Implant Tooth-Supported Removable Partial Denture with at Least 15-Year Long-Term Follow-Up Eitan Mijiritsky, DMD;* Adi Lorean, DMD;† Ziv Mazor, DMD;‡ Liran Levin, DMD§
ABSTRACT Purpose: The aim of the present report is to describe the long-term follow-up of cases treated with implant tooth-supported removable partial denture (ITSRPD) after at least 15 years. Materials and Methods: The study sample comprised 20 consecutively partially edentulous patients treated with ITSRPD. Implants were placed in order to improve unfavorable removable partial denture design resulting from unfavorable teeth distribution and biomechanical considerations, esthetic, or periodontal challenges. All patients were followed up every 6 months for the first 2 years and annually thereafter for at least 15 years. Recall visits for professional cleaning and oral hygiene re-enforcement were scheduled every 3 to 6 mounts. Results: A total of 42 implants were placed in 20 patients and restored with ITSRPD. All implants and prosthetic devices functioned successfully throughout the 15 years of follow-up. Three patients had gone through further implant placement several years after ITSRPD was provided, and a fixed implant-supported restoration was provided on the original and new implants. No implant failure was noted during follow-up, resulting in a rate for implant survival of 100% for the study. Marginal bone loss around implants ranged between 0 and 2 mm (mean 0.64 1 0.6 mm). During the follow-up period, prosthetic complications were minor and included one rest rupture. All patients answered a questionnaire and were satisfied with the prosthesis. They reported good chewing ability and stability of the prosthetic devices. Conclusions: ITSRPD can be used with predictable long-term results in carefully selected and well-maintained population. Patients should be advised of their role in maintenance, and a comprehensive recall system is mandatory to obtain satisfactory long-term results. KEY WORDS: alveolar bone, dental implantation, mandible, maxilla, success, survival
INTRODUCTION
overall high implant survival rates were reported for a follow-up time of several years. It seems that ITSRPD might serve as an adequate, cost-effective prosthetic solution for partially edentulous patients who are not immediate candidates for extensive fixed implantsupported restorations. Incorporation of dental implants to improve the removable partial denture (RPD) support and retention and to enhance patient acceptance should be considered during treatment planning for RPDs.2 The implant placement is usually dictated by the biomechanical considerations of the RPD design. Implants may be used for support only, or for direct and indirect retention.1–3 Of high importance, when implant location is planned, future options of using the implants as abutments for implant-supported fixed restoration or implant-supported overdenture should also be considered.1–3
During the last decade, several publications indicated that implant tooth-supported removable partial denture (ITSRPD) can be a predictable treatment modality for partially edentulous patients.1–7 The *Clinical instructor, Department of Oral Rehabilitation, The Maurice and Gabriela Goldschleger School of Dental Medicine, Tel-Aviv University, Israel; †senior surgeon, Department of Maxillo-Facial Surgery, Poriya Hospital, Tiberius, Israel; ‡private practitioner, Ra’anana, Israel; §head of research, School of Dentistry, Rambam Health Care Campus and Faculty of Medicine, Technion, IIT, Haifa, Israel, and Harvard School of Dental Medicine, Boston, MA, USA Reprint requests: Dr. Liran Levin, Department of Periodontology, School of Graduate Dentistry, Rambam Health Care Campus, Haifa, Israel; e-mail: [email protected] © 2013 Wiley Periodicals, Inc. DOI 10.1111/cid.12190
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Clinical Implant Dentistry and Related Research, Volume 17, Number 5, 2015
Mitrani and colleagues6 placed posterior implants away from the fulcrum line to improve support and retention for distal extension RPD by preventing the tissue ward rotation around the fulcrum line. The arch configuration was changed from Kennedy Class I and II into a more favorable Kennedy Class III. Implants placed on distal extension removable prostheses resulted in increased patient satisfaction. However, in Grossmann and colleagues’ report, arch configuration was modified in only 26.1% of the patients, mainly in the maxilla from Kennedy Class I to Kennedy Class III.2 Implants placed in the posterior regions might necessitate further augmentation procedures, such as sinus floor elevation and vertical and/or horizontal ridge augmentation. Therefore, more anterior implants might be used as direct retainers adjacent to abutment teeth. As a result, the teeth are used mainly for support, whereas the implants provide retention. This eliminated the need for buccal clasp arms that cross the vulnerable free gingivae, interfering with self-cleansing and with esthetics.1–3 Moreover, the teeth, as a result, are less subject to unfavorable horizontal forces so periodontal prognosis might be improved. The available data regarding this treatment modality, however, warrant a long-term follow-up on those cases.7 The aim of the present report is to describe the long-term follow-up of cases treated with ITSRPD after at least 15 years. METHODS The study sample comprised 20 consecutively treated patients (13 men, seven women; mean age at the time of implant placement 56 years, range 44–67). The patients were informed, and written informed consent forms were used. The declaration of Helsinki followed. The study subjects were partially edentulous. Only medically healthy patients that were treated with ITSRPD were included. No other exclusion criteria were applied. All patients were examined clinically and radiographically before implant placement. Implants (Zimmer Dental, Carlsbad, CA, USA; Friadent, Mannheim, Germany; or MIS Implants Technologies, Shlomi, Israel) were placed in order to improve unfavorable RPD design resulting from unfavorable teeth distribution and biomechanical considerations, esthetic, or periodontal challenges (i.e., mobile abutment teeth, bone loss, etc.). The length of all the implants was 10 mm or more (ranged between 10 and 13 mm), and the diameter was
3.7 mm or more (ranged between 3.7 and 5 mm). The prosthetic elements that were used with the implants to support the RPDs were ball attachments and bar design connections. Overall, 42 dental implants were placed in the study population. In addition to the implants, teeth were selected as abutments to provide support for the ITSRPDs based on their pulpal and periodontal condition (bone support, mobility, etc.), the presence and type of coronal restoration, the need for indirect retention, and the distribution and number of abutments and implants in the arch. Guiding planes and rest seat preparations were performed after treatment planning and cast survey. Prior to dental implant placement, patients underwent active periodontal phase treatment to achieve a stable periodontal condition with no pockets above 4 mm. All patients were followed up every 6 months for the first 2 years and annually thereafter for at least 15 years. Recall visits for professional cleaning (supragingival and subgingival debridement) and oral hygiene re-enforcement were scheduled every 3 to 6 mounts according to the patients’ periodontal disease history and risk factors. The presence of clinical signs of mobility and gingival inflammation around implants and teeth was evaluated. These included periodontal probing depth, tooth mobility according to Miller’s classification, and bleeding on probing. Radiographic evaluation of bone levels around the implants was also assessed as previously reported.8,9 Prosthetic complications such as loss of retention and fractures of the prosthetic elements were recorded. A questionnaire at the last recall appointment was used to assess patient satisfaction regarding function, esthetics, and convenience of the prosthesis on a 1 to 5 scale (1, very unsatisfied; 5, highly satisfied). RESULTS A total of 42 implants were placed in 20 partially edentulous patients that were restored with ITSRPD and followed up for at least 15 years (Table 1). Maxillary prostheses were provided to 10 patients and mandibular to 10 patients. All implants and prosthetic devices functioned successfully throughout the 15 years of follow-up. Three patients had gone through further implant placement several years after ITSRPD was provided, and a fixed implant-supported restoration was provided on the
61/F
49/F
57/M
44/M
47/F
58/M
51/M
64/F
65/M
48/F
46/F
50/M
67/M
66/F
63/M
55/M
54/F 62/M 61/M
2
3
4
5
6
7
8
9
10
11
12*
13
14
15
16
17
18 19* 20*
No No No
Yes
No
No
No
No
No
No
Yes
No
Yes
No
No
No
Yes
No
No
No
Smoking
Class III mod I Class II mod I Class I
CLASS II mod I
Class I
Class IV
Class II mod I
Class I mod I
Class II mod I
Class III mod I
Class II mod II
Class I mod I
Class I
Class II mod II
Class I
Class II mod I
Class II mod I
Class I
Class I
Class II mod I
Arch Configuration
Rt Max 1st PM Lt Max 1st M Lt Max canine Lt Max 2nd PM Rt Max 1st M Rt Mand canine Rt Mand 2nd PM Rt Mand 1st M Rt Mand1st PM Lt Mand1st PM Rt Max1st M Lt Max 1st PM Rt Max 1st PM Lt Max 1st PM Lt Max 2nd M Lt Mand lat. incisor Rt Mand lat. incisor Lt Mand 2nd PM Rt Mand 2nd PM Lt Mand incisor Rt Mand canine Lt Mand canine Lt Mand 2nd PM Rt Max 1st PM Lt Max 1st PM Rt Mand canine Lt Mand 2nd PM Lt Mand lat incisor Rt Mand lat incisor Rt Max canine Rt Max 1st PM Lt Max 1st PM Lt Mand lat incisor Rt Mand lat incisor Lt Max 1st PM Rt Max 1st PM Lt Max 1st PM Rt Max 2nd M Lt Mand 1st PM Lt Max 1st PM Rt Max canine Rt Max 2nd PM
Implant Location
1 1 0 1 0 0 0 1 1 0 1 0 0 1 1 0 1 1 1 1 2 0 0 1 0 0 1 0 1 0 0 1 0 1 0 0 2 1 2 1 1 1
Marginal Bone Loss (mm)
Bar Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Bar
189 184 193
193
183
185
190
188
181
185
182
188
189
183
181
180
190
186
Ball Bar Ball Ball Ball Ball Ball Ball
189
192
Follow-Up (Months)
Ball Ball Bar
Ball/Bar Design
*Those patients who had gone through further implant placement several years after ITSRPD was provided and a fixed implant-supported restoration was provided on the original and new implants. ITSRPD, implant tooth-supported removable partial denture; Lt, left; M, molar; Mand, mandibular; Max, maxillary; PM, premolar; Rt, right.
53/M
Age/Gender
1
Patient No.
TABLE 1 Patient Information
Implant Tooth-Supported Removable Partial Denture 919
920
Clinical Implant Dentistry and Related Research, Volume 17, Number 5, 2015
A
B
C
D
Figure 1 A and B, Original implant tooth-supported removable partial denture (ITSRPD) of patient no. 12 on Table 1. C and D, After adding two distal implants, a fixed restoration could be provided using the old and new implants. This highlights the importance of carefully planning implant position when choosing the ITSRPD modality to enable future transition to fixed implant-supported restoration.
original and new implants (Figure 1). No implant failure was noted during follow-up, resulting in a rate for implant survival of 100% for the study. During the follow-up period, prosthetic complications were minor and included one rest rupture of a clasp assemble around a natural mandibular tooth. No clinical signs of mobility or gingival inflammation around implants and teeth were reported. Probing depths around all implants were less than 5 mm with no bleeding on probing present. Marginal bone loss around implants ranged between 0 and 2 mm (mean 0.64 1 0.6 mm; see Table 1). All patients answered the questionnaire and were satisfied with the prosthesis. They reported good chewing ability and stability of the prosthetic devices (Table 2).
DISCUSSION ITSRPD can be considered as an alternative to conventional RPDs and implant-supported fixed partial prostheses when the implant’s insertion is limited by bone height and thickness or by financial reasons. In this situation, a small number of implants can be placed to
TABLE 2 Self-Reported Patients’ Satisfaction from the Prosthesis on a 1–5 Scale
Function (n = 20) Esthetics (n = 20) Convenience (n = 20)
Mean Score
SD
Range
4.6 4.8 4.75
0.6 0.4 0.4
3–5 4–5 4–5
Scale: 1 = very unsatisfied; 5 = highly satisfied.
Implant Tooth-Supported Removable Partial Denture
stabilize the RPD, provide comfort, and increase patient masticatory efficacy.7 The available literature as well as our current report suggests that the association of RPD with implant improves the prosthetic biomechanics, resulting in greater patient satisfaction and high survival rates for the implants with stable bone level around the implants.1–7 A recent systematic review revealed high implant success rate and increasing patient satisfaction for RPD associated with implants in Kennedy classes I and II. However, some prosthetic complications and need of repair were observed.7 The authors reported that there is also a lack of information about long-term success of implants associated with RPDs to enhance their safety and predictability in daily prosthodontics practice.7 Thus, the results of the present study, with 15 years of follow-up, might serve as a good indication for the long-term success of ITSRPD in carefully selected and well-maintained population. The stable bone level around the implants is an encouraging finding that might also be attributed to the strict maintenance program provided to those patients. As for conventional RPD, Vermeulen and colleagues reported that only 40% of conventional metal frame RPD survived 5 years when abutment retreatment served as a failure criterion.10 The proposed design of ITSRPD seems to benefit the abutment periodontal health and long-term influence on abutment prognosis. However, as periodontal disease and dental caries are still a concern in RPD wearers, patients should be advised of their role in maintenance, and a definite recall system is mandatory to obtain satisfactory long-term results. Campos and colleagues conducted a study aimed to elucidate the ability of conventional free-end RPD, supported by implants to influence swallowing threshold parameters and nutrient intake. Their results showed that subjects using free-end RPD retained by implants experienced better mastication and increased nutrient intake compared with conventional RPD.11 Furthermore, an increased intake of energy, carbohydrates, protein, fiber, calcium, and iron after 2 months with free-end RPD over implants was observed. To assess implant-supported RPDs in vivo, Ohkubo and colleagues12 treated five patients with posterior mandibular edentulism using RPDs that were either supported or not supported by endosseous implants.
921
The masticatory movements, occlusal force, contact points, center of occlusal force, and patients’ preferences were measured to compare the ITSRPDs with conventional RPDs. Within the limitations of their pilot study, they have concluded that ITSRPDs tended to have lower values for mean time and coefficient of variation of masticatory movement compared with the conventional RPDs, except for the opening phase. ITSRPDs had greater occlusal force than the conventional RPDs, and all the patients preferred the implant-supported RPDs for all criteria (comfort, chewing, retention, and stability). As reviewed and suggested by Grossmann and colleagues,1 implants should be placed in the area of the second molars in distal extension patients, adjacent to the distal abutment in case future-fixed restoration is an option, and medially in Kennedy Class IV arch. Future transformation of the case to a fixed implant-supported restoration should be always in mind when planning ITSRPD (see Figure 1). CONCLUSIONS Within the imitations of this report, in this long-term follow-up of 20 patients with ITSRPD, it seems that this treatment modality can be used with predictable longterm results in carefully selected and well-maintained population. Patients should be advised of their role in maintenance, and a comprehensive recall system is mandatory to obtain satisfactory long-term results. REFERENCES 1. Grossmann Y, Nissan J, Levin L. Clinical effectiveness of implant-supported removable partial dentures: a review of the literature and retrospective case evaluation. J Oral Maxillofac Surg 2009; 67:1941–1946. 2. Grossmann Y, Levin L, Sadan A. A retrospective case series of implants used to restore partially edentulous patients with implant-supported removable partial dentures: 31-month mean follow-up results. Quintessence Int 2008; 39:665–671. 3. Mijiritsky E. Implants in conjunction with removable partial dentures: a literature review. Implant Dent 2007; 16:146–154. 4. Mijiritsky E, Ormianer Z, Klinger A, Mardinger O. Use of dental implants to improve unfavorable removable partial denture design. Compend Contin Educ Dent 2005; 26:744– 746. 5. Mijiritsky E, Karas S. Removable partial denture design involving teeth and implants as an alternative to unsuccessful fixed implant therapy: a case report. Implant Dent 2004; 13:218–222.
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6. Mitrani R, Brudvik JS, Phillips KM. Posterior implants for distal extension removable prostheses: a retrospective study. Int J Periodontics Restorative Dent 2003; 23:353–359. 7. de Freitas RF, de Carvalho Dias K, da Fonte Porto Carreiro A, Barbosa GA, Ferreira MA. Mandibular implant-supported removable partial denture with distal extension: a systematic review. J Oral Rehabil 2012; 39:791–798. 8. Levin L, Hertzberg R, Har-Nes S, Schwartz-Arad D. Longterm marginal bone loss around single dental implants affected by current and past smoking habits. Implant Dent 2008; 17:422–429. 9. Levin L, Nitzan D, Schwartz-Arad D. Success of dental implants placed in intraoral block bone grafts. J Periodontol 2007; 78:18–21.
10. Vermeulen AH, Keltjens HM, van’t Hof MA, Kayser AF. Ten-year evaluation of removable partial dentures: survival rates based on retreatment, not wearing and replacement. J Prosthet Dent 1996; 76:267–272. 11. Campos CH, Gonçalves TM, Rodrigues Garcia RC. Implant retainers for free-end removable partial dentures affect mastication and nutrient intake. Clin Oral Implants Res. DOI: 10.1111/clr.12165 12. Ohkubo C, Kobayashi M, Suzuki Y, Hosoi T. Effect of implant support on distal-extension removable partial dentures: in vivo assessment. Int J Oral Maxillofac Implants 2008; 23:1095–1101.
ABSTRACT Purpose: The aim of the present report is to describe the long-term follow-up of cases treated with implant tooth-supported removable partial denture (ITSRPD) after at least 15 years. Materials and Methods: The study sample comprised 20 consecutively partially edentulous patients treated with ITSRPD. Implants were placed in order to improve unfavorable removable partial denture design resulting from unfavorable teeth distribution and biomechanical considerations, esthetic, or periodontal challenges. All patients were followed up every 6 months for the first 2 years and annually thereafter for at least 15 years. Recall visits for professional cleaning and oral hygiene re-enforcement were scheduled every 3 to 6 mounts. Results: A total of 42 implants were placed in 20 patients and restored with ITSRPD. All implants and prosthetic devices functioned successfully throughout the 15 years of follow-up. Three patients had gone through further implant placement several years after ITSRPD was provided, and a fixed implant-supported restoration was provided on the original and new implants. No implant failure was noted during follow-up, resulting in a rate for implant survival of 100% for the study. Marginal bone loss around implants ranged between 0 and 2 mm (mean 0.64 1 0.6 mm). During the follow-up period, prosthetic complications were minor and included one rest rupture. All patients answered a questionnaire and were satisfied with the prosthesis. They reported good chewing ability and stability of the prosthetic devices. Conclusions: ITSRPD can be used with predictable long-term results in carefully selected and well-maintained population. Patients should be advised of their role in maintenance, and a comprehensive recall system is mandatory to obtain satisfactory long-term results. KEY WORDS: alveolar bone, dental implantation, mandible, maxilla, success, survival
INTRODUCTION
overall high implant survival rates were reported for a follow-up time of several years. It seems that ITSRPD might serve as an adequate, cost-effective prosthetic solution for partially edentulous patients who are not immediate candidates for extensive fixed implantsupported restorations. Incorporation of dental implants to improve the removable partial denture (RPD) support and retention and to enhance patient acceptance should be considered during treatment planning for RPDs.2 The implant placement is usually dictated by the biomechanical considerations of the RPD design. Implants may be used for support only, or for direct and indirect retention.1–3 Of high importance, when implant location is planned, future options of using the implants as abutments for implant-supported fixed restoration or implant-supported overdenture should also be considered.1–3
During the last decade, several publications indicated that implant tooth-supported removable partial denture (ITSRPD) can be a predictable treatment modality for partially edentulous patients.1–7 The *Clinical instructor, Department of Oral Rehabilitation, The Maurice and Gabriela Goldschleger School of Dental Medicine, Tel-Aviv University, Israel; †senior surgeon, Department of Maxillo-Facial Surgery, Poriya Hospital, Tiberius, Israel; ‡private practitioner, Ra’anana, Israel; §head of research, School of Dentistry, Rambam Health Care Campus and Faculty of Medicine, Technion, IIT, Haifa, Israel, and Harvard School of Dental Medicine, Boston, MA, USA Reprint requests: Dr. Liran Levin, Department of Periodontology, School of Graduate Dentistry, Rambam Health Care Campus, Haifa, Israel; e-mail: [email protected] © 2013 Wiley Periodicals, Inc. DOI 10.1111/cid.12190
917
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Clinical Implant Dentistry and Related Research, Volume 17, Number 5, 2015
Mitrani and colleagues6 placed posterior implants away from the fulcrum line to improve support and retention for distal extension RPD by preventing the tissue ward rotation around the fulcrum line. The arch configuration was changed from Kennedy Class I and II into a more favorable Kennedy Class III. Implants placed on distal extension removable prostheses resulted in increased patient satisfaction. However, in Grossmann and colleagues’ report, arch configuration was modified in only 26.1% of the patients, mainly in the maxilla from Kennedy Class I to Kennedy Class III.2 Implants placed in the posterior regions might necessitate further augmentation procedures, such as sinus floor elevation and vertical and/or horizontal ridge augmentation. Therefore, more anterior implants might be used as direct retainers adjacent to abutment teeth. As a result, the teeth are used mainly for support, whereas the implants provide retention. This eliminated the need for buccal clasp arms that cross the vulnerable free gingivae, interfering with self-cleansing and with esthetics.1–3 Moreover, the teeth, as a result, are less subject to unfavorable horizontal forces so periodontal prognosis might be improved. The available data regarding this treatment modality, however, warrant a long-term follow-up on those cases.7 The aim of the present report is to describe the long-term follow-up of cases treated with ITSRPD after at least 15 years. METHODS The study sample comprised 20 consecutively treated patients (13 men, seven women; mean age at the time of implant placement 56 years, range 44–67). The patients were informed, and written informed consent forms were used. The declaration of Helsinki followed. The study subjects were partially edentulous. Only medically healthy patients that were treated with ITSRPD were included. No other exclusion criteria were applied. All patients were examined clinically and radiographically before implant placement. Implants (Zimmer Dental, Carlsbad, CA, USA; Friadent, Mannheim, Germany; or MIS Implants Technologies, Shlomi, Israel) were placed in order to improve unfavorable RPD design resulting from unfavorable teeth distribution and biomechanical considerations, esthetic, or periodontal challenges (i.e., mobile abutment teeth, bone loss, etc.). The length of all the implants was 10 mm or more (ranged between 10 and 13 mm), and the diameter was
3.7 mm or more (ranged between 3.7 and 5 mm). The prosthetic elements that were used with the implants to support the RPDs were ball attachments and bar design connections. Overall, 42 dental implants were placed in the study population. In addition to the implants, teeth were selected as abutments to provide support for the ITSRPDs based on their pulpal and periodontal condition (bone support, mobility, etc.), the presence and type of coronal restoration, the need for indirect retention, and the distribution and number of abutments and implants in the arch. Guiding planes and rest seat preparations were performed after treatment planning and cast survey. Prior to dental implant placement, patients underwent active periodontal phase treatment to achieve a stable periodontal condition with no pockets above 4 mm. All patients were followed up every 6 months for the first 2 years and annually thereafter for at least 15 years. Recall visits for professional cleaning (supragingival and subgingival debridement) and oral hygiene re-enforcement were scheduled every 3 to 6 mounts according to the patients’ periodontal disease history and risk factors. The presence of clinical signs of mobility and gingival inflammation around implants and teeth was evaluated. These included periodontal probing depth, tooth mobility according to Miller’s classification, and bleeding on probing. Radiographic evaluation of bone levels around the implants was also assessed as previously reported.8,9 Prosthetic complications such as loss of retention and fractures of the prosthetic elements were recorded. A questionnaire at the last recall appointment was used to assess patient satisfaction regarding function, esthetics, and convenience of the prosthesis on a 1 to 5 scale (1, very unsatisfied; 5, highly satisfied). RESULTS A total of 42 implants were placed in 20 partially edentulous patients that were restored with ITSRPD and followed up for at least 15 years (Table 1). Maxillary prostheses were provided to 10 patients and mandibular to 10 patients. All implants and prosthetic devices functioned successfully throughout the 15 years of follow-up. Three patients had gone through further implant placement several years after ITSRPD was provided, and a fixed implant-supported restoration was provided on the
61/F
49/F
57/M
44/M
47/F
58/M
51/M
64/F
65/M
48/F
46/F
50/M
67/M
66/F
63/M
55/M
54/F 62/M 61/M
2
3
4
5
6
7
8
9
10
11
12*
13
14
15
16
17
18 19* 20*
No No No
Yes
No
No
No
No
No
No
Yes
No
Yes
No
No
No
Yes
No
No
No
Smoking
Class III mod I Class II mod I Class I
CLASS II mod I
Class I
Class IV
Class II mod I
Class I mod I
Class II mod I
Class III mod I
Class II mod II
Class I mod I
Class I
Class II mod II
Class I
Class II mod I
Class II mod I
Class I
Class I
Class II mod I
Arch Configuration
Rt Max 1st PM Lt Max 1st M Lt Max canine Lt Max 2nd PM Rt Max 1st M Rt Mand canine Rt Mand 2nd PM Rt Mand 1st M Rt Mand1st PM Lt Mand1st PM Rt Max1st M Lt Max 1st PM Rt Max 1st PM Lt Max 1st PM Lt Max 2nd M Lt Mand lat. incisor Rt Mand lat. incisor Lt Mand 2nd PM Rt Mand 2nd PM Lt Mand incisor Rt Mand canine Lt Mand canine Lt Mand 2nd PM Rt Max 1st PM Lt Max 1st PM Rt Mand canine Lt Mand 2nd PM Lt Mand lat incisor Rt Mand lat incisor Rt Max canine Rt Max 1st PM Lt Max 1st PM Lt Mand lat incisor Rt Mand lat incisor Lt Max 1st PM Rt Max 1st PM Lt Max 1st PM Rt Max 2nd M Lt Mand 1st PM Lt Max 1st PM Rt Max canine Rt Max 2nd PM
Implant Location
1 1 0 1 0 0 0 1 1 0 1 0 0 1 1 0 1 1 1 1 2 0 0 1 0 0 1 0 1 0 0 1 0 1 0 0 2 1 2 1 1 1
Marginal Bone Loss (mm)
Bar Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Ball Bar
189 184 193
193
183
185
190
188
181
185
182
188
189
183
181
180
190
186
Ball Bar Ball Ball Ball Ball Ball Ball
189
192
Follow-Up (Months)
Ball Ball Bar
Ball/Bar Design
*Those patients who had gone through further implant placement several years after ITSRPD was provided and a fixed implant-supported restoration was provided on the original and new implants. ITSRPD, implant tooth-supported removable partial denture; Lt, left; M, molar; Mand, mandibular; Max, maxillary; PM, premolar; Rt, right.
53/M
Age/Gender
1
Patient No.
TABLE 1 Patient Information
Implant Tooth-Supported Removable Partial Denture 919
920
Clinical Implant Dentistry and Related Research, Volume 17, Number 5, 2015
A
B
C
D
Figure 1 A and B, Original implant tooth-supported removable partial denture (ITSRPD) of patient no. 12 on Table 1. C and D, After adding two distal implants, a fixed restoration could be provided using the old and new implants. This highlights the importance of carefully planning implant position when choosing the ITSRPD modality to enable future transition to fixed implant-supported restoration.
original and new implants (Figure 1). No implant failure was noted during follow-up, resulting in a rate for implant survival of 100% for the study. During the follow-up period, prosthetic complications were minor and included one rest rupture of a clasp assemble around a natural mandibular tooth. No clinical signs of mobility or gingival inflammation around implants and teeth were reported. Probing depths around all implants were less than 5 mm with no bleeding on probing present. Marginal bone loss around implants ranged between 0 and 2 mm (mean 0.64 1 0.6 mm; see Table 1). All patients answered the questionnaire and were satisfied with the prosthesis. They reported good chewing ability and stability of the prosthetic devices (Table 2).
DISCUSSION ITSRPD can be considered as an alternative to conventional RPDs and implant-supported fixed partial prostheses when the implant’s insertion is limited by bone height and thickness or by financial reasons. In this situation, a small number of implants can be placed to
TABLE 2 Self-Reported Patients’ Satisfaction from the Prosthesis on a 1–5 Scale
Function (n = 20) Esthetics (n = 20) Convenience (n = 20)
Mean Score
SD
Range
4.6 4.8 4.75
0.6 0.4 0.4
3–5 4–5 4–5
Scale: 1 = very unsatisfied; 5 = highly satisfied.
Implant Tooth-Supported Removable Partial Denture
stabilize the RPD, provide comfort, and increase patient masticatory efficacy.7 The available literature as well as our current report suggests that the association of RPD with implant improves the prosthetic biomechanics, resulting in greater patient satisfaction and high survival rates for the implants with stable bone level around the implants.1–7 A recent systematic review revealed high implant success rate and increasing patient satisfaction for RPD associated with implants in Kennedy classes I and II. However, some prosthetic complications and need of repair were observed.7 The authors reported that there is also a lack of information about long-term success of implants associated with RPDs to enhance their safety and predictability in daily prosthodontics practice.7 Thus, the results of the present study, with 15 years of follow-up, might serve as a good indication for the long-term success of ITSRPD in carefully selected and well-maintained population. The stable bone level around the implants is an encouraging finding that might also be attributed to the strict maintenance program provided to those patients. As for conventional RPD, Vermeulen and colleagues reported that only 40% of conventional metal frame RPD survived 5 years when abutment retreatment served as a failure criterion.10 The proposed design of ITSRPD seems to benefit the abutment periodontal health and long-term influence on abutment prognosis. However, as periodontal disease and dental caries are still a concern in RPD wearers, patients should be advised of their role in maintenance, and a definite recall system is mandatory to obtain satisfactory long-term results. Campos and colleagues conducted a study aimed to elucidate the ability of conventional free-end RPD, supported by implants to influence swallowing threshold parameters and nutrient intake. Their results showed that subjects using free-end RPD retained by implants experienced better mastication and increased nutrient intake compared with conventional RPD.11 Furthermore, an increased intake of energy, carbohydrates, protein, fiber, calcium, and iron after 2 months with free-end RPD over implants was observed. To assess implant-supported RPDs in vivo, Ohkubo and colleagues12 treated five patients with posterior mandibular edentulism using RPDs that were either supported or not supported by endosseous implants.
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The masticatory movements, occlusal force, contact points, center of occlusal force, and patients’ preferences were measured to compare the ITSRPDs with conventional RPDs. Within the limitations of their pilot study, they have concluded that ITSRPDs tended to have lower values for mean time and coefficient of variation of masticatory movement compared with the conventional RPDs, except for the opening phase. ITSRPDs had greater occlusal force than the conventional RPDs, and all the patients preferred the implant-supported RPDs for all criteria (comfort, chewing, retention, and stability). As reviewed and suggested by Grossmann and colleagues,1 implants should be placed in the area of the second molars in distal extension patients, adjacent to the distal abutment in case future-fixed restoration is an option, and medially in Kennedy Class IV arch. Future transformation of the case to a fixed implant-supported restoration should be always in mind when planning ITSRPD (see Figure 1). CONCLUSIONS Within the imitations of this report, in this long-term follow-up of 20 patients with ITSRPD, it seems that this treatment modality can be used with predictable longterm results in carefully selected and well-maintained population. Patients should be advised of their role in maintenance, and a comprehensive recall system is mandatory to obtain satisfactory long-term results. REFERENCES 1. Grossmann Y, Nissan J, Levin L. Clinical effectiveness of implant-supported removable partial dentures: a review of the literature and retrospective case evaluation. J Oral Maxillofac Surg 2009; 67:1941–1946. 2. Grossmann Y, Levin L, Sadan A. A retrospective case series of implants used to restore partially edentulous patients with implant-supported removable partial dentures: 31-month mean follow-up results. Quintessence Int 2008; 39:665–671. 3. Mijiritsky E. Implants in conjunction with removable partial dentures: a literature review. Implant Dent 2007; 16:146–154. 4. Mijiritsky E, Ormianer Z, Klinger A, Mardinger O. Use of dental implants to improve unfavorable removable partial denture design. Compend Contin Educ Dent 2005; 26:744– 746. 5. Mijiritsky E, Karas S. Removable partial denture design involving teeth and implants as an alternative to unsuccessful fixed implant therapy: a case report. Implant Dent 2004; 13:218–222.
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6. Mitrani R, Brudvik JS, Phillips KM. Posterior implants for distal extension removable prostheses: a retrospective study. Int J Periodontics Restorative Dent 2003; 23:353–359. 7. de Freitas RF, de Carvalho Dias K, da Fonte Porto Carreiro A, Barbosa GA, Ferreira MA. Mandibular implant-supported removable partial denture with distal extension: a systematic review. J Oral Rehabil 2012; 39:791–798. 8. Levin L, Hertzberg R, Har-Nes S, Schwartz-Arad D. Longterm marginal bone loss around single dental implants affected by current and past smoking habits. Implant Dent 2008; 17:422–429. 9. Levin L, Nitzan D, Schwartz-Arad D. Success of dental implants placed in intraoral block bone grafts. J Periodontol 2007; 78:18–21.
10. Vermeulen AH, Keltjens HM, van’t Hof MA, Kayser AF. Ten-year evaluation of removable partial dentures: survival rates based on retreatment, not wearing and replacement. J Prosthet Dent 1996; 76:267–272. 11. Campos CH, Gonçalves TM, Rodrigues Garcia RC. Implant retainers for free-end removable partial dentures affect mastication and nutrient intake. Clin Oral Implants Res. DOI: 10.1111/clr.12165 12. Ohkubo C, Kobayashi M, Suzuki Y, Hosoi T. Effect of implant support on distal-extension removable partial dentures: in vivo assessment. Int J Oral Maxillofac Implants 2008; 23:1095–1101.
