The effect of attachment type and implant number on satisfaction and quality of life of mandibular implant-retained overdenture wearers

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1 Original Article The effect of attachment type and implant number on satisfaction and quality of life of mandibular implant-retained overdenture wearers Emre Mumcu, Hakan Bilhan and Onur Geckili Department of Prosthodontics, Faculty of Dentistry, Istanbul University, Istanbul, Turkey doi: /j x The effect of attachment type and implant number on satisfaction and quality of life of mandibular implant-retained overdenture wearers Objective: The aim of this study was to compare the quality of life and patient satisfaction outcomes of two attachment systems in mandibular overdentures with different numbers of supporting implants. Materials and methods: Sixty-two edentulous patients with either splinted or single attachments in mandibular implant overdentures with different numbers of supporting interforaminal implants were investigated for patient satisfaction and quality of life in this retrospective study. Comparisons between groups were perceived by the Mann Whitney U test. Relations among the parameters were investigated by Spearman s rho correlation analysis. The results were evaluated statistically at a significance level of p < Results: No statistically significant association is found between visual analogue scales scores and attachment type as well as implant number (p > 0.05), whereas Oral Health Impact Profile (OHIP)-14 total scores for patients with 4-implant-supported bars were significantly lower than all the other attachment types (p < 0.05). Additionally, a negative (rate = 32.2%), statistically significant association between period of edentulism and total OHIP-14 scores was detected (p < 0.05). Conclusions: A mandibular implant-retained overdenture supported with four implants and bar attachments shows the highest quality of life score and patient satisfaction is not influenced by the number of implants or attachment type. Keywords: overdenture, quality of life, patient satisfaction, dental implants, retrospective study. Accepted 24 February 2011 Introduction Edentulous patients frequently experience problems with conventional mandibular dentures 1. Implant-supported mandibular overdentures (ISMODs) offer edentulous patients a betterretained and more stable prosthesis, resulting in improved oral function and patient satisfaction compared to conventional complete dentures 2 5. ISMODs retained by two-ball attachments have been shown to be effective in the treatment of edentulism 2,6 8. Various numbers of interforaminal implants along with different attachment types can be used for ISMODs, depending on the clinician s preference and financial capability of the patient 9,10. There are various attachments available for the clinicians in the market today such as bar connections, ball attachments, magnets, rigid or nonrigid telescopic copings and locators The impact of ISMODs and these attachment types on patient satisfaction and quality of life is recognised as a critical outcome requiring further investigation 3 5,8,14,15. The most commonly used measure to assess the impact of dental treatments on quality of life is the Oral Health Impact Profile (OHIP), which is a disease-specific measure of an individual s perception of the social impact of oral disorders on their well-being. OHIP s validity and reliability are well established 3 5,8, Visual analogue scales (VAS) are commonly used to measure perceptions of subjective phenomena, such as pain, that are difficult to e618

2 Satisfaction of implant overdentures e619 standardise from individual to individual 6. VAS scores are also used to measure satisfaction with dentures, particularly with respect to comfort 6. It is well known that compared with conventional mandibular complete dentures, ISMODs are more retentive and give rise to higher patient satisfaction 3,8,14. However, the literature lacks clinical studies that compare both quality of life and patient satisfaction outcomes of different attachment systems and different numbers of supporting implants in ISMODs. The present study evaluates the effect of different overdenture attachment types and implant numbers on quality of life and patient satisfaction of patients wearing ISMODs. Materials and methods Sixty-two patients treated with ISMODs and maxillary complete dentures between 2006 and 2007 at a university clinic were invited for this retrospective trial (32 women, 30 men; average age: 64.03; range: years). Patient inclusion criteria are as follows: absence of any systemic disease that was likely to compromise implant outcome, ability to read and sign the written consent and the inserted dental implants should belong to only one specific manufacturer (Astra Tech, Mölndal, Sweden). Surgery had been performed as recommended by the manufacturer (Astra Tech) by an experienced oral and maxillofacial surgeon using a one-stage surgical protocol. The included patients were invited to participate exactly 3 years after prosthetic loading of their implants. Informed written consent with regard to treatment and measurement procedures was given by all patients, and approval from the university ethics commission was duly obtained (reference no. 2597). Patient overdentures comprised five groups: two single interforaminal implants, one group with locator attachments, one group with ball attachments, three single interforaminal implants, three splinted interforaminal implants (bar) and four splinted interforaminal implants (bar). At the recall session, a clinical examination was performed by the same two examiners and prosthetic parameters such as occlusion, tissue adaptation, condition of the retentive mechanism and condition of the denture-bearing tissues were evaluated. Pressure spots were eliminated via grinding from inside the denture base. If the denture base adaptation was not acceptable, a relining was performed. Occlusion was checked for premature contacts, which could have arisen because of wear, and eliminated. Any loosened abutment or occlusal screws were tightened up. Loosened retentive mechanisms were either changed or tightened. Patients with the above-mentioned problems (n = 7, three women, four men; average age: 68.02) were allowed to use their ISMODs for one extra month after the corrections were made before completing the questionnaires. The satisfaction questionnaire records seven aspects of patient satisfaction with their prostheses using a 100-mm VAS. The scales are anchored by the extremes of potential responses (e.g. completely satisfied completely dissatisfied). The patients used the scales to record their personal opinions based on the following factors: general comfort, retention, speech, ease of hygiene maintenance, aesthetics, pain and chewing. The original OHIP consists of 49 questions 16. OHIP-14, the shorter and patient-friendly version, consists of 14 questions and covers the same seven domains as OHIP-49: functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability and handicap 14. The five categories of response for each item are as follows: never, hardly ever, occasionally, fairly often and very often. Items are scored on a five-point scale ranging from 0 = never to 4 = very often. Achievable OHIP-14 scores range from 0 to 56. Lower scores represent higher life quality. A Turkish version of OHIP-14 determined to be valid and reliable was used in this study 19. All the patients completed the Turkish version of OHIP-14 together with the abovementioned satisfaction questionnaire. Statistical analysis Statistical analyses (NCSS 2007 & PASS 2008 Statistical Software; NCSS, Kaysville, UT, USA) were undertaken to explore the potential influence of various numbers of implants and of attachment type on quality of life and patient satisfaction. In addition to descriptive statistics (means and standard deviations for continuous variables, frequencies for categorical variables), quantitative data were compared using the Kruskal Wallis test, and comparisons between groups with normal distributions were detected via the Mann Whitney U test. Relations among the parameters were investigated by Spearman s rho correlation analysis. The results were assessed at the 95% confidence interval or a significance level of Results This study examined relations between VAS and OHIP-14 scores and such parameters as ISMOD

3 e620 E. Mumcu et al. type (number of implants and attachment type), patient age and gender and the period of edentulism in months. There was no statistically significant association between VAS scores and ISMOD type (p > 0.05; Table 1), whereas OHIP-14 scores showed a statistically significant difference among ISMOD types (p < 0.05). OHIP-14 total and psychological discomfort scores of patients with 4-implantsupported bars were significantly lower than all other ISMOD types (p < 0.05; Table 2). There was no statistically significant association between VAS and OHIP-14 scores and patient age and gender (p > 0.05; Tables 1, 2 and 3). The period of edentulism averaged ± months (mean 111 ± for the 2 ball, ± for the two locator, ± 228 for the three ball, ± for the three bar and ± for the four bar group). There was no statistically significant association between VAS scores and the period of edentulism (p > 0.05; Table 3). A statistically significant association between period of edentulism and total OHIP scores and scores on the physical disability domain of OHIP was detected (p < 0.05; 32.2% negative association for OHIP total; 30% negative for physical disability), whereas no statistically significant association was found between the remaining domain scores of OHIP and the period of edentulism (p > 0.05; Table 3). Discussion This investigation assessed the influence of attachment type on patient satisfaction and quality of life of ISMOD patients. Using the VAS, most patients in this study were able to express a useful variety of feelings, especially concerning their dentures, including feelings that predate their enrolment in this clinical trial. ISMODs led to satisfaction improvements that were strikingly large, which supports findings from other studies 10,20. Patients having problems with their ISMODs were allowed to use them for an adaptation period of 4 weeks after the corrections were made before completing the questionnaires. It has been shown that adaptation to new dentures occurs within 3 months 21. As the maxillary complete dentures or ISMODs were not changed, a relatively short 4-week period of adaptation was preferred for these patients in the present study 22. With respect to patient satisfaction, no significant differences appeared between attachment types, even when questions specifically addressed such Table 1 Evaluation of VAS scores related to ISMOD type and gender. Gender ISMOD type 2 Ball (n = 14) 2 Locator (n = 14) 3 Ball (n= 12) 3 Bar (n = 11) 4 Bar (n = 11) Male (n = 20) Female (n = 39) p b p a VAS scores General comfort ± ± ± ± ± ± ± Retention ± ± ± ± ± ± ± Chewing ± ± ± ± ± ± ± Speech ± ± ± ± ± ± ± ± ± ± ± ± ± ± Hygiene maintenance Aesthetics ± ± ± ± ± ± ± Pain ± ± ± ± ± ± ± ISMOD, Implant-supported mandibular overdentures; VAS, Visual analogue scales. Value of significance: p < a Kruskal Wallis test b Mann Whitney U test.

4 Satisfaction of implant overdentures e621 Table 2 Evaluation of OHIP-14 scores related to ISMOD type and gender. Gender ISMOD type 2 Ball (n = 14) 2 Locator (n = 14) 3 Ball (n = 12) 3 Bar (n = 11) 4 Bar (n = 11) Male (n = 20) Female (n = 39) p b p a OHIP-14 scores OHIP total 8.07 ± ± ± ± ± ± ± Functional limitation 0.57 ± ± ± ± ± ± ± Physical pain 1.71 ± ± ± ± ± ± ± Psychological discomfort 1.50 ± ± ± ± ± ± ± Physical disability 2.43 ± ± ± ± ± ± ± Psychological disability 0.78 ± ± ± ± ± ± ± Social disability 0.43 ± ± ± ± ± ± ± Handicap 0.64 ± ± ± ± ± ± ± ISMOD, Implant-supported mandibular overdenture; OHIP, Oral Health Impact Profile. Value of significance: p < a Kruskal Wallis test. b Mann Whitney U test Table 3 Evaluation of VAS and OHIP-14 scores related to patient age and period of edentulism. Age Period of Edentulism r s p r s p VAS scores General comfort ) Retention Chewing ) Speech ) Hygiene maintenance ) Aesthetics Pain OHIP-14 scores OHIP total ) Functional limitation ) Physical pain ) ) Psychological discomfort ) Physical disability ) Psychological disability ) Social disability ) Handicap ) OHIP, Oral Health Impact Profile; VAS, Visual analogue scales. Value of significance: p < 0.05 Spearman s rho test. issues as retention, chewing, speech, aesthetics, pain and hygiene. This result was not surprising and is in agreement with published reports on patient satisfaction with different implant attachment types The only significant negative assessments pertained to magnet attachments, when compared with other attachment types in published reports, which were not examined in the present study 6,26,27. The effect of different ISMOD attachment types on quality of life is studied only rarely. Allen and McMillan compared the effect of various implantsupported treatment types on quality of life and found no significant differences between OHIP scores reported by subjects receiving fixed or removable prostheses 5. However, because the main focus of that study was to evaluate the effect of implant support on quality of life, there was an unequal distribution of patients among the fixed and removable prostheses 5. Bilhan et al. 11 found better scores on the OHIP-14 physical disability domain for locator attachments as compared to ball attachments, in a randomised, within-subject clinical trial. The insignificant OHIP-14 scores we obtained when comparing these two attachment types may be due to the retrospective manner of the present study. In

5 e622 E. Mumcu et al. Bilhan et al. s study, 11 a within-subject comparison between the two attachment types had been performed. However, although not significant, the results of the present study showed better scores on the OHIP-14 physical disability domain for locator attachments (mean 2.43 ± 2.37 for locator attachments, 0.83 ± 1.20 for ball attachments), indicating more comfort with locator attachments during eating. In the present study, four-implant bar-supported mandibular overdenture patients showed excellent quality of life scores significantly lower (better quality of life) in OHIP-14 total and physiological discomfort domain than all the other attachment types. It is thought that this study is the first to compare quality of life outcomes of four implant-supported bars with other attachment types. These results may be attributable to the slight improvement of retention, stability and occlusal equilibration of overdentures with increasing numbers of implants, as suggested elsewhere 28 ; however, it is not necessary to recommend four implants for mandibular overdentures as a standard procedure. Usually, two implants are considered sufficient to support a mandibular overdenture 2, and there is no evidence that such mandibular overdentures fail more often 29. Further, the use of fewer implants is less expensive for the patient 29. In accordance with the present findings, most published studies addressing the possible effects of age and gender on patient satisfaction and quality of life agree that neither age nor gender seem to be important factors 24,27,30. The period of edentulism did not affect satisfaction rate, which is in agreement with published reports 27,30,31. However, this variable, surprisingly, affected the total OHIP-14 and physical disability domain, which focuses on eating comfort, showing that ISMODs improve the quality of life of patients edentulous for a longer period of time. This study has two major limitations. First, a validated Turkish version of the OHIP-EDENT was not available at that time of the study; therefore, the Turkish OHIP-14 had to be used for assessing the OHRQL. OHIP-EDENT is the modified shortened version of OHIP for edentulous patients and has proven to be more suitable for use in edentulism than OHIP Secondly, as this was a retrospective study, it was not possible to monitor patient satisfaction and quality of life scores of patients without implant support and thus to see how much each attachment type affected these scores. Conclusions Within the limitations of this study, it may be concluded that an ISMOD supported with four implants and bar attachments shows the highest quality of life score, whereas patient satisfaction is not influenced by the number of implants or attachment type. While patient age and gender did not influence patient satisfaction and quality of life scores, period of edentulism did so in a negative way. References 1. Millar WJ, Locker D. Edentulism and denture use. Health Rep 2005; 17: Feine JS, Carlsson GE, Awad MA et al. The McGill consensus statement on overdentures. Mandibular two-implant overdentures as first choice standard of care for edentulous patients. Int J Oral Maxillofac Implants 2002; 17: Allen PF, McMillan AS, Walshaw D. A patientbased assessment of implant-stabilized and conventional complete dentures. J Prosthet Dent 2001; 85: Awad MA, Locker D, Korner-Bitensky N et al. Measuring the effect of intra-oral implant rehabilitation on health-related quality of life in a randomized controlled clinical trial. J Dent Res 2000; 79: Allen PF, McMillan AS. A longitudinal study of quality of life outcomes in older adults requesting implant prostheses and complete removable dentures. Clin Oral Implants Res 2003; 14: Cune M, van Kampen F, van der Bilt A et al. Patient satisfaction and preference with magnet, barclip, and ball-socket retained mandibular implant overdentures: a cross-over clinical trial. Int J Prosthodont 2005; 18: Heydecke G, Locker D, Awad MA et al. Oral and general health-related quality of life with conventional and implant dentures. Community Dent Oral Epidemiol 2003; 31: Awad MA, Lund JP, Dufresne E et al. Comparing the efficacy of mandibular implant-retained overdentures and conventional dentures among middleaged edentulous patients: satisfaction and functional assessment. Int J Prosthodont 2003; 16: Naert IE, Gizani S, Vuylsteke M et al. A 5-year prospective randomized clinical trial on the influence of splinted and unsplinted oral implants retaining a mandibular overdenture: prosthetic aspects and patient satisfaction. J Oral Rehabil 1999; 26: MacEntee MI, Walton JN. The economics of complete dentures and implant-related services: a framework for analysis and preliminary outcomes. J Prosthet Dent 1998; 79:

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