Implant retention and support for distal

extension partial removable dental

prostheses: Satisfaction outcomes
Thais Marques Simek Vega Gonçalves, MSc,a
Camila Heitor Campos, MSc,b and
Renata Cunha Matheus Rodrigues Garcia, PhDc
Piracicaba Dental School, University of Campinas, Piracicaba, São
Paulo, Brazil
Statement of problem. The rotational movements of the distal extension denture base of partial removable dental prostheses
frequently harm the prosthesis stability, leading to discomfort during function.

Purpose. This study evaluated the use of distal implants to retain and support partial removable dental prostheses and
assessed the outcomes with respect to specific aspects of patient satisfaction.

Material and methods. Twelve participants (mean age, 62.6
7.8 years) received new conventional mandibular partial
removable dental prostheses and complete maxillary dentures. After 2 months of conventional prosthesis use, the participants
completed a questionnaire assessing their satisfaction. Implants were then inserted bilaterally in the mandibular posterior
region and, after 4 months, ball attachments were placed on the implants and on the partial removable dental prosthesis
acrylic resin base. The implants and remaining teeth were followed up with clinical and image examinations. After 2 months,
satisfaction was reevaluated, and the data were analyzed by the paired Student t test and the Bonferroni correction (a¼.05).

Results. Clinical evaluation found stable periodontal conditions around the implants, no intrusions or mobility of teeth, and
no radiographic changes in bone level. Participants reported significant improvements (P<.05) in retention, comfort,
masticatory capacity, and speaking ability after implant placement.

Conclusions. Implant-retained and -supported removable prostheses improve retention and stability, minimize rotational
movements, and significantly increase participant satisfaction. (J Prosthet Dent 2014;-:---)

Clinical Implications
Implant-retained and -supported partial removable dental prostheses
improve prosthesis performance, increase patient satisfaction, and are
less expensive than implant-retained fixed dental prostheses. Patients
may benefit from the additional retention provided by the placement
of a single implant in the mandible’s posterior region.

Although complete edentulism has
decreased,1 the number of partially
edentulous individuals2 has increased,
probably because of the worldwide ag-
ing population and oral-health-related
prevention policies.1,3 According to
Curtis et al,4 73% of partially edentulous
patients present with missing molars
and premolars, and 40% of these are
classified as Kennedy class I.
Several prosthetic treatment options
are available for partial edentulism,
including resin-bonded dental prosthe-
ses, fixed dental prostheses retained by
teeth or implants, and partial re-
movable dental prostheses (PRDPs),
the most commonly used in clinical
practice.5,6 When compared with
tooth-retained fixed dental prostheses,
PRDPs better maintain tooth structure
and oral hygiene, are less expensive,

Supported by grant No. 2010/12251-0 from Fundação de Amparo a Pesquisa do Estado de São Paulo (FAPESP), Brazil.
a
Graduate student, Department of Prosthodontics and Periodontology.
b
Graduate student, Department of Prosthodontics and Periodontology.
c
Professor, Department of Prosthodontics and Periodontology.

Gonçalves et al
2 Volume
and replace a larger number of teeth.5,7
However, distal extension PRDPs
are associated with some challenges,
including the minimization of biome-
chanical factors (due to resilience dif-
ferences between the alveolar mucosa
and abutment teeth) and limited sta-
bility and retention (due to rotational
movement during mastication). In ad-
dition, discomfort caused by food
retention on the residual ridges and the
appearance of the clasps are common
patient complaints. Periodic relines are
also required to maintain the occlusal
contacts and to avoid deleterious forces
that may increase alveolar reabsorption
or damage the abutment teeth.8,9
Partially edentulous patients can
also be successfully treated by osseoin-
tegrated implant therapy.10 However,
implants in the posterior regions are
limited by poor bone quantity and
quality11-13 and difficulties related to
the position of the inferior alveolar
nerve.10,12-14 Thus, the use of short or
small-diameter implants or additional
surgical procedures (such as bone grafts
or nerve transposition) may be indi-
cated.10 Implants shorter than 10 mm
have been associated with early failure
in the osseointegration process,15,16
and some evidence suggests that surgi-
cally increasing vertical ridge height
is not predictable.17 In addition, some
patients decline or cannot afford multi-
ple surgeries, which further limits
the indications for implant-supported
prostheses.15
Clinical reports have described an
increase in the stability of distal exten-
sion PRDPs with the use of a few stra-
tegically placed implants for retention
and support.18-21 This therapy provides
vertical stabilization for the removable
prosthesis and limited rotational
movements.17,18,21-23 Although patient
satisfaction after implant-retained and
-supported PRDPs19,22,24 has been re-
ported, important features of patient
satisfaction25 related to comfort, re-
tention, masticatory capacity, appear-
ance, ease of cleaning, and speech
have not been reported. Thus, the cur-
rent study’s purpose was to evaluate
the outcomes regarding the specific
The Journal of Prosthetic Dentistry
features of patient satisfaction after
the use of conventional PRDPs and
implant-supported and implant-retained
distal extension PRDPs. The null hy-
pothesis was that patient satisfaction
would not be influenced by the use
of implant-supported and implant-
retained PRDPs.
MATERIAL AND METHODS
Twelve participants (mean age, 62.6

7.8 years) were selected from a part-
ner study approved by the local ethics
committee and developed at Piracicaba
Dental School, University of Campinas,
which included participants scheduled
to receive fixed dental prostheses re-
tained by implants in the mandibular
arch. The number of participants was
estimated on the basis of previous re-
ports.5,21 A minimum of 9 participants
was needed to detect a difference (po-
wer of 80% and an error probability of
5%). In view of the withdrawal rate of
25%, the final sample was established
at 12 volunteers.
To be included in the study, partic-
ipants had to be in good general health
and be completely edentulous in the
maxillary arch and partially edentulous
in the mandibular arch, with only ca-
nines and incisors. In addition, they
also had to have residual ridge volume
and thickness compatible with implant
placement (a minimum of 9 mm from
the residual ridge crest to the inferior
alveolar nerve canal) and 5.5 mm
thickness of residual ridge bone. Par-
ticipants with a history or symptoms
of temporomandibular disorders, par-
afunctional habits, or uncontrolled
systemic disease, which could have
prevented the surgical procedures, were
excluded.
During the first screening, the dental
and medical history was reviewed, an
intraoral clinical examination of the
residual ridges was done, and peri-
apical radiographs of the remaining
teeth were made. All participants re-
ceived a professional dental cleaning
and restorations for dental caries if
necessary. Computed tomography (CT)
and panoramic radiographs were made
- Issue -
to evaluate the amount of bone tissue
and confirm the feasibility of dental
implant placement. The individuals
who agreed to participate in this study
read and signed a consent form.
The proposed oral rehabilitation
plan included a conventional mandib-
ular PRDP supported by distal implants
and ball attachments. As participants
in this study presented with low bone
height in the maxilla for implant
placement, the existing maxillary com-
plete denture was scheduled for
replacement.
The maxillary complete denture
and mandibular PRDP were made ac-
cording to a conventional technique.6
A cobalt-chromium alloy (Dentorium;
Labordental) was used to process
mandibular PRDP frameworks. The
design consisted of a lingual major bar
and circumferential or bar clasp re-
tainers, with lingual support located on
the cingula of the mandibular canines.
The prostheses were inserted and ad-
justed to provide a bilateral balanced
occlusal scheme. Further adjustments
were made after 7, 15, and 21 days
according to individual needs. Partici-
pants also received verbal and written
instructions about denture insertion,
removal, cleaning, and maintenance.
A clinical examination was per-
formed and radiographs were made
to evaluate treatment outcomes. The
amount of biofilm and bleeding on
probing were registered for teeth or
implants during the clinical examina-
tion. In addition, tooth and implant
mobility was evaluated by clinical tests
performed manually, and possible teeth
intrusion was analyzed with radio-
graphs. These treatment outcomes and
participant satisfaction were assessed
after 2 months of conventional pros-
thesis wear.
The satisfaction questionnaire con-
sisted of 13 questions related to overall
satisfaction, retention, comfort, ap-
pearance, ease of cleaning, masticatory
capacity, and speaking ability.26 Par-
ticipants received the questionnaire in-
structions and were left unattended to
answer the questions. Responses were
based on a 100-mm visual analog scale
Gonçalves et al
- 2014 3
(VAS),27 with the extremes represented
by “completely unsatisfied” and “com-
pletely satisfied.” The participants
were asked to mark a dot on the scale
to reflect the level of satisfaction.
Higher scores on the questionnaire
corresponded to greater participant
satisfaction.
After the satisfaction evaluations, CT
images were made and the implants
were inserted. A surgical guide was
fabricated and used during the CT scan
and in the surgical procedure to deter-
mine the appropriate position and
1 Occlusal view of implants with healing caps and ball
inclination of the implants. During the
abutment.
surgery, 2 or 3 implants (Titamax;
Neodent) were placed bilaterally in the
premolar and molar region with a con-
ventional 2-stage technique.18,21 After
implant insertion, the participants were
instructed to leave the mandibular
prosthesis out for 1 week to allow mu-
cosal healing. The PRDPs were then
adjusted and relined, if necessary, with
resilient soft lining material (Ufi Gel P;
Voco), replaced at 4-month intervals.
This procedure allowed implant osseoin-
tegration without damage and restored
esthetics and masticatory function.
After a period of osseointegration,
all implants were exposed, and ball 2 Implant-retained and -supported partial removable dental
attachments (O’ring; Neodent) were prosthesis after ball attachment capture.
attached to the most posterior implants
(Fig. 1) (remaining implants were kept in maintenance instructions and subse- 69
7.3 years), and the implants used
place with the abutment healing caps). quent adjustments after 7, 15, and 21 ranged from 3.75 mm to 6.0 mm in
The torque used on ball attachments days. Clinical and radiographic evalua- diameter and from 7.0 mm to 13.0 mm
was 32 Ncm in accordance with the tion of the implants and teeth and in length. After 2 months of implant-
manufacturer’s instructions. Periapical participant satisfaction evaluation were retained and -supported PRDP use,
radiographs using a long cone paral- done after 2 months of implant-retained the periodontal conditions around the
leling technique were made to evaluate and -supported PRDP use. abutment teeth and implants were stable
and confirm the component fit. The Exploratory analysis found that the (Fig. 1), with no bleeding on probing and
distal extension PRDP acrylic resin base distribution of participant satisfaction minimal plaque around the remaining
was then relieved, and the ball abut- data was normal according to the teeth. No visible plaque was detected
ments were captured intraorally to Shapiro-Wilk test. The data were eval- around the ball attachments. During
enable seating of the attachment in the uated with a statistical program (SAS the clinical examination, no mobility
prosthesis intaglio.21 In spite of the Institute Inc) by using the paired Stu- problems were detected in the teeth or
additional retention of the implant at- dent t test, followed by Bonferroni implants. The periapical radiographs
tachments, the clasp retainers of the correction. Statistical significance was showed no visible bone changes in the
canines were maintained, assisting the determined at a¼.05. natural teeth or implants when com-
PRDP retention. Occlusal adjustments paring the bone level between the implant
were again performed to maintain the RESULTS placement and the evaluation 2 months
bilateral balanced occlusion. The acrylic after insertion of the implant-retained
resin bases of the PRDPs were polished The described treatment was per- and -supported PRDP (Fig. 2). No
(Fig. 2), and the dentures were inserted. formed in 8 women (mean age, 59.4 tooth intrusion was observed in the
Participants also received cleaning and
6.2 years) and 4 men (mean age, radiographs.
Gonçalves et al
4 Volume - Issue -

The baseline evaluation of partici- Table I. VAS scores (mean
standard deviation) for satisfaction features
pant satisfaction was not carried out, related to conventional and implant retained and supported PRDP
because 4 participants were not using
Implant retained
their old and poorly fitting PRDPs,
which could give rise to bias due to the Conventional and supported
unstandardized sample. Specific fea- Feature PRDP, mm PRDP, mm P
tures of participant satisfaction with
Overall satisfaction 53.3
9.8 71
8.9 <.0001
the new maxillary and mandibular
dentures before and after implant Retention
insertion as represented by the mean of Maxilla 67.8
15 78.2
11.6 .01
VAS scores are shown in Table I. Paired Mandible 45.3
16.4 72.2
12.4 <.0001
Student t tests after Bonferroni cor- Comfort
rection found a significant increase
Maxilla 70.5
15.8 81.3
8.1 .004
(P<.05) in overall participant satisfac-
Mandible 50.9
13.3 71.6
11.9 <.0001
tion, retention, comfort, and mastica-
tory capacity for both maxillary and Mastication
mandibular prostheses after the use Maxilla 67.3
15.9 78.9
10.8 <.0001
of implant-retained and -supported Mandible 42.6
12.9 69.8
13.9 <.0001
PRDPs. No significant differences were Speaking ability
observed between the treatments with Maxilla 74.1
12.2 78.8
8.1 .0746
respect to the esthetic appearance and
Mandible 58.4
14.8 78.2
9 .0002
ease of cleaning of either the maxillary
Ease of cleaning
or mandibular prostheses. Participant
satisfaction relating to speaking ability Maxilla 84.1
8.9 84.9
6.9 .288
when the maxillary denture was an- Mandible 74.4
17.4 77.5
9.6 .497
alyzed was not significant (P¼.07). Esthetic
Maxilla 78.4
13.3 82.4
8.9 .141
DISCUSSION
Mandible 67.2
12.8 70.1
13.9 .061

With an increase in the average
lifespan in recent decades, people are
expected to keep more teeth into old
age.1,2 The present study rejected the
null hypothesis by finding that a treat-
ment with strategically placed implants
to retain and support distal extension
PRDPs resulted in increased participant
satisfaction.
VAS assessment found significantly
greater participant satisfaction with re-
spect to the retention, comfort, and
masticatory capacity of both the maxil-
lary and mandibular prostheses after
the use of the implant-retained and
-supported PRDP (Table I). Participants
also reported higher VAS scores with
respect to speaking ability for mandib-
ular prostheses after placement of
the implants. These findings are sup-
ported by previous studies19,24 reporting
increased masticatory ability and satis-
faction in individuals with implant-
retained and -supported PRDPs.
The greater satisfaction of the par-
ticipants with their maxillary prostheses
The Journal of Prosthetic Dentistry
Significant difference, P.05 paired t test and Bonferroni correction.
after implant placement was unex-
pected, because the maxillary prosthe-
ses were not replaced during the study.
The improved retention of the implant-
retained and -supported mandibular
PRDP might have provided patients
with greater comfort during mastica-
tion,19,22,23 explaining the increase in
the satisfaction reported by the in-
dividuals assessed in the present study.
Although participant satisfaction
was found to improve in some aspects,
no significant difference was found
between cleaning skills (P¼.59) and
esthetic quality (P¼.08) before and af-
ter the implant placement. This result
may be explained by the fact that both
treatments involved removable pros-
theses, facilitating cleaning, as reported
by the participants. Although necessary
because of the extension of the denture
base and the use of only 1 posterior ball
attachment, the metal clasps on the
mandibular canines might account for
the dissatisfaction of some participants
with esthetics.
Minimal plaque around the re-
maining teeth and a stable periodontal
status without changes in bone levels
or bleeding on probing were observed
for all participants. These findings are
similar to those reported in clinical
trials19,20,24 and case reports15 which
evaluated the same therapy with a
similar number of participants as in the
present study.21,22
Besides the preservation of proprio-
ception, Chikunov et al9 reported other
advantages related to the implant-
retained and -supported PRDP: a
smaller number of implants, lower cost,
fewer time-consuming clinical and lab-
oratory procedures, simplified hygiene
when compared with fixed dental
prostheses, better distribution of the
masticatory loads to the abutment
teeth and implants, preservation of re-
sidual bone around the implants and
Gonçalves et al
- 2014
remaining teeth, better comfort be-
cause of minimal rotational movement,
treatment compliance, and possible
later conversion into a complete
overdenture.
Physiologic factors related to bone
resorption in the mandibular ridge are
of concern while planning implant
therapies. Kordatzis et al14 investigated
bone resorption in the posterior man-
dibular ridge in a 5-year follow-up and
reported mean values of 1.63 mm for
conventional dentures and 0.69 mm for
implant-retained complete dentures.
Bone is preserved around osseointe-
grated implants as a result of the
remodeling stimuli.7 This concept is
important for the posterior man-
dibular area, where bone height is
often reduced.
Implant morphologic parameters,
such as length and diameter, should
be considered in treatment involving
implant-retained and -supported PRDPs.
The present study used 7- to 13-mm-
long implants, lengths similar to those
reported in previous studies.17,21 Ac-
cording to a finite element analysis
study,16 longer and wider implants
provide better tension distribution
across the alveolar bone. However, the
mandibular posterior region has anat-
omic characteristics that restrict the
use of implants longer than 10 mm.12
Additional surgical procedures (such
as bone grafts or mandibular nerve
transposition) might be considered
during the placement of implants.10
However, it has been reported that
surgically increased vertical ridge
height is not predictable.17 Further
studies are needed to verify the clinical
performance of short implants (less
than 10 mm) to retain distal extension
PRDPs without surgical augmentation.
Knowing how implants and natural
teeth react to masticatory loads would
be valuable. Some authors7,21 do not
recommend a rigid union between teeth
and implants, owing to their different
resiliency under occlusal forces, which
may lead to tooth intrusion or jeo-
pardize the osseointegration process.
Consequently, resilient attachments on
implant-retained and -supported PRDPs
Gonçalves et al
are preferred to rigid connections
because they distribute loads more
favorably across the mucosa and the
bone around the implant.23 Resilient
attachments also provide ease of
placement and repair, effective reten-
tion, low maintenance cost, durability,
and limited interocclusal distance.
The limitations of the present study
included the small number of partici-
pants and the short follow-up period.
Based on the significant differences
found before and after the use of
implant-retained and -supported PRDPs,
it seems unlikely that increasing sample
size would change the results. Never-
theless, a paired experimental design
was used, which avoids bias because
each participant acts as his or her
own control. A previous study19 evalu-
ating implant-retained and -supported
PRDPs in an 8-year follow-up also re-
ported a 93.7% success rate for the
implants and 100% success for clinical
performance of the prostheses. How-
ever, longitudinal clinical trials are
needed to confirm the long-term sta-
bility and success of this type of pros-
theses and the consequences of this
therapy on masticatory function.
In spite of these limitations, the
present study confirmed the effective-
ness and viability of an economical
implant-retained and -supported PRDP
option compared with an implant-
supported fixed dental prosthesis.
CONCLUSIONS
An implant-retained and -supported
PRDP is a feasible and straightforward
treatment that improves overall patient
satisfaction with respect to retention,
comfort, and masticatory capacity.
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- Issue -
Corresponding author:
Dr Renata Cunha Matheus Rodrigues Garcia
Avenida Limeira No. 901
Bairro Areião, Piracicaba
SP 13414-903
BRAZIL
E-mail: regarcia@fop.unicamp.br
Acknowledgments
The authors thank Dr Gabriela Mayrink
Gonçalves and Dr Márcio de Moraes, from the
Department of Oral Diagnostics, Piracicaba
Dental School, University of Campinas,
São Paulo, Brazil, for their surgical assistance.
Copyright ª 2014 by the Editorial Council for
The Journal of Prosthetic Dentistry.
Gonçalves et al