G Model

JJOD 2685 No. of Pages 7

Journal of Dentistry xxx (2016) xxx–xxx

Contents lists available at ScienceDirect

Journal of Dentistry
journal homepage: www.intl.elsevierhealth.com/journals/jden

Implant-supported mandibular removable partial dentures;

patient-based outcome measures in relation to implant position
Charlotte Jensen, DDSa,* , Gerry M. Raghoebar, DMD, PhDb , Wouter Kerdijk, MScc,
Henny J.A. Meijer, DDS, PhDa,b , Marco S. Cune, DDS, PhDa,d
a
University of Groningen, University Medical Center Groningen, Center for Dentistry and Oral Hygiene, Groningen, Department of Fixed and Removable
Prosthodontics and Biomaterials, Groningen, The Netherlands
b
University of Groningen, University Medical Center Groningen, Department of Oral and Maxillofacial Surgery, Groningen, The Netherlands
c
University of Groningen, University Medical Center Groningen, Center for Dentistry and Oral Hygiene, Groningen, Department of Public and Individual Oral
Health, Groningen, The Netherlands
d
St. Antonius Hospital Nieuwegein, Department of Oral-Maxillofacial Surgery, Prosthodontics and Special Dental Care, Nieuwegein, The Netherlands

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

Article history: Objectives: To assess the benefits of implant support to Removable Partial Dentures (RPD) in patients with
Received 30 June 2016 a bilateral free-ending situation in the mandible and to determine the most favorable implant position:
Received in revised form 13 October 2016 the premolar (PM) or the molar (M) region.
Accepted 16 October 2016
Methods: Thirty subjects with a bilateral unbounded posterior saddle received 2 PM and 2 M implants. A
Available online xxx
new RPD was placed. Implant support was provided 3 months later. Two PM implants supported the RPD.
After 3 months the 2 M implants were used or vice versa. Outcome measures included oral health related
Keywords:
quality of life (OHIP-NL49), general health status (SF-36), contentment assessed on a Visual Analogue
Randomized controlled crossover clinical
trial
Scale (VAS) and the number of hours that the RPD was worn. Data were collected prior to treatment, 3
Removable partial denture months after having functioned with a new RPD and after 3 and 6 months with implant support. Finally,
Patient outcomes patients expressed their preferred implant position.
Quality of life Results: The general health status (SF-36) was not influenced. OHIP-NL49 values and mean wearing-time
were statistical significantly more favorable for ISRPD’s, regardless of the implant position. Per day, the
ISRPD’s were worn 2–3 h more than the unsupported new RPD. Patients’ expectations were met as the
VAS-scores of anticipated and realized contentment did not reach a statistical significant level (p > 0.05).
VAS scores for ISRPD’s with M implant support were higher than for PM implant support. Finally, 56.7% of
subjects preferred the M implant support, 13.3% expressed no preference and 30% opted for PM implant
support.
Conclusions: Mandibular implant support favorably influences oral health related patient-based outcome
measures in patients with a bilateral free-ending situation. The majority of patients prefer the implant
support to be in the molar region.
Clinical significance: Patients with a bilateral free-ending situation in the mandible opposed by a
maxillary denture benefit from implant support to their mandibular removable partial denture. Most
patients prefer this support to be in the molar region.
ã 2016 Elsevier Ltd. All rights reserved.

1. Introduction adaptive capacity to function adequately as long as 3–5 occlusal

According to the concept of the shortened dental arch, patients
with reduced numbers of posterior teeth generally have ample
* Corresponding author at: University of Groningen, University Medical Center
Groningen, Center for Dentistry and Oral Hygiene, Department of Fixed and
Removable Prosthodontics and Biomaterials, Antonius Deusinglaan 1, 9713 AV
Groningen, The Netherlands.
E-mail address: c.jensen@umcg.nl (C. Jensen).
units remain, even though their masticatory performance is
impaired [1,2]. Nevertheless, recent prospective studies suggest an
improvement in patients’ Oral Health Related Quality of Life
(OHRQoL) after replacing posterior teeth with a fixed implant-
supported restoration [3,4] or with a Removable Partial Denture
(RPD). RPD problems are frequently recurrent and the positive
effect on OHRQoL is more pronounced in case of an arch that is
interrupted in the anterior [5–8]. The former findings are
particularly interesting, since they relate to a common condition
in clinical practice: the mandibular Kennedy class I or II situation

http://dx.doi.org/10.1016/j.jdent.2016.10.008
0300-5712/ã 2016 Elsevier Ltd. All rights reserved.

Please cite this article in press as: C. Jensen, et al., Implant-supported mandibular removable partial dentures; patient-based outcome
measures in relation to implant position, Journal of Dentistry (2016), http://dx.doi.org/10.1016/j.jdent.2016.10.008
G Model
JJOD 2685 No. of Pages 7
2 C. Jensen et al. / Journal of Dentistry xxx (2016) xxx–xxx
opposed by a full maxillary denture. Under these conditions,
conventional RPD’s may be troublesome and unpredictable as
patients frequently complain from a lack of stability and retention,
discontinue wearing them or insist on replacement by a new one
[9–11], particularly so in cases with unbounded posterior saddles
[12,13]. Occlusal forces move the saddles into a tissue-ward
direction because distal support is lacking, compromising the
anterior abutment teeth as well through potentially destructive
rotational forces. Long term use of an RPD is associated with poor
adaptation of retainers, occlusal disharmony, pain, periodontal
problems and ongoing resorption [14–16].
Several studies in a systematic review showed that providing a
removable partial denture with implant support improves patient
satisfaction in case of bilateral distal-extension partial edentulism,
although they stress the need for long-term randomized controlled
trials [17]. Providing implant support may help improve stability,
retention and chewing ability, patient comfort in general, and even
nutrient intake [15,16,18–22]. A Kennedy class I or II situation is
basically transformed into a class III situation, with a more
favorable transmission of forces from the mucosa toward the
implant(s) and tooth abutment(s). The use of unaesthetic clasps
can often be avoided with implant support [17]. However, the
evidence for implant supported RPD’s (ISRPD’s) is obtained from a
rather heterogeneous group of studies. Populations studied often
include patients with a variety of intraoral conditions and
prostheses with different retention concepts. Furthermore, evi-
dence is often based on case reports or studies of a retrospective
nature with few subjects or finite element methods. Consequently,
better controlled and randomized clinical trials to validate the
outcomes of ISRPD’s are needed [17,23]. The position for the
implant that offers the optimal support is also not elucidated in the
literature.
The aim of this study was to assess the perceived benefits of
implant supported Removable Partial Dentures (ISRPD) in patients
with a bilateral free-ending situation in the mandible who perceive
functional problems with their RPD, yet would like to continue
wearing one and to determine the most favorable implant
position: the premolar (PM) region or molar (M) region.
2. Materials and methods
2.1. Study set-up and patient population
The study was set up as a within-subject comparison
randomized clinical trial for which permission from the medical
ethical committee of the University Medical Center of Groningen
was granted (METc 2011.194). Thirty subjects with a full upper
denture and complaints regarding their bilateral free-ending
mandibular RPD were included. They all had conventional RPD’s
made in the past and either still wore them or had discontinued
wearing them. The following inclusion criteria applied:
- 18 years of age;
- the saddle area reaches until the first mandibular premolar or
cuspid, both left and right;
- the bone volume distal from the most posterior abutment teeth
is sufficient to place the implants. In the premolar region,
implants with a length of 8 mm and a diameter of 3.3 mm and in
the molar region with a length of 6 mm and diameter of 4.1 mm
were inserted. A cone beam CT (CBCT) was used to measure the
bone volume [24];
- the patient is capable of understanding and giving informed
consent.
Potential subjects with medical and general contraindications
for the surgical procedures, with a history of local radiotherapy to
Please cite this article in press as: C. Jensen, et al., Implant-supported mandibular removable partial dentures; patient-based outcome
measures in relation to implant position, Journal of Dentistry (2016), http://dx.doi.org/10.1016/j.jdent.2016.10.008
the head and neck region, who experienced implant loss in the
past, who are incapable of performing basal oral hygiene measures,
with decreased masticatory function due to physical disability or
with active, uncontrolled periodontal pathology of the remaining
dentition were excluded from participation.
2.2. Surgical and prosthetic procedures
All subjects gave informed consent and received 2 implants on
either side of the mandible (Straumann RN, Straumann,
Switzerland) that were provided with cover screws and sub-
merged. Two implants were placed in the premolar region (PM
implant support) and two were placed in the molar region (M
implant support). A surgical guide was used to achieve the right
position and inclination. After 3 months, all implants were exposed
in a second-stage surgery and low healing abutments were
inserted.
A new RPD was made according to standard prosthetic
procedures. The design involved a lingual plate and a clasp on
either side. The housing of the Locator1 abutment (Zest Anchors,
Inc., Escondido, California, USA) was already incorporated in the
RPD, but not the Teflon matrix so it provided neither retention nor
support to the RPD. Three months later and following a
randomization scheme, either the PM or M implants were
provided with a Locator1 abutment. The remaining implants
were left unloaded for future investigation. After 3 months, the
other pair of implants was loaded. Fig. 1 shows an example of a
typical clinical case. A clear timeline is displayed in Fig. 2.
2.3. Patient-based outcome measures
Five patient-based outcome measures were assessed: oral
health related quality of life, patient reported general health status,
general contentment, daily wearing-time of the RPD and patients’
preference for the PM or M implant position. The clinician who
collected the data (CJ) was involved during the inclusion of the
subjects and the organisation of the trial, but provided neither
surgical, nor prosthodontic care.
Oral Health Related Quality of Life (OHRQoL) was considered
the primary outcome measure and assessed using the Dutch
translated and validated version of the Oral Health Impact Profile
questionnaire (OHIP-NL49) [25–27]. It consists of 49 questions
arranged in seven conceptually formulated domains: functional
limitation, physical pain, psychological discomfort, physical
disability, psychological disability, social disability and handicap.
For each item, subjects were asked how frequently they had
experienced the impact of that item in the last month. Responses
are given on a Likert-scale (0-never, 1-hardly ever, 2-occasionally,
3-fairly often, 4-very often). OHIP-NL49 sum scores per domain
and an overall score characterize the OHRQoL impairment in which
higher scores indicate greater OHRQoL impairment.
Patient-reported perceived general health status was deter-
mined using the Dutch translated and validated version of the
Short Form Health Survey (SF-36). It measures to what degree
patients feel disabled during their daily activities [28]. It is
comprised of 36 questions divided into 8 scaled scores which are
transformed into a range from 0 to 100: vitality, physical
functioning, bodily pain, general health perceptions, physical role
functioning, emotional role functioning, social role functioning and
mental health. One additional question addresses changes in
health condition. The lower the score, the more disability.
In addition, patients were asked to express their general
contentment with their oral function during the different stages of
treatment on a Visual Analogue Scale (VAS) ranging from 0 (very
discontent, major concerns) to 100 (very content, no concerns at
all). At the start of treatment they were also asked to express their
G Model
JJOD 2685 No. of Pages 7
C. Jensen et al. / Journal of Dentistry xxx (2016) xxx–xxx
Fig. 1. a. Occlusal view. Locator abutments in the premolar region provide support
and retention to the Removable Partial Denture. The 2 molar implants are not in
function. b. Frontal view. Removable Partial Denture in situ. Blue shimmering lateral
in the denture is caused by the electronic chip to measure wearing-time. c. Occlusal
view. Removable Partial Denture in situ. (For interpretation of the references to
colour in this figure legend, the reader is referred to the web version of this article.)
Fig. 2. Timeline of the randomized clinical cross-over trial including moments of data collection.
Please cite this article in press as: C. Jensen, et al., Implant-supported mandibular removable partial dentures; patient-based outcome
measures in relation to implant position, Journal of Dentistry (2016), http://dx.doi.org/10.1016/j.jdent.2016.10.008
3
expectation with respect to the anticipated ISRPD as a means to
evaluate whether or not patients’ expectations were met at the end
of the study.
Data on OHIP-NL49, SF-36 and general contentment were
collected prior to treatment (with the old RPD), after 3 months of
function with the new RPD without implant support, after 3
months of function with PM implant support and finally after 3
months with M implant support (or vice versa, Fig. 2).
The mean wearing-time per day reflects the patients’ wearing
habits. Alterations assume a shift in patient satisfaction and/or
comfort. A commercially available microelectronic sensor
(TheraMon1, Handelsagentur Gschladt, Hargelsberg, Austria)
was embedded in the lingual or buccal flange of the new
removable partial denture at the position of the first premolar
by means of methylmetacrylate, as described by the manufacturer.
It runs over a period of at least 18 months, measuring the intraoral
temperature in regular intervals and storing it into the integrated
memory microchip. Stored data were transferred to a desktop
computer by a reading station and analysed using dedicated
software (TheraMon1 software, version 2.1.0.13; Handelsagentur
Gschladt). Wearing-time was established for the period with the
new RPD and with the ISRPD during PM as well as M implant
support. Patients were presumed to have worn the denture when
the recorded temperature ranged between 31  C to 39  C. Under
normal conditions, this is the range that covers the vast majority of
intraoral temperature values [29,30].
At the end of the experiment patients were asked to express
their preferred implant position: PM or M after being counselled
about the consequences with respect to the design of their denture.
When favouring the M position, the anterior clasps would have to
remain. Eventually, the dentures were modified according to their
wishes.
2.4. Sample size calculation and statistical analysis
Sample size estimation was based on the primary outcome
measure (OHIP-NL49) given a = 0.05, power = 0.80 and on the basis
of the expected effect size for 2 dependent means (matched pairs)
[31]. The prospected outcome was obtained from a study on oral
health related quality of life as measured by the Oral Health Impact
Factor (OHIP-49) comparing patients treated with implant
supported fixed dentures (implant bridges) and removable partial
dentures without implant support. Mean scores were respectively
G Model
JJOD 2685 No. of Pages 7
4 C. Jensen et al. / Journal of Dentistry xxx (2016) xxx–xxx
22.0 (SD 18.8) and 38.0 (SD 22.2) [32]. Since we included patients
with free-ending bilateral situations only, we presumed the OHIP
value for this particular situation to be higher (i.e. 40) and the
effect of implant support to be less (i.e. 24). Sample size calculation
revealed that 23 subjects were needed to detect this increase in the
primary outcome measure from 40 in the control group (RPD) to 24
in the experimental group (ISRPD, regardless of implant position).
Given the fact that the expected effect in patients with some
remaining natural teeth is presumably smaller than that in
edentulous subjects and compensating for potential dropouts,
the intended number of subjects to be included in the study was set
at 30 patients.
The outcomes of the old, the unsupported new, the PM implant
supported and the M implant supported RPD’s were compared by
1-way analysis of variance and multiple comparison tests after
verification of normal distribution. When the data were not
normally distributed a non-parametric test for related samples
(Friedman’s test) was anticipated. In case of statistical significance
(a = 0.05), post-hoc Wilcoxon signed rank tests were performed
with Bonferroni adjustment for multiple testing. Mann-Whitney U
tests were performed to detect any effects from treatment
sequence (first M, then PM implant support versus first PM, then
M implant support).
3. Results
Patient and treatment characteristics are presented in Table 1.
The sum scores for OHIP-NL49, SF-36, VAS and the mean wearing-
time were not normally distributed (Kolmogorow-Smirnow test’s,
p < 0.05). No differences were found between the treatment
sequences, indicating that which position for implant position was
first administered did not influence patients’ perceptions (Mann-
Whitney U tests, p > 0.05). Hence a possible sequence effect was
not considered in further analyses.
3.1. OHIP-NL49
The mean values for the OHIP-NL49 domains and the OHIP-
NL49 sum score are presented in Table 2. Comparison for the OHIP-
NL49 sum scores showed a statistically significant difference
between the 4 groups (X2(3) = 39.600, p < 0.001). Post-hoc analysis
revealed that overall OHIP-NL49 scores for both implant supported
partial denture groups (PM or M) were significantly lower, than for
the old partial denture and for the new partial denture without
implant support. Providing a new RPD without support did not
lead to a statistical significant improvement of the OHIP-NL49
sum-score as compared to the old RPD. Analysing the different
domains in detail, a similar trend was seen for domain entailing
‘Physical disability’. For the domains ‘Functional Limitation’,
‘Physical Pain’ and ‘Psychological Discomfort’ the new RPD without
support already gave some improvement, which was further
enhanced once the implants were used, be it with M or PM implant
support (Table 2). Psychological disability was improved by M
implant support and not so much when the PM implants were
loaded. For the domains ‘Social Disability’ and ‘Handicap’ no
Table 1
Patient characteristics.
Gender (male/female) 15/15
Mean Age (SD/range) 60.9 (1.2/43.8–71.0)
Group (PMa /Mb) 15/15
Number of remaining natural teeth (5–6/7–8) 16/14
a
PM = implants in premolar region first loaded.
b and patients’ preference for the PM or M implant position, thus
M = implants in molar region first loaded.
Please cite this article in press as: C. Jensen, et al., Implant-supported mandibular removable partial dentures; patient-based outcome
measures in relation to implant position, Journal of Dentistry (2016), http://dx.doi.org/10.1016/j.jdent.2016.10.008
statistically significant differences between the M or PM implant
support were observed.
3.2. SF-36
The mean values for the SF-36 domains are presented in Table 3.
No statistically significant difference could be demonstrated
between conditions for any domains nor for the overall score of
the SF-36.
3.3. Visual analogue scale on contentment
Before the trial started, the subjects expressed their expectation
of contentment with their RPD after treatment with implant
support. Furthermore, they expressed their contentment with the
old RPD, with the new RPD and with the ISRPD’s.
Comparison for contentment with the different RPD’s, old, new
and with implant support were significantly different
(X2(3) = 62.56, p < 0.001). Post hoc analysis revealed that content-
ment with new unsupported RPD’s was significantly higher than
contentment with the old RPD’s (p = 0.008). Contentment with
ISRPD’s was higher than contentment with either old or new
unsupported RPD’s (p < 0.005). Contentment with the ISRPD’s
with M implant support was similar to contentment with PM
implant support (p = 0.18).
Prior to treatment, patients were asked to express their
functional expectations with the final result once their new RPD
was provided with implant support, regardless of the implant
position. Hence the VAS scores for ISRPD’s (M and PM) were
averaged and graphically displayed with patients’ expectations,
and perceived contentment with the old and new, unsupported
RPD in Fig. 3. Patient expectations were met, as indicated by the
fact that the scores for expected and realized contentment with an
ISRPD were not statistically significant different (T = 11, p = 0.78).
3.4. Mean wearing-time
The mean wearing-time per day with the new RPD and with the
ISRPD’s with M and PM implant support were 12.4 h (SD 7.3 h),
15.2 h (SD 6.6 h) and 14.1 h (SD 7.4 h) respectively. Wearing-time
for all conditions ranges from 0.3-23.8 h per day. One patient
poorly adapted to the unsupported RPD and his ISRPD as well
because of severe general health problems that occurred during
the course of the study. Comparison for mean wearing-time was
significantly different between these 3 groups (X2(2) = 25.655,
p < 0.001). Post-hoc Wilcoxon signed-rank tests, revealed that
patients wore their dentures longer on average per day, once they
were supported by implants. The position of the implants, either
PM or M did not significantly influence wearing-time.
3.5. Patient preference
When asked what location they preferred, 13.3% of patients
expressed no preference, 30% preferred the PM implant support
whereas 56.7% preferred the M implant support.
4. Discussion
To investigate whether implant support to a RPD in patients
with a mandibular bilateral free-ending situation has a favorable
influence on patient satisfaction, five patient-based outcome
measures were explored, covering the impact of treatment on Oral
Health Related Quality of Life (OHRQoL), patient reported general
health status, general contentment, daily wearing-time of the RPD
covering a wide range of aspects that are assumed to reflect the
G Model
JJOD 2685 No. of Pages 7

C. Jensen et al. / Journal of Dentistry xxx (2016) xxx–xxx 5

Table 2
Mean sum scores of Oral Health Impact Profile questionnaire (OHIP-NL49) (range 0–196, SD between brackets) at different stages of treatment: old removable partial denture
(Tbaseline), new removable partial denture (TnewRPD), implant supported removable partial denture with support at the molar position (TISRPD-M), implant supported partial
denture with support at the premolar position (TISRPD-PM).

Tbaseline TnewRPD TISRPD-M TISRPD-PM

Functional limitation (max. score 36) 14.9 (6.9) 11.3 (6.1)* 6.5 (3.8)** 6.9 (4.5)**
Physical pain (max. score 36) 10.7 (6.6) 11.4 (7.3) 4.2 (4.1)** 4.5 (5.3)**
Psychological discomfort (max. score 20) 6.9 (5.8) 4.6 (5.2)* 1.8 (2.8)** 2.3 (4.4)**
Physical disability (max. score 36) 9.2 (7.6) 8.2 (7.4) 2.6 (3.0)** 3.1 (4.0)**
Psychological disability (max. score 24) 3.6 (5.5) 3.0 (4.4) 1.0 (2.3)** 2.0 (4.1)
Social disability (max. score 20) 1.9 (3.3) 1.5 (2.2) 0.7 (1.5) 1.1 (2.2)
Handicap (max. score 24) 2.5 (5.0) 1.4 (2.4) 0.8 (1.9) 1.3 (3.4)
OHIP (total) (max. score 196) 49.6 (35.2) 40.3 (31.2) 17.6 (16.6)** 21.2 (26.0)**
*
<Tbaseline (p < 0.008).
**
<Tbaseline and <TnewRPD (p < 0.008).

Table 3
Mean scores for SF-36 (standard deviation between brackets) at different stages of treatment: old removable partial denture (Tbaseline), new removable partial denture
(TnewRPD), implant supported removable partial denture with support at the molar position (TISRPD-M), implant supported partial denture with support at the premolar
position (TISRPD-PM).

Tbaseline TnewRPD TISRPD-M TISRPD-PM

Physical functioning 83.8 (21.0) 79.7 (24.9) 80.5 (22.8) 82.5 (23.3)
Social role functioning 93.5 (13.7) 91.1 (13.3) 89.3 (19.0) 89.3 (15.3)
Physical role functioning 85.8 (31.3) 80.8 (34.5) 79.2 (36.0) 82.5 (36.0)
Emotional role functioning 94.5 (19.7) 94.4 (21.6) 90.0 (23.4) 92.2 (24.3)
Mental health 81.2 (16.8) 83.6 (10.5) 83.0 (13.2) 82.8 (15.9)
Vitality 74.3 (16.1) 72.0 (18.1) 70.0 (17.3) 72.8 (19.5)
Bodily pain 79.4 (24.5) 74.0 (26.9) 74.1 (27.6) 78.2 (26.7)
General Health Perceptions 75.5 (13.9) 73.7 (18.8) 73.2 (16.1) 71.5 (18.5)
Total SF36-score 719.7 (117.1) 701.7 (123.2) 692.6 (132.0) 702.6 (142.9)

No significant differences among the groups for any of the variables.

patients’ perception of the effect of the treatment. The design of
this study was a cross-over randomized clinical trial. Patients were
offered a new unsupported RPD and after three months both an
ISRPD supported in the molar and premolar region for three
months in a random order. In between, we feel that a wash-out
period was not necessary, since it is not likely that the outcome
parameters studied during one intervention would have been of
influence on the following interventions, which were recorded 3
months later. This is confirmed by the fact that no statistically
significant sequence effect was found.
OHRQoL as measured by OHIP-49 improved significantly when
implant support was provided to a newly made RPD (ISRPD), which
is in agreement with the findings of others [7,21,33]. A minimal
important difference (MID) of 6 points (95% CL, 2–9) has been
suggested for OHIP use in dentistry [34]. The MID was defined as
‘the smallest difference in score in the domain of interest which
patients perceive as beneficial and which would mandate, in the
absence of troublesome side effects and excessive cost, a change in
the patient management. John et al. (2009) suggested in the same
study that this MID can be used to approach clinical relevance of
changes in perceived oral health. The observed reduction in OHIP
sum-score and values in the present study amply exceed this
threshold. That being the case, for a patient a cost-effectiveness
consideration needs to be made [35].
The OHRQoL is reported to be highly correlated with the quality
of the prosthesis [36], suggesting that a denture of poor quality
which is replaced by a technically optimized one, will improve
acceptance and satisfaction. In the present study of patients with a
poorly functioning bilateral free-ending mandibular RPD, solely
providing a new RPD proved also being effective. It may mean that
the new RPD provided without support did suffice in increasing the
quality. Patients were even more satisfied when implant support
was provided, meaning that the addition of implant support did
significantly improve overall quality of the construction.
Furthermore, the data suggest that patients’ expectations of
contentment with an ISRPD were met since no significant
difference was seen between expected and actually achieved
contentment. This is seen as an important indicator of the quality
of treatment. It enhances the reputation of the health care provider
and implant dentistry in general. It transforms new patients into
loyal customers and brings new referrals by ‘word of mouth’. Food
getting underneath was and remains a recurrent complaint despite
implant support, as also was observed by others [37].
Whether or not patients wear their (IS)RPD is related to their
contentment with the aesthetics and the absence of pain [11]. An
association between the actual wearing of an RPD and satisfaction
was described before [38]. Objectively documenting the wearing-
time of the (IS)RPD was performed by means of a thermosensitive
device (TheraMon), that is promoted for use in orthodontics to
stimulate (but also check) young patients’ compliance with
treatment [39]. To the knowledge of the authors it has not been
operationalized as an outcome variable for patient satisfaction in
prosthodontics yet. However using a thermosensitive device may
be a useful tool. Electronic wearing-time tracking provides an
accurate estimate. Because of the small size of the chip it is not
uncomfortable to the patient and does not impair function. The
subjects were aware that the blue chip was incorporated in their
(IS)RPD and to what purpose, which may have stimulated them to
wearing the (IS)RPD. Consequently, an overestimation of wearing
time may be present in the data. However, patients’ were aware of
the chip in all conditions so in each condition a similar effect of the
chip may be expected. As a corollary, results in the different phases
of the trial are best judged relative to each other. The improvement
in wearing-time that is seen once implant support is provided,
objectively underscores the observed improved OHIP- and VAS
scores.
In contrast to specific oral health related domains, general
health as measured by SF-36 was not significantly influenced by

Please cite this article in press as: C. Jensen, et al., Implant-supported mandibular removable partial dentures; patient-based outcome
measures in relation to implant position, Journal of Dentistry (2016), http://dx.doi.org/10.1016/j.jdent.2016.10.008
G Model
JJOD 2685 No. of Pages 7

6 C. Jensen et al. / Journal of Dentistry xxx (2016) xxx–xxx

Fig. 3. Mean visual analogue scale (VAS) scores and standard deviations of patients' expected contentment with an Implant Supported Removable Partial Denture (ISRPD)
assessed prior to treatment, present contentment with their old denture (Old RPD) and the actually achieved level of contentment after having functioned with a newly made
Removable Partial Denture without implant support for 3 months (new RPD) or with implant support (ISRPD). Scores for PM and M implant support were averaged. Range 0
(very discontent, major concerns) to 100 (fully content, no concerns at all). Statistical analysis: Expectation = ISRPD > New RPD > Old RPD.

the different treatments. Apparently, in the included, reasonably
healthy subjects, the impact of maxillary edentulism in combina-
tion with a bilateral mandibular free-ending situations has little
impact on their general health concerns, nor do the different
operationalized prosthetic solutions that were offered for this
predicament. This may not be surprising. For edentulous subjects a
disease specific outcome measure like OHIP had better construct
validity properties than a generic one, like SF-36 [40].
Although not evident from the questionnaires or the wearing-
time outcome parameter, over half of the patients express a clear
preference for M implant support. Perhaps the other patient-based
measures are not sensitive or specific enough to record this. The
preference for M implant support may stem from minor differ-
ences in stress or discomfort between the two implant positions. In
mathematical model studies and in a study with a pressure-
sensitive foil it was shown that more distal positions (in the region
of the first or second mandibular molar) induce lower amounts of
stress on the implants and on the residual alveolar ridge, compared
to situations where implants were situated more anteriorly (the
second bicuspid position) [41–43]. From various tested positions,
M support is associated with the least amount of displacement of
the tissues under load [14,44–46]. A more distal position is also
favoured by Grossman et al. who recommended the second molar
position [15]. Hence, the less rotation and the more relieve from
mucosal pressure, the better a RPD is tolerated.
With respect to the biomechanics and design of the denture,
when the support is brought further to the distal, an anterior clasp
or support can usually not be avoided, with aesthetic consequen-
ces. During the course of the present study, a labial retainer to an
anterior natural abutment tooth was always present, both when
the M and when the PM implant support was operationalized.
Patients were informed that would be an inherent consequence
when they would finally choose for M implant support and that
they could probably do without this anterior clasp in case they
would opt for PM implant support. Evidently the patients’ comfort
with M implant support outweighed their dislike of a potentially
aesthetically disturbing anterior retainer since the vast majority
favoured M implant support.
To date there is no information available regarding a difference
in clinical performance between PM or M positioned implants
when used as support for an RPD. The implant placement itself in
the posterior can usually be planned safely on a panoramic
radiograph [24]. With (ultra) short implants becoming available,
the possibilities to provide implant support to a removable partial
denture or provide fixed partial dentures in the resorbed posterior
regions is increasing. It is well advised to plan the position of the
implants in such a way that a fixed partial denture, be it a single or
multiple unit restoration, would still be possible if the patient
desires to convert from a removable to a fixed restorative solution.

Please cite this article in press as: C. Jensen, et al., Implant-supported mandibular removable partial dentures; patient-based outcome
measures in relation to implant position, Journal of Dentistry (2016), http://dx.doi.org/10.1016/j.jdent.2016.10.008
G Model
JJOD 2685 No. of Pages 7
C. Jensen et al. / Journal of Dentistry xxx (2016) xxx–xxx
In conclusion, in patients with a bilateral free-ending situation
in the mandible who perceive functional problems with their RPD
yet would like to continue wearing one, mandibular implant
support favorably influences oral health related patient-based
outcome measures. The majority of patients prefer the implant
support to be in the molar region.
Acknowledgments
This project was supported by a grant from the ITI Foundation,
Switzerland, and by the authors’ institutions. The microelectronic
chips (TheraMon) were made available by Orthosmart, Heerhu-
gowaard, the Netherlands at a reduced cost. Martijn Brenkman of
the Department of Fixed and Removable Prosthodontics and
Biomaterials of the Center for Dentistry and Oral Hygiene,
University Medical Center Groningen is recognized for providing
and modifying all partial dentures during the different stages of
treatment. All removable partial dentures were made at the
maxillofacial dental laboratory Gerrit van Dijk, Groningen the
Netherlands. The authors state that they have no conflicts of
interest.
References
[1] T. Kanno, G.E. Carlsson, A review of the shortened dental arch concept focusing
on the work by the Kayser/Nijmegen group, J. Oral Rehabil. 33 (2006) 850–862.
[2] S. Liang, Q. Zhang, D.J. Witter, Y. Wang, N.H. Creugers, Effects of removable
dental prostheses on masticatory performance of subjects with shortened
dental arches: a systematic review, J. Dent. 43 (2015) 1185–1194.
[3] P.J. van Eekeren, I.H. Aartman, A. Tahmaseb, D. Wismeijer, The effect of implant
placement in patients with either Kennedy class II and III on oral health-
related quality of life: a prospective clinical trial, J. Oral Rehabil. 43 (2016) 291–
296.
[4] K. Fueki, Y. Igarashi, Y. Maeda, K. Baba, K. Koyano, K. Sasaki, et al., Effect of
prosthetic restoration on masticatory function in patients with shortened
dental arches: a multicentre study, J. Oral Rehabil. (2016).
[5] D.B. Armellini, G. Heydecke, D.J. Witter, N.H. Creugers, Effect of removable
partial dentures on oral health-related quality of life in subjects with
shortened dental arches: a 2-center cross-sectional study, Int. J. Prosthodont.
21 (2008) 524–530.
[6] A.A. Swelem, K.G. Gurevich, E.G. Fabrikant, M.H. Hassan, S. Aqou, Oral health-
related quality of life in partially edentulous patients treated with removable
fixed, fixed-removable, and implant-supported prostheses, Int. J. Prosthodont.
27 (2014) 338–347.
[7] K. Fueki, Y. Igarashi, Y. Maeda, K. Baba, K. Koyano, K. Sasaki, et al., Effect of
prosthetic restoration on oral health-related quality of life in patients with
shortened dental arches: a multicentre study, J. Oral Rehabil. 42 (2015) 701–
708.
[8] H. Al-Imam, E.B. Ozhayat, A.R. Benetti, A.M. Pedersen, K. Gotfredsen, Oral
health-related quality of life and complications after treatment with partial
removable dental prosthesis, J. Oral Rehabil. 43 (2016) 23–30.
[9] A.H. Vermeulen, H.M. Keltjens, M.A. van't Hof, A.F. Kayser, Ten-year evaluation
of removable partial dentures: survival rates based on retreatment, not
wearing and replacement, J. Prosthet. Dent. 76 (1996) 267–272.
[10] B. Wagner, M. Kern, Clinical evaluation of removable partial dentures 10 years
after insertion: success rates, hygienic problems, and technical failures, Clin.
Oral Investig. 4 (2000) 74–80.
[11] S. Koyama, K. Sasaki, T. Kawata, T. Atsumi, M. Watanabe, Multivariate analysis
of patient satisfaction factors affecting the usage of removable partial
dentures, Int. J. Prosthodont. 21 (2008) 499–500.
[12] C. Vanzeveren, W. D'Hoore, P. Bercy, G. Leloup, Treatment with removable
partial dentures: a longitudinal study. Part I, J. Oral Rehabil. 30 (2003) 447–
458.
[13] M.Z. Nassani, B. Tarakji, K. Baroudi, S. Sakka, Reappraisal of the removable
partial denture as a treatment option for the shortened dental arch, Eur. J.
Dent. 7 (2013) 251–256.
[14] L.D. Cunha, E.P. Pellizzer, F.R. Verri, J.A. Pereira, Evaluation of the influence of
location of osseointegrated implants associated with mandibular removable
partial dentures, Implant Dent. 17 (2008) 278–287.
[15] Y. Grossmann, J. Nissan, L. Levin, Clinical effectiveness of implant-supported
removable partial dentures: a review of the literature and retrospective case
evaluation, J. Oral Maxillofac. Surg. 67 (2009) 1941–1946.
[16] C. Ohkubo, M. Kobayashi, Y. Suzuki, T. Hosoi, Effect of implant support on
distal-extension removable partial dentures: in vivo assessment, Int. J. Oral
Maxillofac. Implants 23 (2008) 1095–1101.
[17] R.A. Shahmiri, M.A. Atieh, Mandibular Kennedy Class I implant-tooth-borne
removable partial denture: a systematic review, J.Oral Rehabil. 37 (2010) 225–
234.
Please cite this article in press as: C. Jensen, et al., Implant-supported mandibular removable partial dentures; patient-based outcome
measures in relation to implant position, Journal of Dentistry (2016), http://dx.doi.org/10.1016/j.jdent.2016.10.008
7
[18] R. Kaufmann, M. Friedli, S. Hug, R. Mericske-Stern, Removable dentures with
implant support in strategic positions followed for up to 8 years, Int. J.
Prosthodont. 22 (2009) 233–241 (discussion 242).
[19] S. Bortolini, A. Natali, M. Franchi, A. Coggiola, U. Consolo, Implant-retained
removable partial dentures: an 8-year retrospective study, J. Prosthodont. 20
(2011) 168–172.
[20] D. Wismeijer, A. Tawse-Smith, A.G. Payne, Multicentre prospective evaluation
of implant-assisted mandibular bilateral distal extension removable partial
dentures: patient satisfaction, Clin. Oral Implants Res. 24 (2013) 20–27.
[21] W.D. Gates 3rd, L.F. Cooper, A.E. Sanders, G.J. Reside, I.J. De Kok, The effect of
implant-supported removable partial dentures on oral health quality of life,
Clin. Oral Implants Res. 25 (2014) 207–213.
[22] T.M. Goncalves, C.H. Campos, R.C. Garcia, Effects of implant-based prostheses
on mastication, nutritional intake, and oral health-related quality of life in
partially edentulous patients: a paired clinical trial, Int. J. Oral Maxillofac.
Implants 30 (2015) 391–396.
[23] R.F. de Freitas, K. de Carvalho Dias, A. da Fonte Porto Carreiro, G.A. Barbosa, M.
A. Ferreira, Mandibular implant-supported removable partial denture with
distal extension: a systematic review, J. Oral Rehabil. 39 (2012) 791–798.
[24] C. Jensen, G.M. Raghoebar, H.J. Meijer, R. Schepers, M.S. Cune, Comparing two
diagnostic procedures in planning dental implants to support a mandibular
free-ending removable partial denture, Clin. Implant Dent. Relat. Res. (2015).
[25] M.J. Van der Meulen, F. Lobbezoo, M.T. John, M. Naeije, Oral health impact
profile. an instrument for measuring the impact of oral health on the quality of
life, Ned. Tijdschr. Tandheelkd. 118 (2011) 134–139.
[26] M.J. Van der Meulen, M.T. John, M. Naeije, F. Lobbezoo, The dutch version of the
oral health impact profile (OHIP-NL): translation, reliability and construct
validity, BMC Oral Health. 8 (2008) 11.
[27] G.D. Slade, A.J. Spencer, Development and evaluation of the oral health impact
profile, Commun. Dent. Health 11 (1994) 3–11.
[28] R.G. Luthardt, B. Marre, A. Heinecke, J. Gerss, H. Aggstaller, E. Busche, et al., The
randomized shortened dental arch study (RaSDA): design and protocol, Trials
11 (2010) 15.
[29] R.J. Moore, J.T. Watts, J.A. Hood, D.J. Burritt, Intra-oral temperature variation
over 24 hours, Eur. J. Orthod. 21 (1999) 249–261.
[30] C.C. Youngson, C.W. Barclay, A pilot study of intraoral temperature changes,
Clin. Oral Investig. 4 (2000) 183–189.
[31] F. Faul, E. Erdfelder, A. Lang, A. Buchner, G*Power 3: a flexible statistical power
analysis program for the social, behavioral, and biomedical sciences, Behav.
Res. Methods 39 (2007) 175–191.
[32] C. Furuyama, M. Takaba, M. Inukai, R. Mulligan, Y. Igarashi, K. Baba, Oral health-
related quality of life in patients treated by implant-supported fixed dentures
and removable partial dentures, Clin. Oral Implants Res. 23 (2012) 958–962.
[33] T.M. Goncalves, C.H. Campos, R.C. Rodrigues Garcia, Implant retention and
support for distal extension partial removable dental prostheses: satisfaction
outcomes, J. Prosthet. Dent. 112 (2014) 334–339.
[34] M.T. John, D.R. Reissmann, A. Szentpetery, J. Steele, An approach to define
clinical significance in prosthodontics, J. Prosthodont. 18 (2009) 455–460.
[35] C. Jensen, J. Ross, T.L. Feenstra, G.M. Raghoebar, C. Speksnijder, H.J. Meijer, et al.,
Cost-effectiveness of implant-supported mandibular removable partial
dentures, Clin. Oral Implants Res. (2016).
[36] M. Inukai, K. Baba, M.T. John, Y. Igarashi, Does removable partial denture
quality affect individuals' oral health, J. Dent. Res. 87 (2008) 736–739.
[37] C.H. Campos, T.M. Goncalves, R.C. Rodrigues Garcia, Implant retainers for free-
end removable partial dentures affect mastication and nutrient intake, Clin.
Oral Implants Res. 25 (2014) 957–961.
[38] M. Van Waas, J. Meeuwissen, R. Meuwissen, A. Kayser, W. Kalk, M. Van’t Hof,
Relationship between wearing a removable partial denture and satisfaction in
the elderly, Commun. Dent. Oral Epidemiol. 22 (1994) 315–318.
[39] T.C. Schott, G. Goz, Wearing times of orthodontic devices as measured by the
TheraMon(R) microsensor, J. Orofac. Orthop. 72 (2011) 103–110.
[40] P.F. Allen, A.S. McMillan, D. Walshaw, D. Locker, A comparison of the validity of
generic- and disease-specific measures in the assessment of oral health-
related quality of life, Commun. Dent. Oral Epidemiol. 27 (1999) 344–352.
[41] Y. Memari, A. Geramy, A. Fayaz, S. Rezvani Habib Abadi, Y. Mansouri, Influence
of implant position on stress distribution in implant-assisted distal extension
removable partial dentures: a 3D finite element analysis, J. Dent. (Tehran) 11
(2014) 523–530.
[42] Y. Matsudate, N. Yoda, M. Nanba, T. Ogawa, K. Sasaki, Load distribution on
abutment tooth, implant and residual ridge with distal-extension implant-
supported removable partial denture, J. Prosthodont. Res. (2016), doi:http://
dx.doi.org/10.1016/j.jpor.2016.01.008 (Article in press).
[43] W.S. Oh, T.J. Oh, J.M. Park, Impact of implant support on mandibular free-end
base removable partial denture: theoretical study, Clin. Oral Implants Res. 27
(2016) e87–90.
[44] M. Sato, Y. Suzuki, D. Kurihara, H. Shimpo, C. Ohkubo, Effect of implant support
on mandibular distal extension removable partial dentures: relationship
between denture supporting area and stress distribution, J. Prosthodont. Res.
57 (2013) 109–112.
[45] C. Ohkubo, D. Kurihara, H. Shimpo, Y. Suzuki, Y. Kokubo, T. Hosoi, Effect of
implant support on distal extension removable partial dentures: in vitro
assessment, J. Oral Rehabil. 34 (2007) 52–56.
[46] C.M. de Freitas Santos, E.P. Pellizzer, F.R. Verri, S.L. de Moraes, R.M. Falcon-
Antenucci, Influence of implant inclination associated with mandibular class I
removable partial denture, J. Craniofac. Surg. 22 (2011) 663–668.