demonstrated that a bar and clip attachment increased the ability of an abutment to withstand both vertically and horizontally directed forces, and that the edentulous segments posterior to the abutments were able to withstand a 30% increase in load as a result of the increased stability of the anterior part of the prosthesis. Although an observation from studies on overdentures supported by natural tooth roots cannot be automatically extrapolated to those supported by osseointegrated implants, it does suggest a likelihood that there will be similar prosthetic improvement. Indeed, the patients' subjective reports in this study endorse this.</ce:para><ce:para>The relative position of the retentive units used in implant-supported overdentures may have an impact on the load experienced at the implant bone interface. Though associated with minimal morbidity, adverse crown/root ratios and cantilever/support ratios are sometimes encountered in overdentures supported by implants. In the absence of specific information regarding the load-bearing potential of single implants of different dimensions, in various bony locations and under a variety of loading conditions, arbitrary decisions are made based on similar arbitrary concepts of natural tooth support.</ce:para><ce:para>The natural tooth abutment under an overdenture may be vulnerable to loss of tooth vitality, caries, and periodontal ligament breakdown, and the tooth-supported overdenture is adversely affected by overreduction of the remaining teeth, the presence of tissue undercuts and denture fracture. Implant-supported overdentures have different potential complications and maintenance requirements ranging from loosening of prosthetic screws, loosening of retentive units, and fracture of components. In our experience,<ce:cross-ref refid="bib9"><ce:sup>9</ce:sup></ce:cross-ref> costs in time and dollars to deal with complications of implant-supported overdentures are less than those for fixed implant prostheses. However, these published observations differ from those of Davis and Watson<ce:cross-ref refid="bib13"><ce:sup>13</ce:sup></ce:cross-ref> and Walton and MacEntee.<ce:cross-ref refid="bib14"><ce:sup>14</ce:sup></ce:cross-ref></ce:para><ce:para>In this study, variations in localized soft tissue inflammatory responses around the implant transmucosal component or under the bar attachments were observed, usually in the form of simple gingivitis, gingival hyperplasia, or very rarely, fistula formation. Alterations in prosthetic design that allowed for better access for cleaning and tissue massage, plus patient encouragement led to resolution of all adverse tissue reactions. Hygiene maintenance seemed to be more easily accomplished with the bar and clip overdenture design. This issue has special relevance for patients who lack the dexterity to clean the tooth root analog, especially so with the very elderly patients. For most patients, if there is sufficient clearance of the bar to allow a small soft brush to be inserted between it and the mucosa, the patient is able to accomplish adequate hygiene to avoid the uncomfortable nuisance of soft tissue irritations.</ce:para><ce:para>To date, soft tissue recordings and observations in the implant-supported overdenture patients are the same as those reported for the implant-supported fixed prosthesis patients. The evidence suggests that peri-implant tissues do not respond to pathogens in plaque in the same fashion as do periodontal tissues. Also, there appears to be no correlation between observed soft tissue changes and the maintenance or failure of osseointegration.<ce:cross-ref refid="bib8"><ce:sup>8</ce:sup></ce:cross-ref> It could be that new parameters for soft tissue assessment need to be developed so that meaningful data predictive of long-term success or failure can be gathered.</ce:para><ce:para>In 1994, Cune and DePutter<ce:cross-ref refid="bib15"><ce:sup>15</ce:sup></ce:cross-ref> published a comparative evaluation of some outcome measures of implant systems and types of superstructures used in mandibular implant-supported overdentures. They concluded that differences among implant systems in implant survival, health of peri-implant tissues, and ease, degree, and method of oral hygiene were small and probably not clinically relevant.</ce:para><ce:para>The maintenance of the bone level around the isolated overdenture implant abutment appears to be comparable to that around the fixed prosthesis implants, although long-term documentation of the ridge height levels in the adjacent edentulous spaces is still not available. The fact that some patients in this study required relining of their mandibular distal extension regions suggests that the new or renewed ability to generate forces with a more stable prosthesis, led to residual ridge resorptive changes similar to those encountered in long-term wear of distal extension removable prostheses.</ce:para></ce:section><ce:section><ce:section-title>Conclusion</ce:section-title><ce:para>Until recently, the burden of illness sustained by patients suffering the consequences of oral diseases and disorders lacked valid measures. The same could be said about unhappy denture wearers, although these patients were easily identified. The key considerations in attempting to treat these patients were their burden of illness and unpredictable outcome of proposed interventions. The current recognition of determinants of the unhappy or maladaptative denture experience, along with well-argued inclusion and exclusion treatment criteria and treatment outcome measures associated with published prospective osseointegration studies, enable dentists to prescribe specific therapy options for the maladaptive edentulous predicament. It is anticipated that further fine-tuning of currently used measures and further developments in implant biotechnology will enhance prosthodontic therapy. There is a need for less invasive, less expensive, less complex, and equally efficacious and effective treatment options and outcomes in implant prosthodontics. 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implant</sb:maintitle></sb:title></sb:contribution><sb:host><sb:book><sb:date>1989</sb:date><sb:publisher><sb:name>Quintessence</sb:name><sb:location>Chicago</sb:location></sb:publisher></sb:book></sb:host></sb:reference></ce:bib-reference></ce:bibliography-sec></ce:bibliography></tail></article></istex:document></istex:metadataXml><mods version="3.6"><titleInfo lang="en"><title>The notion of implant-supported overdentures</title></titleInfo><titleInfo type="alternative" lang="en" contentType="CDATA"><title>The notion of implant-supported overdentures</title></titleInfo><name type="personal"><namePart type="given">Adrianne</namePart><namePart type="family">Scmitt</namePart><namePart type="termsOfAddress">MSc, DDSa</namePart><affiliation>Faculty of Dentistry, University of Toronto Toronto, Ontario, Canada</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">George A.</namePart><namePart type="family">Zarb</namePart><namePart type="termsOfAddress">BChD, DDS, MS,.MS, FRCD(C)b</namePart><affiliation>Faculty of Dentistry, University of Toronto Toronto, Ontario, Canada</affiliation><role><roleTerm type="text">author</roleTerm></role></name><typeOfResource>text</typeOfResource><genre type="research-article" displayLabel="Full-length article" authority="ISTEX" authorityURI="https://content-type.data.istex.fr" valueURI="https://content-type.data.istex.fr/ark:/67375/XTP-1JC4F85T-7">research-article</genre><originInfo><publisher>ELSEVIER</publisher><dateIssued encoding="w3cdtf">1998</dateIssued><copyrightDate encoding="w3cdtf">1998</copyrightDate></originInfo><language><languageTerm type="code" authority="iso639-2b">eng</languageTerm><languageTerm type="code" authority="rfc3066">en</languageTerm></language><abstract lang="en">Abstract: This article presents a brief review of the methods and techniques to manage the maladaptive edentulous patient. A discussion of the inclusion and exclusion criteria and treatment outcome measures associated with published prospective osseointegrated implant studies are included and specific therapy options are suggested. It is concluded that there is a need for less invasive, less expensive, less complex, and equally effective treatment options such as the implant-supported overdenture for the maladaptive edentulous patient. (J Prosthet Dent 1998;79:60-5.)</abstract><note>This study was made possible by grants from the Ontario Ministry of Health, the Faculty of Dentistry, University of Toronto, and a staff support grant from Nobel Biocare.</note><note>aAssistant Professor, Department of Prosthodontics.</note><note>bProfessor and Head, Department of Prosthodontics.</note><note>Reprint requests to: Dr. Adrianne Schmitt, Department of Prosthodontics, Faculty of Dentistry, University of Toronto, 124 Edward St., Toronto, Ontario, M5G 1G6, CANADA</note><note>10/1/86942</note><note type="content">Table II: Prosthodontic treatment and implant survival outcome</note><relatedItem type="host"><titleInfo><title>The Journal of Prosthetic Dentistry</title></titleInfo><titleInfo type="abbreviated"><title>YMPR</title></titleInfo><genre type="journal" authority="ISTEX" authorityURI="https://publication-type.data.istex.fr" valueURI="https://publication-type.data.istex.fr/ark:/67375/JMC-0GLKJH51-B">journal</genre><originInfo><publisher>ELSEVIER</publisher><dateIssued encoding="w3cdtf">199801</dateIssued></originInfo><identifier type="ISSN">0022-3913</identifier><identifier type="PII">S0022-3913(05)X7048-2</identifier><part><date>199801</date><detail type="volume"><number>79</number><caption>vol.</caption></detail><detail type="issue"><number>1</number><caption>no.</caption></detail><extent unit="issue-pages"><start>6</start><end>106</end></extent><extent unit="pages"><start>60</start><end>65</end></extent></part></relatedItem><identifier type="istex">60F97D6E08C1B3F8B0B8251F1E7F518B618ADF7B</identifier><identifier type="ark">ark:/67375/6H6-LJQ4FT4Q-G</identifier><identifier type="DOI">10.1016/S0022-3913(98)70195-7</identifier><identifier type="PII">S0022-3913(98)70195-7</identifier><accessCondition type="use and reproduction" contentType="copyright">©1998 Editorial Council of The Journal of Prosthetic Dentistry.</accessCondition><recordInfo><recordContentSource authority="ISTEX" authorityURI="https://loaded-corpus.data.istex.fr" valueURI="https://loaded-corpus.data.istex.fr/ark:/67375/XBH-HKKZVM7B-M">elsevier</recordContentSource><recordOrigin>Editorial Council of The Journal of Prosthetic Dentistry., ©1998</recordOrigin></recordInfo></mods><json:item><extension>json</extension><original>false</original><mimetype>application/json</mimetype><uri>https://api.istex.fr/document/60F97D6E08C1B3F8B0B8251F1E7F518B618ADF7B/metadata/json</uri></json:item></metadata><serie></serie></istex></record>Pour manipuler ce document sous Unix (Dilib)
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