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Mandibular complete denture versus single-implant overdenture: A systematic review of patient-reported outcomes

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The single-implant mandibular overdenture (SIMO) has been proposed as an alternative for edentulous patients who are poorly adapted to their dentures due to low retention and stability of the conventional mandibular complete denture (CD). However, there is a lack of evidence regarding the effectiveness of SIMO, which can be measured by examining patient perception of treatment effects. The aim of this systematic review was to assess the comparative results of CD and SIMO treatments by using patient-reported outcome measures. A literature search was carried out in PubMed, Scopus and Cochrane Central databases. The search included studies published up to July 2017. The focus question was: “Do single-implant mandibular overdentures improve patient-reported outcomes compared to conventional complete dentures in edentulous patients?” Eligible studies were randomized clinical trials (RCT) and prospective studies. After initial screening for eligibility and full-text analysis, 11 studies were included for data extraction and quality assessment (five parallel-group RCTs, two crossover RCTs, and four prospective studies). All studies reported marked improvement in satisfaction with the dentures and quality-of-life measures after SIMO treatment, irrespective of variations in implant-treatment protocols and retention systems. Methodological considerations revealed a lack of evidence from RCTs on the comparative effectiveness of the two treatment strategies. Hence, although available evidence suggests considerable improvement in patient-reported outcomes following the insertion of a single implant to retain a mandibular denture, further well-designed comparative studies between SIMO and CD are required to improve the level of evidence and to support the indication of SIMO treatment in routine practice.
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Review
Mandibular complete denture versus single-implant
overdenture: a systematic review of patient-reported
outcomes
T.E.NOGUEIRA,D.R.DIAS&C.R.LELES Department of Prevention and Oral Rehabilitation, School
of Dentistry, Federal University of Goias, Goiania, Brazil
SUMMARY The single-implant mandibular overden-
ture (SIMO) has been proposed as an alternative
for edentulous patients who are poorly adapted to
their dentures due to low retention and stability
of the conventional mandibular complete denture
(CD). However, there is a lack of evidence
regarding the effectiveness of SIMO, which can be
measured by examining patient perception of
treatment effects. The aim of this systematic
review was to assess the comparative results of CD
and SIMO treatments using patient-reported
outcome measures. A literature search was carried
out in PubMed, Scopus and Cochrane Central
databases. The search included studies published
up to July 2017. The focus question was: ‘Do
single-implant mandibular overdentures improve
patient-reported outcomes compared to conven-
tional complete dentures in edentulous patients?’
Eligible studies were randomised clinical trials
(RCT) and prospective studies. After initial
screening for eligibility and full-text analysis, 11
studies were included for data extraction and
quality assessment (five parallel-group RCTs, two
crossover RCTs and four prospective studies). All
studies reported marked improvement in
satisfaction with the dentures and quality of life
measures after SIMO treatment, irrespective of
variations in implant treatment protocols and
retention systems. Methodological considerations
revealed a lack of evidence from RCTs on the
comparative effectiveness of the two treatment
strategies. Hence, although available evidence
suggests considerable improvement in patient-
reported outcomes following the insertion of a
single implant to retain a mandibular denture, fur-
ther well-designed comparative studies between
SIMO and CD are required to improve the level of
evidence and to support the indication of SIMO
treatment in routine practice.
KEYWORDS: patient satisfaction, quality of life,
overdenture, complete denture, patient-reported
outcomes, systematic review
Accepted for publication 10 August 2017
Background
Despite the significant decline in the prevalence and
incidence of total tooth loss in the last decades at the
global, regional and country levels (1), the continuing
rate of decline in edentulism is projected to slow,
compensated partially by population growth and age-
ing (2). Nevertheless, edentulism is still a relevant
health problem and there are significant barriers to
oral health care of older people. Poor socio-economic
conditions of older people also contribute to their
under-utilisation of oral health services even when
these are available (3), which reinforces the need for
accessible and cost-effective treatments that minimise
the financial barrier in oral health care.
Conventional complete dentures are the most com-
mon treatment for edentulous subjects worldwide
and, in general, edentulous patients treated with
©2017 John Wiley & Sons Ltd doi: 10.1111/joor.12550
Journal of Oral Rehabilitation 2017
Journal o f Oral Rehabilitation
conventional complete dentures (CD) are well
adapted to their dentures. Most of them, particularly
older individuals, have expectations limited to well-
functioning CDs and are less likely to be candidates
for implant therapy (4). However, reports of
impaired function, oral pain and discomfort are fre-
quent, especially about the mandibular denture.
Patient complaints and dissatisfaction with the den-
tures may be related to technical aspects of the treat-
ment but may also be due to prognostic factors that
are multifactorial and largely dependent on clinical,
psychological and behavioural aspects of the patients
(5). For these difficult clinical situations, especially
for patients with edentulous mandible, implant-sup-
ported or implant-retained dentures are recom-
mended to improve denture retention and stability
and increase overall oral comfort, function and psy-
chosocial well-being.
The mandibular overdenture retained by two
implants has been recommended as the minimum
standard of care for the edentulous mandible (6, 7).
However, in recent years, the single-implant
mandibular overdenture (SIMO) has been proposed
as an alternative to more complex overdenture
designs (8, 9). SIMO is assumed to be simpler and less
costly than both the fixed-implant treatment and the
overdenture retained by two implants. It is also con-
sidered a more feasible option for geriatric patients,
who are less likely to adhere to complex implant
interventions, because of its diminished functional
demands and because of the favourable local bone
condition in the symphyseal region, which ensures
satisfactory primary implant stability (8).
Previous clinical studies showed satisfactory results
of SIMO treatment using clinical outcomes such as
implant survival rate, marginal bone loss and implant
stability over time, as well as improved patient satis-
faction and quality of life (10). The post-loading
implant survival in 1- and 2-implant mandibular
overdentures was compared in a meta-analysis, and
no significant difference was observed between the
two treatment modalities (11). Another review, which
gathered evidence from clinical studies, suggested that
SIMO could be a reliable alternative for elderly
patients on the basis of implant survival, patient satis-
faction and prosthodontic maintenance (12). How-
ever, it is difficult to make reliable comparisons across
clinical studies because they differed greatly on the
experimental design, use of different implant and
retention systems, loading protocols and evaluation of
distinct clinical outcomes.
There is sound evidence available about the positive
impacts of the 2-implant mandibular overdenture on
patient-reported outcomes, such as oral health-related
quality of life and satisfaction, when compared to CD
(1315). Similarly, preliminary reports showed that
there is no detrimental effect on denture mainte-
nance, patient satisfaction, implant survival and peri-
implant bone loss when the number of implants is
reduced from two to one (16, 17). However, the
incremental effect of SIMO is still poorly understood
when CD, which is still the standard of care in the
majority of health systems worldwide, is considered
the reference for comparison. In addition, the impact
of SIMO based on an assessment from the patient’s
perspective is critical to reveal whether this treatment
truly improves a patient’s health status and quality of
life. Those two outcomes are crucial aspects of a
patient-centred approach to oral health care.
The aim of this review was to assess the changes in
patient-reported outcome measures between CD and
SIMO treatment. The focus question was as follows:
‘Do single-implant mandibular overdentures improve
patient-reported outcomes compared to conventional
complete dentures in edentulous patients?’ The study
hypothesis is that SIMO provides significant improve-
ments for CD wearers when patient-reported out-
comes are considered.
Methods
Search strategy
The ‘Preferred Reported Items for Systematic Reviews
and Meta-Analysis’ (PRISMA) guidelines were used as a
reference for reporting this systematic review (18). A
broad systematic literature search was conducted in
PubMed, Scopus and Cochrane Central focusing on clin-
ical studies of edentulous subjects treated with SIMO.
The last literature search was performed in July 2017.
The question and the search strategy were struc-
tured based on the ‘PICOS’ method: ‘Population’
edentulous patients; ‘Intervention’ single-implant
mandibular overdenture; ‘Comparator’ conventional
mandibular denture; ‘Outcome’ patient-reported
outcomes; ‘Study design’ randomized controlled tri-
als (RCTs) and single-arm prospective studies. A
detailed description of the search strategy containing
©2017 John Wiley & Sons Ltd
T. E. NOGUEIRA et al.
2
MeSH terms, keywords, Boolean operators and their
combinations for PubMed and Scopus is detailed in
Table 1. No time frame was used to limit the number
of eligible studies, and no language restriction was
considered for this review.
Selection criteria
To be included in this systematic review, the study
had to be preferably classified as a randomised
controlled trial (RCT), but prospective studies with
beforeafter comparisons were also considered, and
all of them had to include at least 10 SIMO patients.
RCTs had to include conventional denture wearers as
an active comparator (control group), and single-arm
prospective studies had to have assessed patients
treated with conventional dentures as the baseline
treatment. Moreover, one or more patient-reported
outcomes had to be assessed in the study. The
patient-reported outcomes are important because
Table 1. Electronic databases and search strategies according to the PICO question components
Database Search strategy
PubMed (P) #1 (mouth, edentulous[MeSH Terms]) OR mouth, edentulous[Title/Abstract]) OR mouth, toothless[Title/
Abstract]) OR edentul*[Title/Abstract]) OR edentulous patients[Title/Abstract]) OR toothless patients[Title/
Abstract]) OR jaw, edentulous[MeSH Terms]) OR jaws, edentulous[Title/Abstract])
(I) #2 (denture, overlay[MeSH Terms]) OR denture, overlay[Title/Abstract]) OR overdenture*[Title/Abstract])
OR implant overdenture[Title/Abstract]) OR mandibular overdenture[Title/Abstract]) OR single implant[Title/
Abstract]) OR one implant[Title/Abstract]) OR midline implant[Title/Abstract]) OR median implant[Title/
Abstract]) OR single implant overdenture[Title/Abstract]) OR single-implant overdenture[Title/Abstract])
(C) #3 (denture, complete[MeSH Terms]) OR denture, complete[Title/Abstract]) OR denture[Title/Abstract])
(O) #4 (quality of life[MeSH Terms]) OR quality of life[Title/Abstract]) OR patient satisfaction[MeSH Terms]) OR
patient satisfaction[Title/Abstract]) OR satisfaction with the denture*[Title/Abstract]) OR patient outcome
assessment[MeSH Terms]) OR patient outcome assessment[Title/Abstract]) OR research, patient-centered
outcomes[Title/Abstract]) OR outcome assessment, patient[Title/Abstract]) OR patient*reported outcome*[Title/
Abstract]) OR patient*centered outcome*[Title/Abstract]) OR patient*related outcome*[Title/Abstract]) OR
patient*oriented outcome*[Title/Abstract]) OR treatment outcome[MeSH Terms] OR treatment outcome[Title/
Abstract]) OR effectiveness, clinical[Title/Abstract]) OR patient*relevant outcome*[Title/Abstract]) OR clinical
efficacy[Title/Abstract]) OR treatment effectiveness[Title/Abstract]) OR treatment efficacy[Title/Abstract]) OR
rehabilitation outcome[Title/Abstract])
#1 AND #2 AND #3 AND #4
Scopus (P) #1 ‘mouth, edentulous’ OR ‘mouth, toothless’ OR edentul*OR ‘edentulous patients’ OR ‘toothless patients’
OR ‘jaw, edentulous’ OR ‘jaws, edentulous’
(I) #2 ‘denture, overlay’ OR overdenture*OR ‘implant overdenture’ OR ‘mandibular overdenture’ OR ‘single
implant’ OR ‘one implant’ OR ‘midline implant’ OR ‘median implant’ OR ‘single implant overdenture’ OR
‘single-implant overdenture’
(C) #3 ‘denture, complete’ OR ‘denture’
(O) #4 ‘quality of life’ OR ‘patient satisfaction’ OR ‘patient outcome assessment’ OR ‘research, patient-centered
outcomes’ OR ‘outcome assessment, patient’ OR ‘patient-reported outcome*’ OR ‘patient-centered
outcome*’OR ‘patient-related outcome*’ OR ‘patient-oriented outcome*’ OR ‘treatment outcome’ OR
‘effectiveness, clinical’ OR ‘patient-relevant outcome*’ OR ‘clinical efficacy’ OR ‘treatment effectiveness’ OR
‘treatment efficacy’ OR ‘rehabilitation outcome’
#1 AND #2 AND #3 AND #4
Cochrane
Central
(P) #1 edentulous mouth OR toothless mouth OR edentulous OR edentulism OR edentulous patients OR
toothless patients OR edentulous jaw
(I) #2 overdenture OR implant overdenture OR mandibular overdenture OR single implant OR one implant OR
midline implant OR median implant OR single implant overdenture
(C) #3 complete denture OR denture
(O) #4 quality of life OR patient satisfaction OR patient outcome assessment R patient-centered outcomes OR
patient-reported outcome OR patient-centered outcome OR patient-related outcome OR patient-oriented
outcome OR treatment outcome OR clinical effectiveness OR patient-relevant outcome OR clinical efficacy OR
treatment effectiveness OR treatment efficacy OR rehabilitation outcome
#1 AND #2 AND #3 AND #4
©2017 John Wiley & Sons Ltd
SINGLE-IMPLANT MANDIBULAR OVERDENTURES 3
they are reports that come directly from patients
about how they feel or function in relation to a
health condition and its treatment without interpre-
tation by healthcare professionals or anyone else
(19). In vitro studies and reviews were excluded. In
the case of multiple studies from a single cohort and
with the same study design, we used the following
criteria to decide which data to use in this review: if
the publications from the same cohort reported dif-
ferent patient-reported outcomes (i.e. patient satisfac-
tion in one and oral health-related quality of life in
another), both of them were included; if the same
outcome was reported in the multiple papers, only
the publication with the longest follow-up was
included.
After completing the PubMed and Scopus searches,
two reviewers (DRD and TEN) independently read
all titles and abstracts (when available) to identify
eligible studies. The full-text versions were obtained
for studies appearing to meet the inclusion criteria or
when the titles and abstracts presented insufficient
data to make a clear decision. The reviewers (DRD
and TEN) then assessed the full-text version indepen-
dently to judge whether the studies met the inclu-
sion criteria. A specific protocol for full-text reading
was formulated and used to record the rationale for
making a decision. Disagreements between the
reviewers were decided by discussion and a third
review author (CRL) was consulted if necessary.
Additionally, a manual search was performed in the
reference lists of all selected articles, aiming to iden-
tify studies with titles that seemed relevant but that
may have been missed through the PubMed,
Cochrane CENTRAL and Scopus searches.
Data extraction and quality assessment
A data extraction form was designed and used by the
two review authors (DRD and TEN) independently.
The following information was extracted from the
studies: first author, year of publication, study design,
country, implant and retention system, surgical and
loading protocols, number of patients and details of
the outcomes reported, including method of assess-
ment and time intervals. When any clarification or
information was needed, the corresponding authors
were contacted by e-mail.
Moreover, an adapted version of the Cochrane
checklist for describing and assessing patient-reported
outcomes in clinical trials (20) was used as a guide to
assess the quality of the included studies.
Results
Eleven studies fulfilled the eligibility criteria and were
included in the final list. Figure 1 presents a flow dia-
gram, based on PRISMA guidelines, of the detailed data
search used for this review, the identification and selec-
tion processes, the number of excluded studies and the
reasons for exclusion. Three studies were excluded
because they reported previous results of the same
patient cohorts (2123) from those already included.
Table 2 details the main characteristics of the
selected studies. Studies differed widely with regard to
the follow-up period (mean follow-up time of
218 months, range: 160 months), implant and
retention systems used and the surgical and implant
loading protocols. Three different methodological
designs were identified in the included studies: five
parallel-group trials (16, 17, 2426), two crossover
clinical trials (27, 28) and four prospective studies
(single-group trials) (8, 2931). In the selected stud-
ies, the sample size ranged from 10 to 158 partici-
pants, and patient-reported outcomes were assessed in
328 SIMO patients.
Tables 3 and 4 describe the assessment of the meth-
ods that were used for the evaluation of patient satis-
faction and quality of life outcomes in the studies
included in this review. The most common instru-
ments used to measure patient-reported outcomes
were rating scales to measure satisfaction with care
(8, 16, 2427, 2931) and oral health-related quality
of life instruments (17, 28, 30). Irrespective of the
outcomes measured and related instruments, all stud-
ies showed satisfactory ability to detect changes
between treatments and patient condition. However,
the great variation in measurements and methods did
not allow for the calculation of a common summary
statistic for each study to describe the observed inter-
vention effect.
In summary, all studies reported a positive effect on
satisfaction and quality of life measures after rehabili-
tation with SIMO compared with the conventional
denture treatment, which was the reference interven-
tion. This improvement was found irrespective of
variations in implant and prosthodontic procedures
and materials. However, due to the absence of a stan-
dard outcome measure, a simple descriptive analysis
©2017 John Wiley & Sons Ltd
T. E. NOGUEIRA et al.
4
was performed by calculating the difference between
initial and final measurements in order to identify the
magnitude of change after SIMO treatment (Table 5).
Discussion
This systematic review summarised evidence from clin-
ical studies regarding the effect of SIMO treatment on
patient-reported outcomes after the insertion of a single
implant to retain a mandibular overdenture in conven-
tional denture wearers. Overall results suggest a signifi-
cant improvement in patient satisfaction and a
reduction in oral health-related quality of life impacts.
Nevertheless, the heterogeneity among primary studies
and the absence of randomised clinical trials comparing
SIMO with CD may render meaningless any pooled
estimate in a meta-analysis. Hence, this review is lim-
ited to a descriptive summary of the selected studies
that described patient-reported outcomes, as well as an
analysis of the main weaknesses and strengths of the
methods used for outcome assessment in those studies.
Although the earliest reports identified in this topic
were dated nearly two decades ago (8, 32), there are
relatively few studies on SIMO, considering the high
and growing number of publications in the implantol-
ogy field. Furthermore, our literature search did not
identify any results of randomised clinical trials that
compared edentulous subjects receiving SIMO as the
intervention and CD as the control treatment. How-
ever, a study protocol of an ongoing randomised con-
trolled trial comparing SIMO and CD conducted by
our research group was retrieved by our search and
the results will possibly contribute to an answer for
the focus question of this systematic review (33).
Even though there were limitations of the studies
included in this review, a clear superiority of SIMO
compared to CD was observed when considering
patient-reported outcomes. Conversely, previous stud-
ies that used patient-reported outcome measures also
reported the non-inferiority characteristics of SIMO
compared to the two-implant overdenture, suggesting
that SIMO could also be a viable alternative for
patients with higher surgical risks or impaired health
conditions, such as very old patients, or in situations
when simplification of the intervention is desirable
due to financial restrictions (16, 17).
Fig. 1. Flow diagram of articles
screened through the review process.
©2017 John Wiley & Sons Ltd
SINGLE-IMPLANT MANDIBULAR OVERDENTURES 5
Table 2. Main characteristics of the studies included in the systematic review
Authors/Year Study design Country
Implant
system(s)
Retention
system(s)
Surgical
protocol
Loading
protocol
Number
of SIMO
wearers
Follow-up
period
Patient-reported
outcome(s) Instrument(s)
Cordioli
et al.,
1997 (8)
Single-group design
(CD?SIMO)
Italy 3i implant O’ring/Ball
attachment
2-stage CL 21 Up to 5
years
Satisfaction (stability,
retention, masticatory
function, migrating
pain, use of adhesive
pastes)
VAS
Liddelow &
Henry,
2010 (29)
Single-group design
(CD?SIMO)
Australia Branemark
machined/
TiUnite
implants
O’ring/Ball
attachment
1-stage IL 32 Up to 3
years
Satisfaction (pain,
comfort, appearance,
function, stability,
speech, hygiene,
overall satisfaction)
VAS
Harder
et al., 2011
(30)
Single-group design
(CD?SIMO)
Germany Camlog
implant
Gold matrix/
Ball
attachment
1/2-stages EL 11 1 month Chewing ability and
OHRQoL
VAS and
OHIP-49
Cheng et al.,
2012 (27)
Crossover design
(locator vs.
magnetic
attachment)
China Straumann
standard
implant
Magnetic and
Locator
attachments
1-stage CL 13 3 months Satisfaction (comfort
level, speech,
chewing ability,
stability and
retention, overall
satisfaction)
VAS
Kronstrom
et al., 2014
(17)
Parallel-group
design (SIMO vs.
2-implant
overdenture)
Canada Branemark
TiUnite
implant
O’ring/Ball
attachment
1-stage IL 11 13 years OHRQoL OHIP-Edent
Grover et al.,
2014 (28)
Crossover design
(shortened vs.
conventional
dental arch)
India Zimmer
tapered
implant
Magnetic
attachment
1-stage EL 10 Up to 3
months
OHRQoL OHIP-49
(continued)
©2017 John Wiley & Sons Ltd
T. E. NOGUEIRA et al.
6
Table 2. (continued)
Authors/Year Study design Country
Implant
system(s)
Retention
system(s)
Surgical
protocol
Loading
protocol
Number
of SIMO
wearers
Follow-up
period
Patient-reported
outcome(s) Instrument(s)
Bryant et al.,
2015 (16)
Parallel-group
design (SIMO vs.
2-implant
overdenture)
Canada Straumann
implant
O’ring/Ball
attachment
2-stage EL 42 Up to 5 years Overall satisfaction VAS
Tavakolizadeh
et al., 2015
(25)
Parallel-group
design (SIMO vs.
2-implant
overdenture)
Germany/
Iran
Implantium
implant
O’ring/Ball
attachment
1/2-stages IL 10 Up to 1 year Satisfaction (overall
satisfaction, social life,
chew hard foods,
comfort, fit)
VAS
Ismail et al.,
2015 (24)
Parallel-group
design (ball vs.
magnetic
attachment)
Egypt/
Saudi
Arabia
Dyna Dental
implant
Ball and
Magnetic
attachment
2-stage CL 10 Up to 2 years Satisfaction and
function complaints
5-point scale
Bhat et al.,
2016 (31)
Single-group design
(CD?SIMO?2-
IOD?3-IOD)
India Snap
Equinox
implant
Dalla Bona
attachment
2-stage CL 10 1 month Satisfaction
(appearance, speech,
chewing and self-
confidence for the
dentures; retention/
stability, comfort,
pain and handling for
the lower denture)
Grade scale
up to 10
Passia et al.,
2017 (26)
Parallel-group
design (IL-SIMO
vs. CL-SIMO)
Germany Camlog
implant
Ball
attachment
1/2-stages IL or CL 158 4 months Satisfaction (pain,
comfort, appearance,
function, cleaning,
stability/fit and
overall evaluation)
VAS
CD, conventional denture; IOD, implant overdenture; CL, conventional loading; IL, immediate loading; EL, early loading; OHRQoL, oral health-related quality of life; VAS,
visual analogue scale; OHIP, Oral Health Impact Profile; OHIP-Edent, Oral Health Impact Profile for Edentulous.
©2017 John Wiley & Sons Ltd
SINGLE-IMPLANT MANDIBULAR OVERDENTURES 7
Table 3. Quality assessment of the methods used for the evaluation of quality of life in the included studies
Authors/Year
What were the
patient-reported
outcome(s)
measured?
Who completed
the instruments?
How was the
measurement scale?
Was the
instrument
used as originally
proposed?
Was the
instrument
validated
previously
(reference
provided?)
Was evidence of
prior validation
for use in this
population
presented?
Does the instrument
have ability to
measure change?
Harder et al.,
2011 (30)
Oral health-
related quality
of life
Not reported Oral Health Impact Profile
(OHIP-49)
questionnaire [a 5-point
scale (0 =never,
1=hardly ever,
2=occasionally,
3=fairly
often and 4 =very
often)]
Not reported Yes Yes Yes
Kronstrom
et al., 2014 (17)
Oral health-
related quality
of life
Self-administered Oral Health Impact Profile
for Edentulous
(OHIP-EDENT)
questionnaire [five
response
alternatives ranging from
a negative opinion
(‘very often’) to a
positive (‘never’)]
Yes Yes Yes Yes
Grover et al.,
2014 (28)
Oral health-
related quality
of life
Self-administered OHIP-49 questionnaire
(no scale reported)
Unclear No reference
provided
No Yes
©2017 John Wiley & Sons Ltd
T. E. NOGUEIRA et al.
8
Table 4. Quality assessment of the methods used for the evaluation of patient satisfaction in the included studies
Authors/Year
What were the patient-
reported outcome(s)
measured?
Who completed
the instruments?
How was the
measurement scale?
Was the
instrument
used as
originally
proposed?
Was the instrument
validated previously
(reference provided?)
Was evidence of
prior validation
for use in this
opulation
presented?
Does the
instrument have
ability to measure
change?
Cordioli
et al., 1997 (8)
Patient satisfaction based
on oral comfort and
function (prosthesis
stability and retention,
masticatory function,
migrating pain and use
of adhesive pastes)
Self-administered VAS unclear scaling Yes No (a reference was
provided but do not
describe a
validation process)
No Yes
Liddelow &
Henry,
2010 (29)
Patient satisfaction based
on oral comfort and
function (general
satisfaction, social life,
mastication of hard food,
comfort and fit)
Self-administered VAS 0100 score Yes Yes Yes Yes
Harder et al.,
2011 (30)
Patient’s perception of
chewing ability of eight
different hard and soft
foods
Self-administered VAS no markings
between the endpoints
(interpreted as 0 and
100%)
Not reported No No Yes
Cheng et al.,
2012 (27)
Patient satisfaction
(comfort, speech,
chewing ability,
retention and stability
and overall satisfaction)
Self-administered VAS 100-mm scale,
from left (0) as
completely unsatisfied
and right (100) as
completely satisfied
Not reported No No Yes
Bryant et al.,
2015 (16)
Patient satisfaction
(overall satisfaction with
the lower denture)
Self-administered VAS 10-cm
uninterrupted scale
representing a
continuum of feelings,
with ‘unsatisfied’ at one
end and ‘satisfied’ at the
other
Not reported No No Yes
(continued)
©2017 John Wiley & Sons Ltd
SINGLE-IMPLANT MANDIBULAR OVERDENTURES 9
Table 4. (continued)
Authors/Year
What were the patient-
reported outcome(s)
measured?
Who completed
the instruments?
How was the
measurement scale?
Was the
instrument
used as
originally
proposed?
Was the instrument
validated previously
(reference provided?)
Was evidence of
prior validation
for use in this
opulation
presented?
Does the
instrument have
ability to measure
change?
Tavakolizadeh
et al., 2015 (25)
Patient comfort and
function (general
satisfaction, social life,
mastication of hard and
soft foods and fit)
Self-administered VAS 100-mm line
anchored at the
beginning and end by
opposing statements
(‘not at all satisfied’ to
‘extremely satisfied’)
Yes Yes Yes Yes
Ismail et al.,
2015 (24)
Patient satisfaction and
complaints
Unclear Scale ranging from 1 to 5
Level of satisfaction:
very good, good,
satisfactory, sufficient,
not satisfactory;
Complaints: no, mild,
moderate, severe, very
severe complaints
Yes No (a reference was
provided but do
not describe a
validation process)
No Yes
Bhat et al.,
2016 (31)
Patient satisfaction Unclear Questionnaire (eight
questions, without
figures or line designs,
maximum score of 10)
Not reported No No Yes
Passia et al.,
2017 (26)
Patient satisfaction (pain,
comfort, appearance,
function, cleaning,
stability/fit and overall
evaluation)
Self-administered VAS no markings
between the endpoints
(interpreted as 0 and
100%)
Yes No (a reference was
provided but do
not describe a
validation process)
No Yes
VAS, visual analogue scale.
©2017 John Wiley & Sons Ltd
T. E. NOGUEIRA et al.
10
Four included studies were classified as prospective
studies, designed as single-group trials in which all
study participants received the same intervention and
then were followed over time to have their response
observed in a beforeafter comparison of measured
outcomes. Despite its simplicity, inferences from sin-
gle-arm trials are limited due to the inability to distin-
guish between the effect of the treatment and the
difficulty with interpreting the response without a
frame of reference for comparison (34). Conclusions
drawn from these studies may be considered prelimi-
nary evidence of the efficacy and safety of SIMO
treatment. Even though the selected studies reported
relatively small sample sizes, most of them were pow-
erful enough to detect differences, mainly for within-
group comparison of single-group studies. These dif-
ferences could be detected because of the marked
increase in patient satisfaction after SIMO treatment
when compared to CD. On the other hand, the small
sample sizes limit the ability to test the effect of speci-
fic patients’ conditions on clinical and radiographic
outcomes, and the detection of significant general and
local risk factors.
Besides the wide spectrum of outcome measures in
implant and prosthodontic interventions, this review
focused on outcomes directly reported by the patient.
Patient-reported outcomes include any evaluation
obtained directly from patients through interviews, self-
completed questionnaires, diaries or other data collec-
tion tools such as hand-held devices and web-based
forms (19). The measuring instrument must be stan-
dardised and show external validity to reduce bias and
provide comparable results among different studies.
Currently, there is an increasing focus in clinical studies
on placing patients at the centre of healthcare research
and on evaluating clinical care. The goal is to improve
the patient’s experience and ensure that research is both
robust and of maximum value for the use of health
interventions and products (35). Patient-reported out-
comes are also suggested to be of more importance in
the future compared to any other outcomes for exam-
ple, clinical, physiological or caregiver-reported out-
comes because patient feedback and change in patient
behaviour are essential to improve treatment adherence
and satisfaction with care (36).
In general, we observed a lack of information
regarding the use of data collection instruments
among studies, the absence of references related to the
respective validation process, how the instrument was
used (self-completed or interview) and how the result-
ing data were analysed. One study reported the Oral
Health Impact Profile (OHIP) as a questionnaire to
measure patient satisfaction (17); whilst it is known
that OHIP does not measure any positive aspects of
oral health and excludes perceptions of satisfaction
with oral health, changes in oral health, prognosis or
self-reported diagnoses and all impacts in the OHIP are
conceptualised as adverse outcomes (37).
This systematic review highlighted the need for
additional evidence derived from rigorously designed
and delivered randomised clinical trials, as well as
subsequent reports containing high-quality descrip-
tions of all aspects of the study methodology. Such
studies and reports would enable a systematic apprai-
sal and interpretation of results, which could provide
sound evidence about the effectiveness of SIMO com-
pared to other treatments and about the improvement
of patient-reported outcomes for poorly adapted CD
wearers.
Conclusions
The available evidence suggests a considerable
improvement in patient-reported outcomes following
Table 5. Estimates of the magnitude of change (beforeafter
difference) in patient-reported outcome between initial
(complete denture phase) and last measurements in the individ-
ual studies for patients treated with single-implant mandibular
overdentures
Patient satisfaction Baseline
Last
follow-up Difference*
Bhat et al. (31)
2439150
Bryant et al. (16)
381688307
Cheng et al. (27)
85097074
Ismail et al. (24)
1337480
Liddelow & Henry (29)
30 83 530
Tavakolizadeh et al. (25)
2771440
Cordioli et al. (8)
§§
Harder et al. (30)
§§
Passia et al. (26)
§§
OHIP score Baseline Last
follow-up
Difference
(points)
Harder et al. (30) 490250240
Kronstrom et al. (17) 508832324
Grover et al. (28)
§§
*0100 converted scale.
General satisfaction.
Satisfaction with chewing ability.
§
No summary data available.
©2017 John Wiley & Sons Ltd
SINGLE-IMPLANT MANDIBULAR OVERDENTURES 11
the insertion of a single implant to retain a mandibular
denture. The results observed in the selected studies
also suggest that the instruments used to measure
patient-reported outcomes were able to detect the
changes between treatments; however, poor reporting
and lack of standardised instruments and scale mea-
sures make it difficult any attempt to combine data
from these studies in a meta-analysis. To add evidence
and support the indication of SIMO, further studies
specifically designed to compare SIMO and CD are
needed.
Acknowledgments
There was no source of funding for this systematic
review. There are no conflict of interests in connec-
tion with this article. No review protocol was
published before.
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©2017 John Wiley & Sons Ltd
SINGLE-IMPLANT MANDIBULAR OVERDENTURES 13
... A comparison of conventional complete dentures with implant-supported dentures on two implants shows a significant improvement in patients' comfort, oral health-related quality of life, denture stability, phonetics and, finally, increased masticatory efficiency [8,[14][15][16]. The positive influence of the use of implants was also observed when comparing conventional complete dentures with centrally inserted implants in the lower jaw to support a complete denture [17,18]. Although this has improved the conditions for a more multifaceted nutritional intake, the literature does not demonstrate a significant change in dietary habits in this context [19,20]. ...
... They are characterized by the fact that an increase in chewing ability and patient satisfaction can be achieved with little effort and at minimal financial cost. While the performance in comparison to conventional [17,18] and implant-supported prostheses on two implants [28,29] has also been investigated, there is little evidence regarding different loading protocols of the implants. Therefore, the aim of the present study was to investigate the influence of direct or delayed loading of midline implants in the mandible. ...
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Objectives Single midline implants in the edentulous mandible can be used to support existing complete dentures to improve patients’ satisfaction and masticatory efficiency. The impact on patients’ dietary habits and the influence of the loading protocol of the implants was the subject of this study. Materials and methods In this prospective randomized clinical trial, edentulous patients with existing complete dentures in both jaws were treated with a single midline implant in the mandible. In group A, the implants were loaded immediately, in group B the loading was delayed after three months. Patients were asked to report on their nutritional intake before implant placement and 12, 24 and 60 months after loading using a standardized two-part questionnaire. Results Nutritional intake regarding the frequency of consumption of the requested food items did not change significantly during the 60-months study period, regardless of the loading protocol. In contrast, the second part of the questionnaire revealed that after 60 months, there was a significant decrease in avoidance of food, that had a coarse and hard texture in both groups. This significant decrease was observable in the group A in the first 12 and 24 months and in the group B after 60 months. Conclusion A change in the patients’ dietary habits due to the insertion of a single midline implant in the mandible to support the existing complete denture cannot be observed, independently to the loading protocol. Clinical relevance Improving the chewing efficiency by single midline implants in the edentulous mandible does not lead to a change in dietary habits.
... [11] Coutinho et al. reported positive outcomes after a 5-year follow-up study on patient-related outcomes using mandibular single-implant overdenture. [12,13] Passia et al. conducted a study on edentulous patients to assess the intraindividual chewing efficiency and observed an improvement in masticatory efficiency, irrespective of the number of implants. [14] Masticatory efficacy declines as a person becomes completely edentulous. ...
... [15,16] Studies conducted with single-implant overdenture have shown improvement in patient satisfaction, and in terms of masticatory efficiency, it provides varying results. [8][9][10][11][12][13][14]17] Recent systematic reviews show improvement in masticatory efficiency with implant overdentures, despite the implant number, and have promising results even with single-implant overdentures. [6,8,11,12,18,19] Single-implant mandibular overdenture is relatively less challenging and potentially less complicated for older populations. ...
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Aim: The aim of this within-subject prospective clinical study was to investigate the scope of single implant mandibular overdenture by assessing its masticatory efficiency, clinical performance, and patient satisfaction compared to conventional complete dentures. Settings and design: Prospective In Vivo Study. Material and methods: This prospective in vivo study was conducted in the Department of Prosthodontics and Crown and Bridge, Christian Dental College, Ludhiana. A total of 12 completely edentulous patients received a single implant in the mandibular anterior midline region. After the healing period, the conventional maxillary and mandibular dentures were fabricated. 15 days post insertion of the conventional dentures, patients were evaluated for masticatory efficiency, clinical performance including retention and stability, and patient satisfaction. To evaluate the masticatory efficiency blue raspberry and original pink "Hubba Bubba tape gum" were used as a test food. Colorimetric analysis was done to assess variance of hue. To assess clinical performance, retention, and stability of the mandibular denture was recorded using a digital force gauge and was tabulated as per CU-modified Kapur's criteria. OHIP-14 index was used to assess patient satisfaction. After evaluation of the parameters of conventional dentures, the denture was converted into an implant-retained mandibular denture by chairside conversion with locator attachments. 15 days post-implant loading, parameters of the implant retained mandibular overdenture were assessed again followed by statistical analysis. Statistical analysis used: The masticatory efficiency was assessed using a paired t-test. The patient satisfaction was sequentially assessed with Wilcoxon signed rank test and thereafter paired t-test was used to compare between conventional complete denture and overdenture. Clinical performance was assessed using the Wilcoxon signed rank test. Results: The masticatory efficiency of single implant mandibular overdenture was higher than that of conventional complete dentures. The clinical performance of the overdenture was higher than that of the conventional denture. Stability being a time-dependent parameter might need longer follow-ups for further conclusions. Patient satisfaction with single implant retained overdenture was significantly higher than conventional complete dentures. Conclusion: Single implant mandibular overdenture has improved masticatory efficiency, clinical performance, and patient satisfaction compared to conventional complete dentures.
... Nogueira et al. conducted a comprehensive evaluation and reported that single implant-retained overdentures improved patient satisfaction compared to standard full denture treatment [71]. Several studies demonstrated that single implant-retained overdentures outperformed traditional two implant-retained overdentures in terms of implant success and marginal bone loss [72][73][74][75][76][77][78][79]. ...
... Alsaheb et al. reported a 100% survival rate for immediate loading and early loading and a 92.8% survival rate for delayed loading [75]. The success rates reported in the studies varied between 88% and 100%, with the majority of studies reporting success rates above 90% [68][69][70][71][72][73][74][75][76][77][78][79][80][81][82][83][84][85][86][87]. ...
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The absence of teeth, known as edentulism, poses considerable obstacles in prosthodontic care and greatly affects a person's well-being. Conventional complete dentures frequently lead to problems like instability and insufficient retention, especially in the lower jaw. Fortunately, the introduction of dental implants has transformed the way we approach edentulous patients, as they now offer support and enhanced retention for removable prostheses, thus revolutionizing their treatment. While a consensus exists on using two implants for retaining mandibular overdentures, the associated cost may be prohibitive for economically disadvantaged individuals. As a solution, the concept of single implant-retained mandibular overdentures has emerged, catering to individuals with limited financial resources and complete tooth loss. This review explores the efficacy and suitability of the single implant overdenture approach, along with an overview of treatment options for edentulous patients, including traditional dentures, tooth-supported overdentures, and implant-supported overdentures. The preservation of bone, improvements in functional abilities, and psychological benefits associated with overdentures are discussed. Moreover, various classifications and prosthetic options for implant overdentures, specifically for mandibular cases, are presented. This literature review aims to provide a comprehensive understanding of possible treatment options and focus on the single implant-retained mandibular overdenture approach and its implications in prosthodontic rehabilitation for edentulous patients.
... Implant-supported prostheses are useful in overcoming functional, aesthetic, or psychological problems in edentulous individuals [1][2][3][4] . Improvements in mastication efficiency and ability have been reported in studies comparing implant-supported dentures and conventional removable complete dentures [5][6][7][8] . Overdentures supported by 1 to 6 implants have become a common and effective treatment 9,10) . ...
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This study aimed to apply finite element analysis (FEA) to simulate the oral environment of a patient with an implant-supported overdenture prosthesis. A 3D mandibular model was created for a 45-year-old female patient from CT images, with mucosal thickness measured at 3 mm on average using ultrasonography. The overdenture prosthesis was scanned with an intraoral scanner and placed onto the 3D mandibular model. Displacement of the prosthesis and von Mises stress values of the implant, surrounding bone tissue, implant-prosthesis components, and mucosa were calculated under various masticatory loads. The study found that anterior mastication generated higher stress compared to unilateral and bilateral mastication. The addition of a third implant significantly reduced stress and improved prosthesis stability, particularly during bilateral mastication.
... 14,17,18 The advantage of implant-retained mandibular complete dentures over conventional mucosa-retained complete dentures in terms of support, masticatory efficiency, and quality of life has already been demonstrated in previous studies. [19][20][21][22][23][24] In our study, both the placement of complete dentures on single implants and mini-implants were found to have a positive effect on the OHRQoL of the study participants. ...
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Objectives The study compares three minimally invasive approaches for the retention of implant supported mandibular complete dentures, particularly focusing on patient satisfaction. Background The McGill Consensus Statement recommends restoration of the edentulous mandible with an overdenture retained on two implants. Alternatively, less invasive treatment concepts with shorter treatment times have been developed for critical cases. Material and Methods Thirty‐nine patients (with a total of 78 implants) with advanced mandibular bone atrophy were randomly assigned to three groups: “single standard implant‐retained overdentures” (SSO) and “mini‐implant‐retained overdentures” (MO), which was further subdivided into “two mini‐implant‐retained overdentures” (TMO) and “four mini‐implant‐retained overdentures” (FMO). The technical and biological parameters and oral health‐related quality of life were evaluated over a 10‐year period. Data were analysed for group comparisons and longitudinal trend analysis. Results Sixteen patients (42%) dropped out during the study period. At the time of follow‐up, 98.4% of the implants were in situ. The first need for technical intervention occurred after 3.8 ± 1.1, 4.2 ± 0.9, and 4.6 ± 1.3 years in the TMO, SSO, and FMO groups, respectively. Attachment exchange (39%) was the most frequently performed intervention in all groups. Healthy peri‐implant and mucosal conditions were observed in 74% and 40% of patients after 1 and 10 years, respectively. The OHIP‐G14 score was 22.6 before implantation, 7.6 at 1 year (effect size [ES]: 1.1), and 5.4 at 10 years (ES: 2.3). Conclusion Irrespective of the minimal concept selected, complete mandibular dentures retained on implants improved the subjective perception of the quality of life. Application of these alternative minimal concepts may be practical in clinical practice.
... However, patients often encounter challenges associated with these removable prostheses, including diminished stability and compromised chewing function in comparison to natural teeth or fixed prosthetics. 2 Implant-supported restorations demonstrated efficacy and reliability as a viable solution for the rehabilitation of patients with edentulous mandibles. These restorations can be in the form of removable prostheses, fixed prostheses, or fixed-detachable prostheses with processed acrylic teeth, known as 'hybrid prostheses'. ...
... Last but not least, the patient-reported outcome measures analyzed in the present study also show a significant positive impact of c-SIMOs, with improvements in all tested domains, already present from the first post-insertion visit and persisting throughout the entire follow-up, with almostperfect scores in all tests at 1 year. The majority of studies on midline SIMOs have also shown marked improvements both in OHRQoL and patient satisfaction [7,8,17,18,20,52,53]. However, there is limited information on PROMs with SIMOs even at medium-term follow-up [16,20]. ...
Article
Full-text available
Objectives The aim of this multi-center pilot study was to assess the viability and feasibility of a novel treatment concept – the canine-positioned single implant mandibular overdenture (c-SIMO), with the single implant placed on the patient's preferred chewing side instead of the midline. Materials and methods Participants received a single implant in the canine region of their preferred chewing side, based on an Asymmetry Index observed during mastication. The pre-existing mandibular denture was transformed into a c-SIMO on a spherical attachment. The primary outcome was oral health-related quality of life (OHRQoL), measured with GOHAI and OHIP-EDENT. Secondary outcomes included denture satisfaction index (DSI), chewing efficiency (CE), maximum bite force (MBF), implant survival and success, and prosthetic maintenance. Data analysis included descriptive statistics and bivariate comparison tests. Results Fifteen participants received the c-SIMO treatment (mean age: 69.9 ± 7.0). Implant success and survival rates were 100% at 1 year. Patient-reported outcome measures improved significantly compared to pre-treatment values (OHIP-EDENT: p = 0.001; DSI: p = 0.001; GOHAI: p = 0.002). Masticatory outcomes also improved significantly (CE: p = 0.001; overall MBF: p = 0.005). Post-implant, MBF was significantly higher in the ipsilateral side compared to the contralateral side at 2 weeks (p = 0.019) and 3 months (p = 0.015), but no longer at T3 (p = 0.730). Common prosthodontic events included denture base adjustments (n = 17) and matrix activation (n = 9). Conclusions This pilot study concludes that c-SIMO is a promising treatment option, and a potential alternative to the single midline implant overdenture. Clinical relevance The novel treatment concept of a canine-positioned single implant mandibular overdenture could be a viable treatment alternative to the midline positioning.
... Overdentures that are implant-assisted or implant-retained are suggested choices for improving retention, stability, and improving edentulous patients functionally and socially (7). Dental implants have substantially improved patient satisfaction, masticatory function, the health of residual supporting structures, and general quality of life for edentulous patients (8). ...
... SIMOs enhance patient reported consequences compared to CDs respecting satisfaction, measures of the quality of life regardless to variance in protocols of the implant treatment and the retention systems. Even though attainable evidence proclaimed remarkable enhancement in reported outcomes of patients following SIMOs insertion, further comparative studies between SIMOs and complete dentures are inevitably requisite to advocate SIMOs in routine practice (12). ...
Article
BACKGROUND: Edentulous mandible rehabilitation via single implant mandibular overdenture (SIMO) became mundane as a facile therapy averred promising results. SIMO was reported to prone to fracture thus, represented a concern for the clinicians. OBJECTIVES: This study targeted at assessing satisfaction of the patient and Oral Health-Related Quality of Life OHRQoL referring to (SIMO) reinforced by metal or PEEK frameworks in comparison to conventional complete denture CD. MATERIALS AND METHODS: Eighteen complete dentures were delivered for the eligible participants (group I). Three months later, they were evaluated for satisfaction of patient and OHRQoL. Patient satisfaction was performed employing the visual analog scale (VAS). Assessment of OHRQoL by oral health impact profile (OHIP-14) was accomplished. Through pursuing the delayed loading protocol, in the midline region of the mandible, single implant was inserted. Each patient received two overdentures utilizing a crossover design; metal reinforced (Group II) and PEEK reinforced overdentures (Group III). Patient Satisfaction and OHRQoL for groups (II and III) were carried out following three months of using each overdenture. Questions of VAS and OHIP-14 were evaluated for both overdentures. RESULTS: SIMOs revealed statistically significant improvement compared to traditional dentures. Non-significant difference between SIMOs reinforced with metal or PEEK was demonstrated except for denture stability and retention in favor of PEEK reinforced SIMOs. CONCLUSION: SIMOs ameliorated patient satisfaction together with OHRQoL when compared with CDs no matter the involved reinforcement material was. SIMOs reinforced with PEEK are deemed advantageous over the metal ones in terms of denture stability and retention.
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Full-text available
SUMMARY Based on available investigations and current trends in oral rehabilitation published in the dental literature, an attempt is made to describe the possible future role of complete dentures. For edentulous patients, complete dentures have for long been the only prosthodontic treatment option. Whereas a large number of edentulous patients report satisfaction with denture usage, a smaller number are unable to adapt; for such patients, sophistication of clinical and technical processes or quality of denture-supporting tissues, appear to have little influence on patient-perceived outcomes. Since the 1980s, osseointegrated dental implants have dramatically improved the therapeutic possibilities, especially so for maladaptive patients. Those able to access such treatment can expect significant improvements in oral functional status and quality of life. While there is a downward trend in edentulism in several countries, it is region-specific, confirming the overriding influence of socio-economic factors on health status. In most societies, despite ageing populations, the need for complete dentures is not likely to reduce in the near future. Whereas a two- or even a one-implant overdenture for the edentulous mandible is increasingly regarded as a minimum standard of care in many developed countries, its routine prescription for the majority in the world who are disadvantaged is unrealistic; for them, even ‘low-tech’ therapies like conventional dentures are beyond their reach. Improving the conventional management of edentulous patients is a necessity and requires a keener focus by researchers, educators and clinicians in the developed world on the needs of populations with fewer resources. KEYWORDS: decision-making, dental implants, edentulism, epidemiology, implant overdentures, prevalence, quality of life, treatment choice Accepted for publication 14 November 2009
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