The International Journal of Prosthodontics

236
M
any elderly patients exhibit a highly reduced den-
tition with regard to number of teeth, periodontal
disease, and caries. In these cases, fabrication of fixed
prostheses becomes impossible. In the past, such pa-
tients were often in danger of being rendered completely
edentulous, with fabrication of complete dentures, or if
possible, overdenture treatment with support of a few
remaining teeth was provided.
13
In 1969, Morrow et al
4
and Lord and Teel
5
described overdenture treatment,
and textbooks presented various concepts and techni-
cal aspects of overdenture fabrication
6,7
with remaining
roots. During the 1980s, more biologic concepts were
introduced to overdenture design with the primary goal
to maintain periodontal health. The so-called perio-
overdenture in its most refined design was described.
6,8
This included a symmetric distribution of 4 or more
tooth roots with gold copings and precision attach-
ments, mostly located in the anterior jaw segment, from
first premolar to first premolar.
The goals of maintenance of roots are to prevent
alveolar bone resorption, provide better load trans-
Purpose: In the present cohort study, overdentures with a combined root and implant
support were evaluated and compared with either exclusively root- or implant-
supported overdentures. Results of a 2-year follow-up period are reported, namely
survival of implants, root copings, and prostheses, plus prosthetic complications,
maintenance service, and patient satisfaction. Materials and Methods: Fourteen
patients were selected for the combined overdenture therapy and were compared
with 2 patient groups in which either roots or implants provided overdenture support.
Altogether, 14, 17, and 15 patients (in groups 1, 2, and 3, respectively) were matched
with regard to age, sex, treatment time, and observation period. The mean age was
around 67 years. Periodontal parameters were recorded, radiographs were taken, and
all complications and failures were registered during the entire observation time. The
patients answered a 9-item questionnaire by means of a visual analogue scale (VAS).
Results: One implant failed and 1 tooth root was removed following longitudinal root
fracture. Periodontal/peri-implant parameters gave evidence of good oral hygiene for
roots and implants, and slight crestal bone resorption was measured for both.
Technical complications and service performed were significantly higher in the first
year (P < .04) in all 3 groups and significantly higher in the tooth root group (P < .03).
The results of the VAS indicated significantly lower scores for satisfaction, speaking
ability, wearing comfort, and denture stability with combined or exclusive root support
(P < .05 and .02, respectively). Initial costs of overdentures with combined or root
support were 10% lower than for implant overdentures. Conclusion: The concept of
combined root and implant support can be integrated into treatment planning and
overdenture design for patients with a highly reduced dentition. Int J Prosthodont
2006;19;236243.
a
Assistant Professor, Department of Prosthodontics, School of Dental
Medicine, University of Berne, Berne, Switzerland.
b
Professor and Chair, Department of Prosthodontics, School of
Dental Medicine, University of Berne, Berne, Switzerland.
Correspondence to: Prof Dr Regina Mericske-Stern, Department
of Prosthodontics, School of Dental Medicine, University of Berne,
Freiburgstrasse 7, CH-3010 Bern, Switzerland. Fax: + 41 31 632 49
33. E-mail: regina.mericske@zmk.unibe.ch
Clinical Evaluation of 3 Overdenture Concepts with Tooth
Roots and Implants: 2-Year Results
Stefan Hug, Dr Med, Dr Med Dent
a
/Dimosthenis Mantokoudis, Dr Med Dent
a
/
Regina Mericske-Stern, Prof Dr Med Dent
b
Hug.qxd 5/8/06 2:34 PM Page 236
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Hug et al
Volume 19, Number 3, 2006
237
mission of the prosthesis to the underlying structures,
maintain sensory feedback, and achieve better stabil-
ity of the dentures. Further, the psychologic aspects of
not being completely edentulous must be emphisized.
Several studies have shown that tooth loss leads to
advanced atrophy of the maxilla and mandible.
911
Crum and Rooney
9
have shown that maintaining nat-
ural roots may prevent or retard alveolar bone loss in
the mandible and that oral tactile sensibility is en-
hanced. Other studies demonstrated by means of com-
parative measurements that the threshold of minimal
perceived pressure was significantly lower with over-
dentures supported by tooth roots than by im-
plants.
1215
This is ascribed to the presence of recep-
tors in the periodontal ligament. Another important
aspect of overdenture use appears to be the stability
of the prosthesis, which is reached by fixation of the
denture itself to a few abutments. In removable
prosthodontics a symmetric bilateral distribution is
suggested to enhance stability of the prosthesis if a very
limited number of teeth can be maintained.
16
Over the past several decades, titanium implants
have been promoted as successful for tooth replace-
ment
1719
and it was reported that less bone atrophy
was observed in edentulous mandibles when implants
were placed.
20
Studies
2124
showed a high success
rate for implant overdentures in the mandible, whereas
treatment outcome with maxillary overdentures ap-
peared to be less predictable.
25
More recent studies in-
dicate that maxillary overdentures may be successful
in well-planned cases.
2529
A combination of tooth and implant support is doc-
umented for fixed partial prostheses
30
but rarely for
overdentures. A recent case report suggested the use
of implants and teeth in combination with removable
partial prostheses.
31
The aim of this preliminary study was to evaluate
overdenture treatment with tooth root and/or implant
support. Assessed treatment outcomes were survival of
roots and implants, periodontal health, prosthetic com-
plications, and patient satisfaction. The hypothesis was
that the performance of overdentures with a combined
tooth root/implant support is not different from that of
overdentures with exclusive root or implant support.
Materials and Methods
Patient Cohorts
During a time period of 3 years, 14 patients were se-
lected who received overdentures with combined
root/implant support (group 1). To evaluate this treat-
ment modality, 2 additional patient groups were se-
lected for comparison, either with only root support
(group 2) or only implant support (group 3). Groups 2
and 3 were matched to group 1 with regard to age,
gender, and treatment period. They both were selected
by means of computer randomization, based on the
chart numbers. All patients were at least 60 years old
at the time of treatment. After completion of the sur-
gical and prosthodontic therapy all patients were in-
cluded in a regular maintenance system. The follow-up
period was 2 years for all 3 groups.
Into group 1, 14 patients (7 men, 7 women, median
age 67.5) were allocated with an extremely reduced
number of teeth and/or asymmetric, unilateral distrib-
ution of roots for overdenture support. They all re-
ceived at least one additional implant to enhance sta-
bility and anchorage of the overdenture. Figure 1 is a
schematic illustration of possible distribution of roots
and implants in the maxilla or mandible. In the present
study, only variation A of abutment distribution was
found in the mandible. Group 2 comprised 17 patients
(9 men, 8 women, median age 69), all with remaining
roots, and group 3 comprised 15 patients (7 men, 8
women, median age 69.2), all with implants. Table 1
gives an overview of the 3 groups, the number of over-
dentures in the respective jaw, and the distribution of
implants and tooth roots. The limitation of such a co-
hort study is that the treatment modality was not at-
tributed at random to the 3 groups but with regard to
the individual treatment needs and possibility. However,
in the present context an RCT would not be ethical.
Roots, Implants, and Overdentures
All roots were provided with root copings and anchor-
age such as Mini Gerber Plus (Cendres Metaux), or ball
anchors (Dalla Bona, Cendres Metaux). Fifteen 2-part
Straumann implants (ITI Dental Implant System,
Straumann) were used in combination with single ball
Fig 1 Schematic illustration of possible combined root and im-
plant support. Black = remaining roots; Red = possible locations
of additional implants.
Hug.qxd 5/8/06 2:34 PM Page 237
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The International Journal of Prosthodontics
238
Clinical Evaluation of 3 Overdenture Concepts
anchors and the remaining implants with individually
cast conical abutments in group 1. Maxillary implants
in group 3 were connected with a splinting bar (U-
shaped Dolder bar). Straumann implants were placed
according to a standard protocol.
32
Figures 2 to 4 give examples of typical overdenture
designs for the maxilla. The design of the mandibular
overdenture was mostly that of a complete denture in
all 3 groups with only 2 supporting roots and/or im-
plants, while the design of the maxilla was palatal free,
often with a horseshoe design.
Clinical and Radiographic Parameters
At the time of the final delivery of the overdenture, clin-
ical and radiographic measurements were performed
and repeated once a year: Plaque Index, bleeding on
probing, and probing depth at 4 root or implant sites.
33
The measurements were performed with a HAWE Click
Probe (Hawe Neos) calibrated to 0.25 N. Radiographs
were taken using the long-cone right-angle technique
for roots and a few orthopantomographs (OPT). Roots
were assessed by means of the following criteria: (1) dis-
tance from coping margin to first bone contact (DCB),
(2) total root length, (3) length of the post, and (4)
length of filled and (5) unfilled root remaining. Caries
and periapical lesions were noted. Measurements of dis-
tance from implant shoulder to first bone contact (DIB)
were taken at mesial and distal sites for implants.
According to the literature,
34,35
linear radiographic mea-
surements are rather reliable. The reference to known
implant dimensions was useful to eliminate errors
caused by distortion. Changes in crestal bone level were
calculated by comparing the distance of DIB respective
to DCB on both radiographs. Since some radiographic
follow-up was done by OPT, only 62 roots and 60 im-
plants that had a documentation with periapical radi-
ographs were included in the measurements.
Prosthetic Complications and
Maintenance Service
Prosthetic complications recorded during the 2-year
observation period were analyzed in 3 categories (mod-
ified according to Kiener et al
26
):
1a. Complications related to implant components and
anchorage devices: loosening of abutments; broken,
loose, or lost female retainers followed by placement
of new retainers; tightening of female retainers
1b. Complications related to root components and an-
chorage devices: loosening/loss of precision at-
tachment with need for recementation; broken,
loose, or lost female retainers followed by place-
ment of new retainers; tightening of female retain-
ers; root fracture; endodontic problems
2. Mechanical and structural failures of the overden-
ture: fracture of denture base resin, fracture of
teeth, fracture of cast framework, need for changes
of prosthetic design followed by fabrication of new
prosthesis
3. Prosthesis-related adjustments: sore spots, relining
of overdenture, occlusal adjustments, changes of
tooth arrangement for esthetic reasons, excessive
wear of teeth
For all patients, 2 recall visits per year were sched-
uled with hygienic procedures for which the patients
were charged. Further unscheduled visits were regis-
tered. The following maintenance services were not
charged in the first year: loose or broken female re-
tainers, tightening of retainers or occlusal screws, re-
cementation of copings, minor occlusal adjustment,
and replacement of broken teeth. The means of all ini-
tial costs (treatment costs) were calculated for each
group.
Prosthetic Questionnaire: Visual Analogue Scale
Two years after delivery of the denture and at the end
of the reported observation period, all patients were
asked to answer a 9-item questionnaire using visual
analogue scales (VAS). The questions were borrowed
from known questionnaires that investigate oral
healthrelated quality of life.
36
A comparison by ques-
tionnaire with the initial situation was not made since
the oral conditions were highly different when the
patients were seen the first time. Some patients still
had many teeth, without any prosthesis, while other
patients had long experience in wearing a removable
prosthesis. The variables were: (1) ease of hygiene, (2)
general satisfaction with overdentures, (3) ability to
speak, (4) comfort of wearing overdenture, (5) esthetic
appearance, (6) stability of overdenture during func-
Table 1 Distribution of Overdentures (OD), Roots, and
Implants in 3 Cohorts
Group 1 Group 2 Group 3 Total
No. of patients with ODs
Maxilla 4 5 3 12
Mandible 6 8 7 21
Maxilla and mandible 4 4 5 13
Total no. of ODs 18 21 20 59
No. of root copings
Maxilla 22 32 54
Mandible 10 24 34
Total 32 56 88
No. of implants
Maxilla 10 33 43
Mandible 10 24 34
Total 20 57 77
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Volume 19, Number 3, 2006
239
Fig 2a Four copings, 1 implant in position of the right second
premolar for overdenture anchorage in the maxilla.
Fig 2b Open design of overdenture around roots.
Fig 3a Five root copings for overdenture anchorage in the
maxilla.
Fig 3b Open design with mostly free palate.
Fig 4a Four implants with a connecting bar for overdenture an-
chorage.
Fig 4b Horseshoe design of overdenture, with coverage of the
implants by the denture base (closed design).
Hug.qxd 5/8/06 2:34 PM Page 239
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The International Journal of Prosthodontics
240
Clinical Evaluation of 3 Overdenture Concepts
tion, (7) ability to chew, (8) handling of the overden-
ture when placing or removing it, and (9) general
problems with the overdenture as experienced by the
patients. One independent examiner who had not
been involved in the treatment of the patients did the
supervision when the patients completed the VAS
questionnaire.
Statistical analysis
Descriptive statistical analysis was applied for patient
demographics and distribution of roots, implants, and
overdentures. For comparison of clinical parameters,
parametric and nonparametric testing was used. Global
analysis of the questionnaire was done by Kruskal-
Wallis test for all 3 groups ( = .05) and pairwise (
Bonf
= 3 = .016%) with the Mann-Whitney U-test.
Prosthetic complications were evaluated by the chi-
square test and the Fisher exact test. All statistics were
performed with SAS 8.2 (SAS).
Results
Survival of Tooth Roots and Implants
In group 1, one tooth root was lost during the obser-
vation time due to longitudinal root fracture; this root
had been in function for 1.3 years . One implant failed
in group 3 after 2 years. A second implant was placed,
which healed successfully and was incorporated into
the overdenture design.
Clinical Parameters and Radiographs
Periodontal and peri-implant parameters gave evi-
dence of good oral hygiene in all 3 groups with in-
significant variations and changes. Therefore no de-
tailed figures are given. Moderate horizontal marginal
crestal bone loss was found for implants and tooth
roots. At mesial and distal sites of implants about 0.8
1.1 mm of bone loss was observed. Bone loss around
tooth roots was about 0.3 0.9 mm. No distinct differ-
ence could be seen between mesial and distal sites.
Prosthetic Complications
The prosthetic plan was maintained in all patients and
no dentures had to be remade. The overall number of
prosthetic complications was 121 (33 in group 1, 56 in
group 2, and 32 in group 3) (Table 2). During the en-
tire 2-year period, adjustments and repairs of the den-
tures were observed more frequently in group 2, but not
at a statistically significant level. However, significantly
more complications were found in the first year for all
3 groups when compared to the second year (chi-
square: P < .04) Additionally, group 2 exhibited a sig-
nificantly higher number of complications in the first
year than groups 1 and 3 (Fisher exact test: P < .03).
The number of visits during the treatment phase
was slightly higher for groups 1 and 2 because of the
higher investment during the preparatory phase with
periodontal and endodontic treatment of roots. A min-
imum of 15 visits was calculated for groups 1 and 2 with
Table 2 Prosthetic Complications
First year Second year Total*
Implant anchorage system Group 1 Group 2 Group 3 Group 1 Group 2 Group 3 Group 1 Group 2 Group 3
Complication
Loosening of abutment 4 5 9
Broken, loose, lost retainers 3 1 2 5 1
Retightening of female retainer 3 2 3 6 2
Root anchorage system
Need for recementation 2 3 2 3
Loosening of female retainer 2 1 2 1
Retightening of female retainer 6 21 1 4 7 25
Root fracture 1 1
Repair of denture
Fracture of resin denture base 1 1
Fracture of teeth 2 3 2 1 2 2 4 4
Fracture of cast framework
Redesign of new denture 1 1 1 1
Adjustment of denture
Sore spots 2 15 7 1 1 3 16 7
Occlusal adjustment 4 4 4 3 4 4 7
Rearrangement of teeth 1 1 1 1 1 1
Total 23 49

21 10 7 11 33 56 32
*Complications: first year > second year (chi-square test: P .04) in all groups.

Total complications: group 2 > groups 1 and 3 in the first year (Fisher exact test: P < .03).
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Volume 19, Number 3, 2006
241
a median of 20.3 and 18.7 visits, respectively, as com-
pared to a median of 15.4 visits for group 3 and a min-
imum of 13. The mean number of unscheduled visits
during the 2-year maintenance period was 3.1 in group
1, 3.8 in group 2, and 2.6 in group 3. Initial costs for the
treatment were lower by 10% in groups 1 and 2, mainly
as a result of the higher costs of implants and bar as-
sembly in group 3.
Questionnaire (VAS)
Figure 5 shows the results obtained by means of the
questionnaire (VAS). All 9 questions showed a ten-
dency to higher mean values with exclusive implant
support (group 3). The median values ranged between
76 and 95.5 for group 1, 82 and 95 for group 2, and 94
and 96 for group 3. Patients of groups 1 and 2 rated the
following items significantly lower: general satisfaction,
ability to speak, wearing comfort, and overdenture sta-
bility. A few patients in groups 1 and 2 expressed some
dissatisfaction and concerns, with low ratings between
40 and 80 on the VAS scale; 1 patient in group 1 was
really dissatisfied with oral comfort, chewing function,
and stability (< 40).
Discussion
This cohort study aimed to evaluate an overdenture
concept with combined root-implant support and to
compare short-term treatment outcomes with well-
known standard procedures, with either root or implant
support. Some studies indicate a limited prognosis for
roots because of their greater susceptibility to caries
and periodontal problems.
1,37,38
Caries rates of up to
35% were reported even in the presence of a high
standard of oral hygiene. In those studies the roots
were not covered by copings. Another study
39
found
that caries was only a minor problem because small
caries lesions could mostly be controlled using minor
restorations and topical fluoride treatment. It was also
shown
40
that caries development under overdentures
could be inhibited completely with daily application of
chlorhexidine-fluoride gel. In the present study we
found no caries lesions, either clinically or radi-
ographically. This may be a result of the regular recalls
and short observation period. A recent study with long-
term results exhibited a high survival rate (80%) of
roots, with periodontitis, endodontic problems, caries,
and root fractures being the reasons for failure.
41
Some of the overdentures in the present study had
an open framework around copings and a closed den-
ture base around implants. This difference in design
could affect soft tissue health with better prognosis for
roots and more gingival hyperplasia, particularly under
a bar. Otherwise, slightly subgingival margins of gold
copings could contribute to some tissue irritation and
inflammation around roots as compared to the smooth
implant surface. Altogether, periodontal and peri-im-
plant parameters showed mostly healthy soft tissues at
the time of re-examination in all groups; to date, the in-
fluence of the overdenture design and retention mech-
anism on the peri-implant tissues is not clear.
* *
* **
** ** **
120
100
80
60
40
20
0
EH AS EA AC GP
Group 1
Group 2
Group 3
V
A
S

s
c
o
r
e
s
GS CW SO HO
Fig 5 Results from 9-item questionnaire (VAS).
*P < .05, **P < .02. EH = ease of hygiene; GS
= general satisfaction; AS = ability to speak; CW
= comfort of wear; EA = esthetic appearance;
SO = stability of overdenture; AC = ability to
chew; HO = handling of the overdenture when
placing or removing it; GP = general problems.
Hug.qxd 5/8/06 2:34 PM Page 241
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242
Clinical Evaluation of 3 Overdenture Concepts
The radiographic analysis is of moderate signifi-
cance since radiographic measurements were not
available for all implants and roots. Measurements of
roots were less reliable since landmarks of known size
are missing. Implants with macrostructures of known
size enable fairly accurate measurements. The average
crestal bone loss of 0.8 mm is in accordance with find-
ings of various studies.
34,35
These latter studies re-
ported that bone loss for implants was pronounced
during the healing phase (0.8 to 1.0 mm) and in the first
year of the loaded period.
Prosthetic results for maxillary and mandibular im-
plant overdentures have been described,
26,27,42
while
studies on prosthetic complications of root copings
are missing. Nevertheless, complications, failures, and
maintenance service as identified in the present study
were typical for overdentures and in accordance with
the available observations.
4244
The main problem was
identified with the anchorage system. As reported in
various studies,
2125
significantly more prosthetic ser-
vice had to be provided in the first year, mainly for over-
dentures with exclusive support by tooth roots.
The evaluation of the VAS shows that most patients
rated their satisfaction and function with the dentures
quite high. Patients with exclusive implant support
rated all questions slightly higher, significantly for the
questions regarding general satisfaction, ability to
speak, wearing comfort, and overdenture stability. A
few patients in groups 1 and 2 were dissatisfied, par-
ticularly after failures (root fracture) and in case of fre-
quent recementation of copings or activation of female
parts. It is not clear whether this problem had a bio-
mechanical origin with the combined root and implant
support. One might conclude that a bar provides bet-
ter overall comfort because of stable retention and in-
creased support area.
Initial costs for the treatment with implants were
lower by 10% for groups 1 and 2. Since treatment con-
cepts and costs highly depend on governmental pol-
icy and on healthcare systems, the difference in net ini-
tial costs as presented here may not be of general,
global validity. Furthermore, lower initial costs may be
outweighed by more maintenance service. This ten-
dency was observed in the 2-year follow-up observa-
tion period with a higher number of unscheduled vis-
its for patients in group 2. However, the observation
period was still too short to draw conclusions.
Four items of the VAS (satisfaction, wearing comfort,
stability, speaking) were rated significantly lower by
groups 1 and 2. In group 3 more patients had a bar sup-
port, which could provide better stability and thus good
wearing comfort as compared to single abutments. In
fact, in a previous longitudinal study on mandibular over-
dentures, changes from single ball anchors to bars were
frequently observed.
42
An open design of the maxillary
denture as it was found in some patients of groups 1 and
2 may impair speaking ability and favor food trapping and
thus give an explanation for lower ratings as well.
Conclusions
Within the limits of the employed research design, the
present study shows that combined root and implant
support for overdentures can achieve results compa-
rable to treatment with either tooth roots or implants.
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Literature Abstract
Biomechanical effects of fixed partial denture therapy on strain patterns of the mandible
This study tested the hypothesis that 3-unit fixed partial dentures (FPD) change strain patterns in the mandible under loading. Four
human cadaver mandibles with missing first molars were artificially loaded on each individual tooth. Surface cortical bone strains
were measured with multiple strain gauges during loading of up to 250 N. Three-unit FPDs with a chamfer margin were fabricated
using type IV gold alloy. Strain measurements were repeated to assess strain patterns after treatment. Paired-sample tests for data
were used to assess the strain pattern before and after treatment ( = .05).The results showed that no differences in strain pattern
were found before and after FPD placement. When the posterior retainers or the pontic were loaded, the strain pattern differed on
the buccal cortices. The strain levels increased posteriorly but decreased significantly anteriorly. The differences were under 100.
The author concluded that 3-unit FPD treatment did not alter the deformation pattern of the mandible under loading.
Yamashita J, Wang Q, Dechow PC. J Prosthet Dent 2006;95:5562. References: 30. Reprints: Dr Junro Yamashita, Department of Biologic
Materials and Sciences, Division of Prosthodontics School of Dentistry, University of Michigan, 1011 N University Ave, Ann Arbor, MI 48109-1078.
Fax: 734 763 3453Ansgar C. Cheng, Singapore
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