journal of prosthodontic research 62 (2018) 1–9

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Journal of Prosthodontic Research

journal homepage: www.elsevier.com/locate/jpor

Review

A systematic review of studies comparing conventional complete

denture and implant retained overdenture
Ahmad Kutkuta,* , Elizangela Bertolib , Robert Frazera , Gitanjali Pinto-Sinaib ,
Rodrigo Fuentealba Hidalgoa , Jamie Studtsc
a
Division of Prosthodontics, College of Dentistry, University of Kentucky, Lexington,KY, USA
b
Division of Restorative Dentistry, College of Dentistry, University of Kentucky, Lexington, KY, USA
c
Department of Behavioral Science, College of Medicine, University of Kentucky, Lexington, KY, USA

A R T I C L E I N F O A B S T R A C T

Article history: Purpose: Several studies reported better outcomes when restoring edentulous mandible with unsplinted
Received 28 April 2017 IODs compared to CCDs; however, it is not clear if these outcomes remain when the full literature is
Received in revised form 5 June 2017 considered. The aim of this systematic review is to compare conventional complete dentures (CCDs) to
Accepted 12 June 2017
unsplinted implant-retained overdentures (IODs) with regard to efficacy, satisfaction and quality of life.
Available online 27 June 2017
Study selection: The main question addressed was: How do CCDs compare to unsplinted IODs with regard
to efficacy, satisfaction and quality of life? Three databases were electronically searched to identify
Keywords:
articles comparing CCD to unsplinted IOD. Twenty-six articles were selected and reviewed in full. Of
Conventional complete denture
Implant
these selected articles, twenty-five compared CCDs restoring function in both arches to a maxillary CCD
Overdenture opposing a mandibular IOD retained by two unsplinted implants. Only one articles compared a maxillary
Efficacy CCDs to a maxillary IOD.
Satisfaction Results: Outcome measures varied among the studies, including the Oral Health Impact Profile (OHIP),
Quality of life visual analogue scales (VAS), and masticatory performance tests. Overall, IODs were associated with
significantly better patient’s masticatory performance and quality of life as indicated by Oral Health as
Related to Quality of Life (OHRQoL). Mandibular unsplinted IODs were more likely than CCDs to be
associated with improved OHRQoL for edentulous patients and were associated with significantly higher
ratings of overall satisfaction, comfort, stability, ability to speak and ability to chew.
Conclusions: Results of this systematic review indicate the superiority of IODs retained by two unsplinted
mandibular implants when compared to CCDs with regards to efficacy, satisfaction and quality of life.
© 2017 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.

1. Introduction and handicap have been associated with a negative impact on

Edentulism or complete tooth loss can be due to periodontal
disease, abscess formation, trauma, and vertical tooth fracture.
Common consequences of tooth loss include progressive alveolar
bone resorption and decreased masticatory performance [1].
Edentulism has two major problems disability because it limits a
patient’s ability to perform two essential tasks in life: speaking
and eating, and handicap, because significant changes are needed
in order to compensate for the deficiencies [2]. Both disability
psychosocial well-being, especially when considering elders [1–3].
Edentulism affects oral and general health in addition to quality
of life [3].
Treatment for edentulism includes conventional complete
dentures (CCDs), implant-retained overdentures (IODs) and, in
some cases, implant supported full arch fixed complete denture
prostheses. In the past, the most common treatment for
edentulism has been to restore function with complete removable
dentures. Due to the fact that, edentulism causes progressive bone

* Corresponding author at: University of Kentucky, College of Dentistry, Division of Prosthodontics, 800 Rose St. D646, Lexington, KY 40536, USA. Fax: +1 8592571847.
E-mail address: ahmad.kutkut@uky.edu (A. Kutkut).

http://dx.doi.org/10.1016/j.jpor.2017.06.004
1883-1958/ © 2017 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.
2 A. Kutkut et al. / journal of prosthodontic research 62 (2018) 1–9
loss, treatment with CCDs is limited and detrimental changes
continue overtime [1–4]. Common problems, especially with
mandibular CCDs, include lack of stability and retention, soreness
and pain and further loss of function [4].
IODs are an alternative treatment option for edentulism that
promises to overcome many of the limitations with CCDs. Studies
have compared the use of CCDs to IODs to restore edentulous
patients, especially the use of mandibular IODs retained by two
unsplinted implants. Indeed, the use of mandibular IODs retained
by two unsplinted implants is considered to be the first choice of
treatment for edentulous elderly patients who are unsatisfied with
CCDs [5]. In general, mandibular IODs may be a preferable option
due to several advantages such as; possible decrease resorption of
the residual ridges, may improve stability and retention, and
possible additional improvement in the patient’s quality of life and
satisfaction [6–9]. The use of implants has dramatically improved
treatment choices for most edentulous patients, but it may not be
suitable for all patients particularly in less prosperous countries
[10] or for patients who are unable to afford costs associated with
this treatment option [11].
Even though the number of studies comparing the two
modalities of treatment is extensive, definitive conclusions from
these studies are not obvious due to heterogeneous methodologi-
cal designs and instruments used to assess outcomes. The most
commonly documented standardized instrument in the literature
was the Oral Health Impact Profile (OHIP) survey [12]. Other
methodological approaches were used as ad hoc instruments
included; Likert Scale Questionnaire [13], Visual Analogue Scale
[13], McGill Patient Satisfaction Questionnaire [14], Denture
Satisfaction Questionnaire [15], Denture Complaint Questionnaire
[15], and Oral Impacts on Daily Performances [16].
The OHIP questionnaire has acceptability, reliability, and validity
pertaining to assessment of Oral Health as Related to Quality of Life
(OHRQoL) [12]. Short versions of this instrument with supportive
estimates of reliability and validity, such as OHIP-14, OHIP-20 and
the OHIP-EDENT, are also considered valuable instruments and
present a more succinct battery of questions to evaluate the
perceived impact of oral health on subjects’ well-being in edentulous
patients [17–19]. Most available literature compares the use of
CCDs restoring function in both arches to a maxillary CCD opposing
a mandibular IOD retained by two implants.
To investigate the available literature evaluating outcomes of
CCDs and IODs, a systematic review of literature was conducted to
answer a fundamental question: how do CCDs compare to
unsplinted IODs with regards to efficacy, satisfaction and quality
of life? In this project efficacy was defined as how well the two
modalities of treatment impacted (CCDs versus IODs) function
[20]. Satisfaction was defined as patient satisfaction with their
dentures, and quality of life was defined as a multidimensional
variable assessing physical, social and emotional well-being [21]
Systematic reviews are one key element of evidence-based
healthcare. Khan et al. describe a step-by-step process for
conducting a systematic review, and outlined the quality elements
inherent in each step [22]. The first step involves framing questions
for a review by identifying the problem “edentulism”, intervention
“dentures”, comparison group “CCDs vs IODs”, and outcomes
“efficacy, satisfaction, and quality of life.” Subsequently, the
relevant work was identified in the literature, which was followed
by assessing the quality of selected studies based on a priori
eligibility criteria. Eligible articles must have compared CCDs with
mandibular IODs (overdenture retained by two unsplinted
implants), used appropriately rigorous designs (e.g., randomized
controlled trials (RCT), prospective cohort studies, retrospective
cohort studies, case–control studies, cross-sectional designs, or
other clinical trial designs that addressed the main study question).
After that, the evidence reported was summarized and interpreted
to generate recommendations and conclusions. Based on this
methodology, this systematic literature review was conducted to
compare CCDs to IODs with regards to efficacy, satisfaction, and
quality of life. To our knowledge, this is the first systematic review
conducted for unsplinted implant retained overdenture modality
of treatment.
2. Material and methods
2.1. Search method and identification of studies
A systematic search of the literature was conducted. Three
scientific databases were electronically searched to identify
articles comparing CCDs to unsplinted IODs with regards to
efficacy, satisfaction and quality of life from the earliest available
dates through January, 2017. The search was conducted using
PubMed/Medline (NCBI), Dentistry and Oral Science Source (DOSS;
EBSCO) and Cochrane Register of Controlled Clinical Trials (EBSCO)
with no limits applied to the initial search. Key words included
were; “complete dentures” or “conventional dentures” and “over-
dentures” or “implant retained dentures” or “implant retained
overdenture” or “implant supported dentures.” This search was
followed by hand-searching (checking references of the relevant
review articles and eligible studies for additional literature).
This systematic review was conducted following the PRISMA-P
guidelines [23]. Ultimately, the search was limited to published
peer-reviewed articles only. Duplicate articles were removed along
with articles not published in English. Titles of manuscripts were
thoroughly scrutinized to exclude articles that clearly were not
comparing the two treatment modalities. Whenever articles’ titles
were not sufficiently informative to judge relevance, study
abstracts were also scrutinized. Examples of articles excluded
during this step were previous literature reviews, articles
describing techniques used for either modalities or comparisons
with fixed prostheses. Subsequently, article abstracts were
independently analyzed by two investigators (A. K. & R. F.) to
determine potentially qualifying articles.
The criteria developed by Dixon-Woods and co-workers
[24,25]. were used to assess the quality of studies included in
this review. Studies with good quality had to meet the following
criteria: clarity of the research questions to be addressed;
suitability of quantitative methods in relation to the studies’ aims
and objectives; appropriate sampling technique in regard to the
research questions and data generation. Articles were then
reviewed in full independently by two investigators (A. K. & E.
B) to determine inclusion in this review based on a quality
assessment tool for quantitative studies [26]. This tool assesses the
internal and external validity for each study.
The following criteria were rated for selected studies:
1) Selection bias as strong (80–100%), moderate (60–79%), or weak
(<60%).
2) Allocation bias (strong: if the study design was RCT, moderate: if
the study design was Two-Group Quasi Experimental, Weak: if
the study design was Case Control or Before/After study).
3) Confounding is a situation where there were factors (other than
the intervention) presented which influence the outcome under
investigation.
4) Blinding (detection bias), strong: if Yes, Weak: if No or Not
reported.
5) Data collection methods whether the outcomes have been
measured with valid and reliable instruments.
6) Withdrawals and dropouts as strong: (80–100%), moderate:
(60–79%), or weak: (<60%).
7) Statistical analysis must have a sufficient sample size to have
the ability (or power) to detect significant differences between
 A. Kutkut et al. / journal of prosthodontic research 62 (2018) 1–9
comparison groups. A lack of a significant effect could be due to
the study having insufficient numbers, rather than the
intervention being ineffective.
8) Intervention integrity to provide a comprehensive picture of
intervention integrity, five dimensions of the intervention were
measured; adherence, exposure, quality of delivery, participant
responsiveness, and program differentiation (to prevent con-
tamination).
2.2. Inclusion criteria
For inclusion in this review, articles needed to meet two
inclusion criteria. First, articles must have compared CCDs with
mandibular IODs (overdenture retained by two unsplinted
implants). Additionally, the study must have employed one of
the following methodologies: randomized controlled trial (RCT),
prospective cohort study, retrospective cohort study, case–control
study, cross-sectional designs, or other clinical trial designs that
were able to answer the main study question. For randomized
controlled trials, 5 criteria were used for assessment: (1)
randomization described, (2) allocation concealment reported,
(3) intention-to-treat analysis performed, (4) blinded assessment
stated, and (5) a priori power calculation performed. For cohort and
other studies, these criteria were used: (1) representative sample
of adequate size, (2) well-matched samples, (3) adjustment for
confounders in analyses, (4) blinded assessment stated, and (5)
dropouts reported (for prospective studies only). Methodological
quality and risk of bias were assessed independently by the
reviewer according to Cooper [27]
2.3. Exclusion criteria
Any articles that were not published in English were excluded.
Articles comparing less than two implants, more than two
implants, or bar attachment to splint implants for the mandibular
arch were excluded. Articles that presented low level of evidence,
such as studies with small sample size, finite element studies,
literature reviews, and laboratory studies were excluded.
3. Results
3.1. Study selection
The preliminary search of the three databases identified
3402 articles. A total of 66 articles were excluded because they
were not published in English. Article titles that clearly did not
compare the two treatment modalities were also excluded. After
eliminating duplicates among the databases, 100 abstracts were
selected for additional review. Review of the 100 remaining article
abstracts for relevance, in terms of addressing the main research
questions, eliminated another 59 papers, reducing the pool to
41 papers that proceeded to the full review stage. From this pool,
five articles were excluded because they compared different
modalities of treatment such as bar attachment, one implant only
or more than 2 implants. Additionally, 15 more articles were
excluded due to low quality evidence/methodological design
limitations (e.g., small sample size (5 papers), and administration
of self-structured not specific validated questionnaire (10 papers)).
See Fig. 1 for a complete breakdown of studies considered. The
remaining 26 articles were evaluated using the quality assessment
tool for quantitative studies [28]. Of the 26 studies, 13 were
considered to have low risk of bias, 11 were categorized as having
moderate risk of bias, and 2 were considered to have high risk of
bias (Table 1). The majority of studies with low risk of bias were
randomized control trials (50%). Most other cohort studies were
3
considered having moderate risk of bias (43%), and the other
studies were recognized as high risk of bias were mainly case–
control studies (7%). The main weakness detected in all reviewed
studies was failure to blind participants and providers.
A summary of the studies, methods, results, and outcomes
included in this review is presented in Tables 1 and 2.
3.2. Comparisons between mandibular CCDs and IODs
3.2.1. Results from OHIP and OHRQoL
Of the thirteen studies that assessed quality of life, in seven
studies [1,30,31,38,39,44,45], the results of the OHIP and other
OHRQoL measurements were described in details and indicated a
marked difference in response to the two treatments provided. It
has been reported that a substantial improvement in the OHIP and
OHRQoL for IODs population when compared to CCDs. In one
study, participants who received IODs reported significantly better
total OHIP scores than CCDs group, with a 1.5 times larger
magnitude of effect [45]. In another study [8], OHIP and OHRQoL
are similar for both groups. The results of studies conducted in
more than one country indicated that international and cultural
differences have an impact on the contribution of IODs to different
aspects of OHRQoL [31]. However, the overall findings are in
agreement with results from randomized clinical trials on the
positive impact of IODs on OHRQL of edentulous patients [31]. A
significantly higher proportion of the participants in the implant
group in North America reported improvement in OHIP, compared
to those who received conventional dentures (93% vs. 52%
respectively) [31,44,45]. In South America, 100% of participants
who received IODs reported improvement in OHIP, compared to
66% in the CCDs group. Differences in mean change scores among
those who expressed improvement were not significantly different
between sites or treatments [31,44,45]. To summarize, data
suggest that individuals who receive mandibular IODs maintain
a better OHIP and OHRQoL than CCDs, and the magnitude of
difference is likely consistent with a clinically relevant outcome.
3.2.2. Patient satisfaction
In twelve of thirteen studies, the IODs group reported signifi-
cantly higher ratings of overall satisfaction [1,9,16,30,
32,39,42,43,46,47,49,52]. In two studies, edentulous seniors who
received IODs rated their general satisfaction approximately 25–36%
higher than did a comparable group provided with CCDs [1,43]. In
one study [16], patients with IODs were more satisfied (83.3%) than
patients with CCDs (16.7%) with their dentures. In another study [3],
prosthodontists and patients both rated mandibular IODs as
significantly superior to CCDs regarding general satisfaction. There
was only one study that showed similarity of the satisfaction of
CCDs users to those of IODs users [8].
3.2.3. Functional limitation
Functional limitation refers to difficulty chewing, food catching,
and dentures not fitting properly. The CCDs group and IODs group
were significantly different with respect to functional limitation.
The results observed in eleven studies [9,16,30–32,43,44–47,49]
suggested that mandibular IODs were associated with significantly
greater ability to function than CCDs for edentulous individuals.
Patients with CCDs reported that they experienced more difficulty
in biting (66.9%) and chewing (75.7%) food than the patients with
IODs (33.3% and 24.3%, respectively) [16]. In one study [43] the
IODs group rated the ability to chew with mean difference of
17.3 mm higher than CCDs. Another study [46] reported a
significant difference between the IODs group and the CCDs group
regarding the mandibular prosthesis which was dislodged by
opening the mouth in CCDs. The prosthesis also moved more than
3 mm in the midline when rotating it by pressing slightly
4 A. Kutkut et al. / journal of prosthodontic research 62 (2018) 1–9
Fig. 1. Description of included records in the systematic review.
downward against the supporting tissues in CCDs. Again, data from
the same study [8], comparing the chewing ability of varying
textures of foods, showed no significant differences between the
two groups. In summary, the findings of the majority of these
studies supported that, patients with IODs performed better
functions with comfort of their dentures, could eat a wide range of
food items with less difficulty, and experienced less impact on
various daily life aspects than patients with CCDs.
3.2.4. Physical pain
Physical pain includes; painful aching, uncomfortable to eat,
sore spots, and uncomfortable dentures. The results observed in
nine of ten studies addressed this domain [30–32,38,44–47,49]
indicated that mandibular IODs are associated with less physical
pain and discomfort than CCDs for edentulous individuals.
Compared to the CCDs group, the mean pain and discomfort
rating for the IODs group were significantly lower. In one [8] of the
ten studies addressed this domain, there was no significant
difference between the groups in relation to physical pain and
discomfort.
3.2.5. Psychological limitations
Psychologic discomfort includes; worry, upset, embarrassment,
and self-consciousness. The results found in nine of ten studies
[9,30–32,38,39,44,45,49] suggested that mandibular IODs showed
significantly lower rating of psychological disability, psychological
discomfort, and psychological limitations than CCDs for edentu-
lous individuals. In only one [8] of ten studies there were no
significant differences between the groups in relation to psycho-
logical limitations.
3.2.6. Physical disability
Physical disability includes; avoid eating, interrupt meals, and
unable to eat. Findings from nine of ten studies [9,30–
32,38,39,44,45,49] indicated that the CCDs group and IODs group
were significantly different with respect to physical disability.
Mandibular IODs showed significantly better rating of physical
disability than CCDs for edentulous individuals. In only one of the
studies that compared to the approaches on physical disability
showed no significant differences between the groups [8].
3.2.7. Social disability
Social disability includes; social tolerance, irritability, social
isolation, and sexual function. Previous research on edentulism has
demonstrated a consistently negative impact on social and sexual
life [48]. In one study [48], IODs group had a social and sexual life
score was approximately 0.7 units better on the five-point scale
than subjects with CCDs group. The IODs group were 34% less
uneasy in sexual activity than the CCDs group. Findings from ten of
eleven reviewed studies [9,30,31,32,38,39,44,45,48,49], found that
mandibular IODs provide greater improvement in unease in
intimate social activities than CCDs. In one study [8], there was no
significant difference between the groups in relation to social
disability. Significant correlations were found between the ratings
for social and sexual life, and the assessments of prosthesis
dysfunction for social activities when speaking, eating, yawning,
and kissing [48]. The highest correlations were found between
ratings for ‘prosthesis dysfunction when kissing’ and ratings of
‘feeling uneasy when kissing’ and in ‘feeling uneasy in sexual
relations’ [48]. Correlations between ‘dysfunction when speaking’;
‘dysfunction on yawning’ and ‘avoid conversation’ were moderate
[48]. Correlations between dysfunction and avoiding sport and
refusing invitations were low to insignificant [48]. IODs treatment
had a significant effect on all social and sexual impacts items as
well, except avoiding conversation, refusing invitation and
avoiding sport [48]. The prostheses were rated as significantly
less dysfunction after IOD treatment during all activities: eating,
speaking, yawning and kissing [48]
 A. Kutkut et al. / journal of prosthodontic research 62 (2018) 1–9 5

Table 1
Systematic review: reviewed articles with their outcomes: complete maxillary conventional dentures opposing mandibular unsplinted implant-retained overdentures.

Author Year Number of Study design Follow up Questionnaire type Outcome Risk of bias
individuals (N)
Ahmad et al. 2015 N = 29 Prospective clinical 1 year VAS IODs group showed 2 times greater contact Moderate
[41] trial Cone beam surface deformation on the mucosa than CCDs risk
group.
IODs group presented at least twice the residual
ridge resorption as CCDs group.
Awad et al. 2014 N = 203 Prospective Baseline OHIP-20 IODs group showed statistically significant Moderate
[31] multicenter study 6 month improvement in OHRQoL and masticatory risk
efficiency.
Sun et al. [38] 2014 N = 50 RCT 6 month OHIP-49 IODs group showed statistically significant Low risk
improvement in OHRQoL and masticatory
efficiency.
Yunus et al. 2014 N = 17 Prospective clinical 1 year OHIP-14 IODs group showed statistically significant Moderate
[39] trial improvement in OHRQoL. risk
Hamdan et al. 2013 N = 207 RCT Baseline 24 hr dietary recall by At 1 year no significant difference in nutritional Low risk
[50] 12 month telephone interviews intake.
Harris et al. 2013 N = 122 RCT CCD: OHIP-49 At 3 months: CCDs group showed significant Low risk
[30] 6 month Denture Satisfaction improvement in OHRQoL and satisfaction.
IOD: Questionnaire At 6 months CCDs group no further improvement.
3 month IODs group showed significant additional
improvements in satisfaction.
Awad et al. 2012 N = 255 RCT Baseline Likert scale questionnaire IODs group showed significant improvement in Low risk
[51] 6 month ability to chew and food habits; clinically
12 month important differences in blood nutrients and
health parameters were not observed.
Geckili et al. 2012 N = 100 Case control 4 years VAS IODs group showed significantly increased High risk
[32] retrospective OHIP-49 patient satisfaction and bite force.
Krennmair 2012 N = 19 Crossover RCT Base line VAS IODs group showed significantly increased Low risk
et al. [52] 1 year McGill patient satisfaction patient satisfaction.
questionnaire
Moyniham 2012 N = 54 Prospective parallel Baseline VAS IODs group: patients ate more fiber and Moderate
et al. [36] trial 3 month 3 day dietary were more satisfied at all time frames. risk
6 month analysis by a nutritionist
Toman et al. 2012 N = 30 Clinical trial N/A Masticatory performance Masticatory performance of patients with Moderate
[40] and mandibular Implant supported complete dentures was higher risk
movement patterns were than that with patients with conventional
compared complete dentures.
Jabbour et al. 2012 N = 153 Longitudinal Base line OHIP-20 CCDs and IODs: A statistically significant Low risk
[45] cohort study 1 year improvement in OHRQoL.
2 year IODs group showed significantly better total OHIP
scores than those wearing CCD.
Geckili et al. 2011 N = 78 Cross over trial 6 month OHIP-14 IODs group showed statistically significant Moderate
[44] OHQoL-UK improvement in OHRQoL. risk
Rashid et al. 2011 N = 102 RCT 6 month VAS IODs group showed significantly increased Moderate
[9] patient satisfaction. risk
Hobkirk et al. 2009 N = 31 Case control study 7 year Denture satisfaction IODs group showed better subjective function High risk
[46] questionnaire after 7 years and showed significantly increased
(20 questions) patient satisfaction.
Denture complaint
questionnaire.
OHIP-14
Hobkirk et al. 2008 N = 60 Case control study 6 month Denture satisfaction IODs group showed significantly increased Moderate
[47] questionnaire patient satisfaction. risk
(20 questions)
Denture complain
questionnaire
Assunção 2007 N = 34 RCT 2 month OHIP Not specified CCDs and IODs groups: No significant differences Moderate
et al. [8] between the two groups in relation to comfort, risk
aesthetic, chewing ability, overall satisfaction,
pain, functional, phonetic, social, and
psychological limitations.
IODs group showed significantly increased
patient satisfaction.
Allen et al. [1] 2006 N = 79 RCT 3 month OHIP-49 CCDs and IODs groups reported significant Low risk
improvement OHRQoL and denture satisfaction.
IODs group showed significant greater OHRQoL
(pre-/post-treatment OHIP change scores).
Heydecke 2005 N = 102 RCT 2 month SIQ IODs group showed significant improvement for Low risk
et al. [48] OHIP-49 stability, speaking, kissing and yawning.
Heydecke 2005 N = 60 RCT 1 year OHIP-20 IODs group showed a 33% improvement in Low risk
et al. [53] OHRQoL.
Awad et al. 2003 N = 60 RCT 2 month VAS IODs group showed significantly increased Low risk
[49] OHIP-49 patient satisfaction and higher ratings on
OHIP-EDENT comfort, stability, and ability to chew.
6 A. Kutkut et al. / journal of prosthodontic research 62 (2018) 1–9

Table 1 (Continued)
Author Year Number of Study design Follow up Questionnaire type Outcome Risk of bias
individuals (N)
Heydecke 2003 N = 60 RCT Base line VAS IODs group showed significantly increased Low risk
et al. [42] 2 months patient satisfaction.
Morais et al. 2003 N = 60 RCT Baseline VAS IODs group showed improved dietary intake and Low risk
[54] 6 month OHRQoL nutritional state.
12 month
Thomason 2003 N = 60 RCT Base line VAS IODs group showed significantly increased Low risk
et al. [43] 2 month patient satisfaction.
6 month
Melas et al. 2001 N = 83 Cohort N/A OIDP (Oral impacts on IODs group showed significantly increased Moderate
[16] (Retrospective) daily performances) patient satisfaction, less difficulty to eat, and risk
experienced less impact on daily life than patients
with CCD.

IODs: implant-retained overdentures.

CCDs: conventional complete dentures.
VAS: visual analogue scale.
OHIP: Oral Health Impact Profile.
OHRQoL: oral health-related quality of life.

Table 2
Systematic review: reviewed articles with their outcomes: complete maxillary conventional dentures compared to maxillary implant-retained overdentures.

Author Year Number of Study design Follow up Questionnaire Outcome Risk of bias
individuals (N) type
Zembic and 2014 N = 21 Prospective Base line OHIP-20E Maxillary IODs (two implants) provided significant Moderate
Wismeijer [55] clinical trial 2 month VAS short-term improvement over CDDs in OHRQoL. risk

IODs: implant-retained overdentures.

CCDs: conventional complete dentures.
VAS: visual analogue scale.
OHIP: Oral Health Impact Profile.
OHRQoL: oral health-related quality of life.

3.2.8. Handicap
Handicap includes inability to enjoy daily activities and finding
life unsatisfying. The findings from ten studies [9,16,30–
32,38,39,44,45,49] indicated that the CCDs group and IODs group
were significantly different with respect to handicap domain.
Mandibular IODs showed significant improvements on handicap
domain than CCDs for edentulous individuals. In one study [8], no
significant difference was reported between the groups in relation
to handicap domain.
3.3. Masticatory performance tests
3.3.1. Chewing and bite force evaluation
The results from reviewed literature indicated that, IODs
achieve better stability than CCDs [9,16,30–32,38–40,43–48,52].
This increase in stability can be reflected in increased chewing
forces, improve chewing experience, significantly improve
patients’ masticatory performance, and discomfort during func-
tion. The masticatory forces stimulate salivary secretion, which
facilitate mastication and also relieve discomfort during function.
Muller et al. [33] found that very old patients who depend on help
for activities of daily living and wear IODs were not only
functioning better but also developed a higher maximum
voluntary bite force than patients with CCDs. However, subjects
wearing mandibular IODs were found to have higher bite forces
than that of patients with CCDs. Geckili et al. [27] reported that, the
measurement of bite force “MBF” of patients in IODs group ranged
from 60.5 to 305.5 N (mean 127.23 N), whereas CCDs Group MBF
values varied between 21 and 144 N (mean 53.09 N). The MBF of
IODs Group was significantly higher than the MBF of CCDs group.
Melas et al. [16] reported that, the patients with CCDs experienced
more difficulty in biting (66.9%) and chewing (75.7%) food than the
patients with IODs (33.3% and 24.3%, respectively). This study also
showed a marginally statistically significant difference for the
difficulty in swallowing food between the two groups. On the other
hand, Sun et al. [38] reported that, masticatory efficiency “ME” was
increased significantly with IODs while Toman et al. [40] reported
that, masticatory performance in patients with IODs was
significantly higher than that with CCDs. There was no significant
difference between groups with respect to masticatory area but in
one study8 that reported no significant differences between the
groups in relation to chewing ability domain.
3.3.2. Nutritional intake and dietary improvements
Despite the quality-of-life benefits from IODs addressed previ-
ously, the adequately powered studies reviewed here failed to reveal
evidence of nutritional advantages for independently living medi-
cally healthy edentate elders wearing IODs over those wearing CCDs
in their dietary intake [16,36,50,51,54]. However, those wearing IODs
were significantly more likely to take in their nutrients through fresh,
whole fruits and vegetables [51]. Moynihan et al. [36] reported that,
dietary intervention benefits denture patients who are receptive to
dietary advice in the dental clinic, modestly better improvement in
diet for those patients with IODs. Awad et al. [51] showed that,
although patients who received IODs had significant improvement in
ability to chew and food habits, clinically important differences in
blood nutrients and health parameters were not observed between
groups. Morais et al. [54] measured the nutritional state before and
6 months after treatment. Significant improvements in anthropo-
metric parameters were detected in the IODs group but not in the
CCDs group. Significant increases were seen in concentrations of
serum albumin, hemoglobin, and B12 with no significant difference
between groups.
3.4. Residual ridge resorption (RRR)
Only one study described that contact surface deformation on
the mucosa which was two times greater within the IODs group
 A. Kutkut et al. / journal of prosthodontic research 62 (2018) 1–9
when compared to the CCDs group [41]. Ahmad et al. [41] reported
that, IODs resulted in at least twice RRR as CCDs due to higher
hydrostatic stress and less effective energy absorption capabilities
of the mucosa underneath the IODs. The mean reduction in bone
volume associated with IODs was 3.8%  4.5%, which is around
twice that of CCDs (1.9%  0.4%) [41]. While implants associated
with the IODs provide stronger bite force, they could potentially
concentrate hydrostatic stress and cause greater RRR compared to
a CCDs [41]. The state of the mucosa and bone supporting
mandibular dentures is a poor predictor of patient satisfaction with
both IODs and CCDs. The fact that prosthodontists rate mandibular
IODs superior to CCDs is in accordance with patient evaluations of
these prostheses [42].
3.5. Cost and maintenance
Provision of IODs instead of a CCDs improves oral-health-related
quality of life by approximately 33% even though the mean cost of
treatment was $2057 for CCD and $3650 for IOD treatment [53]. In
addition to substantial improvement, the estimated incremental
cost of the overdenture was reported $226 per year [47,53]. The
total chairside time needed by the clinician to treat the IODs cases
was more than that required for the CCDs cases [47]. When the
total time taken by the prosthodontist calculated for each visit and
for each procedure, the additional time of 45 min reported for
IODs cases [47]. The average time taken by the technician for the
IODs was 20 min greater than for the CCDs cases [47].
Regarding maintenance, based on this systematic review,
prosthodontic maintenance efforts did not differ between both
modality of treatments but there may be a slightly increased need
for maintenance for the implant retained overdenture with more
frequent matrix activation [46,52].
3.6. Comparisons between maxillary CCDs versus maxillary IODs:
(Table 2)
One study was identified and reviewed that addressed a
comparison between maxillary CCDs and IODs [55]. This study
showed that maxillary IODs using 2 implants provided significant
short-term improvement in OHRQoL when compared to maxillary
CCDs [55]. Zembic and Wismeijer [55] reported that, the comparison
of CCDs and maxillary IODs revealed significantly increased
satisfaction for functional limitation (difference of 33.2 mm),
psychological discomfort (difference of 36.7 mm), physical disability
(difference of 36.3 mm), and social disability (difference of 23.5 mm).
Additionally, general satisfaction, chewing ability, speech, and
stability significantly improved in the IODs group.
4. Discussion
This systematic review aimed to identify published articles
comparing outcomes among patients treated with CCDs versus
IODs, across three clinically-relevant variables: efficacy, patient
satisfaction, and quality of life. Locker mentioned in 1998, “The
ultimate and overriding aim of any health care intervention should
be to reduce pain and discomfort, improve function and enhance
psychosocial well-being” [6]. Additionally, it has been reported
that satisfaction is the most important goal for edentulous
patients, [7] making it an important outcome to consider. Treating
CCD wearers with implants to retain their dentures led to obvious
improvements of patients’ satisfaction with their oral status as
measured by questionnaires and interviews. In the majority of the
studies, IODs were superior to CCDs with regards to efficacy,
satisfaction, and quality of life. The currently available evidence
suggests increased efficacy for patients treated with IODs when
compared to those treated with CCDs. Implant retained
7
overdentures seem to be a more valuable option compared to
CCDs for patients seeking to overcome their functional deficien-
cies.
Psychometric and outcome instrumentations varied among the
studies, which included the OHIP, visual analogue scale (VAS), and
masticatory performance tests. (Table 1) A total of 25 articles were
reviewed and reported significantly increased patient satisfaction
for the mandibular IOD group compared to the CCDs group [1,7–
9,12,29–37]. It is noteworthy to mention that a few articles
reported that patients who received a CCD were also fully or
moderately satisfied with their removable prosthesis [7,8]. While
patient reported satisfaction can be influenced by a variety of
factors, the consistent and reliable findings that IODs were
associated with higher patient satisfaction ratings provide strong
evidence to suggest that patients preferred IODs and experienced
subjective outcomes that were superior to CCDs [9,29].
Overall, patients with CCDs experienced more negative impact
on daily life related to the wearing of their dentures than patients
with IODs. A large body of evidence suggests that a patient’s quality
of life improved after treatment with mandibular IODs [30,37,56–
58]. The impact of edentulism on daily life was strongly affected in
this patient population by the treatment received. Patients
receiving IODs were less likely than wearers of CCDs to report a
negative impact related to difficulty in eating, smiling, speaking
clearly, social contact with other people, “going out,” or main-
taining emotional stability. These negative impacts may have
disabled or handicapped complete denture wearers [16]. Addi-
tionally, patients treated with IODs reported superior outcomes in
both the psychological and the handicap domains compared to
those who received a CCD [31]. These results were higher because
edentulous patients who choose mandibular implant overdentures
have significantly greater improvements in satisfaction, despite
their relatively higher cost, than those who choose conventional
dentures [1,8,9].
While IODs wearers demonstrate a superior outcomes in the
average maximum bite force (MBF), it still remains significantly
lower than dentate patients [34]. Bite force is a factor that influences
the efficiency of the masticatory system, but there is not a direct
association with patient satisfaction [50]. Patient satisfaction
depends on multiple factors including; bite forces, esthetics, and
treatment expectations [35]. It was found, that even though the
mandibular IOD showed higher MBF, there was no evidence of a
clear association between MBF and patient satisfaction or quality
of life [32].
Edentulous patients are receptive to dietary advice given in the
dental clinic, but studies indicate only modest improvements in
diet for those patients with IODs [29,36,56–59,60]. In view of the
strong evidence showing such changes reduce risk of chronic
diseases, such as obesity, diabetes, cardiovascular disease and
cancer [59], these positive dietary effects should be perceived as a
considerable health benefit of this combined form of prosthetic
rehabilitation and diet intervention [36,60].
Taken together, the results of this systematic review emphasize
the superiority of mandibular IOD established in most studies, a
finding that is not surprising given that decreased retention and
stability of mandibular CCDs are regular complaints among
conventional dentures wearers evidenced by the widespread use
of dental adhesives [61,62]. Much emphasis has been given to
comparisons between the two modalities of treatment (CCDs and
IODs), but only a few publications have discussed economic cost/
maintenance and monitoring of residual ridge integrity. Long-term
outcomes studies are necessary to elucidate these important
concerns.
A systematic review evaluating cost-effectiveness of dental
implants has concluded that for patients with mandibular
edentulism, dental implants were associated with higher initial
8 A. Kutkut et al. / journal of prosthodontic research 62 (2018) 1–9
cost but greater improvements in OHRQL in comparison with CCDs
[62]. Nonetheless, patients must be informed of long-term
prosthodontic maintenance requirements [63]. As mentioned
earlier, implant retained overdenture may not be suitable for
patients who are unable to afford the upfront or maintenance costs
associated with this option of treatment. Although the dearth of
studies of the cost-effectiveness of other oral health interventions
prevents us from concluding that the implant therapy would be
considered ‘cost-effective' or acceptable to payers, it does provide
important information to decision-makers and patients about the
costs and benefits of these therapies. It also provides an important
first contribution to a body of evidence from which a consensus on
critical criteria could emerge [53]. Providing edentulous patients
with mandibular two-implant prostheses improves their dietary
intake and nutritional state [54].
Ambiguous results have been reported in the literature regarding
the effects of mandibular IOD on the antagonistic maxillary ridge
resorption with results ranging from increased maxillary bone
resorption [64] to no evidence of increased maxillary bone loss [65].
In regards to marginal bone loss around mandibular implants,
evidence suggests no difference in marginal bone loss relative to
implant type or attachment designs [66]. Recently, Ahmad et al.
reported two times greater contact surface deformation on the
mucosa for patients treated with IODs compared to patients treated
with CCDs. The patients in the IODs group presented at least twice
the residual ridge resorption as the patients in the CCDs group [41].
However, not all studies indicate improved quality of life with a
mandibular IOD [8,32]. In one study [8], subjects were divided into
2 groups; maxillary and mandibular CCDs users or maxillary CCDs
opposed by mandibular IODs. Subjects were invited to complete a
survey based on the OHIP to evaluate their satisfaction levels and
quality of life with their prostheses. There were no significant
differences between the groups in relation to comfort, aesthetics,
chewing ability, overall satisfaction, pain, functional, phonetic,
social, and psychological limitations. Although the stability of the
mandibular IOD was enhanced compared to a conventional
denture, the quality of life and satisfaction levels were similar
for both the groups. Another retrospective study followed
100 edentulous subjects that had either a maxillary and
mandibular CCD or maxillary CCD and mandibular IOD over a
period of 4 years [58]. The groups were compared in terms of
patient satisfaction, quality of life, and bite force. It was concluded
that after 4 years of function, subjects wearing mandibular
overdentures supported by two implants had higher values for
bite force and patient satisfaction scores, but similar QOL scores
when compared to CCD wearers.
Very few articles have compared maxillary overdentures to
maxillary conventional denture. This systematic review included
only 1 study comparing these two modalities of treatment. Zembic
et al. [55] found significant improvement in patient satisfaction
related to speech, comfort, esthetics, stability, chewing ability and
general satisfaction of the IOD when compared with conventional
maxillary dentures in a rather short period of two months [55].
One of the major challenges to clinicians when treating
maxillary edentulous patients involves poor quality and quantity
of the maxillary bone. When maxillary bone support appears to be
a concern in the fabrication of conventional dentures, the question
of how many implants are necessary to improve patient
satisfaction still remains unclear. Klemetti [56] suggested maxil-
lary trabecular bone to be a poorer foundation for implants than
mandibular cortical bone [56]. The added benefits of four splinted
implants versus two unsplinted maxillary implants have been
questioned. Mericske-Stern et al. [57] suggested a completely
implant-supported maxillary overdenture rather than a two-
implant retained and tissue-borne overdentures [57]. However,
with the limited number of studies and the widely varying
conclusions about the appropriate number of implants for
improved maxillary IODs patient satisfaction, we can only
conclude that more research in this area is still required.
5. Limitation of this systematic review
Even though there is a substantial volume of articles available
about patients with CCDs treated with IODs, almost all of these
articles are about the mandible. In this review, we included only
one study on maxillary overdentures. Thus, conclusions are based
mostly on data about mandibular overdentures and might not be
applicable for maxillary overdentures. Next to this, only a few
articles have a follow-up of longer than 1 year. So, long-term
results are based on a small amount of data. Also the methods used
in the reviewed studies are various; therefore, it is only partly
possible to compare the results of the different studies. This review
of literature included research designs that suitable to answer the
research question. The eligibility criteria based on demonstration
of reliability and validity for both, the independent and dependent
variable. Extraneous variations between methods that reported in
reviewed articles may influence research findings, therefore
methods to control relevant confounding variables is a challenge
to report consistency between studies. Additional RCTs are
necessary for evaluating these two modalities of treatments.
Moreover, in these kinds of clinical studies for testing subjective
evaluations of patients, the double blind comparative study is
impossible. Hawthorne effect and a publication bias are common.
6. Conclusion
The results of this systematic review indicate the superiority of
IODs retained by two unsplinted mandibular implants when
compared to a CCDs. In general, patients treated with mandibular
IODs scored higher in satisfaction, quality of life, function and bite
force than patients treated with a CCDs. The effect on QoL is
uncertain. There is little research about maxillary overdentures, so
the results of this systematic revieware mainly related to mandibular
IODs. Because the overwhelming amount of research done on
mandibular overdentures with a follow-up of 1 year, future research
should focus on long-term results and maxillary overdentures. Due
to the limited number of studies with inconsistent results comparing
maxillary CCDs to maxillary IODs, definitive conclusions cannot be
drawn. Further longitudinal studies are necessary to evaluate these
two modalities of treatment.
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