Qual Life Res (2015) 24:919926
DOI 10.1007/s11136-014-0817-2
Influence of different prosthodontic rehabilitation options on oral
health-related quality of life, orofacial esthetics and chewing
function based on patient-reported outcomes
elebic
Sanja Persic Asja C
Accepted: 29 September 2014 / Published online: 8 October 2014
Springer International Publishing Switzerland 2014
Abstract
Purpose The aim was to assess influence of different
prosthodontic rehabilitation options on improvement of
orofacial esthetics, chewing function (CF) and oral health-
related quality of life.
Methods Patients treated with 70 conventional complete
dentures (CDs), 38 implant-supported mandibular com-
plete dentures opposed to maxillary CDs, 56 conventional
removable partial dentures, 15 implant-supported remov-
able partial dentures, 25 conventional fixed partial dentures
(FPDs) and 59 implant-supported fixed partial dentures
(IFPDs) were included. The survey was conducted using
the three questionnaires: the OHIP-CRO14, the Orofacial
Esthetic Scale (OES-CRO) and the Chewing Function
Questionnaire (CFQ), and administrated twice: at the
baseline prior the therapy and 3 months after prosthodontic
rehabilitation had been finished.
Results The after-treatment scores were significantly
better than the baseline scores (p \ 0.001) for the OES,
OHIP14 and CF questionnaires in all types of treatments.
The two-factor ANOVA showed no significant difference
for the OES after-treatment scores between different
rehabilitation options and implant presence, but the
OHIP14 and CFQ after-treatment scores were significantly
better in FPD and IFPDs than in removable implant and
conventional denture wearers. The score change was
S. Persic (&)
Department of Prosthodontics, School of Dental Medicine,
University of Zagreb, Gunduliceva 5, 10000 Zagreb, Croatia
e-mail: persic@sfzg.hr
elebic
A. C
Department of Prosthodontics, School of Dental Medicine and
Clinical Hospital Centre Zagreb, University of Zagreb, Zagreb,
Croatia
significantly higher in all implant removable denture
patients for the OES, OHIP and CFQ. The lowest score
change was registered in the FPD wearers. (p \ 0.01).
Conclusions Removable denture implant patients most
benefited from implant support, but IFPD and FPD had the
best after-treatment scores. The assessed clinical parame-
ters may help dentists in choice of the best rehabilitation
option with the highest treatment effect.
Keywords OHRQoL
Orofacial esthetic scale
Chewing
function questionnaire
Prosthodontic therapy
Dental
implant support
Patients outcome
Introduction
In order to make a decision about the most appropriate
treatment option in prosthodontic rehabilitation, a dentist
must understand the benefits of prosthodontic therapy. The
improvement of oral health-related quality of life (OHR-
QoL)including chewing function and orofacial esthetics
as important parts of patients well-beinghas become the
main goal in dentistry. The chewing function is one of the
most important functions of orofacial system. Reduced
number of natural teeth, poor quality and/or inadequate
choice of prosthodontic therapy may cause impairment of a
chewing function [1, 2]. Improvement of orofacial esthetics
is also very important for patients acceptance of new
dentures and their overall satisfaction [3, 4] and is one of
the main reasons why patients seek dental treatment [3].
Better OHRQoL has been observed in individuals who are
satisfied with their dental appearance [3, 4].
Since missing teeth are related with a reduced chewing
ability, impaired esthetics and reduced OHRQoL, adequate
prosthodontic rehabilitation is necessary for patient well-
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being. However, different types of treatment can be applied
for the same clinical status, so it is very important to
choose the option which will best fulfill each patients
expectations.
Until recently, the principal treatment options were
either fixed partial dentures (FPDs) (in those patients who
had some of their posterior teeth present), removable par-
tial dentures (RPDs) (in patients when FPDs could no
longer be made, mostly due to the loss of posterior teeth)
and complete dentures (CDs) in completely edentulous
patients. However, there were drawbacks, as many studies
revealed that diet was poor and speech unclear in RPD and
CD patients [5, 6]. Studies found the success of such
treatment often depended mostly on patients adaptive
capacity to overcome reduced retention and stability of
RPDs and CDs [7, 8].
The implant-prosthodontic therapy has become an
important treatment modality in the last three decades as
many studies confirm a significant benefit of increasing
patients OHRQoL [911]. Implant insertion enables
treatment with an implant fixed partial denture (IFPD)
instead of a RPD. Implants also provide a significant
improvement of stability and retention of implant-sup-
ported removable partial dentures (IRPDs) and implant-
supported complete dentures (ICDs) [1215].
All previous studies were concerned mostly on OHR-
QoL. However, improvement of orofacial esthetics and a
chewing function also plays an important role in patients
acceptance of any type of prosthodontic rehabilitation [14,
16]. The most world-wide spread questionnaire to measure
OHRQoL is the OHIP Questionnaire [1726], which is
supposed to be the seven-dimensional Questionnaire con-
cerned mostly with physical, psychological and social oral
health well-being, although recent studies revealed only
four OHIP dimensions [20, 2224]. As the OHIP14
Questionnaire does not contain enough questions related to
esthetics [2224], the OES Questionnaire has been recently
developed as the unidimensional instrument. It measures
only orofacial esthetics [27, 28]. Moreover, the unidi-
mensional Chewing Function Questionnaire (CFQ) has
also been recently developed in response to the lack of
similar psychometrically approved questionnaires in the
dental literature [29]. One study used the food intake
Questionnaire to measure chewing function, but the study
was mostly based on different raw Japanese foods [30].
The newly developed CFQ measures impacts of impaired
chewing function in prosthodontic patients who eat foods
common in the European and USA cultural milieu.
The objective of this study was to assess influence of
different conventional and implant-supported types of
prosthodontic rehabilitation options on orofacial esthetics,
chewing function and OHRQoL.
Materials and methods
Participants
The study included 263 patients (101 men and 162 women,
mean age 62.34 12.69) who were treated either with
conventional or with implant-supported dentures at the
Department of Prosthodontics, School od Dental Medicine,
University of Zagreb in a period from the September 2011
till the February 2014. The ethic committee of the Dental
School approved the study. Each participant signed the
informed consent.
The participants were categorized according to their
degree of oral treatment: complete denture wearers,
removable partial denture wearers and FPDs wearers. They
were also categorized into two groups according to implant
support: without implants (no) and with implant support
(yes) (Table 1). At baseline, when seeking prosthodontic
rehabilitation, all patients were without any dental implant
in their mouths.
Only those participants whose removable dentures had
satisfactory retention and stability after the treatment were
included in the study. A specialist of prosthodontics eval-
uated the quality of new dentures and rated complete and
removable partial dentures retention and stability using the
15 scale (1 represented poor and 5 represented excellent
quality). Prior to the assessment, three different dentists
(specialists in prosthodontics) separately evaluated 30 dif-
ferent RPDs and 30 CDs. Kappa test revealed sufficient
consistency between them, both for CDs (0.760.92) and

Table 1 Sample overview (number, age, gender)

Sample Sample type N Age mean (SD) Age range % Women

Complete denture wearers (CDs) Convenience 70 67.31 (10.26) 4593 57.10

Removable partial denture wearers (RPDs) Convenience 56 63.10 (12.02) 3685 60.7
Fixed partial denture wearers (FPDs) Convenience 25 52.84 (16.83) 2778 68
Implant-supported complete denture wearers (ICDs) Convenience 38 65.47 (8.39) 4276 78.9
Implant-supported removable partial denture wearers (IRPDs) Convenience 15 65.4 (8.16) 5580 53.3
Implant-supported fixed partial denture wearers (IFPDs) Convenience 59 56.08 (10.96) 3574 55.9

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920 Qual Life Res (2015) 24:919926

being. However, different types of treatment can be applied
for the same clinical status, so it is very important to
choose the option which will best fulfill each patients
expectations.
Until recently, the principal treatment options were
either fixed partial dentures (FPDs) (in those patients who
had some of their posterior teeth present), removable par-
tial dentures (RPDs) (in patients when FPDs could no
longer be made, mostly due to the loss of posterior teeth)
and complete dentures (CDs) in completely edentulous
patients. However, there were drawbacks, as many studies
revealed that diet was poor and speech unclear in RPD and
CD patients [5, 6]. Studies found the success of such
treatment often depended mostly on patients adaptive
capacity to overcome reduced retention and stability of
RPDs and CDs [7, 8].
The implant-prosthodontic therapy has become an
important treatment modality in the last three decades as
many studies confirm a significant benefit of increasing
patients OHRQoL [911]. Implant insertion enables
treatment with an implant fixed partial denture (IFPD)
instead of a RPD. Implants also provide a significant
improvement of stability and retention of implant-sup-
ported removable partial dentures (IRPDs) and implant-
supported complete dentures (ICDs) [1215].
All previous studies were concerned mostly on OHR-
QoL. However, improvement of orofacial esthetics and a
chewing function also plays an important role in patients
acceptance of any type of prosthodontic rehabilitation [14,
16]. The most world-wide spread questionnaire to measure
OHRQoL is the OHIP Questionnaire [1726], which is
supposed to be the seven-dimensional Questionnaire con-
cerned mostly with physical, psychological and social oral
health well-being, although recent studies revealed only
four OHIP dimensions [20, 2224]. As the OHIP14
Questionnaire does not contain enough questions related to
esthetics [2224], the OES Questionnaire has been recently
developed as the unidimensional instrument. It measures
only orofacial esthetics [27, 28]. Moreover, the unidi-
mensional Chewing Function Questionnaire (CFQ) has
also been recently developed in response to the lack of
similar psychometrically approved questionnaires in the
dental literature [29]. One study used the food intake
Questionnaire to measure chewing function, but the study
was mostly based on different raw Japanese foods [30].
The newly developed CFQ measures impacts of impaired
chewing function in prosthodontic patients who eat foods
common in the European and USA cultural milieu.
The objective of this study was to assess influence of
different conventional and implant-supported types of
prosthodontic rehabilitation options on orofacial esthetics,
chewing function and OHRQoL.
Materials and methods
Participants
The study included 263 patients (101 men and 162 women,
mean age 62.34 12.69) who were treated either with
conventional or with implant-supported dentures at the
Department of Prosthodontics, School od Dental Medicine,
University of Zagreb in a period from the September 2011
till the February 2014. The ethic committee of the Dental
School approved the study. Each participant signed the
informed consent.
The participants were categorized according to their
degree of oral treatment: complete denture wearers,
removable partial denture wearers and FPDs wearers. They
were also categorized into two groups according to implant
support: without implants (no) and with implant support
(yes) (Table 1). At baseline, when seeking prosthodontic
rehabilitation, all patients were without any dental implant
in their mouths.
Only those participants whose removable dentures had
satisfactory retention and stability after the treatment were
included in the study. A specialist of prosthodontics eval-
uated the quality of new dentures and rated complete and
removable partial dentures retention and stability using the
15 scale (1 represented poor and 5 represented excellent
quality). Prior to the assessment, three different dentists
(specialists in prosthodontics) separately evaluated 30 dif-
ferent RPDs and 30 CDs. Kappa test revealed sufficient
consistency between them, both for CDs (0.760.92) and

Table 1 Sample overview (number, age, gender)

Sample Sample type N Age mean (SD) Age range % Women

Complete denture wearers (CDs) Convenience 70 67.31 (10.26) 4593 57.10

Removable partial denture wearers (RPDs) Convenience 56 63.10 (12.02) 3685 60.7
Fixed partial denture wearers (FPDs) Convenience 25 52.84 (16.83) 2778 68
Implant-supported complete denture wearers (ICDs) Convenience 38 65.47 (8.39) 4276 78.9
Implant-supported removable partial denture wearers (IRPDs) Convenience 15 65.4 (8.16) 5580 53.3
Implant-supported fixed partial denture wearers (IFPDs) Convenience 59 56.08 (10.96) 3574 55.9

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Qual Life Res (2015) 24:919926
for RPDs (0.750.90), but it was decided that only one of
the dentists should evaluate all patients. However, only
those patients whose removable dentures were assessed as
excellent or very good were allowed to take a part in the
study. Other patients were excluded, as the low quality of
their dentures could negatively affect the results of a
prosthodontic rehabilitation. Some previous studies showed
that gender, monthly income and education level affected
results of satisfaction with new prosthodontic restorations
as patients with low education level and low monthly
income had lower expectations than higher educated
patients and those with higher income [1618, 31, 32].
Therefore, all available patients with medium or high
education level who reported sufficient income for normal
everyday life and who fulfilled the criteria of having good-
quality dentures after treatment were included.
Sample size and sampling strategy for each sample group,
together with gender and age, are presented in Table 1. A
total of 70 patients received conventional CDs in both jaws,
and 38 edentulous patients received implant-supported
mandibular complete dentures (ICDs) together with con-
ventional CDs in the maxilla (ICD group). A total of 56
patients received conventional RPDs Kennedy Class I or II
(0, 1 or maximum 2 modification spaces in posterior areas) in
both jaws, while 15 patients received implant-supported
removable partial dentures (IRPD: 9 patients received IRPDs
in the mandible and 6 patients received IRPDs in the max-
illa). A total of 25 patients received conventional FPD dis-
tally from a canine, or including a canine tooth (10 FPDs in
the maxilla and 5 FPDs in the mandible, 10 patients received
FPD in both jaws); 59 patients received implant-supported
fixed partial dentures (IFPDs; 38 IFPDs were made in the
maxilla, and 21 IFPDs were made in the mandible; only 6
IFPDs included frontal teeth, while all other IFPDs were
bridges distally from a canine, or including a canine, as
implant had been inserted in the canine region) (Table 1).
Two types of dental implants were inserted to a total of
112 implant patients: MIS C1 (Israel) (60 patients) or
Straumann (Swiss) (52 patients). All implants had standard
platform widths (3.75 or 4.2 mm). All dentures were
attached to implants by ball attachments.
Questionnaires
All patients completed three questionnaires: the Croatian
version of the short form of the Oral Health Impact Profile
(OHIP14) [33, 34], the Croatian version of the Orofacial
Esthetic Scale (OES-CRO) [27] and the Chewing Function
Questionnaire (CFQ) [29]. Using the OHIP14 question-
naire, patients rated their oral health on a scale ranging
from 0 to 4: Zero indicated the absence of problems; higher
scores indicated more impaired oral health. Summary
scores ranged from 0 to 56. Using the OES-CRO, patients
921
rated their orofacial esthetic on a scale ranging from 1 to 5
(1 = completely unsatisfied; 5 = completely satisfied;
summary score ranged from 1 to 40; the higher summary
score indicated greater satisfaction with esthetics). The
assessment scale for the CFQ ranged from 0 to 4 (zer-
o = absence of problems, 4 = the most impaired chewing
function). Summary scores obtained from the ten questions
in the CFQ ranged from 0 to 40; higher summary score
indicated more impaired chewing function.
The questionnaires were administrated twice: first time
(baseline scores) when patients came to a dental office
seeking prosthodontic rehabilitation, and the second time
3 months after the new dentures were provided and all
adjustments were made. All questionnaires were psycho-
metrically tested in previous studies and were proved to
have excellent psychometric properties [27, 29, 33, 34].
Summary scores of these three questionnaires (OHIP14,
OES and CFQ) enable monitoring changes of patients
orofacial esthetics, chewing function and OHRQoL (score
change), as well as comparison of after-treatment scores
between different types of prosthodontic treatments.
Statistical analysis
The data analysis was made using the SPSS software
(version 17.0, SPSS Inc., Chicago, IL, USA). Paired sam-
ples t test was used to test the significance of the differ-
ences between the baseline summary scores and the after-
treatment summary scores for all provided treatment
options.
The two-factor ANOVA was performed for the depen-
dent variable: the after-treatment summary score and two
factors: different types of prosthodontic therapy (CD, RPD,
FPD) and implant support (yes, no), with the baseline
summary score as a covariate. The Pearson coefficients of
correlation were calculated between the variables: the
baseline summary scores and the after-treatment summary
scores.
The two-factor ANOVA was also performed for the
dependent variable: the score change (difference
between the baseline and the after-treatment summary
scores) to test the effects of factors: different types of
prosthodontic treatment (CD, RPD, FPD) and implant
support (yes, no), also including the baseline scores as
covariates. The Pearson coefficients of correlation were
calculated between the score change and the baseline score.
P value of \0.05 was considered statistically significant.
Results
The baseline and the 3-month after-treatment scores for
each questionnaire in the CD, RPD and FPD patients with
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Table 2 Significance of the Types of Before treatment: Baseline After-treatment t df p

differences of the baseline prosthodontic after-treatment mean mean values
scores and after-treatment treatment Questionnaire values (SD) (SD)
scores for the OES score
Questionnaire, OHIP14
Questionnaire and Chewing CDs OES 26.04 (7.47) 35.80 (4.03) -11.37 69 \0.001
Function Questionnaire (CFQ)
OHIP 22.76 (11.0) 8.44 (5.68) 12.639 69 \0.001
in complete, partial removable
and fixed denture patients with CFQ 22.70 (8.63) 11.41 (6.26) 12.364 69 \0.001
and without dental implants ICDs OES 23.74 (7.05) 36.68 (3.27) -10.309 37 \0.001
OHIP 24.53 (8.89) 4.40 (3.51) 12.77 37 \0.001
CFQ 27.68 (8.30) 7.23 (2.84) 15.941 37 \0.001
RPDs OES 24.29 (6.45) 34.93 (4.17) -12.677 55 \0.001
OHIP 21.21 (11.18) 5.71 (5.02) 11.927 55 \0.001
CFQ 19.70 (9.47) 8.55 (4.98) 9.924 55 \0.001
IRPDs OES 23.07 (8.03) 35.20 (4.14) -4.919 14 \0.001
OHIP 29.07 (9.38) 3.93 (2.52) 9.98 14 \0.001
CFQ 25.67 (8.62) 4.94 (3.61) 7.404 14 \0.001
CD complete denture, ICD FPDs OES 29.56 (4.97) 35.00 (3.72) -6.38 24 \0.001
implant-supported complete OHIP 16.8 (12.50) 3.44 (3.68) 6.003 24 \0.001
denture, RPD removable partial
CFQ 12.92 (8.39) 5.00 (4.09) 5.761 24 \0.001
denture, IRPD implant-
supported removable partial IFPDs OES 25.90 (6.91) 36.8 (2.96) -11.889 58 \0.001
denture, FPD fixed partial OHIP 21.80 (11.67) 2.98 (3.30) 13.587 58 \0.001
denture, IFPD implant- CFQ 18.64 (9.66) 3.86 (3.49) 11.277 58 \0.001
supported fixed partial denture

and without dental implant support are presented in
Table 2, together with the significance of the differences
(paired Students t test). All of the observed scores were
significantly better after treatment in comparison with the
baseline scores for all types of rehabilitation options
(p \ 0.001). All patients rated their esthetics significantly
better after the treatment (higher scores), and all patients
had significantly lower OHIP14 and CFQ scores (better
OHRQoL and better chewing function).
For the dependent variable, the after-treatment esthetic
score (OES after-treatment scores), the two-factor analysis
of variance revealed no significant effects of the factor:
different types of prosthodontic therapy (CD, RPD, FPD)
(F = 1.602; p = 0.204), while a significant effect was
obtained for the factor: implant support (yes, no)
(F = 6.29; p = 0.03) and for the covariate: the baseline
OES score (F = 16.74; p \ 0.001). Three month after
prosthodontic rehabilitation, all patients with conventional
dentures were equally satisfied with their esthetic out-
comes, but patients with implant dentures were more sat-
isfied. However, the RPD patients had the lowest OES
scores in both, implant and non-implant groups. The
baseline OES scores were weakly and positively correlated
with the OES after-treatment scores (r = 0.231; p \ 0.01).
The after-treatment OHIP scores were significantly
different in different types of prosthodontic therapy (CD,
RPD, FPD) (F = 8.225; p \ 0.001) and implant support
(yes, no) (F = 24.356; p \ 0.001). The covariate of the
baseline OHIP score also elicited significant effects
(F = 52.64; p \ 0.001). All patients with dental implants
had significantly lower OHIP after-treatment scores (sig-
nificantly better OHRQoL) than patients without dental
implants in all three types of prosthodontic rehabilitation
(CD, RPD, FPD). Patients with CDs had the highest OHIP
after-treatment scores (the worst OHRQoL). In both,
implant and non-implant groups, FPD patients rated better
their OHRQoL than RPD and CD patients. The lowest
OHIP score was registered in the IFPD patients. The
baseline OHIP14 scores were positively and significantly
correlated with the OHIP14 after-treatment scores
(r = 0.376; p \ 0.01).
For the dependent variable, the after-treatment CFQ
scores, the two-factor analysis of variance revealed sig-
nificant effects of both factors: the type of prosthodontic
treatment (CD, RPD, FPD) (F = 9.82; p \ 0.001) and
implant support (yes, no) (F = 37.68; p \ 0.001), with a
significant effect of the covariatethe baseline CFQ
summary score (F = 35.28; p \ 0.001). The CFQ after-
treatment scores was significantly higher (more impaired
chewing function) in all types of conventional denture
wearing (non-implant patients) than in implant patients. In
both, implant and non-implant patients, CD wearers had
higher CFQ after-treatment scores (more chewing diffi-
culties) than both, RPD patients and FPD patients; the RPD

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Fig. 1 Mean values and standard deviations of the summary score
change [difference between baseline summary scores (before treat-
ment) and after-treatment summary scores (3 month after prosth-
odontic rehabilitation)] of three Questionnaires in different types of
prosthodontic treatment (CD = complete denture, n = 70;
RPD = removable partial denture, n = 56; FPD = fixed partial
wearers had higher CFQ after-treatment scores than
patients with FPDs (p \ 0.001). The lowest CFQ after-
treatment score (best chewing ability) was registered in the
IFPD patients. The after-treatment CFQ scores were posi-
tively and significantly correlated with the CFQ baseline
scores (r = 0.352; p \ 0.01).
The variable, the score change (difference between the
baseline and the after-treatment scores), for all three
questionnaires is presented in Fig. 1.
For the dependent variable: the OES score change, the
two-factor ANOVA showed a significant effect of the
factor: dental implant support (yes, no) (F = 6.29;
p = 0.013) and the covariate: the baseline OES score
(F = 703.48; p \ 0.001), but not of the factor: type of
prosthodontic treatment (CD, RPD, FPD) (F = 1.542;
p = 0.216) (Fig. 1a). All patients with dental implant
support had significantly higher OES score change in all
types of denture wearing, compared with non-implant
patients. The FPD patients without dental implant support
had the lowest OES score change. The OES score change
showed strong, negative and significant correlation with the
OES baseline score (r = -0.860; p \ 0.01).
Considering the dependent variable, the OHIP14 score
change (Fig. 1b), the significant effects were obtained for
both factors: type of prosthodontic treatment (CD, RPD,
FPD) (F = 8.29; p \ 0.001) and implant support (yes, no)
(F = 24.464; p \ 0.001), as well as for the covariate:
baseline OHIP scores (F = 1,292.35; p \ 0.001).
Removable denture wearers showed higher score changes
elicited by a therapy than fixed denture wearers in both
groups, with and without implant support. Implant
923
denture, n = 25; ICD = implant-supported complete denture,
n = 38; IRPD = implant-supported removable partial denture,
n = 15; IFPD = implant-supported fixed partial denture, n = 59.
a Orofacial Esthetic Scale score difference (OES D-Score); b Oral
Health Impact Profile score difference (OHIP14 D-Score); c Chewing
Function Questionnaire score difference (CFQ D-Score)
patients showed higher score change than non-implant
patients in all groups. The OHIP14 score changes were
negatively, strongly and significantly correlated with the
OHIP14 baseline scores (r = -0.899; p \ 0.01) revealing
higher score changes in patients with worse OHRQoL at
baseline.
For the dependent variable, the CFQ score change, the
ANOVA showed a significant effect of both factors: the
type of prosthodontic treatment (F = 10.96; p \ 0.001)
and the implant support (F = 35.24; p \ 0.001), as well as
of the covariate, baseline CFQ score (F = 726.52;
p \ 0.001). All patients had significantly higher CFQ score
changes when their dentures were supported by dental
implants. Removable denture patients had higher score
changes than patients with FPDs in conventional and
implant-supported denture wearing (Fig. 1c). The lowest
CFQ score change was registered in the IFPD and the FPD
patients.
Discussion
A therapists understanding of a patients expectations and
satisfaction has become a crucial requirement for treatment
planning and decision making. Satisfaction with a prosth-
odontic therapy depends on many different factors such as
denture function or appearance, absence of pain, physical
adaptability of an individual [14, 68, 35, 36]. Patient
psychological factors, personality factors and social factors
may affect acceptance and satisfaction of any prosth-
odontic appliance [37, 38]. Many studies confirmed that
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924
patient-based outcome measures were necessary in clinical
decision making, and therefore, specific instruments were
developed to help clinicians and researchers to assess
patient-based outcomes [32, 39, 40].
In order not to jeopardize results by possible low-quality
dentures, in the present study, we excluded patients whose
removable dentures had not met excellent criteria. How-
ever, it is very difficult to standardize all parameters that
may contribute to the after-treatment summary scores or to
score changes. Some studies showed that gender and edu-
cation level affected satisfaction with prosthodontic resto-
rations [1618, 31, 32]. Therefore, we excluded low
educated patients as they might have had lower expecta-
tions. All studied participants were living in a city and had
a satisfactory income, so lack of money was not the reason
why patients received a certain type of prosthodontic
rehabilitation. Only anatomical restriction of residual
alveolar ridges or an attitude toward receiving dental
implants was a reason why some patients received con-
ventional prosthodontic therapy instead of implant-sup-
ported dentures.
Better after-treatment rating of orofacial esthetics in
patients with implant-supported dentures in comparison
with conventional denture patients may be attributed to
their increased and high overall satisfaction. Some of the
patients had previous experience with conventional
removable denture wearing and in their enthusiasm with
the benefits provided by a dental implant support they
probably rated even the esthetics better than conventional
removable denture patients. Moreover, some patients who
received IFPDs had a missing canine at baseline, which
was visible (implant was inserted into the canine region),
while the FPD patients had their own canines (which were
later prepared for a FPD). Some patients replaced con-
ventional clasp retained RPDs with IRPDs and thus
overcame the clasp visibility. The lowest after-treatment
OES scores registered in this study in conventional RPD
patients may be attributed to the visibility of denture
clasps. The lowest OES score change registered in the
FPD patients may be attributed to the fact that FPDs were
constructed in the posterior parts of the jaws, so patients
were probably not much concerned about their orofacial
esthetics even before treatment. Relatively weak but sig-
nificant correlation between the baseline and the after-
treatment OES scores may be attributed to patients
psychological factors and personality, i.e., the patients
who rated orofacial esthetics better (or worse) at baseline
did the same after treatment. However, effects of the
covariate, baseline summary scores, as well as negative
and strong significant correlation between the baseline
OES scores and the OES score change revealed that
patients with the worst baseline ratings most benefited
considering orofacial esthetics.
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Qual Life Res (2015) 24:919926
Although all implant removable denture patients had
higher after-treatment OHIP scores (worse OHRQoL) than
the IFPDs and the FPDs, they improved their OHRQoL by
provided prosthodontic rehabilitation to the highest extent
(the highest OHIP score change, Fig. 1b). Significantly
lower OHIP after-treatment scores in all groups with dental
implant support indicates that implant patients more ben-
efited from the received therapy than non-implant patients.
In both, implant and non-implant groups, better OHRQoL
in the FPD than in the RPD and CD patients was attributed
to the adverse effects of removable dentures such as palatal
coverage, resiliency of oral mucosa and denture move-
ments when chewing foods. The lowest OHIP after-treat-
ment score, registered in the IFPD patients, may be
attributed to the fact that they were the most enthusiastic
patients as related to the benefit of a therapy, as some of
them replaced their previous RPDs with IFPDs, and/or they
were aware that they would, without dental implants,
receive removable dentures. The results of improved
OHRQoL elicited by a provided therapy in this study are in
line with previous papers, especially those reporting ben-
efits from a dental implant therapy [13, 16, 4146]. The
results for the after-treatment OHIP scores in the IFPD and
the FPD groups are in line with another study which reg-
istered better 3-year after-treatment OHIP scores in the old
IFPD patients [41].
The CFQ after-treatment scores were significantly
affected by a type of prosthodontic therapy, implant sup-
port and the covariate, namely baseline score. Significantly
lower CFQ after-treatment scores in removable implant
denture patients can be attributed to better stability and
retention of removable dentures provided by implant sup-
port. Although dental implants improved retention and
support of removable dentures, the outcome never reached
the achievements of FPDs or IFPDs, as removable denture
patients had significantly more impaired chewing function
than fixed denture patients in both, implant and non-
implant groups. The worst CFQ after-treatment score in the
implant-supported denture group registered in the ICD
patients may be attributed to the fact that only mandibular
CD was supported by dental implants opposed by a con-
ventional CD. The highest CFQ score change registered in
implant removable denture patients indicates that they
improved their chewing function to a highest extent.
Obviously, implant removable denture patients most ben-
efited from the implant support by enhancing retention and
stability of removable dentures; however, their after-treat-
ment scores still remained higher than in both implant and
non-implant fixed denture groups. The lowest CFQ score
change elicited by a therapy in the FPD group was attrib-
uted to the fact that those patients were able to chew dif-
ferent foods with their remaining teeth even before they
received FPDs.
Qual Life Res (2015) 24:919926
Overall, all baseline scores were weakly and positively
related to the after-treatment scores, which was attributed
to patients personality traits (those patients who rated
better at baseline did same after treatment). The effect of
the covariate: baseline summary score and negative and
strong correlation between the baseline summary score and
the score change can be attributed to the fact that patients
with the worst baseline ratings most benefited from the
provided therapy.
Overall, implant therapy enhanced chewing function
and OHRQoL more than conventional treatment options.
Moreover, esthetic outcomes were better in the implant
groups, probably due to their increased overall satisfaction.
In their enthusiasm, they rated esthetics better than patients
with conventional dentures.
The limitations of the present study are the sample size
variability among the six studied groups, possible differ-
ences of antagonistic jaw status in some of the studied
groups and/or absence of patient personality judgment.
The major strength of this study is the assessment of
patient-reported measures related to esthetics, chewing
function and OHRQoL for six different prosthodontic
treatment modalities. Moreover, results of this study,
obtained from the CFQ and the OES questionnaires for the
different prosthodontic rehabilitation options with and
without dental implants, have not been reported yet.
Conclusions
All patients regardless of the type of prosthodontic treat-
ment significantly improved their orofacial esthetics,
chewing function and OHRQoL. All implant patients better
improved OHRQoL, chewing function and orofacial
esthetics than conventional treatment groups (CD, RPD,
FPD). The implant removable denture patients improved
chewing function and OHRQoL to the highest extent by the
provided therapy (highest CFQ and OHIP14 score differ-
ences), but still had higher after-treatment scores (more
impairment) than the FPD and the IFPD group. The IFPD
followed by the ICD and the CD patients best rated oro-
facial esthetics. Baseline scores were weakly positively
related with the after-treatment scores and strongly, nega-
tively with the score changes. The results obtained in this
study from the three questionnaires, which assessed
important clinical parameters, may help dentists in decision
making to choose the most appropriate rehabilitation
option with the highest treatment effect.
Acknowledgments To the Ministry of Science of Croatia for
funding the University Research Project: Contemporary prosth-
odontic procedures, materials and OHRQoL dependent on a degree of
oral rehabilitation.
925
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