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Journal of Dentistry
journal homepage: www.intl.elsevierhealth.com/journals/jden
A R T I C L E I N F O
A B S T R A C T
Article history:
Received 30 June 2016
Received in revised form 13 October 2016
Accepted 16 October 2016
Available online xxx
Objectives: To assess the benets of implant support to Removable Partial Dentures (RPD) in patients with
a bilateral free-ending situation in the mandible and to determine the most favorable implant position:
the premolar (PM) or the molar (M) region.
Methods: Thirty subjects with a bilateral unbounded posterior saddle received 2 PM and 2 M implants. A
new RPD was placed. Implant support was provided 3 months later. Two PM implants supported the RPD.
After 3 months the 2 M implants were used or vice versa. Outcome measures included oral health related
quality of life (OHIP-NL49), general health status (SF-36), contentment assessed on a Visual Analogue
Scale (VAS) and the number of hours that the RPD was worn. Data were collected prior to treatment, 3
months after having functioned with a new RPD and after 3 and 6 months with implant support. Finally,
patients expressed their preferred implant position.
Results: The general health status (SF-36) was not inuenced. OHIP-NL49 values and mean wearing-time
were statistical signicantly more favorable for ISRPDs, regardless of the implant position. Per day, the
ISRPDs were worn 23 h more than the unsupported new RPD. Patients expectations were met as the
VAS-scores of anticipated and realized contentment did not reach a statistical signicant level (p > 0.05).
VAS scores for ISRPDs with M implant support were higher than for PM implant support. Finally, 56.7% of
subjects preferred the M implant support, 13.3% expressed no preference and 30% opted for PM implant
support.
Conclusions: Mandibular implant support favorably inuences oral health related patient-based outcome
measures in patients with a bilateral free-ending situation. The majority of patients prefer the implant
support to be in the molar region.
Clinical signicance: Patients with a bilateral free-ending situation in the mandible opposed by a
maxillary denture benet from implant support to their mandibular removable partial denture. Most
patients prefer this support to be in the molar region.
2016 Elsevier Ltd. All rights reserved.
Keywords:
Randomized controlled crossover clinical
trial
Removable partial denture
Patient outcomes
Quality of life
1. Introduction
According to the concept of the shortened dental arch, patients
with reduced numbers of posterior teeth generally have ample
http://dx.doi.org/10.1016/j.jdent.2016.10.008
0300-5712/ 2016 Elsevier Ltd. All rights reserved.
Please cite this article in press as: C. Jensen, et al., Implant-supported mandibular removable partial dentures; patient-based outcome
measures in relation to implant position, Journal of Dentistry (2016), http://dx.doi.org/10.1016/j.jdent.2016.10.008
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JJOD 2685 No. of Pages 7
the head and neck region, who experienced implant loss in the
past, who are incapable of performing basal oral hygiene measures,
with decreased masticatory function due to physical disability or
with active, uncontrolled periodontal pathology of the remaining
dentition were excluded from participation.
2.2. Surgical and prosthetic procedures
All subjects gave informed consent and received 2 implants on
either side of the mandible (Straumann RN, Straumann,
Switzerland) that were provided with cover screws and submerged. Two implants were placed in the premolar region (PM
implant support) and two were placed in the molar region (M
implant support). A surgical guide was used to achieve the right
position and inclination. After 3 months, all implants were exposed
in a second-stage surgery and low healing abutments were
inserted.
A new RPD was made according to standard prosthetic
procedures. The design involved a lingual plate and a clasp on
either side. The housing of the Locator1 abutment (Zest Anchors,
Inc., Escondido, California, USA) was already incorporated in the
RPD, but not the Teon matrix so it provided neither retention nor
support to the RPD. Three months later and following a
randomization scheme, either the PM or M implants were
provided with a Locator1 abutment. The remaining implants
were left unloaded for future investigation. After 3 months, the
other pair of implants was loaded. Fig. 1 shows an example of a
typical clinical case. A clear timeline is displayed in Fig. 2.
2.3. Patient-based outcome measures
Five patient-based outcome measures were assessed: oral
health related quality of life, patient reported general health status,
general contentment, daily wearing-time of the RPD and patients
preference for the PM or M implant position. The clinician who
collected the data (CJ) was involved during the inclusion of the
subjects and the organisation of the trial, but provided neither
surgical, nor prosthodontic care.
Oral Health Related Quality of Life (OHRQoL) was considered
the primary outcome measure and assessed using the Dutch
translated and validated version of the Oral Health Impact Prole
questionnaire (OHIP-NL49) [2527]. It consists of 49 questions
arranged in seven conceptually formulated domains: functional
limitation, physical pain, psychological discomfort, physical
disability, psychological disability, social disability and handicap.
For each item, subjects were asked how frequently they had
experienced the impact of that item in the last month. Responses
are given on a Likert-scale (0-never, 1-hardly ever, 2-occasionally,
3-fairly often, 4-very often). OHIP-NL49 sum scores per domain
and an overall score characterize the OHRQoL impairment in which
higher scores indicate greater OHRQoL impairment.
Patient-reported perceived general health status was determined using the Dutch translated and validated version of the
Short Form Health Survey (SF-36). It measures to what degree
patients feel disabled during their daily activities [28]. It is
comprised of 36 questions divided into 8 scaled scores which are
transformed into a range from 0 to 100: vitality, physical
functioning, bodily pain, general health perceptions, physical role
functioning, emotional role functioning, social role functioning and
mental health. One additional question addresses changes in
health condition. The lower the score, the more disability.
In addition, patients were asked to express their general
contentment with their oral function during the different stages of
treatment on a Visual Analogue Scale (VAS) ranging from 0 (very
discontent, major concerns) to 100 (very content, no concerns at
all). At the start of treatment they were also asked to express their
Please cite this article in press as: C. Jensen, et al., Implant-supported mandibular removable partial dentures; patient-based outcome
measures in relation to implant position, Journal of Dentistry (2016), http://dx.doi.org/10.1016/j.jdent.2016.10.008
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JJOD 2685 No. of Pages 7
Fig. 1. a. Occlusal view. Locator abutments in the premolar region provide support
and retention to the Removable Partial Denture. The 2 molar implants are not in
function. b. Frontal view. Removable Partial Denture in situ. Blue shimmering lateral
in the denture is caused by the electronic chip to measure wearing-time. c. Occlusal
view. Removable Partial Denture in situ. (For interpretation of the references to
colour in this gure legend, the reader is referred to the web version of this article.)
Fig. 2. Timeline of the randomized clinical cross-over trial including moments of data collection.
Please cite this article in press as: C. Jensen, et al., Implant-supported mandibular removable partial dentures; patient-based outcome
measures in relation to implant position, Journal of Dentistry (2016), http://dx.doi.org/10.1016/j.jdent.2016.10.008
G Model
JJOD 2685 No. of Pages 7
22.0 (SD 18.8) and 38.0 (SD 22.2) [32]. Since we included patients
with free-ending bilateral situations only, we presumed the OHIP
value for this particular situation to be higher (i.e. 40) and the
effect of implant support to be less (i.e. 24). Sample size calculation
revealed that 23 subjects were needed to detect this increase in the
primary outcome measure from 40 in the control group (RPD) to 24
in the experimental group (ISRPD, regardless of implant position).
Given the fact that the expected effect in patients with some
remaining natural teeth is presumably smaller than that in
edentulous subjects and compensating for potential dropouts,
the intended number of subjects to be included in the study was set
at 30 patients.
The outcomes of the old, the unsupported new, the PM implant
supported and the M implant supported RPDs were compared by
1-way analysis of variance and multiple comparison tests after
verication of normal distribution. When the data were not
normally distributed a non-parametric test for related samples
(Friedmans test) was anticipated. In case of statistical signicance
(a = 0.05), post-hoc Wilcoxon signed rank tests were performed
with Bonferroni adjustment for multiple testing. Mann-Whitney U
tests were performed to detect any effects from treatment
sequence (rst M, then PM implant support versus rst PM, then
M implant support).
3.1. OHIP-NL49
The mean values for the OHIP-NL49 domains and the OHIPNL49 sum score are presented in Table 2. Comparison for the OHIPNL49 sum scores showed a statistically signicant difference
between the 4 groups (X2(3) = 39.600, p < 0.001). Post-hoc analysis
revealed that overall OHIP-NL49 scores for both implant supported
partial denture groups (PM or M) were signicantly lower, than for
the old partial denture and for the new partial denture without
implant support. Providing a new RPD without support did not
lead to a statistical signicant improvement of the OHIP-NL49
sum-score as compared to the old RPD. Analysing the different
domains in detail, a similar trend was seen for domain entailing
Physical disability. For the domains Functional Limitation,
Physical Pain and Psychological Discomfort the new RPD without
support already gave some improvement, which was further
enhanced once the implants were used, be it with M or PM implant
support (Table 2). Psychological disability was improved by M
implant support and not so much when the PM implants were
loaded. For the domains Social Disability and Handicap no
The mean wearing-time per day with the new RPD and with the
ISRPDs with M and PM implant support were 12.4 h (SD 7.3 h),
15.2 h (SD 6.6 h) and 14.1 h (SD 7.4 h) respectively. Wearing-time
for all conditions ranges from 0.3-23.8 h per day. One patient
poorly adapted to the unsupported RPD and his ISRPD as well
because of severe general health problems that occurred during
the course of the study. Comparison for mean wearing-time was
signicantly different between these 3 groups (X2(2) = 25.655,
p < 0.001). Post-hoc Wilcoxon signed-rank tests, revealed that
patients wore their dentures longer on average per day, once they
were supported by implants. The position of the implants, either
PM or M did not signicantly inuence wearing-time.
3. Results
Table 1
Patient characteristics.
Gender (male/female)
Mean Age (SD/range)
Group (PMa /Mb)
Number of remaining natural teeth (56/78)
a
b
15/15
60.9 (1.2/43.871.0)
15/15
16/14
Please cite this article in press as: C. Jensen, et al., Implant-supported mandibular removable partial dentures; patient-based outcome
measures in relation to implant position, Journal of Dentistry (2016), http://dx.doi.org/10.1016/j.jdent.2016.10.008
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JJOD 2685 No. of Pages 7
Table 2
Mean sum scores of Oral Health Impact Prole questionnaire (OHIP-NL49) (range 0196, SD between brackets) at different stages of treatment: old removable partial denture
(Tbaseline), new removable partial denture (TnewRPD), implant supported removable partial denture with support at the molar position (TISRPD-M), implant supported partial
denture with support at the premolar position (TISRPD-PM).
Tbaseline
TnewRPD
TISRPD-M
TISRPD-PM
14.9 (6.9)
10.7 (6.6)
6.9 (5.8)
9.2 (7.6)
3.6 (5.5)
1.9 (3.3)
2.5 (5.0)
49.6 (35.2)
11.3 (6.1)*
11.4 (7.3)
4.6 (5.2)*
8.2 (7.4)
3.0 (4.4)
1.5 (2.2)
1.4 (2.4)
40.3 (31.2)
6.5 (3.8)**
4.2 (4.1)**
1.8 (2.8)**
2.6 (3.0)**
1.0 (2.3)**
0.7 (1.5)
0.8 (1.9)
17.6 (16.6)**
6.9 (4.5)**
4.5 (5.3)**
2.3 (4.4)**
3.1 (4.0)**
2.0 (4.1)
1.1 (2.2)
1.3 (3.4)
21.2 (26.0)**
Table 3
Mean scores for SF-36 (standard deviation between brackets) at different stages of treatment: old removable partial denture (Tbaseline), new removable partial denture
(TnewRPD), implant supported removable partial denture with support at the molar position (TISRPD-M), implant supported partial denture with support at the premolar
position (TISRPD-PM).
Physical functioning
Social role functioning
Physical role functioning
Emotional role functioning
Mental health
Vitality
Bodily pain
General Health Perceptions
Total SF36-score
Tbaseline
TnewRPD
TISRPD-M
TISRPD-PM
83.8 (21.0)
93.5 (13.7)
85.8 (31.3)
94.5 (19.7)
81.2 (16.8)
74.3 (16.1)
79.4 (24.5)
75.5 (13.9)
719.7 (117.1)
79.7 (24.9)
91.1 (13.3)
80.8 (34.5)
94.4 (21.6)
83.6 (10.5)
72.0 (18.1)
74.0 (26.9)
73.7 (18.8)
701.7 (123.2)
80.5 (22.8)
89.3 (19.0)
79.2 (36.0)
90.0 (23.4)
83.0 (13.2)
70.0 (17.3)
74.1 (27.6)
73.2 (16.1)
692.6 (132.0)
82.5 (23.3)
89.3 (15.3)
82.5 (36.0)
92.2 (24.3)
82.8 (15.9)
72.8 (19.5)
78.2 (26.7)
71.5 (18.5)
702.6 (142.9)
Please cite this article in press as: C. Jensen, et al., Implant-supported mandibular removable partial dentures; patient-based outcome
measures in relation to implant position, Journal of Dentistry (2016), http://dx.doi.org/10.1016/j.jdent.2016.10.008
G Model
JJOD 2685 No. of Pages 7
Fig. 3. Mean visual analogue scale (VAS) scores and standard deviations of patients' expected contentment with an Implant Supported Removable Partial Denture (ISRPD)
assessed prior to treatment, present contentment with their old denture (Old RPD) and the actually achieved level of contentment after having functioned with a newly made
Removable Partial Denture without implant support for 3 months (new RPD) or with implant support (ISRPD). Scores for PM and M implant support were averaged. Range 0
(very discontent, major concerns) to 100 (fully content, no concerns at all). Statistical analysis: Expectation = ISRPD > New RPD > Old RPD.
Please cite this article in press as: C. Jensen, et al., Implant-supported mandibular removable partial dentures; patient-based outcome
measures in relation to implant position, Journal of Dentistry (2016), http://dx.doi.org/10.1016/j.jdent.2016.10.008
G Model
JJOD 2685 No. of Pages 7
Please cite this article in press as: C. Jensen, et al., Implant-supported mandibular removable partial dentures; patient-based outcome
measures in relation to implant position, Journal of Dentistry (2016), http://dx.doi.org/10.1016/j.jdent.2016.10.008