Review article

Should edentulous patients be constrained to removable

complete dentures? The use of dental implants to improve
the quality of life for edentulous patients

Ilser Turkyilmaz1, Andrea M. Company2 and Edwin A. McGlumphy3

1
Department of Prosthodontics, Dental School, University of Texas Health Science Center at San Antonio, TX, USA; 2Department of Restorative
and Prosthetic Dentistry, College of Dentistry, The Ohio State University, Columbus, OH, USA; 3Department of Restorative and Prosthetic
Dentistry, College of Dentistry, The Ohio State University, Columbus, OH, USA

doi:10.1111/j.1741-2358.2009.00294.x
Should edentulous patients be constrained to removable complete dentures? The use of dental
implants to improve the quality of life for edentulous patients
Background: Nowadays, there is some speculation among dental educators that the need for complete
dentures will significantly decrease in the future and that training in their provision should be removed
from the dental curriculum.
Objective: To sensitise the reader to the functional shortcomings of complete denture therapy in the
edentulous patient and present restorative options including implants to improve edentulous quality of life
in these patients.
Methods: Information retrieval followed a systematic approach using PubMed. English articles published
from 1964 to 2008, in which the masticatory performance of patients with implant-supported dentures was
assessed by objective methods and compared with performance with conventional dentures, were
included.
Results: National epidemiological survey data suggested that the adult population in need of one or two
complete dentures will increase from 35.4 million adults in 2000 to 37.9 million adults in 2020. Clinical
studies have showed that the ratings of general satisfaction were significantly better in the patients treated
with implant overdentures post-delivery compared with the complete denture users. In addition, the
implant group gave significantly higher ratings on comfort, stability and ability to chew. Furthermore,
patients who received mandibular implant overdentures had significantly fewer oral health-related quality
of life problems than did the conventional group.
Conclusion: Implant-supported dentures including either complete overdentures or a hybrid prosthesis
significantly improve the quality of life for edentulous patients compared with conventional removable
complete dentures. Therefore, the contemporary dental practitioner should consider other options as well
as conventional removable complete dentures to restore edentulous patients.

Keywords: implant, edentulous, denture, satisfaction, hybrid.

Accepted 12 February 2009

the dental curriculum, as well as a common belief

Introduction
Trends in edentulism and denture use
Recently, there has been informed speculation
among restorative dentists and dental educators
that the need for dentures will decrease markedly
in the future. There is also interest over whether
complete denture training should be removed from
Ó 2009 The Authors
Journal compilation Ó 2009 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2010; 27: 3–10
based on epidemiological trends that the number of
edentulous adults will decrease. Retention rates
for natural teeth are increasing, and anecdotal
reports reveal that some dental schools are
having difficulty finding complete denture patients
for students to treat1. Although the percentage
of edentulous adults has decreased in the
past 20 years, demographic trends including the
3
4 I. Turkyilmaz et al.

increase in size and age of the older population Table 2 Number of US adults (in thousands) who need
should not be overlooked2. In contrast to common one or two dentures.
belief, as the baby boom generation matures into
the upper age groups, the demand for complete Age group (years) 1991 2000 2010 2020
dentures will increase over the next 12 years.
25–34 858 670 613 601
Middle-aged (45–64 years) population groups have
35–44 3770 3841 2928 2614
already had enhanced oral health compared with
45–54 5612 7332 7711 5850
previous generations, and the percentage of eden- 55–64 7667 7836 10 232 10 595
tulous adults is expected to further decrease. 65–74 7675 6837 7054 9164
However, there will be a large increase in the 75–84 6166 6613 5934 6381
number of older adults. The combined influence of 85+ 1900 2287 2654 2681
a decrease in the percentage of edentulous adults in Total number 33 648 35 416 37 126 37 886
each age group and an increase in the number of of adults
older adults was analysed in this article. Demand at 30 283 31 874 33 413 34 097
Data on the number of people in each age-spe- 90% utilisation
cific category were obtained from US Census Total number of 53 839 56 493 59 265 61 043
edentulous arches
statistics2,3. Population projections used in this
analysis were taken from the 1996 Statistical
Abstracts of the United States. Table 1 shows the arches was multiplied by the age-specific popula-
1991 population census and the 2000, 2010 and tion size for each year. The projected decrease for
2020 projections for the US population. Several year 2000 was 10% below the 1991 percent e-
substantial trends have been noted from the 1991– dentulism rate; the projected decrease for 2010 was
2020 data: (i) the total adult population will 20% below the 1991 rate and the projected de-
increase significantly from 187 020 000 to 245 139 crease for year 2020 was 30% below the 1991 rate.
000 people; (ii) as baby boomers age, the number of Even with these significant percentage decreases in
adults aged 55 to 74 years will increase by 86%, edentulism, an increase in the actual number of
from 39 280 000 to 73 099 000; (iii) the number of adults will result in an increase in the number of
adults aged 18 to 35 years will not decrease and (iv) dentures needed over the next 12 years. The total
the number of senior adults aged 75 years and of edentulous maxillary, mandibular and combined
older will increase by 61%, from 13 489 000 to arches multiplied by 0.9 equals the projected de-
21 835 000. Thus the US population will age and mand for and use of dentures. Table 2 shows the
grow dramatically over the next 12 years. Wein- edentulous population estimates and the total
traub and Burt4 estimated decreases in the per- number of adults for 1991, 2000, 2010 and 2020.
centage of edentulism for maxillary and mandibu- The real number of dentures needed will be dou-
lar arches for each age group of 10% for year 2000, bled, as most of these people are edentulous in both
20% for year 2010 and 30% for year 2020. Table 2 arches. The bottom row of Table 2 shows the total
shows data obtained when the percentage edent- number of edentulous arches from 1991 to 2020,
ulism in maxillary, mandibular and complete meaning that the demand for complete dentures
will increase.
Dental practitioners should be aware of the
Table 1 Population projections by year and age group in
functional limitations and various restorative op-
thousands.
tions for edentulous patients. Missing teeth, which
are not replaced with prosthesis, results in a poor
Age group quality of life comparable with the effects of cancer
(years) 1991 2000 2010 2020
or renal disease on physical well-being scales5. Of
18–24 26 351 26 258 a
30 138 29 919 particular concern is the mandibular arch as a
25–34 42 889 37 233 38 292 42 934 lower denture often reveals functional problems
35–44 39 268 44 659 38 521 39 612 when compared with the natural dentition. Mas-
45–54 25 743 37 030 43 564 37 740 ticatory performance of people wearing complete
55–64 21 006 23 962 35 283 41 714 dentures is less than 20% of those with a natural
65–74 18 274 18 136 21 057 31 385 dentition6,7. The common reasons for dissatisfac-
75–84 10 311 12 315 12 680 15 375 tion are pain, areas of discomfort, poor denture
85+ 3178 4259 5671 6460
stability and difficulties in eating8. Functional loss
Total 187 020 203 852 225 206 245 139
results from the lack of support and stability, but it
a
Middle estimates of population size. is also affected by reduced salivary flow, decreased
Ó 2009 The Authors
Journal compilation Ó 2009 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2010; 27: 3–10

motor control of the tongue, reduced bite force and
diminished oral sensory function9–12. A recent
study by Ikebe et al.10 on 30 edentulous patients
indicated that 67% of the variation in masticatory
performance is associated with a variation in these
factors.
Clinical studies have indicated that poorer mas-
ticatory performance, patient-related factors such
as ridge height and clinical factors, and technical
quality of dentures affect the patient’s levels of
satisfaction6,7,13,14. Therefore, a detailed history
including questions related to levels of masticatory
function and impact of existing dentures on quality
of life is vital for the treatment planning of the
edentulous patient. There are many options for
restoring the mandibular arch in the edentulous
patient and the options presented in this paper
include a new conventional denture, an implant
overdenture using two or four implants with either
a bar and clip or ball attachments and a complete
implant-supported fixed prosthesis. The relevant
dental literature and related prosthetic methods,
when restoring the edentulous patient, will be
reviewed.
Conventional complete dentures
A new denture can result in improvements in
patient reports of overall satisfaction including
aesthetics, comfort and speech15. However, new
conventional complete dentures will often not
improve functional outcomes15. Awad et al.15
found no improvement to ease chewing carrots,
apples, cheese, sausage, bread or lettuce after new
conventional dentures were provided.
When compared with younger patients, older
denture wearers tend to experience more func-
tional problems8,16. Smith et al.16 observed that
among elderly denture patients, 25% experienced
pain when chewing and 41% needed more time for
chewing. This may be related to age-related phys-
iological changes, such as decreased motor control
of the tongue, decreased biting force or medication-
induced xerostomia. Therefore, the long-term
denture patient who has acceptable function with
age and time may need to be considered for an
implant-supported overdenture due to decrease in
function over years. Also, patients requesting im-
plants often state more psychosocial and functional
problems and are harder to satisfy than patients
requesting conventional dentures8,17. There is a
wide variety in the ability of edentulous patients to
tolerate complete dentures. Some patients adapt
easily to a conventional denture and may report
relatively high levels of function15,18. Other pa-
Ó 2009 The Authors
Journal compilation Ó 2009 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2010; 27: 3–10
Use of dental implants for edentulous patients 5
tients do not have high levels of masticatory func-
tion, but this functional limitation does not ad-
versely impact quality of life reports19. A detailed
dental history, with questions on function and
quality of life measures, including asking patients
what foods they are capable of eating and if current
levels of function adversely impact on daily living,
can be helpful to dental practitioners.
A simple food scale utilised in previous studies
consisted of food listed in increasing levels of dif-
ficulty from soft chewable materials, such as mac-
aroni, dry bread and crackers, to carrots, meats and
peanuts, the latter being difficult for most individ-
uals20. A more detailed measure of the impact of
edentulism on oral health can be obtained by using
the Oral Health Impact Profile (OHIP), a 49-item
questionnaire21,22.
Two implants and ball attachments
The McGill consensus statement on overdentures
suggested mandibular two-implant overdentures as
the first choice of standard care for edentulous
patients23. The evidence currently available sug-
gests that the restoration of the edentulous man-
dible with a conventional denture is no longer the
most appropriate first choice prosthodontic treat-
ment. Dental literature manifested that a 2-implant
overdenture should become the first choice of
treatment for the edentulous mandible.
Many different types of attachments have been
used for implants. If the outcome measured is ini-
tial patient satisfaction, then there is probably very
little difference between ball attachments, magnets,
ERA attachments or Hader bars23–26. However,
several studies with long-term outcomes reported
that the number of adjustments and repairs with
ball attachments was significantly greater than with
a bar and clip27. When compared, the ball attach-
ments are less expensive, require less chairtime,
less technical expertise and will probably provide
the same initial level of patient satisfaction. How-
ever, when implants are malpositioned or diver-
gent, a bar and clip will usually provide a better
functional and aesthetic outcome than the other
form of attachment. Walton observed that ball
attachments used in 100 patients needed three
times more repairs than the bar and clip, and pa-
tients rated the bar and clip more successful27.
Retention of the prosthesis is the main factor for
favourable patient satisfaction, and less patient
satisfaction could be expected if an attachment is
not functioning appropriately28.
Awad et al.25 compared elderly patients’ satis-
faction and oral health-related quality of life with
6 I. Turkyilmaz et al.
mandibular two-implant-supported overdentures
and conventional dentures. Sixty edentulous
patients were randomly assigned to two groups:
patients treated with maxillary conventional den-
tures, and either a mandibular conventional
denture or an overdenture supported by two
implants with ball retainers. Patients rated their
general satisfaction, as well as other features of
their dentures (comfort, stability, ability to chew,
speech, aesthetics and cleaning ability), prior to
treatment and 2 months post-delivery. They
observed that the ratings of general satisfaction
were significantly better in the group treated with
mandibular two-implant overdentures 2 months
post-delivery. In addition, the implant group gave
significantly higher ratings on comfort, stability and
ability to chew. Furthermore, these patients had
significantly fewer oral health-related quality of life
problems than did the conventional group.
Two or four implants and a bar
Several studies comparing implant-supported
overdentures with conventional dentures with
measured outcomes, such as patient function, de-
gree of satisfaction and impact on quality of life, are
available8,13,15. The implant overdenture retained
by a bar/clip has higher patient satisfaction
regarding comfort, stability and ability to chew19,25.
Also, functional outcomes indicate significant
improvements in the ability to masticate, particu-
larly hard food13,15.
A clinical study by Awad et al.15 included 104
edentulous adults, aged 35 to 65 years. The pa-
tients were randomly assigned to two groups that
received either a mandibular conventional denture
(n = 48) or an overdenture supported by two
dental implants with a connecting bar (n = 54). All
subjects rated their general satisfaction and other
features of their original dentures and their new
prostheses (comfort, stability, ability to chew,
speech, aesthetics and cleaning ability) on 100-mm
visual analogue scales prior to treatment and 2
months post-delivery. Oral health-related quality
of life was also evaluated pre- and post-treatment.
The mean general satisfaction score was signifi-
cantly higher in the overdenture group (64) than in
the conventional denture group (89). Furthermore,
the implant group gave significantly higher ratings
on three additional measures of the prostheses
[comfort (89), stability (91) and ease of chewing
(91)]. The corresponding scores were 64, 64 and 61
in the conventional denture group. The results also
showed that the former group was better able to eat
carrots, apples, cheese, bread and sausage. They
Journal compilation Ó 2009 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2010; 27: 3–10
concluded that a mandibular two-implant-sup-
ported overdenture as opposed by a maxillary
conventional denture is a more satisfactory treat-
ment than conventional dentures for edentulous
adults.
Heydecke et al. 29 determined the impact of
mandibular two-implant overdentures or conven-
tional complete dentures on leisure and sexual
activities. In 102 subjects, a Social Impact Ques-
tionnaire was used to assess the impact on social
and sexual activity, including avoiding conversa-
tion, refusing invitations, avoiding sport and feeling
uneasy when kissing and in sexual relationships
and the looseness of the prostheses during such
activities. Ratings were recorded on categorical
scales at baseline and 2 months after treatment.
They found significant improvements in the im-
plant overdenture group for looseness when eating,
speaking, kissing and yawning 2 months after
delivery of the prosthesis and significantly less post-
treatment problems for all parameters.
A 5-year follow-up study by Visser et al.30 in-
cluded 30 patients treated with an overdenture
supported by two implants and 30 patients treated
with an overdenture supported by four implants.
They observed significant improvements in satis-
faction before and after treatment. However, they
observed no differences in satisfaction between the
groups, suggesting that the use of four implants did
not result in improved satisfaction when compared
with using only two.
Completely implant-supported fixed hybrid denture
It has been suggested that prostheses supported by
five implants are more comfortable and stable than
overdentures supported by two or four implants31.
Pain and sore spots are often the chief concerns and
limiting factors in wearing conventional dentures.
Although two inter-foraminal implants provide
some support, the prosthesis is still implant- and
tissue-supported. When additional implants, which
also help with the preservation of bone, are placed,
significant improvements in support, function and
comfort are possible31.
Clinical studies including the introduction of
five-implant-supported mandibular hybrid den-
tures are available in the dental literature32,33.
Friberg et al.32 presented the long-term treatment
outcome of patients with severely resorbed eden-
tulous mandibles treated with dental implants. A
total of 260 implants were inserted in 49 patients,
all of whom exhibited severe resorption of edentate
mandibles. Fixed implant-supported prostheses
were fabricated for 45 patients, whereas four pa-
Ó 2009 The Authors

tients received overdentures. Seventeen implants
failed during the study period (cumulative implant
survival rate 92.3% at l0-year follow-up). Implant-
supported restorations were worn continuously
throughout the investigation by all study patients.
No major clinical or restoration complications oc-
curred in the followed patients, and the patients
reported being satisfied with their hybrid dentures.
The results of their study showed that placement of
short implants without the use of bone grafting
procedures for reconstruction of severely atrophic
edentulous mandibles is a predictable treatment
procedure.
In another study, Feine et al.34 determined most
patients reported that a fixed prosthesis provided
better stability and chewing ability than an im-
plant-supported removable prosthesis, being able to
eat harder food such as carrots, apples and sausage.
However, patients who valued aesthetics and
cleaning ability were generally more satisfied with
an implant-supported removable prosthesis34.
Early or immediate loading protocols of dental implants
The prognostic predictability of the classic two-step
concept for rehabilitation of edentulism has been
well documented during the last three decades35,36.
However, a lengthy period for osseointegration, the
need for several appointments, the need for tem-
porary complete dentures and multiple relines of
these temporary restorations for classic implant
treatment with a fixed-detachable mandibular
prosthesis have been the main disadvantages raised
by both patients and dental practitioners35,36. The
consistently high success rates of the original
treatment concept, the patients’ desire and con-
tinuous improvements in implant materials, de-
signs and surface treatment techniques have led
dental practitioners to reduce the total treatment
time, with modified surgical and prosthodontic
protocols37,38. One-stage surgery and early or
immediate loading, which are among the more
recent advances in implant dentistry, have dem-
onstrated promising results, particularly in the
anterior mandible where bone quality tends to be
high39,40.
Early or immediate loading of dental implants
supporting overdentures
The dental literature has few clinical studies with
the early loading of unsplinted dental implants
supporting mandibular overdentures38,41. Turkyil-
maz et al.38 treated 26 edentulous patients using
two unsplinted dental implants supporting a man-
Ó 2009 The Authors
Journal compilation Ó 2009 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2010; 27: 3–10
Use of dental implants for edentulous patients 7
dibular overdenture. All implants were placed in
the canine regions of each mandible according to
the one-stage surgery protocol. The test group, in
which the overdenture was connected one week
after surgery, and control group, in which the
overdenture was connected 3 months after sur-
gery, were compared. No implant from either
group was lost during a 2-year period. Clinical peri-
implant parameters, clinical implant stability mea-
surements and marginal bone resorptions showed
no statistical differences between the two groups
over 2 years. They concluded that early loading
approach of two dental implants supporting man-
dibular overdenture does not appear to jeopardise
peri-implant soft tissue health, marginal bone
resorption or implant stability.
Payne et al. 41 evaluated the success rates of two
types of implants with early 2-week functional
loading of paired mandibular interforaminal im-
plants with overdentures. Two implants were
placed in the anterior mandible of all participants
using one-stage surgical procedures. Previously
constructed conventional mandibular dentures
(opposing maxillary complete dentures) were
temporarily relined and worn by the participants
for the first 2 weeks. Two weeks after implant
surgery, the mandibular dentures had the tissue
conditioner removed and the appropriate matrices
included for an unsplinted prosthodontic design.
No implant from either group was lost. There were
no significant differences in marginal bone loss,
peri-implant parameters or prosthodontic mainte-
nance between the groups over the study period.
They reported that 1-year follow-up data indicated
that early functional loading of the two different
types is possible as early as 2 weeks after implant
surgery.
Early or immediate loading of dental implants
supporting hybrid dentures
The Brånemark Novum method is one of the
immediate loading protocols available42–44. The
outcomes from clinical follow-up studies have
showed that the Brånemark Novum method is a
useful and safe technique for immediate loading of
mandibular implant-supported prostheses. The
clinical protocol involves the rigid connection of
the implants at the time of surgery, a pre-fabricated
titanium framework, elimination of the traditional
impression procedure and delivery of a permanent
fixed prosthesis on the day of implant placement.
The advantages of the Novum system include the
following: 1-day teeth, one surgical procedure,
immediate positive psychological reinforcement for
8 I. Turkyilmaz et al.
the patient, no extended treatment, no casting and
no impressions44. The disadvantages are as follows:
inability to provide individual crown-and-bridge
units, inability to use for Class II division 1 patients,
lack of additional implants if one implant fails,
difficulty of coordinating with dental laboratory,
expensive reusable components, patient selection
limited by mandibular height, width, shape, size
and density and mental foramina position44.
The OSU (Ohio State University) acrylic frame
method is a more recent method, including no final
impression procedure, developed in response to
some of the difficulties presented with a pre-fabri-
cated metal framework45. The OSU acrylic frame
method consists of an adjustable acrylic resin
framework allowing maximum adaptability for
each mandible’s arch size and shape to accelerate
the fabrication of the metal framework of the final
prosthesis. Thus, final immediate load mandibular
hybrid prosthesis can be fabricated in 4 days. The
advantages of the OSU method over the Brånemark
Novum systems include the following: (i) it can be
used for all patients regardless of the shape of the
arch or limited distance between the mental
foramina; (ii) the surgeon is not limited to a single
number, shape, surface and manufacturer of im-
plant as the OSU method can be used with any
implant system; (iii) misalignments or level dis-
parity between the implants can be easily corrected
using abutments with different heights and angles
and (iv) it is less expensive as no special surgical or
prosthetic armamentarium is needed. Also, it does
not require any final impression procedure that
could cause discomfort to an already exhausted
patient after the surgical procedures, thus decreas-
ing the possibility of damaging the surgical site or
irritation of the mucosa with the impression
material. The primary disadvantage of the tech-
nique is that the framework is not pre-fabricated
and must be cast and fitted. At least 3 or 4 days are
needed to complete the final restoration.
Conclusions
In contrast to common belief, national epidemio-
logical survey data have indicated that the eden-
tulous adult population will increase from 35.4
million adults in 2000 to 37.9 million adults in
2020. Implants have revolutionised restorative
dentistry and have provided benefits for patient
care. Implant-supported dentures, either complete
overdenture or hybrid, significantly improve the
quality of life for edentulous patients compared
with conventional removable complete dentures.
Therefore, the contemporary dental practitioner
Journal compilation Ó 2009 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2010; 27: 3–10
should always consider other options as well as
conventional removable complete denture therapy
to restore edentulous patients.
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Correspondence to:
Dr Ilser Turkyilmaz, Department of Prosthodontics,
Dental School, University of Texas, Health Science
Center at San Antonio, 7703 Floyd Curl Drive,
MSC 7912, San Antonio, 78229-3900 TX, USA.
Tel.: 210-567-6450
Fax: 210-567-6376
E-mail: turkyilmaz@uthscsa.edu
Ó 2009 The Authors