The Influence of Momentary Retention Forces on

Patient Satisfaction and Quality of Life of

Two-ImplantRetained Mandibular Overdenture Wearers
Onur Geckili, PhD, DDS1/Altug Cilingir, PhD, DDS1/Ozge Erdogan, DDS2/
Aysun Coskun Kesoglu, DDS2/Caglar Bilmenoglu, DDS2/Arda Ozdiler, DDS2/Hakan Bilhan, PhD, DDS3
Purpose: The purpose of this study was to assess the influence of momentary retention forces on patient
satisfaction and quality of life of two-implantretained mandibular overdenture wearers. Materials and
Methods: Edentulous patients who had been rehabilitated with two-implantsupported mandibular
overdentures with single attachments and maxillary complete dentures at a university clinic were included in
this study. The overdenture attachments were either ball or locator attachments. All the patients completed
the Turkish version of the Oral Health Impact Profile-14 (OHIP-14) and the visual analog scale (VAS) satisfaction
questionnaires. Momentary retention forces of the overdentures were measured using a custom-made
dynamic testing machine. Results: Fifty-five patients were included in this study. No statistically significant
association was detected between momentary retention forces and VAS scores (P > .05), but higher retention
forces presented significantly better quality of life scores in the social disability and handicap domains of OHIP14 (P < .05). Conclusion: Within the limitations of this clinical study, it may be presumed that although higher
instant retention force of an implant-retained overdenture provides better quality of life, it does not affect
patient satisfaction. INT J ORAL MAXILLOFAC IMPLANTS 2015;30:397402. doi: 10.11607/jomi.3774
Key words: interforaminal implants, mandibular overdenture, momentary retention forces, patient satisfaction,
quality of life

eing edentulous is a handicap and negatively affects

the quality of life of most patients.1 The traditional
treatment of edentulism with conventional complete
dentures is limited, mainly because of instability of the
mandibular dentures, diminished chewing ability, and
continuing bone resorption, particularly in the mandible.13 With the introduction of dental implants in the
early 1980s, the compulsion to undergo conventional
complete denture treatment has been eliminated for
edentulous patients.1,2 It has been shown that the use
of two to four implants to support a mandibular overdenture can be an effective treatment for edentulous
patients who have persistent problems caused by a
conventional mandibular denture.2,3 Furthermore, a
1 Associate

Professor, Istanbul University, Faculty of Dentistry,

Department of Prosthodontics, Istanbul, Turkey.
2Doctoral Student, Istanbul University, Faculty of Dentistry,
Department of Prosthodontics, Istanbul, Turkey.
3Associate Professor, Okan University, Faculty of Dentistry,
Department of Prosthodontics, Istanbul, Turkey.
Correspondence to: Associate Professor Dr Hakan Bilhan,
Okan University, Faculty of Dentistry, Department of
Prosthodontics, 34959 Tuzla-Istanbul, Turkey.
Email: hakan.bilhan@okan.edu.tr
2015 by Quintessence Publishing Co Inc.

panel of experts agreed that a two-implantretained

mandibular overdenture should become the first
choice of treatment for the edentulous mandible in a
symposium held at McGill University in 2002.3
It is well known that, compared to conventional
mandibular complete dentures, two-implantretained
mandibular overdentures give rise to patient satisfaction and quality of life.2,46 Studies focusing on these
measures often use visual analog scales (VAS), which
measure perceptions of subjective phenomena for
the evaluation of patient satisfaction,2,46 and an Oral
Health Impact Profile (OHIP), which is a disease-specific measure of an individuals perception of the social
impact of oral disorders on their well-being for the
evaluation of quality of life.2,7
A variety of attachment systems are used to connect implants to mandibular overdentures. Implants
may be splinted or left unsplinted while connecting
to the prosthesis.8 The selection of an attachment system is very important and plays a vital role in fulfilling
the retention expectation of patients and minimizing
postinsertion maintenance requirements.1,4 Therefore,
evaluation of retention of the overdentures at the delivery of the prosthesis and after function could be beneficial for the clinicians because the attachment system
could be adjusted according to the patients desires.9,10
The International Journal of Oral & Maxillofacial Implants 397

Geckili et al

For the two-implantretained mandibular overdentures, the most common attachment used has been
the ball attachment.4,8 Some years ago, a new prefabricated self-aligning attachment system fitting most
implant systems was introduced, the Locator attachments (Zest Anchors).11 The Locator system can be an
alternative to ball attachments, especially when the
interarch distance is insufficient for ball attachments
matrices.4,11
Although patients report a strong preference for a
more retentive prosthesis,9 the possible influence of
momentary retention forces of two-implantretained
mandibular overdentures on patient satisfaction and
quality of life has never been investigated to the authors knowledge. Therefore, this retrospective study
was conducted to evaluate the potential influence of
momentary retention forces on patient satisfaction
and quality of life of two-implantretained mandibular
overdenture wearers.

MATERIALS AND METHODS

Patient Selection
The study sample comprised all edentulous patients
who were rehabilitated with two-implantretained
mandibular overdentures and maxillary complete dentures at a university clinic between 2010 and 2011. All
patients were personally invited by mail or telephone
to participate in this clinical examination. The requirements of the Helsinki Declaration were fulfilled, and
the patients provided informed consent (reference
no. 2597). As a routine in the present clinic, all patients
treated with dental implants were invited for a recall
session at 6 months and each year after loading. The
included patients had been wearing the two-implant
retained mandibular overdenture for exactly 2 years,
and no maintenance procedures had been employed
for their prosthesis. To prevent a misleading result and
to ensure evaluation of a homogenous group, patients
having had any maintenance procedures at the firstyear recall appointment (minority) were excluded.
Patient overdentures were of two types: two single interforaminal implants with ball attachments (n = 22)
or two single interforaminal implants with Locator attachments (n = 33).
Surgery had been performed as suggested by the
implant manufacturer (Astra Tech) by an experienced
oral and maxillofacial surgeon using a single-stage
surgical protocol. The overdentures were fabricated by
five specialists in prosthodontics using a standard prosthetic method12 that included balanced articulation
with anatomically shaped acrylic resin teeth (Enigma,
Davis Schottlander & Davis) and maximal extension of
the denture base using functional impression methods
398 Volume 30, Number 2, 2015

and were delivered to the patients exactly 1 months

after insertion of the implants, consistent with the early loading protocol.1,4 The implants were connected
to the overdentures either by ball or Locator attachments, decided randomly using a lottery method at
the time of the treatment by the specialists. Among
the three retention inserts in different colors representing altered retention forces, the pink inserts were
used for Locator attachments and the yellow Preci Clix
inserts (Preat Precision Attachments) were used for
the ball attachments, both of which provide medium
retention.11

Measurement of the Momentary

Retention Forces
The momentary retention forces were measured for
each patient using a custom-made dynamic testing
machine designed for the present study and calibrated
previously under both in vitro and in vivo conditions.
The machine consisted of two units: a manual test
stand (SLJ Manual Test Stand, Wenzhou Sundoo Instruments), which was manufactured for various testing
purposes such as tension/compression tests, insertion/withdrawing tests, and fracture tests; and a push/
pull force gauge calibrated for measurements between
0 and 100 N (SN-50 Force Gauge, Wenzhou Sundoo
Instruments), which was attached to the manual test
stand. The force gauge had a metal holder at the bottom part, which was fabricated from an aluminum alloy and contained a hole for attaching the specimens
to be tested.
A thermoplastic impression compound (Impression Compound, Kerr) was softened using hot water
and applied to a mandibular metal stock impression
tray (Dentsply Caulk). The two-implantretained mandibular overdenture was positioned into the impression tray; after the impression compound was set, the
tray with the overdenture stabilized with the impression compound was inserted in the patients mouth.
The selected patient was positioned in a chair with the
impression tray and two-implantretained mandibular overdenture in his or her mouth, and the tray was
screwed to the metal holder of the force gauge using
an apparatus (Fig 1). The cyclical arm of the testing
machine was turned to apply a vertical pull-out force
to the tray until the two-implantretained mandibular
overdenture was separated from the abutments. The
peak vertical force was recorded as the momentary retention force value.

Patient Satisfaction and Quality of Life

Measurements
A satisfaction questionnaire recording seven aspects
of patient satisfaction with the use of two-implant
retained mandibular overdentures using a 100-mm

Geckili et al

VAS was prepared. The scales were anchored by the extremes of potential responses (eg, completely satisfied
and completely dissatisfied).13 The patients used the
scales to record their personal opinions about the twoimplantretained mandibular overdentures based on
the following factors, respectively: general comfort,
retention, chewing, speech, ease of hygiene maintenance, esthetics, and pain.
For the assessment of quality of life, instead of the
original OHIP consisting of 49 questions,14 the Turkish-language OHIP-14,15 which is a shorter and more
patient-friendly version that covers the same seven domains (functional limitation, physical pain, psychologic
discomfort, physical disability, psychologic disability,
social disability, and handicap) as the original OHIP,
was used in the present study. The five response options for each item were never, hardly ever, occasionally, fairly often, and very often. Items were scored on a
5-point scale ranging from 0 = never to 4 = very often.
Lower scores presented higher quality of life.13 All the
patients completed the Turkish version of OHIP-14 together with the VAS satisfaction questionnaire.

Fig 1 Measurement of the momentary retention forces.

Statistical Analyses
For the statistical analysis of the results, SPSS (Statistical Package for Social Sciences) (Version 15.0 for
Windows, SPSS) was used. The relevance of the parameters to the normal distribution was analyzed using
the Kolmogorov-Smirnov test. Aside from descriptive
statistics (means and standard deviations), the MannWhitney U test was used for the comparison of two
group parameters. The relations between the parameters were evaluated using Spearmans rho correlation
analyses. The results were assessed at the 95% confidence interval, at a significance level of P < .05.

RESULTS
Among the 98 edentulous patients who were rehabilitated with two-implantretained mandibular overdentures and maxillary complete dentures in the stated
time interval, 55 patients (31 women, 24 men; average
age, 64.40 years; range, 55 to 72 years) were included
in the study group.
For the evaluation of the effect of age, the patients
were divided into two groups: the patients older than
65 years comprised one group (n = 30), whereas the
patients younger than 65 years comprised the other
group (n = 25). There was no statistically significant
association between VAS scores and patient age
(P > .05; Table 1); whereas OHIP-14 scores showed a
statistically significant difference among patient age in
the physical disability domain. The physical disability
scores of patients older than 65 years were found to

be significantly higher than those of younger patients

(P < .05). There was no statistically significant association between OHIP-14 total scores or the other domain
scores and patient age (P > .05; see Table 1).
There was no statistically significant association
between VAS and OHIP-14 scores and patient sex
(P > .05) except for the first question of the VAS, which
addressed the general comfort of the patients, and the
physical disability domain of OHIP-14. Female patients
showed higher scores on the first question of VAS and
lower physical disability domain scores on the OHIP-14
(P < .05; Table 2).
Attachment types did not affect the VAS scores significantly (P > .05), whereas significantly lower scores
were reported for the social disability and handicap
domains of the OHIP-14 for patients using Locator
attachments (P =.031 and P =.032, respectively). No
other significant difference was detected between the
attachment types related to the other domains of the
OHIP-14 or the OHIP-14 total scores (P > .05).
The momentary retention forces ranged from 0 to
18 N (mean, 10.39 N) and are shown in Fig 2. No significant association was detected between momentary
retention forces and VAS scores (P > .05). However,
higher momentary retention forces were associated
with significantly lower social disability and handicap
domain scores on the OHIP-14 (P =.029 and P =.030,
respectively). No other significant association was detected between momentary retention forces and the
OHIP-14 total and the remaining domains of OHIP-14
(P > .05).
The International Journal of Oral & Maxillofacial Implants 399

Geckili et al

Table 1

Association Between VAS and OHIP-14 Scores and Patient Age

Age
< 65 y (n = 30)
Mean SD (Median)

> 65 y (n = 25)
Mean SD (Median)

Question 1

88.07 21.42 (95)

83.24 23.75 (93)

.375

Question 2

84.77 20.61 (90)

81.60 29.77 (94)

.340

Question 3

86.83 20.32 (92.5)

85.84 23.71 (94)

.558

Question 4

87.03 21.27 (96)

87.56 17.10 (95)

.757

VAS

Question 5

80.83 26.26 (90)

80.84 26.84 (94)

.871

Question 6

84.80 20.09 (94)

93.28 9.06 (98)

.144

Question 7

84.23 20.29 (94)

82.28 27.73 (98)

.403

OHIP-14
OHIP total

3.40 5.61 (2)

4.72 5.98 (2)

.412

Functional limitation

0.17 0.46 (0)

0.20 0.41 (0)

.554

Physical pain

1.07 1.39 (1)

1.44 1.71 (1)

.477

Psychologic discomfort

1.07 1.64 (0.5)

1.32 1.97 (0)

.985

Physical disability

0.63 1.67 (0)

1.44 2.08 (1)

.028*

Psychologic disability

0.27 1.14 (0)

0.20 0.58 (0)

.542

Social disability

0.10 0.40 (0)

0.08 0.40 (0)

.683

Handicap

0.10 0.40 (0)

0.04 0.20 (0)

.652

*P < .05

Table 2

Association Between VAS and OHIP-14 Scores and Patient Sex

Sex

VAS

Women (n = 31)
Mean SD (Median)

Men (n = 24)
Mean SD (Median)

Question 1

89.48 20.48 (95)

82.37 23.05 (89.5)

.027*

Question 2

87.97 20.25 (95)

83.17 25.15 (93.5)

.416

Question 3

84.35 24.61 (93)

82.00 25.94 (90)

.227

Question 4

84.97 23.79 (100)

90.25 11.00 (93.5)

.375

Question 5

83.48 26.45 (95)

77.42 26.21 (89)

.077

Question 6

86.77 20.56 (98)

91.08 8.65 (92.5)

.706

Question 7

82.16 22.56 (95)

84.87 25.61 (96.5)

.401

OHIP-14
OHIP total

3.45 5.53 (2)

4.71 6.10 (2.5)

.531

Functional limitation

0.13 0.43 (0)

0.25 0.44 (0)

.153

Physical pain

1.19 1.40 (1)

1.29 1.73 (1)

.823

Psychologic discomfort

1.10 1.70 (0)

1.29 1.92 (0)

.904

Physical disability

0.58 1.67 (0)

1.54 2.06 (1)

.011*

Psychologic disability

0.26 1.12 (0)

0.21 0.59 (0)

.485

Social disability

0.10 0.40 (0)

0.08 0.41 (0)

.730

Handicap

0.10 0.40 (0)

0.04 0.20 (0)

.698

*P < .05

DISCUSSION
The mandibular two-implantretained mandibular
overdenture is a cost-effective treatment modality for
the edentulous patient, and as the popularity of this
400 Volume 30, Number 2, 2015

treatment increases, it is valuable to analyze the factors affecting its success in the long term.
Although the patients are routinely recalled every
year for evaluation of their two-implantretained mandibular overdentures, the patients who had received

no maintenance for their overdentures for 2 years were

selected for the present study to provide uniform standards for all patients.
Metal impression trays were preferred over plastic
trays when measuring the retention forces in the present study to avoid deformation of the plastic during
the pull-out tests. The retention and stability of the
overdentures have been publicized as the most important factors for improving patient satisfaction.16,17
However, although the two-implantretained mandibular overdentures of 20 subjects provided no retention
(see Fig 2), the results of the present study showed no
relationship between patient satisfaction and momentary retention forces. This result is in accordance with
the results of Burns and colleagues,18 who had reported of equal patient satisfaction results in a prospective
clinical trial. It has been found that after 6 to 12 months
of use, the retention force values decrease to approximately 10% to 30%,19 and sufficient stabilization of the
overdentures occurs even if the attachment systems
provide 5- to 7-N retention forces.10 It should be emphasized that initial retention influences patient acceptance of the prosthesis.6 Present results show that
after an adaptation period, the patients were usually
satisfied with their two-implantretained mandibular
overdentures even if the retention was lost. This may
be due to the sense of security with their prostheses
because of the initial retention,7 as well as the effect
of the abutments on the stability of the two-implant
retained mandibular overdentures even if the retention was lost. On the other hand, it should be noted
that higher momentary retention forces caused better
quality of life scores in the social disability and handicap domains, indicating that the patients having more
retentive overdentures had been less embarrassed and
uncomfortable because of problems with their prostheses. It should also be noted that retention is not
the only factor affecting patient satisfaction, as highlighted previously,17 and additional studies should be
conducted to improve these points.
An interesting finding of the present study was the
effect of age on quality of life. Although there was
no association between age and patient satisfaction,
which is in accordance with other studies,2024 the
physical disability domain scores of patients older than
65 years were significantly higher than those of younger patients, corresponding to lower quality of life. The
OHIP-14 physical disability domain covers questions
about disruption of meals and poor diet because of
the two-implantretained mandibular overdentures
retention and stability.18 This effect may be attributed
to the higher degree of mandibular atrophy, especially in the posterior regions, leading to intolerance to
loading forces by the mucosa and eating problems in
older subjects25,26; two-implantretained mandibular

Momentary retention forces (N)

Geckili et al

20
18
16
14
12
10
8
6
4
2
0

10

20

30
Subjects

40

50

60

Fig 2 Momentary retention forces in the included subjects.

overdentures retention and stability are provided by

both the mucosa and implants.18
In the present study, it was also demonstrated that
women reported better physical disability scores on
the OHIP-14 and higher satisfaction scores related to
the overall treatment outcomes. This result supports
the findings of Awad and Feine,20 who emphasized
that patient satisfaction is highly dependent on gender, and women, in general, have a more positive view
of removable dentures. However, it should be emphasized that when the samples were divided into two
groups, the small sample size and unequal percentage
of genders restricted comparison between men and
women in the present study.
The lower scores detected on the social disability
and handicap domain scores of the OHIP-14 of the patients using Locator attachments, which corresponds
to a better quality of life, are in accordance with a previous study.4 When the vertical space for placing ball
attachments in a two-implantretained mandibular
overdenture was inadequate, the lingual part of the
overdenture had to be overcontoured in the present
study, and the tongue space may have been restricted,
as stated previously.4 This might be the reason for the
poorer quality of life results for those with ball attachments. However, it should be emphasized that the outcomes may have been affected by the quality of the
dentures made by different operators, although all
were qualified prosthodontists, rather than by the attachment system only.
It should also be noted that because a validated Turkish version of the OHIP-EDENT was not available;,the
Turkish OHIP-14 had to be used for assessing the quality of life in the present study, which may be regarded
as a limitation. OHIP-EDENT is the shortened version of
OHIP prepared for edentulous patients and has proven to be more appropriate for use in edentulism than
OHIP-14.27
The International Journal of Oral & Maxillofacial Implants 401

Geckili et al

CONCLUSIONS
Within the limitations of this study, one may conclude
that momentary retention of two-implantretained
mandibular overdentures does not affect patient satisfaction but provides better quality of life.

ACKNOWLEDGMENTS
The authors would like to thank Enishan Ozcan, working as
a PhD student in Istanbul Technical University Faculty of Mechanical Engineering, for his efforts in the production of the
custom-made device for measuring the retention forces of the
overdentures. The authors reported no conflicts of interest related to this study.

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