Periodontology 2000, Vol.

66, 2014, 119131

Printed in Singapore. All rights reserved

2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

PERIODONTOLOGY 2000

Implant-assisted complete
prostheses
E L H A M E M A M I , P I E R R E -L U C M I C H A U D , I M A D S A 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 component of oral health is the number of remaining teeth,
with tooth loss resulting in partial or complete edentulism 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 worldwide (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 conventional dentures to osseointegrated implantassisted prostheses (42, 52, 97). Currently, there is a
great demand for dental-implant therapy (71). This
treatment 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 surgical morbidity.
In fact, edentate patients treated with implantassisted 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 considering the rehabilitation of edentulous jaws using
implant-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 implantsupported overdenture or implant-tissue-supported

overdenture for an implant-assisted removable prosthesis and implant xed complete denture for an
implant-assisted xed prosthesis. In this review, we
have attempted to summarize the existing terminology in a way that will facilitate the use of the appropriate 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 usually supported by implants and soft tissues, but can
be supported by implants alone, depending on the
superstructure used. They can also be removed by
the patients themselves (Fig. 4). Various terminologies 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 elements, such as ball or Locator, attached to implants
(120) (Figs 4A and 5A). In these cases, the tissue support 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 superstructures and their posterior support from mucosal
tissues (such as an ovoid/round bar with no cantilever) (Fig. 5B), whereas implant-supported overdentures (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 characteristics, infrastructure (number and position of
implants) and prosthesis material (17, 89).

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Emami et al.
A

Fig. 1. Implant-assisted xed prostheses.

Fig. 2. Implant-assisted xed prostheses.

Fig. 3. Implant-assisted xed prostheses.

Fig. 4. Implant-assisted removable

prostheses. (A) Two Locators attachments provide retention and anterior support for the prosthesis. (B) A
long Dolder bar is used to provide
retention and most of the anterior
and posterior support for the prosthesis.

Fig. 5. Simple
attachments.
(A)
Locator attachments. (B) Short Dolder bar attachment

Each prosthesis may have different long-term

patient-reported or clinical outcomes, and wise treatment planning should take into account a vast array

120

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

success/survival rates, prosthetics success rate, functional ability, time to retreatment, maintenance,

Implant-assisted complete prostheses

A

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 maxillary implants with unilateral cantilever and four CEKA attachments for
retention.

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 various treatments to assist both clinicians and patients.
The objective of this manuscript was to scope the literature 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 alternatives 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 implantassisted overdentures compared with conventional
dentures? (ii) What are the indications for prescribing
xed dentures? (iii) What are the indications for prescribing implant-assisted overdentures? (iv) What are
the differences between xed dentures and implantassisted overdentures in terms of patient-reported
and clinician-measured outcomes? Finally, knowledge gaps and clinical recommendations were highlighted.

Advantages of implant-assisted
xed or removable prostheses
compared with conventional
dentures
The results of several randomized controlled trials
with short- and long-term follow-ups conrm that
mandibular 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 mandibular implant-assisted dentures are more satised
and have a better oral health-related quality of life
than do those with conventional dentures, independently of sociodemographic factors, anatomy, number 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 mandibular two-implant overdenture has been recommended
as the minimal standard of care for edentate patients
(37, 94). A meta-analysis of eight randomized controlled trials published since 2007 indicated that,
when compared with mandibular conventional complete 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 a
follow-up study indicating that oral health-related
quality of life will improve following delivery of conventional 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 satisfaction and maintenance vs. the two-implant overdentures (104).
Even though implant-assisted prostheses were
superior over conventional dentures for restoring
edentulous mandibles, the completely edentulous
maxilla is usually successfully restored with conventional dentures because of greater retention and stability. 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.

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Emami et al.

In general, there is limited evidence available on the

benets of maxillary implant-assisted complete prostheses over conventional dentures. Thus, no rm
conclusions can be made as to whether one is superior to the other. However, the implant-assisted treatments 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 are
more complex than those performed in the mandible,
and treatment success relies on the meticulous
assessment of several factors such as esthetics, phonetics, bone and soft-tissue quality/quantity and biomechanical factors (64).

Indications for implant

overdentures
A successful prosthetic treatment relies on evidencebased comprehensive treatment planning, in which
several 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 signicant 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 patients chief reason for seeking implant treatment, an implant overdenture may be the best alternative. 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 therefore 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 ability
to 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 complications (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,

122

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

though the xed counterpart was rated as more efcient 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 completely 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 suggested 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 recommended 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 lingual
aspect 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-overdentures, but depending on the system used, as much as
20 mm could be needed. For an example, when using
a 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

Implant-assisted complete prostheses

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

patients whose tongues cannot reach the palate (tongue hypomobility) could also benet from the shortened distance offered by the acrylic thickness of the
overdenture, and the use of a xed prosthesis in these
cases could potentially cause speech problems.

Indications for implant-xed

dentures
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
with xed dentures (28). However, for a xed 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). If
soft or hard tissues have to be replaced vertically by
the prosthesis, a xed restoration consisting of acrylic
al bar (Figs 1,7) could
supported by a metallic Montre
be used instead of a porcelain-fused-to-metal prosthesis. 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 buccally ared 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 movement and a need for lip support. Hygiene is more difcult 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-xed

dentures and implant-assisted
overdentures in terms of patientreported 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 and
long-bar implant-supported overdentures using
patient-based outcomes of various aspects of the
prostheses. Almost equal numbers of study participants 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 tendency 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 maxillary xed overdentures

Fig. 7. Montr
eal bars. (A) Occlusal
view (same bar as Figure 1). (B)
Front view of a second bar with
guide pins.

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Emami et al.

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 satisfaction 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 signicantly
higher percentage of correct sounds with the overdentures than with the xed dentures. There were no
signicant differences in error rates between the two
maxillary implant overdentures with and without palatal 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 dentures demonstrated greater improvement in esthetics,
taste and speech. In a 10-year follow-up of clinical
studies comparing xed dentures with implant-supported overdentures, Quirynen et al. (79) showed
that patients were highly satised with both treatment types. Patients with xed dentures were slightly
more satised with chewing ability and general satisfaction.
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 differences. 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 manufacturing (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 healthrelated quality of life and were less satised in general, 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

124

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 rate success
Implant survival and success have been widely examined in implant research on xed and removable
prostheses. Researchers have attempted to understand 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 typespecic 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 implantsurvival 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) estimated the rate of implant loss for different prosthetic
designs. They found that implant loss during function was higher for overdentures (range: 5.65.9%)
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 success, 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 period, Schwartz-Arad et al. (87) reported a total cumulative 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 Steenberghe et al. (98) reported a 97.2% cumulative success 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

Implant-assisted complete prostheses

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 maxillary xed prosthesis, and greater implant failures were observed for
overdentures in the maxilla (47). This dissimilarity
could 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 overdenture 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 concluded 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 planned overdentures
with those supporting xed 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 will
increase 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-mucositis, tissue hyperplasia and residual ridge resorption (22, 116).
A limited number of studies have compared these
types of complication for implant-assisted xed/
removable dentures. Berglundh et al. (8) systematically reviewed the incidence of biologic and technical 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 practice-based study in Italy, a 3.9-year follow-up of biologic 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 difference 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 general. 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 loading 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 overdenture attachment types detected no bone loss around
mandibular implant overdentures (22). These ndings agree with numerous other studies demonstrating 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 resorption of two implant-retained mandibular overdentures and xed dentures on ve or six implants in the
posterior mandibular up to 7 years after insertion.
They reported that patients rehabilitated with overdentures had low rates of residual ridge resorption,
whereas patients with xed prostheses showed bone
apposition.
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 retentive mechanisms, as well as the need to reline and/or
remake the prostheses (5, 24, 25).
Tinsely et al. (95) compared the maintenance
complications for xed dentures and implant-supported overdentures. The long-term maintenance,
including the incidence of remakes, relines and general adjustments, was higher for implant-supported
overdentures than for xed dentures. Naert et al.
(70) reported the need for relatively low maintenance care of mandibular implant overdentures

125

Emami et al.

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 aftercare need (33%), followed by need for relines (19%)
and overdenture clip/attachment fracture (16%).
A higher frequency of prosthetic complications was
also reported for maxillary implant-supported overdentures 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-supported xed prostheses. Most complications
occurred in the rst year, independent of prosthesis
design. Direct screw xation of the superstructure,
having a xed prosthesis and use of CAD-CAM technology appeared to reduce complications. They also
found a signicant difference between gold and titanium 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 tissue hyperplasia compared with the absence of this
complication in the titanium group). Davis and coworkers (24) examined the dental records, over a 5year 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 study ndings, Berglundh et al. (8) demonstrated 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-year
mean). This higher incidence of complications was
also noted for implant components. These data indicate that, although overdentures are a more economical alternative to xed prostheses, they may need
greater long-term maintenance, which would necessarily increase cost.
Cost-effectiveness
Continuous increases in the cost of alternative
implant therapies have led to an expansion of costeffectiveness studies. Accordingly, different costeffectiveness assessment methods have been applied
to compare implant-assisted xed prostheses, overdentures 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

Indications

Removable

Fixed

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

Disadvantages

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

More mucosal problems

More implants required

Wear of components

Accumulation of food posteriorly

More difcult and expensive to make, adjust and redo

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Implant-assisted complete prostheses

and greater maintenance needs, mandibular implantassisted overdentures seem to be the best option in
terms of cost-effectiveness (6, 121).
In contrast to these results, a small study by Palmqvist et al. (73) indicated that clinical and laboratorywork costs were relatively similar for 17 edentate participants who randomly received three implant-xed
prostheses (All-in-One concept) with varying numbers of implants or overdentures supported by a Dolder bar. However, these results are not in agreement
with the majority of studies, which concluded that
the implant-assisted overdentures are the most costeffective treatments (46, 122). Our review found that
the number of research studies in this eld is still limited, and the majority of these few studies used a
short follow-up period (46, 92) and they did not compare different designs of implant-assisted overdentures (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 methods. 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 trials 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 perceptions 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 oralhealth care and encourage clinicians to emphasize
cautious treatment planning so that patient dissatisfaction and potential lawsuits can be avoided.

Conclusion and clinical

recommendation
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 constraints, hygiene capacities and anatomic factors as
key elements in their decision-making process
regarding the choice of removable and xed implantassisted prostheses.

Acknowledgments
We acknowledge Maha Masri and Nathalie Clairoux
for their assistance with the literature search. Figures
presented in this manuscript were reproduced by courlanie Me
nassa.
tesy of Drs Pierre Luc Michaud and Me
Dr Emami holds a Canadian Institutes of Health
Research (CIHR) Clinician Scientists Salary Award.

References
1. Abnet CC, Qiao YL, Dawsey SM, Dong ZW, Taylor PR,
Mark SD. Tooth loss is associated with increased risk of
total death and death from upper gastrointestinal cancer,
heart disease, and stroke in a Chinese population-based
cohort. Int J Epidemiol 2005: 34: 467474.
2. Akoglu B, Ucankale M, Ozkan Y, Kulak-Ozkan Y. Five-year
treatment outcomes with three brands of implants supporting mandibular overdentures. Int J Oral Maxillofac
Implants 2011: 26: 188194.
3. Allen PF, McMillan AS. A longitudinal study of quality of
life outcomes in older adults requesting implant prostheses and complete removable dentures. Clin Oral Implants
Res 2003: 14: 173179.
4. Andreiotelli M, Att W, Strub JR. Prosthodontic complications with implant overdentures: a systematic literature
review. Int J Prosthodont 2010: 23: 195203.
5. Attard NJ, Zarb GA. Long-term treatment outcomes
in edentulous patients with implant overdentures: the
Toronto study. Int J Prosthodont 2004: 17: 425433.
6. Attard NJ, Zarb GA, Laporte A. Long-term treatment costs
associated with implant-supported mandibular prostheses
in edentulous patients. Int J Prosthodont 2005: 18: 117
123.
7. Awad MA, Lund JP, Dufresne E, Feine JS. Comparing the
efcacy of mandibular implant-retained overdentures and
conventional dentures among middle-aged edentulous
patients: satisfaction and functional assessment. Int J
Prosthodont 2003: 16: 117122.
8. Berglundh T, Persson L, Klinge B. A systematic review of
the incidence of biological and technical complications in
implant dentistry reported in prospective longitudinal
studies of at least 5 years. J Clin Periodontol 2002: 29(Suppl 3): 197212; discussion 232-193.
9. Boerrigter EM, Geertman ME, Van Oort RP, Bouma J, Raghoebar GM, van Waas MA, vant Hof MA, Boering G, Kalk

127

Emami et al.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.
22.

23.

24.

W. Patient satisfaction with implant-retained mandibular

overdentures. A comparison with new complete dentures
not retained by implantsa multicentre randomized clinical trial. Br J Oral Maxillofac Surg 1995: 33: 282288.
Boerrigter EM, Stegenga B, Raghoebar GM, Boering G.
Patient satisfaction and chewing ability with implant-retained mandibular overdentures: a comparison with new
complete dentures with or without preprosthetic surgery. J
Oral Maxillofac Surg 1995: 53: 11671173.
Bouma J, Boerrigter LM, Van Oort RP, van Sonderen E, Boering G. Psychosocial effects of implant-retained overdentures. Int J Oral Maxillofac Implants 1997: 12: 515522.
Branemark PI, Svensson B, van Steenberghe D. Ten-year
survival rates of xed prostheses on four or six implants ad
modum Branemark in full edentulism. Clin Oral Implants
Res 1995: 6: 227231.
Brennan M, Houston F, OSullivan M, OConnell B. Patient
satisfaction and oral health-related quality of life outcomes of implant overdentures and xed complete dentures. Int J Oral Maxillofac Implants 2010: 25: 791800.
Bressan E, Tomasi C, Stellini E, Sivolella S, Favero G, Berglundh T. Implant-supported mandibular overdentures: a
cross-sectional study. Clin Oral Implants Res 2012: 23:
814819.
Bretz WA, Weyant RJ, Corby PM, Ren D, Weissfeld L, Kritchevsky SB, Harris T, Kurella M, Sattereld S, Visser M,
Newman AB. Systemic inammatory markers, periodontal
diseases, and periodontal infections in an elderly population. J Am Geriatr Soc 2005: 53: 15321537.
Brodeur JM, Benigeri M, Naccache H, Olivier M, Payette M.
Trends in the level of edentulism in Quebec between 1980
and 1993. J Can Dent Assoc 1996: 62: 159160, 162156.
Bryant SR, MacDonald-Jankowski D, Kim K. Does the type
of implant prosthesis affect outcomes for the completely
edentulous arch? Int J Oral Maxillofac Implants 2007: 22
(Suppl): 117139.
Burns DR, Unger JW, Elswick RK Jr, Beck DA. Prospective
clinical evaluation of mandibular implant overdentures:
Part I-Retention, stability, and tissue response. J Prosthet
Dent 1995: 73: 354363.
Burns DR, Unger JW, Elswick RK Jr, Giglio JA. Prospective
clinical evaluation of mandibular implant overdentures:
Part IIPatient satisfaction and preference. J Prosthet Dent
1995: 73: 364369.
Carallo C, Fortunato L, de Franceschi MS, Irace C, Tripolino C, Cristofaro MG, Giudice M, Gnasso A. Periodontal
disease and carotid atherosclerosis: are hemodynamic
forces a link? Atherosclerosis 2010: 213: 263267.
Carlsson GE. Responses of jawbone to pressure. Gerodontology 2004: 21: 6570.
Cehreli MC, Karasoy D, Kokat AM, Akca K, Eckert S. A systematic review of marginal bone loss around implants
retaining or supporting overdentures. Int J Oral Maxillofac
Implants 2010: 25: 266277.
Cunha-Cruz J, Hujoel PP, Nadanovsky P. Secular trends in
socio-economic disparities in edentulism: USA, 1972-2001.
J Dent Res 2007: 86: 131136.
Davis DM, Packer ME, Watson RM. Maintenance requirements of implant-supported xed prostheses opposed by
implant-supported xed prostheses, natural teeth, or complete dentures: a 5-year retrospective study. Int J Prosthodont 2003: 16: 521523.

128

25. Davis DM, Rogers JO, Packer ME. The extent of maintenance required by implant-retained mandibular overdentures: a 3-year report. Int J Oral Maxillofac Implants 1996:
11: 767774.
26. de Albuquerque Jr RF, Lund JP, Tang L, Larivee J, de
Grandmont P, Gauthier G, Feine JS. Within-subject comparison of maxillary long-bar implant-retained prostheses
with and without palatal coverage: patient-based outcomes. Clin Oral Implants Res 2000: 11: 555565.
27. de Grandmont P, Feine JS, Tache R, Boudrias P, Donohue
WB, Tanguay R, Lund JP. Within-subject comparisons of
implant-supported mandibular prostheses: psychometric
evaluation. J Dent Res 1994: 73: 10961104.
28. DeBoer J. Edentulous implants: overdenture versus xed. J
Prosthet Dent 1993: 69: 386390.
29. Douglass CW, Shih A, Ostry L. Will there be a need for
complete dentures in the United States in 2020? J Prosthet
Dent 2002: 87: 58.
30. Drago C, Carpentieri J. Treatment of maxillary jaws with
dental implants: guidelines for treatment. J Prosthodont
2011: 20: 336347.
31. Duyck J, Van Oosterwyck H, Vander Sloten J, De Cooman
M, Puers R, Naert I. Magnitude and distribution of occlusal
forces on oral implants supporting xed prostheses: an in
vivo study. Clin Oral Implants Res 2000: 11: 465475.
32. Ellis JS, Burawi G, Walls A, Thomason JM. Patient satisfaction with two designs of implant supported removable
overdentures; ball attachment and magnets. Clin Oral
Implants Res 2009: 20: 12931298.
33. Elter JR, Champagne CM, Offenbacher S, Beck JD. Relationship of periodontal disease and tooth loss to prevalence of coronary heart disease. J Periodontol 2004: 75:
782790.
34. Emami E, de Grandmont P, Rompre PH, Barbeau J, Pan S,
Feine JS. Favoring trauma as an etiological factor in denture stomatitis. J Dent Res 2008: 87: 440444.
35. Emami E, Heydecke G, Rompre PH, de Grandmont P,
Feine JS. Impact of implant support for mandibular dentures on satisfaction, oral and general health-related quality of life: a meta-analysis of randomized-controlled trials.
Clin Oral Implants Res 2009: 20: 533544.
36. Esposito M, Hirsch JM, Lekholm U, Thomsen P. Biological
factors contributing to failures of osseointegrated oral
implants. (I). Success criteria and epidemiology. Eur J Oral
Sci 1998: 106: 527551.
37. Feine JS, Carlsson GE, Awad MA, Chehade A, Duncan WJ,
Gizani S, Head T, Lund JP, MacEntee M, Mericske-Stern R,
Mojon P, Morais J, Naert I, Payne AG, Penrod J, Stoker GT,
Tawse-Smith A, Taylor TD, Thomason JM, Thomson WM,
Wismeijer D. The McGill consensus statement on overdentures. Mandibular two-implant overdentures as rst
choice standard of care for edentulous patients. Montreal,
Quebec, May 24-25, 2002. Int J Oral Maxillofac Implants
2002: 17: 601602.
38. Feine JS, de Grandmont P, Boudrias P, Brien N, LaMarche
C, Tache R, Lund JP. Within-subject comparisons of
implant-supported mandibular prostheses: choice of prosthesis. J Dent Res 1994: 73: 11051111.
39. Fisher MA, Borgnakke WS, Taylor GW. Periodontal disease
as a risk marker in coronary heart disease and chronic kidney disease. Curr Opin Nephrol Hypertens 2010: 19: 519
526.

Implant-assisted complete prostheses

40. Francetti L, Agliardi E, Testori T, Romeo D, Taschieri S, Del
Fabbro M. Immediate rehabilitation of the mandible with
xed full prosthesis supported by axial and tilted implants:
interim results of a single cohort prospective study. Clin
Implant Dent Relat Res 2008: 10: 255263.
41. Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. Clinical complications with implants and implant prostheses. J
Prosthet Dent 2003: 90: 121132.
42. Gunne HS, Bergman B, Enbom L, Hogstrom J. Masticatory efciency of complete denture patients. A clinical
examination of potential changes at the transition from
old to new denture. Acta Odontol Scand 1982: 40: 289
297.
43. Heydecke G, Boudrias P, Awad MA, De Albuquerque RF,
Lund JP, Feine JS. Within-subject comparisons of maxillary
xed and removable implant prostheses: patient satisfaction and choice of prosthesis. Clin Oral Implants Res 2003:
14: 125130.
44. Heydecke G, Locker D, Awad MA, Lund JP, Feine JS. Oral
and general health-related quality of life with conventional
and implant dentures. Community Dent Oral Epidemiol
2003: 31: 161168.
45. Heydecke G, McFarland DH, Feine JS, Lund JP. Speech
with maxillary implant prostheses: ratings of articulation. J
Dent Res 2004: 83: 236240.
46. Heydecke G, Penrod JR, Takanashi Y, Lund JP, Feine JS,
Thomason JM. Cost-effectiveness of mandibular two-implant overdentures and conventional dentures in the
edentulous elderly. J Dent Res 2005: 84: 794799.
47. Hutton JE, Heath MR, Chai JY, Harnett J, Jemt T, Johns RB,
McKenna S, McNamara DC, van Steenberghe D, Taylor R,
Watson RM, Herrmann I Factors related to success and
failure rates at 3-year follow-up in a multicenter study of
overdentures supported by Branemark implants. Int J Oral
Maxillofac Implants 1995: 10: 3342.
48. Jabbour Z, Emami E, de Grandmont P, Rompre PH, Feine
JS. Is oral health-related quality of life stable following
rehabilitation with mandibular two-implant overdentures?
Clin Oral Implants Res 2012: 23: 12051209.
49. Jemt T. Fixed implant-supported prostheses in the edentulous maxilla. A ve-year follow-up report. Clin Oral
Implants Res 1994: 5: 142147.
50. Jemt T, Chai J, Harnett J, Heath MR, Hutton JE, Johns RB,
McKenna S, McNamara DC, van Steenberghe D, Taylor R,
Watson RM, Herrmann I. A 5-year prospective multicenter
follow-up report on overdentures supported by osseointegrated implants. Int J Oral Maxillofac Implants 1996: 11:
291298.
51. Joshipura KJ, Wand HC, Merchant AT, Rimm EB. Periodontal disease and biomarkers related to cardiovascular
disease. J Dent Res 2004: 83: 151155.
52. Kapur KK, Soman SD. Masticatory performance and efciency in denture wearers. 1964. J Prosthet Dent 2006: 95:
407411.
53. Katsoulis J, Brunner A, Mericske-Stern R. Maintenance of
implant-supported maxillary prostheses: a 2-year controlled clinical trial. Int J Oral Maxillofac Implants 2011:
26: 648656.
54. MacEntee MI, Walton JN. The economics of complete dentures and implant-related services: a framework for analysis and preliminary outcomes. J Prosthet Dent 1998: 79:
2430.

55. MacEntee MI, Walton JN, Glick N. A clinical trial of patient

satisfaction and prosthodontic needs with ball and bar
attachments for implant-retained complete overdentures:
three-year results. J Prosthet Dent 2005: 93: 2837.
56. Meijer HJ, Raghoebar GM, Batenburg RH, Visser A, Vissink
A. Mandibular overdentures supported by two or four endosseous implants: a 10-year clinical trial. Clin Oral
Implants Res 2009: 20: 722728.
57. Meijer HJ, Raghoebar GM, Vant Hof MA. Comparison of
implant-retained mandibular overdentures and conventional complete dentures: a 10-year prospective study of
clinical aspects and patient satisfaction. Int J Oral Maxillofac Implants 2003: 18: 879885.
58. Meijer HJ, Raghoebar GM, Vant Hof MA, Visser A, Geertman ME, Van Oort RP. A controlled clinical trial of
implant-retained mandibular overdentures; ve-years
results of clinical aspects and aftercare of IMZ implants
and Branemark implants. Clin Oral Implants Res 2000:
11: 441447.
59. Mericske-Stern R. Treatment outcomes with implant-supported overdentures: clinical considerations. J Prosthet
Dent 1998: 79: 6673.
60. Mericske-Stern RD, Taylor TD, Belser U. Management of
the edentulous patient. Clin Oral Implants Res 2000: 11
(Suppl 1): 108125.
61. Mertens C, Steveling HG. Implant-supported xed prostheses in the edentulous maxilla: 8-year prospective
results. Clin Oral Implants Res 2011: 22: 464472.
62. Michalowicz BS, Durand R. Maternal periodontal disease
and spontaneous preterm birth. Periodontol 2000 2007: 44:
103112.
63. Michalowicz BS, Novak MJ, Hodges JS, DiAngelis A, Buchanan W, Papapanou PN, Mitchell DA, Ferguson JE, Lupo V,
Boll J, Matseoane S, Steffen M, Ebersole JL. Serum
inammatory mediators in pregnancy: changes after periodontal treatment and association with pregnancy outcomes. J Periodontol 2009: 80: 17311741.
64. Misch CE. Dental implant prosthetics. St Louis: Mosby-Elsevier, 2005.
65. Misch CE. Contemporary implant dentistry. St Louis, Missouri: Mosby Elsevier, 2008.
66. Mojon P, Thomason JM, Walls AW. The impact of falling
rates of edentulism. Int J Prosthodont 2004: 17: 434440.
67. Montes CC, Pereira FA, Thome G, Alves ED, Acedo RV, de
Souza JR, Melo AC, Trevilatto PC. Failing factors associated
with osseointegrated dental implant loss. Implant Dent
2007: 16: 404412.
68. Mustapha IZ, Debrey S, Oladubu M, Ugarte R. Markers of
systemic bacterial exposure in periodontal disease and
cardiovascular disease risk: a systematic review and
meta-analysis. J Periodontol 2007: 78: 22892302.
69. Naert I, Alsaadi G, van Steenberghe D, Quirynen M. A
10-year randomized clinical trial on the inuence of
splinted and unsplinted oral implants retaining mandibular overdentures: peri-implant outcome. Int J Oral Maxillofac Implants 2004: 19: 695702.
70. Naert IE, Hooghe M, Quirynen M, van Steenberghe D. The
reliability of implant-retained hinging overdentures for the
fully edentulous mandible. An up to 9-year longitudinal
study. Clin Oral Investig 1997: 1: 119124.
71. Narby B, Kronstrom M, Soderfeldt B, Palmqvist S. Changes
in attitudes toward desire for implant treatment: a longitu-

129

Emami et al.

72.

73.

74.

75.

76.

77.

78.
79.

80.

81.

82.

83.

84.

85.

86.

dinal study of a middle-aged and older Swedish population. Int J Prosthodont 2008: 21: 481485.
Okoro CA, Balluz LS, Eke PI, Ajani UA, Strine TW, Town M,
Mensah GA, Mokdad AH. Tooth loss and heart disease:
ndings from the Behavioral Risk Factor Surveillance System. Am J Prev Med 2005: 29: 5056.
Palmqvist S, Owall B, Schou S. A prospective randomized
clinical study comparing implant-supported xed prostheses and overdentures in the edentulous mandible: prosthodontic production time and costs. Int J Prosthodont 2004:
17: 231235.
Palmqvist S, Sondell K, Swartz B. Implant-supported maxillary overdentures: outcome in planned and emergency
cases. Int J Oral Maxillofac Implants 1994: 9: 184190.
Pan S, Dagenais M, Thomason JM, Awad M, Emami E,
Kimoto S, Wollin SD, Feine JS. Does mandibular edentulous bone height affect prosthetic treatment success? J
Dent 2010: 38: 899907.
Petersen PE, Bourgeois D, Ogawa H, Estupinan-Day S,
Ndiaye C. The global burden of oral diseases and risks to
oral health. Bull World Health Organ 2005: 83: 661669.
Petersen PE, Kandelman D, Arpin S, Ogawa H. Global oral
health of older peoplecall for public health action. Community Dent Health 2010: 27: 257267.
Pihlstrom BL, Michalowicz BS, Johnson NW. Periodontal
diseases. Lancet 2005: 366: 18091820.
Quirynen M, Alsaadi G, Pauwels M, Haffajee A, van Steenberghe D, Naert I. Microbiological and clinical outcomes
and patient satisfaction for two treatment options in the
edentulous lower jaw after 10 years of function. Clin Oral
Implants Res 2005: 16: 277287.
Raghoebar G. A randomized prospective clinical trial on
the effectiveness of three treatment modalities for patients
with lower denture problems. A 10 year follow-up study
on patient satisfaction. Int J Oral Maxillofac Surg 2003: 32:
498503.
Raghoebar GM, Meijer HJ, Stegenga B, vant Hof MA,
van Oort RP, Vissink A. Effectiveness of three treatment
modalities for the edentulous mandible. A ve-year randomized clinical trial. Clin Oral Implants Res 2000: 11:
195201.
Raghoebar GM, Meijer HJ, Stellingsma K, Vissink A.
Addressing the atrophied mandible: a proposal for a treatment approach involving endosseous implants. Int J Oral
Maxillofac Implants 2011: 26: 607617.
Raghoebar GM, Meijer HJ, vant Hof M, Stegenga B, Vissink A. A randomized prospective clinical trial on the effectiveness of three treatment modalities for patients with
lower denture problems. A 10 year follow-up study on
patient satisfaction. Int J Oral Maxillofac Surg 2003: 32:
498503.
Rashid F, Awad MA, Thomason JM, Piovano A, Spielberg
GP, Scilingo E, Mojon P, Muller F, Spielberg M, Heydecke
G, Stoker G, Wismeijer D, Allen F, Feine JS. The effectiveness of 2-implant overdentures - a pragmatic international
multicentre study. J Oral Rehabil 2011: 38: 176184.
Sadowsky SJ. Treatment considerations for maxillary
implant overdentures: a systematic review. J Prosthet Dent
2007: 97: 340348.
Sanna A, Nuytens P, Naert I, Quirynen M. Successful outcome of splinted implants supporting a planned maxillary overdenture: a retrospective evaluation and

130

87.

88.

89.
90.

91.

92.

93.
94.

95.

96.

97.

98.

99.

100.

101.

102.

comparison with xed full dental prostheses. Clin Oral

Implants Res 2009: 20: 406413.
Schwartz-Arad D, Kidron N, Dolev E. A long-term study of
implants supporting overdentures as a model for implant
success. J Periodontol 2005: 76: 14311435.
Shimazaki Y, Soh I, Saito T, Yamashita Y, Koga T, Miyazaki
H, Takehara T. Inuence of dentition status on physical
disability, mental impairment, and mortality in institutionalized elderly people. J Dent Res 2001: 80: 340345.
Simon H, Yanase RT. Terminology for implant prostheses.
Int J Oral Maxillofac Implants 2003: 18: 539543.
Stoker GT, Wismeijer D, van Waas MA. An eight-year follow-up to a randomized clinical trial of aftercare and
cost-analysis with three types of mandibular implant-retained overdentures. J Dent Res 2007: 86: 276280.
Stolzenberg-Solomon RZ, Dodd KW, Blaser MJ, Virtamo J,
Taylor PR, Albanes D. Tooth loss, pancreatic cancer, and
Helicobacter pylori. Am J Clin Nutr 2003: 78: 176181.
Takanashi Y, Penrod JR, Chehade A, Klemetti E, Lund JP,
Feine JS. Surgical placement of two implants in the anterior edentulous mandiblehow much time does it take?
Clin Oral Implants Res 2003: 14: 188192.
The Academy of Prosthodontics. The glossary of prosthodontic terms. J Prosthet Dent 2005: 94: 1092.
Thomason JM, Feine J, Exley C, Moynihan P, Muller F, Naert I, Ellis JS, Barclay C, Butterworth C, Scott B, Lynch C,
Stewardson D, Smith P, Welfare R, Hyde P, McAndrew R,
Fenlon M, Barclay S, Barker D. Mandibular two
implant-supported overdentures as the rst choice standard of care for edentulous patientsthe York Consensus
Statement. Br Dent J 2009: 207: 185186.
Tinsley D, Watson CJ, Russell JL. A comparison of hydroxylapatite coated implant retained xed and removable
mandibular prostheses over 4 to 6 years. Clin Oral
Implants Res 2001: 12: 159166.
Trakas T, Michalakis K, Kang K, Hirayama H. Attachment
systems for implant retained overdentures: a literature
review. Implant Dent 2006: 15: 2434.
Trulsson M, Gunne HS. Food-holding and -biting behavior
in human subjects lacking periodontal receptors. J Dent
Res 1998: 77: 574582.
van Steenberghe D, Quirynen M, Naert I, Maffei G, Jacobs
R. Marginal bone loss around implants retaining hinging
mandibular overdentures, at 4-, 8- and 12-years follow-up.
J Clin Periodontol 2001: 28: 628633.
van Waas MA, Denissen HW, de Koomen HA, de Lange
GL, van Oort RP, Wismeyer D, Wolf JW. Dutch consensus
on guidelines for superstructures on endosseous implants
in the edentulous mandible. J Oral Implantol 1991: 17:
390392.
Vercruyssen M, Marcelis K, Coucke W, Naert I, Quirynen
M. Long-term, retrospective evaluation (implant and
patient-centred outcome) of the two-implants-supported
overdenture in the mandible. Part 1: survival rate. Clin
Oral Implants Res 2010: 21: 357365.
Vergnes JN. Treating periodontal disease may improve
metabolic control in diabetics. Evid Based Dent 2010: 11:
7374.
Volzke H, Schwahn C, Hummel A, Wolff B, Kleine V, Robinson DM, Dahm JB, Felix SB, John U, Kocher T. Tooth
loss is independently associated with the risk of acquired
aortic valve sclerosis. Am Heart J 2005: 150: 11981203.

Implant-assisted complete prostheses

103. Walton JN. A randomized clinical trial comparing two
mandibular implant overdenture designs: 3-year prosthetic outcomes using a six-eld protocol. Int J Prosthodont 2003: 16: 255260.
104. Walton JN, Glick N, Macentee MI. A randomized clinical
trial comparing patient satisfaction and prosthetic outcomes with mandibular overdentures retained by one or
two implants. Int J Prosthodont 2009: 22: 331339.
105. Walton JN, MacEntee MI, Hanvelt R. Cost analysis of fabricating implant prostheses. Int J Prosthodont 1996: 9: 271
276.
106. Wathen WF. International implications of oral health in
America: a report of the Surgeon General. Quintessence
Int 2000: 31: 697.
107. Watson RM, Jemt T, Chai J, Harnett J, Heath MR, Hutton
JE, Johns RB, Lithner B, McKenna S, McNamara DC, Naert
I, Taylor R. Prosthodontic treatment, patient response,
and the need for maintenance of complete implant-supported overdentures: an appraisal of 5 years of prospective study. Int J Prosthodont 1997: 10: 345354.
108. Watt RG. Strategies and approaches in oral disease prevention and health promotion. Bull World Health Organ
2005: 83: 711718.
109. Widbom C, Soderfeldt B, Kronstrom M. A retrospective
evaluation of treatments with implant-supported maxillary overdentures. Clin Implant Dent Relat Res 2005: 7:
166172.
110. Wismeijer D, Van Waas MA, Vermeeren JI, Mulder J, Kalk
W. Patient satisfaction with implant-supported mandibular overdentures. A comparison of three treatment strategies with ITI-dental implants. Int J Oral Maxillofac Surg
1997: 26: 263267.
111. Wright PS, Glantz PO, Randow K, Watson RM. The effects
of xed and removable implant-stabilised prostheses on
posterior mandibular residual ridge resorption. Clin Oral
Implants Res 2002: 13: 169174.
112. Wyatt CC. The effect of prosthodontic treatment on alveolar bone loss: a review of the literature. J Prosthet Dent
1998: 80: 362366.

113. Zarb B. Prothodontic treatment for edentulous patients:

complete dentures and implant-supported prostheses.
St-Louis: Mosby, 2004.
114. Zarb GA, Schmitt A. The longitudinal clinical effectiveness
of osseointegrated dental implants: the Toronto Study.
Part II: the prosthetic results. J Prosthet Dent 1990: 64: 53
61.
115. Zarb GA, Schmitt A. The longitudinal clinical effectiveness
of osseointegrated dental implants: the Toronto study.
Part III: problems and complications encountered. J Prosthet Dent 1990: 64: 185194.
116. Zarb GA, Schmitt A. The edentulous predicament. II: the
longitudinal effectiveness of implant-supported overdentures. J Am Dent Assoc 1996: 127: 6672.
117. Zitzmann NU, Marinello CP. Treatment plan for restoring
the edentulous maxilla with implant-supported restorations: removable overdenture versus xed partial denture
design. J Prosthet Dent 1999: 82: 188196.
118. Zitzmann NU, Marinello CP. Treatment outcomes of xed
or removable implant-supported prostheses in the edentulous maxilla. Part I: patients assessments. J Prosthet
Dent 2000: 83: 424433.
119. Zitzmann NU, Marinello CP. Treatment outcomes of xed
or removable implant-supported prostheses in the edentulous maxilla. Part II: clinical ndings. J Prosthet Dent
2000: 83: 434442.
120. Zitzmann NU, Marinello CP. A review of clinical and technical considerations for xed and removable implant prostheses in the edentulous mandible. Int J Prosthodont 2002:
15: 6572.
121. Zitzmann NU, Marinello CP, Sendi P. A cost-effectiveness
analysis of implant overdentures. J Dent Res 2006: 85: 717
721.
122. Zitzmann NU, Sendi P, Marinello CP. An economic evaluation of implant treatment in edentulous patients preliminary results. Int J Prosthodont 2005: 18: 2027.

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