A RETROSPECTIVE REVIEW OF DENTAL IMPLANT SUPPORTED PROSTHESES RESTORED IN A PROSTHODONTIC RESIDENCY PROGRAM IN THE UNITED STATES OF AMERICA

By Kavitha P. Das, B.D.S., M.P.H., M.S. Edited by James M. Soberman, M.S., D.D.S., F.A.G.D, F.A.C.D

January 2011 SAHITYA BHAWAN PUBLISHERS & DISTRIBUTORS (P) LTD.

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Contents

Abstract.. Introduction Background Purpose... Materials and Methods... Results. Discussion.. Conclusion.. Appendix. References..

Acknowledgements I would like to thank the faculty, staff and colleagues who assisted in the completion of the project

Abstract

Introduction This report describes the outcomes of a retrospective chart review on dental implant supported prostheses restored in the Department of Prosthodontics at Columbia University College of Dental Medicine. The purpose of this review is to evaluate the success rate of implants restored in a prosthodontic residency program in a university setting, and assess post insertion visits and complications with respect to the restored implants. Socio economic data, relevant medical and dental information was collected and reviewed. For this retrospective study, the prostheses were categorized as single implant crowns, implant supported fixed partial dentures, complete fixed implant supported prostheses and complete removable implant supported prostheses.

This report is phase I of a two phase study. Phase I includes a comprehensive chart review.

Materials and Methods All charts of patients treated in the Department of Prosthodontics from the year 2001 to 2006 were included in this study. A total of 101 charts were reviewed and 68 charts were narrowed down for the purpose of

this study. Charts that did not have information on the patients treatment plan were excluded from the 101 charts reviewed.

Results A total of three hundred and sixty implants were restored with an implant success rate of 97.5%. More women were treated in the Department of Prosthodontics when compared to men. The mean age of the patient was 61 years. The most frequently restored dental implant was Biomet3I Osseotite, with implant single crowns forming the largest group of prostheses restored. Hispanics and Whites formed the most frequently treated groups of patients in this department, followed by Asians; and self pay and Medicaid were the largest payment methods. Periodontal problems followed by crowns on natural teeth were the most frequent dental history recounted; hypertension followed by penicillin allergy were the most frequently encountered medical complications; calcium supplements and multivitamins were the medications listed most regularly; forty six percent stated that comprehensive care and 30% stated the need for implant retained restoration as their chief complaint. Panoramic radiographs were the most requested radiographs. The average duration of treatment was 1.9 years and implant failure was the most commonly seen implant related complication.

Limitations of the study The major drawback of this study is the small sample size (68). A larger sample would more accurately reveal the breakdown of various treatment options provided to the patients.

Introduction Osseointegrated dental implants have changed the approach to dental treatment. The number of dental implants placed in the United States has increased, and it is estimated that the field of implant dentistry will continue to grow by approximately 12% annually.1 The American Dental Association has reported the average survival rates of multiple implant designs placed in various clinical situations as more than 90%.2 It has been estimated that more than 90% of surgical specialty dentists place implants, 90% of prosthodontists restore implants, and 78% of general dentists have used implants to support fixed and removable prosthesis compared to 65% fifteen years ago. 3 The increased acceptance of dental implant treatment is attributable to several factors, including patients expectations and acceptance, endorsement by dentists and increased predictability of implant-supported restorations.4,5

Background 7

In 1951, in Lund, Sweden, Dr. Branemark, an orthopedic surgeon discovered that it was extremely difficult to recover bone-anchored titanium chambers that were embedded in bone as a part of a vital microscopic animal and human study. The titanium had seemingly bonded to living bone tissue. Dr. Branemark successfully demonstrated that under carefully controlled conditions titanium could be structurally integrated into living bone with a very high degree of predictability and, without long-term soft tissue inflammation or ultimate fixture rejection. Dr. Branemark named the phenomenon osseointegration. The first practical application of osseointegration was the implantation of new titanium roots in an edentulous patient in 1965. The discovery of use of titanium as the material of choice for implantation was also a chance discovery. Dr. Emneus an orthopedic surgeon who was studying various metals for hip-joint replacement introduced it to Dr. Branemark.
6

More than forty years later, the field of dental implants has grown exponentially.7, 8 The vast majority of dental implants can be simply defined as a titanium screw that is placed within the jawbone allowing a crown, fixed partial denture or complete denture to be attached to it. Early implants used in the mid-twentieth century came in a variety of shapes. These varied from implant frameworks that rested in direct contact with the bone beneath the soft tissues, to blade shaped implants that were placed within the alveolar bone. Most implants are 8

commonly cylindrically shaped, and are usually placed into a preprepared site within the maxillary or mandibular bone.9 Purpose Given the current trend in increased implant utilization by specialists and general dentists, it is imperative that dental school curriculum in the United States includes comprehensive training in implant dentistry. A few studies have been published on the training provided in dental school settings. These studies have reported that the implant survival of dental implants placed in a university setting is comparable to implants placed by experienced clinicians
1,10

and that the implant

success rate does not vary depending on the implant system used. According to a study on pre doctoral implant dentistry training in the United States published by Lim et al in 2008 11, 84 % of the schools reported that implant dentistry is part of the curriculum, and 75% of the schools reported that the training provided was for an average of 5.5 months. Research has been carried out on the success or failure of different implant supported prostheses, however, this has not been evaluated in university settings in prosthodontic residency programs. Research needs to be carried out on implant prostheses design and related factors in a prosthodontic residency setting.

The purpose of this report is to present the outcomes of phase I of a retrospective study on dental implants restored in a prosthodontic residency in a university setting in the United States. The first phase comprised of a chart review of patients who had dental implants restored at the Department of Prosthodontics at Columbia University College of Dental Medicine.

Materials and Methods

The study population consisted of patients treated at the Department of Prosthodontics at Columbia University College of Dental Medicine from the year 2001 to 2006.

Phase I: A chart review: The chart review included a comprehensive overview of the study subjects background, medical history, dental history, insurance type and implant prostheses related information. Information on nineteen variables was collected. Patients registered in the Department of Prosthodontics were identified using billing codes used to delineate various procedures for prosthetic treatment. From this master list, charts retained in the chart room 10

were identified and selected based on their availability in the chart room. Nineteen variables were identified as relevant to the study and the data was entered into an excel spreadsheet. Appendix 1 - list of variables collected from the chart review.

Phase II: Clinical and radiographic evaluation of the implant supported prostheses: The clinical evaluator measuring clinical parameters will fill out a questionnaire and will assess different clinical parameters on prostheses and implant supported prostheses success/failure will complete the questionnaire. This questionnaire will address specific clinical variables related to the prosthesis and will include radiographic evaluation of the prostheses as well as complications associated with the prostheses. Appendix 2 -lists details on the clinical variables to be included in the study. A self-administered questionnaire on OHRQOL to be filled out by the study subject: The use of a validated instrument strengthens a study .The OHRQOL will be measured using the validated instrument, the Oral Health Impact Profile (OHIP). The OHIP was developed with the aim of

11

providing a comprehensive measure of self-reported dysfunction, discomfort and disability attributed to oral conditions. These impacts were intended to complement traditional oral indicators of clinical disease.
12

The questionnaire will also collect data on each study

members occupation, education, income and related sociodemographic information. This questionnaire will be administered to the patient. Appendix 3- OHIP-14.

This report will enumerate the results of phase I- the chart review.

Results

A total of 101 charts were reviewed and 68 charts were narrowed down for the purpose of this study. Charts that did not include treatment plan details were excluded from the study.

Socio Demographic Variables: Sex: The results of this study revealed that more women were treated in the Department of Prosthodontics. Sixty two percent were women and 38% were men.

12

Sex distribution

Race: Information with respect to race was not available in all charts. Based on availability, it was found that Hispanics and Whites comprised most of the treated patients, followed by Asians and African Americans.

Race distribution

13

Age distribution:

Age distribution

Most of the patients treated were between the age group of 62 to 69 years. Interestingly, the third largest age group was above the age of 80. The patients age was between 22 and 87 years with a mean age of 61. The mode was 67 years.

Health Insurance Type: Most of the patients paid out of pocket for their treatment, followed by Medicaid. Medicare, MetLife, NYS Empire Plan and Careington Care followed this.

14

Insurance type

History: Medical History: The most frequently occurring medical disorder was hypertension, followed by penicillin allergy. Most patients said that they had no significant medical history (n=24). Interestingly, only 3 of the 68 charts reviewed had data on smoking history. None of the patients claimed to be current smokers. One patient was listed as current pipe smoker.

15

Medical History

Dental History: Periodontal problems, crowns, root canal treated teeth, restorations (both composite and amalgam) and dental implants were most commonly cited as past dental treatment procedures. Partial edentulism was the second highest past dental treatment, preceded by periodontal problems. Only 5% of the patients reported having a history of decay whereas 15% of the patients reported having periodontal problems.

16

Dental history

Chief Complaint: Majority of the patients stated that comprehensive care was their chief reason for wanting dental treatment (46%) and the second highest chief complaint was the patients perceived need for an implantretained restoration (30%). Only 7% reported aesthetics as a chief complaint. Nine percent wanted crowns on natural teeth.

Chief complaint

17

Medications: Calcium supplements and multivitamins were the most commonly listed medications followed by Synthyroid and Hydrochlorothiazide.

Medications

Radiographs: Panoramic radiographs, periapical radiographs and full mouth series were frequently requested. Only 6% of the patients had a CT scan taken.

18

Radiographs requested

Treatment plan for implant supported prostheses:

Treatment Plan

For the purpose of this study, implant supported prostheses were divided into four categories: 1. Implant single crown 2. Implant fixed partial denture 19

3. Completely edentulous removable prostheses 4. Completely edentulous fixed prostheses A vast majority of the restorations provided in the clinic were implant single crowns (88%). This was followed by implant fixed partial dentures and completely fixed partial dentures (9%). Removable full arch implant supported prostheses comprised less than 3% of the restorations.

Implant systems: Three hundred and sixty implants were restored. The most frequently used implant system was the Biomet3I Osseotite followed by Branemark system MkIII and Biomet3I Osseotite Certain.

Frequency of Implant Systems Utilized

Ninety-six Biomet3I Osseotite external connection implants were placed. This was followed by Branemark system MkIII and Biomet 20

Certain internal connection. Sixty-eight Replace Select (internal

Type of Implant Straumann Biomet3I Certain Biomet3I Osseotite Branemark MkII Brannemark MkIII Branemark MkIV Nobel Biocare Replace Select

Number 6 82 96 9 90 9 68

connection) implants were placed and restored.

Implant length: The most frequently restored implant length was 11.5mm followed by 13mm and 10mm. The shortest implants placed were 8.5mm.

21

Implant length

Duration of treatment:

Total time taken from start of prostheses to delivery. The yaxis represents the number of patients.

22

Time taken from start of prostheses to delivery was computed for all the patients. Twenty one percent of the total prostheses were delivered in 400 to 500 days, 13% in fewer than 100 days and 9% in 200 to 300 days. For the purpose of this study the prostheses start date was the date that the final impression was taken. On an average it took one year and nine months to complete the prostheses.

Complications:

The most frequently occurring complication was implant failure, which amounted to 41% of all complications. Exposed implant threads was

23

the second complication at 36%, followed by food impaction or problems due to proximal contacts.

Follow up visits: One follow up visit post insertion was the most common, followed by two visits.

Follow up visits

Data on follow up visits were not available. The vast majority of patients did not return for follow up visits. Follow up visits were more likely to be documented in cases that had complications. Discussion

This report enumerates the results of a retrospective chart review on existing patient charts available in the College of Dental Medicine at Columbia University, New York. The Phase I of this study focused on gathering data on the patients background, history, chief complaint, type of prostheses, implant type and duration of treatment. 24

Awareness of dental implant treatment modalities has increased, and thus implant treatments are more commonly accepted .For the majority of the population, the clinical success of dental implant therapy has improved such that it has been recognized as standard of care for certain prostheses types.13 Due to advancement of technology and the current ease of accessibility to information, the general public is able to research, visualize, and understand the advantages of dental implant treatment. Improved chewing force and overall improved functionality of implant-supported prostheses had been reported by Berg,14 Carlson et al15 and Lindquist.16 Ease of accessibility to information, more effective techniques and methodologies that reflect a higher success rate is also the reason for increased acceptance of dental implant supported prostheses. However, careful patient selection is needed to ensure successful outcome. The patient needs to have an accurate assessment of the procedures, the length of treatment time, risks and alternatives to implant treatment. The trends in various new designs and methods are fast paced and patients need to be informed of various options available to them.

Prostheses type: It must be noted that majority of the implants restored in the Department of Prosthodontics were single crown 25

implants. This chart review also revealed that 88 porcelain fused to metal crowns were placed in the same population. This is a lot less than the total number of implant supported single crowns, which comprised 88% of all the implant, supported prostheses restored. Lindh and Gunne, found in their meta analysis that implant survival was slightly better for single crowns when compared with fixed implant supported prostheses.17 However, Weber and Sukotjo did not find higher success with implant single crowns when compared to fixed splinted prostheses in a study published in 2007.18

Implant success: A total of three hundred and sixty implants were restored with an implant success rate of 97.5%. According to Carl Misch, the term early implant success is suggested for a span of 1 to 3 years, intermediate implant success for 3 to 7 years, and long-term success for more than 7 years. The implant success rate should also include the associated prosthetic success or survival rate. Since this study reviewed charts from 2001 to 2005, success can be categorized as intermediate success of the implant.19 Information on the prostheses type will be collected in the second phase of the study to determine the success and survival rate of an implant supported prostheses. The type of abutment, the form of retention (cement or screw retained) and the type of restorative material used will also be evaluated for determining overall prosthetic success. 26

Implant type: The results on implant success rate obtained in this study are comparable with data published on implant success in experienced clinicians and residents in other surgical and general residency programs. In a retrospective study published in 2004, on implant success in a general dentistry residency program, authors Mohamed Maksoud and Clifford Starr state that the implant success rate was 98.2% after a follow up of 6 months to 4 years.Error! Bookmark not
defined.

The study population was 57% women and 43% men. The implant

system evaluated in this study were SteriOss (NobelBiocare, Branemark Novum ,Taperer-Lock (Zimmer Dental), and ITI (Straumann). The success rate of implants placed in private practice has been documented. In a study, which analyzed the success of 1003, implants placed in 376 patients, the authors Lemmerman et al, state that the success rate was approximately 95%.
20

Bahat

demonstrated similar implant success rate in private practice in another study where 660 Branemark implants were followed for 5 to 12 years.21 The success rate in the Bahat study was 93.4%. In the current retrospective chart review, 62% were women and 38% were men. The implant systems restored here were Straumann, Biomet 3I Certain, Biomet3I Osseotite, Branemark MkII, Branemark MkIII and Branemark MkIV.

27

Implant length: The most frequently used length for dental implants restored in the department were 11.5mm followed by 13mm and 10mm. This in accordance with literature published by Jemt and Lekholm,
22

Naert et al;

23

Weng et al and Herrmann et al,

24

which has

favored the placement of longer implants to increase implant survival rate. Babbush and Shimura study also demonstrated that longer dental implants had a higher success rate.25 However, various authors have reported good survival rates with shorter implants. Van Steenberghe et al,
26

Friberg et al,

27

Jemt,

28

and Lekholm et al

29

have

demonstrated that adequate survival of implants can be obtained with the use of short implants. Some authors believe that the use of implants over 12mm have higher chance of failure due to operator factors such as longer drilling time, lesser ability of coolant to penetrate the osteotomy, or inadvertent, increased drilling force to get a deeper osteotomy. et al
32 xvii

Buser et al,
33

30

Ellegaard et al,

31

Stellingsma

and Feldman et al,

reported that implant length did not appear

to significantly influence the implant survival rate . In this retrospective chart review, 33% of the implants were 13mm long and 37% were 10mm long. The shortest implant restored in the Department of Prosthodontics was 8.5mm long. This accounted for 3% of all the implants restored. Seventy of the 360-implant sites had bone augmentation.

28

Implant abutment interface: According to a literature review published in 2008, author Theoharidou states that most invitro studies except one, have demonstrated that internal connection implants are more mechanically stable than external connection when restoring single implant crowns.34 Peirmatti et al, in their invitro study have shown that external connection has better mechanical stability than internal connection. Some authors prefer the use of internal connection implants for sites where higher torque values are needed.35 However, research conducted in the US market reveals that external connection implants are still more frequently used than internal connection implants despite an increase in the sales of internal connection implants in recent years.
35

Data collected from this retrospective study

shows that both internal and external connection implants were restored. Fifty seven percent of the implants were external connection and 43% were internal connection implants.

Radiographs: The most frequently requested radiographs were the panoramic radiograph (32%) followed by full mouth series radiographs (31%) and periapical radiographs (30%). Only 6 percent of the patients had CT scans requested. One patient had a CT scan requested for Nobel guide surgery.

29

Complications: Implant failure requiring removal of the fixture was the most frequently seen complication and amounted for 41% of all complication. Among the failed implants, 33% of the failed implant sites had bone augmentation (Bioss). Implant failure was seen more frequently in men (7) than in women (2). One patient with implant failure was a pipe smoker. Thread exposure of more than two to three threads due to bone resorption was the second most frequently seen complication (36%). The other complications reported were stripping of the screw, food impaction and incorrect placement of the implant.

Duration of treatment: For the purpose of this study the prostheses start date was the date that the final impression was taken. On an average it took one year and 9 months to complete the prostheses. There is a paucity of literature available on the average time taken to deliver prostheses in a Prosthodontic residency setting, so comparison with another program is not possible. Factors that could account for the length of procedure could be: 1) Treatment provided by residents in a residency program 2) Treatment is provided in a university setting requiring authorization of procedures, and 3) Lack or delayed availability of prosthetic implant parts and materials

Health Insurance: The dental school at Columbia University accepts 30

Medicaid and self-payment for treatments rendered, which is reflected in the insurance plan distribution among the patients. Forty four percent of the patients were self-pay and Medicaid covered 31%. Despite the coverage extended for conversion of complete dentures to implant supported removable prostheses, the percentage of overdentures (2%) was lower than the percentage of fixed full arch prostheses delivered (3%).

Age: It is estimated that New York City will see substantial increases in its elderly population. The number of persons ages 65 and over is projected to rise 44.2 percent, from 938,000 in 2000 to 1.35 million in 2030. The average age of the patient treated in the Prosthodontic department reflects this trend. The highest age group treated in the department was between the ages of 60 to 70 years and the third highest group was above the age of 80 years. To achieve predictable esthetic and functional outcomes of implant treatment for geriatric patients, comprehensive diagnosis and treatment planning is required. The patients medical and dental history for bruxism, periodontal disease, tobacco use, uncontrolled diabetes mellitus and metabolic diseases of bone need to be assessed and evaluated before implants treatment.36

31

Medical History: In this study, the patients medical history listed hypertension, arthritis and diabetes type 2 as some of the most common medical disorders. Fiorellini et al and Klokkevold have stated that patients with Type 2 Diabetes are at higher risk for failure of implants,37 particularly older patients.

Smoking history: This chart review also revealed that smoking habits of patients in both adult and geriatric patient was not routinely documented. According to a dental literature review conducted by Perry Klokkevold in 2007 using Medline, Cochrane Collaboration and Embase databases, the author concluded that smoking adversely affects the outcome of implant survival and success rate.38 SanchezPerz et al and PK Moy et al, have reported elevated complications related to smoking after controlling for age and other medical conditions;39,40 it is thus, important to assess smoking history in the elderly. The data from this study revealed no current cigarette smokers and one pipe smoker.

Race: The breakdown of various groups according to race in the retrospective study is in accordance with data on the race distribution in New York City. According to projections from the U.S. Census Bureau, the New York City has the largest Asian (Chinese) population 32

of any city outside of Asia and the largest Puerto Rican population anywhere in the world. The largest Dominican population outside of Santo Domingo resides in New York City.
41

Forty three percent of the

citys population is White. The largest groups of people treated in the department belong to the Hispanic (31%), White (31%) or Asian (25%) background. African Americans comprised 13% of this population. Although variations in implant success in different ethnicities has not been observed, there are very few studies reporting on race and implant success. One study, a retrospective multicenter cohort study on two stage implants published in 2006, carried out in the South Korean population states that there is no significant difference in implant success rate in the Korean population and other published data on implant success.42 Utilization of health services: Utilization of health services varies by gender and age. Some studies report that females are more likely to seek care than males.43,
44

However, other studies state that there is no

variation in health seeking behavior in males and females.45 Some published studies have stated that older men are more likely to seek care. 46Mustard et al, state that expenditure for health is the same for men and women.
47

The data gathered from this chart review shows

that women are more likely to seek dental treatment than men. The average age for women was 59 years and the average age for men was 65 years. 33

Missing data and lack of documentation: A large number of charts reviewed had missing data or did not systematically document dental services rendered. Data on socio economic variables, smoking behavior and race were not consistently documented. However, data on implant type was included in all the 68 charts reviewed. This could be due to the use of stickers provided by the manufacturer. Using standardized forms to document prosthetic and surgical procedures might aid the documentation process.

Conclusions

A hundred and one charts were reviewed and 68 charts were included in this study. The following are the outcomes of the chart review: 1. The implant success rate is comparable to the general population and other general and surgical residency programs. 2. Implant single crowns were the most frequently restored prostheses. 3. External connection implants with length 10mm and above were the most frequently utilized implant. 4. Branemark implant system was the most frequently used implant.

34

5. The average time for completion of a prostheses was 1 year and nine months. The results of this study will be strengthened by increasing the sample size and by evaluating the implant-supported prostheses by clinical and radiographic examinations.

Appendix 1 CHART REVIEW SHEET SES INFORMATION Sex Dob Race Medical history Medications Insurance type Chief complaint Dental history Radiographs Treatment plan IMPLANTS RELATED INFORMATION Date implants placed Type of implants placed Bone augmentation Other relavent information wrt implants Complications PROSTHESES Start date of prosthetic treatment Date delivered Number of post insertion visits Complications associated with the prostheses Other

35

Appendix 2 Clinical Evaluation Questionnaire Study number: 1) Is prosthesis mobility present? Yes No No

2) Is there mobility of implants? Yes

3) Is there any sign of localized infection around the implants or implant prosthesis? a. Gingival irritation: Severe Minor b. Suppuration present: Yes Moderate No

4) Is bone loss noted around the implants? Greater than 50% - Yes No 5) Oral hygiene status around implant prosthesis- Good Fair Poor 6) Is the patient satisfied with prosthesis mastication? Very satisfied Generally satisfied Dissatisfied 36

7) Is patient satisfied with esthetic outcome? Very satisfied Generally satisfied Dissatisfied 8) Is patient satisfied with phonetic outcome? Very satisfied Generally satisfied Dissatisfied 9) Were you satisfied with the time limit of treatment? Yes No 10)Are there any soft tissue complications around implants or prosthesis? Yes No 11)List prosthetic complications associated with the prostheses

Appendix 3 Oral Health Impact Profile Questionnaire Study number: Sex: Age: Occupation: Race: Insurance type: Education: Income:

Functional Limitations 1. Have you had trouble pronouncing any words because of problems with your teeth, mouth, or dentures? (0.51) 2. Have you felt that your sense of taste has worsened because of problems with your teeth, mouth, or dentures? (0.49) Physical Pain 3. Have you had painful aching in your mouth? (0.34) 37

4. Have you found it uncomfortable to eat any foods because of problems with your teeth, mouth, or dentures? (0.66)

Psychological Discomfort 5. Have you been self conscious because of your teeth, mouth, or dentures? (0.45)

6. Have you felt tense because of problems with your teeth, mouth, or dentures? (0.55)

Physical Disability 7. Has your diet been unsatisfactory because of problems with your teeth, mouth, or dentures? (0.52)

8. Have you had to interrupt meals because of problems with your teeth, mouth, or dentures? (0.48)

Psychological Disability 9. Have you found it difficult to relax because of problems with your teeth, mouth, or dentures? (0.60)

10. Have you been a bit embarrassed because of problems with your teeth, mouth, or dentures? (0.40)

Social Disability 11. Have you been a bit irritable with other people because of problems with your teeth, mouth, or dentures? (0.62)

38

12. Have you had difficulty doing your usual jobs because of problems with your teeth, mouth, or dentures? (0.38)

Handicap 13. Have you felt that life in general was less satisfying because of problems with your teeth, mouth, or dentures? (0.59) 14. Have you been totally unable to function because of problems with your teeth, mouth, or dentures? (0.41)

References

39

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3

Carl Misch, Dental Implant prosthetics, 2005

4 Muller F, Wahl G, Fuhr K: Age-related satisfaction with complete dentures, desire for improvement and attitude to implant treatment. Gerodontology 11:7, 1994 5 Maico D. Melo, DMD, Grant McGann, DDS and George Obeid, DDS: Survey of Implant Training in Oral and Maxillofacial Surgery Residency Programs in the United States 2007 American Association of Oral and Maxillofacial Surgeons,J Oral Maxillofac Surg 65:2554-2558, 2007
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D, Azran G. Retrospective clinical review of dental implants placed in a university training program, Journal of Oral Implantology, vol xxx, no. 1, 2004 Lim MVC, Afsharzand Z, Rashedi B et al. Pre doctoral implant education in US dental schools. Journal of Prosthodontics 2005, Vol14, Issue 1, 4656
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12 Measuring oral health and quality of life: Published by: Department of Dental Ecology, School of Dentistry, University of North Carolina. September, 1997. Edited by Gary D. Slade Fiene JS, Carlsson GE, Awad MA, et al. The McGill consensus statement on overdentures. Mandibular two implant overdentures as the first choice standard of care for the edeuntulous mandible. Gerodontology. 2002 Jul;19(1):3-4.
13

14 Berg E. The influence of some anamnestic, demographic, and clinical variables on patient acceptance of new complete dentures. Acta Odontologica Scandinavica 1984; Vol 42, Issue 2,11927. 15 Carlsson GE, Otterland A, Wennstrom A, Odont D. Patient factors in appreciation of complete dentures. The Journal of Prosthetic Dentistry

1967;17:3228. 16 Lindquist LW, Carlsson GE, Hedegard B, Lundquist LW. Changes in bite force and chewing efficiency after denture treatment in edentulous patients with denture adaptation difficulties. Journal of Oral Rehabilitation 1986;13:219. Lindh T, Gunne J, Tillberg A, Molin MA. A meta analysis of implants in partial edentulism, Clinijcal Oral implant Res, 1998.9,80-90
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Weber HP , Sukotjo C. Does the type of implant prosthesis affect the outcomes in a partially edentulous patient, International Journal of Oral and Maxillofacial Implants,2007, 22 (Suppl), 140 - 172
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