Original Paper

Med Princ Pract 2023;32:61–70 Received: April 1, 2022

Accepted: January 10, 2023
DOI: 10.1159/000529154 Published online: February 3, 2023

Double Crown-Retained Removable Prostheses

Supported by Implants or Teeth and Implants:
A Long-Term Clinical Retrospective Evaluation
Gregor-Georg Zafiropoulos a Moosa Abuzayeda b Colin Alexander Murray c
Mirza Rustum Baig d
aDepartment
of Surgical Sciences, College of Dentistry, Kuwait University, Kuwait, Kuwait; bDepartment of
Prosthodontics, College of Dentistry, MBR University, Dubai, United Arab Emirates; cDepartment of Preventive
and Restorative Dentistry, College of Dental Medicine, University of Sharjah, Sharjah, United Arab Emirates;
dDepartment of Restorative Sciences (Prosthodontics), College of Dentistry, Kuwait University, Kuwait, Kuwait

Highlights of the Study

• Double crown telescopic dentures using implants or teeth-implants as abutments are a good option
for the restoration of partially or completely edentulous arches, avoiding extensive bone augmentative
surgeries.
• Double crown telescopic dentures with distal cantilevers produce better results in terms of technical
complications compared to those with distal extension saddle.

Keywords
Double crowns · Telescopic implant · Tooth-implant
connection · Removable prostheses · Overdentures
Abstract
Objectives: The objective of this retrospective clinical study
was to investigate the survival rates and complications of
implant (I)-retained or tooth-implant (TI)-retained prosthe-
ses and abutments (teeth, implants) over a mean observa-
tion period of 11.26 years. The study also aimed to analyze
the differences and complication rates between implant-re-
tained double crown removable dental prostheses (I-DC-
RDPs) versus tooth-implant-retained double crown remov-
able dental prostheses (TI-DC-RDPs). Material and Methods:
We reviewed the clinical data of 110 nonsmokers (mean age
= 53.9 years) who received DC-RDPs in maxillary or mandib-
ular arches. 153 teeth and 508 implants were used to restore
partially edentulous (PE; TI-DC-RDPs; n = 53) and completely
edentulous (CE; TI-DC-RDPs; n = 57) arches. Two designs of
the distal extension were used: cantilevers (CANs) and sad-
dles (SADs). Restorations were examined for abutment sur-
vival, mechanical, or biological complications. Results: The
10-year survival rates were 99.3% (95% CI: 95.4–99.9%) for
teeth and 99.3% (95% CI: 97.5–99.7%) for implants. The cu-
mulative rates of TI- and I-RDPs free of technical complica-
tions were 77% and 86%, respectively. The risk of complica-
tions was not significantly different between the CAN and
SAD subgroups of I-RDPs (p > 0.05). However, for TI-RDPs,
technical complication risk was significantly higher in SAD
type compared with CAN restorations (p = 0.02). Conclu-
sions: I- and TI-DC-RDPs seem to be recommendable for res-
toration of CE or PE arches. The technical and biological com-
plication rates were lower for I-DC-RDPs in the CE arches

Karger@karger.com © 2023 The Author(s). Correspondence to:

www.karger.com/mpp Published by S. Karger AG, Basel Gregor Georg Zafiropoulos, gregorgeorg.zafiropoulous @ ku.edu.kw
This is an Open Access article licensed under the Creative Commons
Attribution-NonCommercial-4.0 International License (CC BY-NC)
(http://www.karger.com/Services/OpenAccessLicense), applicable to
the online version of the article only. Usage and distribution for com-
mercial purposes requires written permission.
than for TI-DC-RDPs in the PE arches. Regarding the RDP de-
sign, CAN prostheses produced significantly fewer technical
complications than did SAD prostheses.
© 2023 The Author(s).
Published by S. Karger AG, Basel
Introduction
The rehabilitation of completely edentulous (CE) or
partially edentulous (PE) patients with implant (I)-re-
tained prostheses or tooth-implant (TI)-retained pros-
theses can be challenging [1–4]. The feasibility of avail-
able restorative options depends on anatomical consider-
ations, including usable inter-arch space, which inform
strategic decisions to maintain or extract teeth for im-
plant placement [5–7]. Patient-dependent factors, such as
individual preferences, expectations, and financial/insur-
ance considerations, also influence treatment planning.
One treatment option is to use removable dental pros-
theses (RDPs) based on double crowns (DCs, telescopic),
achieved with splinting implants, teeth, or teeth and im-
plants [1, 3, 5, 7]. PE jaws with few remaining abutment
teeth can be restored optimally with tooth-implant-re-
tained double crown removable dental prostheses (TI-
DC-RDPs) [5–9]. In CE arches, implant-retained double
crown removable dental prostheses (I-DC-RDPs) are an
effective attachment-retained overdenture option [10–
13]. DCs were first placed on natural teeth in the 1960s
and have been widely applied for denture support [1, 3, 7,
14]. This approach allows easy access for oral hygiene
maintenance [4, 9, 12, 15, 16], and in the event of abut-
ment (natural tooth or implant) loss, the system may be
adapted to achieve sufficient support for RDPs [3, 14, 17,
18]. Telescopic attachments provide excellent retention
owing to the frictional interaction between the primary
crowns (PrCs) and secondary crowns (SecCrs) [5, 13, 17].
Hard- and soft-tissue deficits can be managed with acryl-
ic and/or ceramic/composite veneer materials, depend-
ing on the prosthesis design [1, 3, 5, 17, 19]. However,
limitations for these restorations include inter-arch space
requirements for construction and extensive tooth prepa-
ration, as well as meticulous, technique-sensitive fabrica-
tion processes.
Types of DCs include rigid parallel-walled telescopic
crowns, rigid tapered conical crowns, rigid tapered elec-
troformed gold crowns, and nonrigid (or resilient) tele-
scopic crowns with clearance fit. Additional variations in
construction method, materials, and retentive features
are available [5, 19–24]. Several investigators have as-
sessed factors affecting the survival of teeth and implants
62 Med Princ Pract 2023;32:61–70
DOI: 10.1159/000529154
with I- and TI-retained RDPs, including DC system type,
numbers, and positions of abutment teeth and implants
[1, 5, 9, 14, 24–27]. Most studies of outcomes for I- and
TI-RDPs with rigid telescopic designs have been retro-
spective and conducted on 20–30 patients; larger group
and long-term follow-up (>10 years) data are scarce [3,
5]. Various RDP framework materials and fabrication
techniques have been used, and the clinical performance
in terms of biological and mechanical complications and
maintenance requirements has been compared [3, 4, 10,
12, 19, 28, 29]. To the best of our knowledge, there are no
reports comparing complication types and rates between
metal-composite resin cantilever (CAN) and hybrid met-
al-composite resin/acrylic resin free-end saddle (SAD)
design-based DC-RDPs.
The primary objective of this retrospective study was
to investigate the long-term survival of implants and nat-
ural tooth abutments with I- and TI-RDPs using rigid
electroformed gold DC designs. Technical and biological
complication types and frequencies were compared be-
tween TI-DC-RDPs and I-DC-RDPs. A secondary objec-
tive was to evaluate and compare prosthetic complica-
tions and periodontal/peri-implant outcomes between
CAN and SAD design DC-RDPs, for TI-DC-RDPs and
I-DC-RDPs. The null hypotheses were that there would
be no differences in terms of biological and technical
complication rates between (i) TI-DC-RDPs and I-DC-
RDPs and (ii) CAN and SAD designs for both TI- and I-
DC-RDPs.
Materials and Methods
Study Population
In this private practice-based, non-randomized retrospective
study, data from 53 PE and 57 CE arches in 110 nonsmoking pa-
tients (59 males and 51 females; mean age 53.9 years [range: 35–
76]) restored with DC-RDPs during the period 2000–2016 were
analyzed. The sample included I- and TI-DC-RDPs, supported by
a total of 508 dental implant abutments and 153 natural tooth
abutments (Table 1). All patients underwent dental extraction and
periodontal treatment at least 3 months prior to the commence-
ment of the treatment presented in this report.
Patients were informed orally and in writing (i.e., informed
consent) about the planned treatment procedures and given at
least 2 weeks for consideration. Patients had the right to withdraw
consent and to interrupt treatment at any time without repercus-
sions. For each patient, the treatment plan and the informed con-
sent were approved by the national health authorities, which also
approved the analysis of the cases and the publication of the results
(Dental Council North-Rhine; Germany; No.: RA 232.20 AK-cls).
All procedures were performed by the first author.
Zafiropoulos/Abuzayeda/Murray/Baig
 Table 1. Patient demographics

Groups Age, years, Females, Males, Observation, years, N of follow-up visits,

mean (range) N (%) N (%) mean (range) mean (range)

A1 – mxl 52.0 (38–61) 7 (44) 9 (56) 11.2 (3–16) 33.1 (10–44)

A2 – mxl 55.3 (38–71) 10 (62) 6 (38) 10.9 (7–15) 32.3 (20–44)
A3 – mdl 52.9 (35–76) 7 (47) 8 (53) 12.0 (7–14) 35.4 (20–42)
A4 – mdl 49.6 (36–73) 2 (20) 8 (80) 11.9 (4–16) 35.3 (11–48)
All A (CE) 52.7 (35–76) 26 (46) 31 (54) 11.4 (3–16) 33.9 (10–48)
B1 – mxl 53.9 (36–72) 9 (43) 12 (57) 11.6 (6–15) 34.2 (18–44)
B2 – mxl 55.4 (41–72) 9 (47) 10 (53) 11.3 (5–15) 33.6 (15–46)
B3 – mdl 56.5 (37–72) 7 (54) 6 (46) 9.9 (6–14) 29.2 (18–42)
All B (PE) 55.1 (36–72) 25 (47) 28 (53) 11.0 (5–15) 32.7 (15–46)
Total 53.9 (35–76) 51 (46) 59 (54) 11.26 (3–16) 33.3 (10–48)
p value* 0.18 0.87 0.44 0.47

CE, complete edentulism; PE, partial edentulism; mxl, maxilla; mdl, mandible. * p value from comparison of total
group A versus total group B.

Selection criteria were as follows: (i) patients who requested RDPs
without maxillary palatal coverage or a mandibular lingual bar/plate;
(ii) no contraindication for implant surgery; (iii) no epilepsy, uncon-
trolled hand twitching, or hand tremor; (iv) no bruxism and/or jaw
clenching; (v) adequate oral hygiene (plaque less than 10% and bleed-
ing on probing less than 8%) at the beginning of implant surgery and/
or restoration; (vi) endodontically treated teeth were not used as the
most distal abutments; (vii) only one restored arch per patient was
selected randomly for inclusion; (viii) second or 3rd molars were ex-
tracted, no implant was placed in these areas, and all restorations
ended at the first molar position; (ix) patients who were unable to
attend the recall appointments or not willing to participate in the
study; and (x) patients with incomplete electronic documentation of
the implant placement, prosthesis fabrication process, and/or follow-
up appointment information.
Initially, 117 patients were enrolled for evaluation in the study.
Applying the abovementioned inclusion and exclusion criteria, 7
patients were excluded from the list. Two patients did not consent
to participate or were unable to attend the recall appointments, 2
patients could not meet the set oral hygiene requirements, and 3
had distal root canal treated teeth. Thus, 110 patients were restored
definitively in one or both arches with I- or TI-DC-RDPs. All re-
stored patients (n = 110) in the study had a minimum follow-up
period of at least 3 years with a maximum of 16 years.
Prosthodontic Treatment and Restoration Design
Implants were placed in accordance with prosthetically driven
protocols: either one-stage (using Straumann Standard Plus [solid
screw], 10 mm of length, Straumann Inst., Basel, Switzerland) or
two-stage (using Camlog root line, 11 mm of length; Camlog Bio-
technologies, Switzerland). They were uncovered and loaded 5
months after placement. The study sample (n = 110) included 2
main groups: group A (CE) (n = 57) and group B (PE) (n = 53),
involving maxillary (mxl) or mandibular (mdl) DC-RDPs. The
prostheses were provided either with CANs (unilateral or bilateral)
or SADs (unilateral or bilateral) and subdivided into subgroups
(A1, A2, A3, A4, B1, B2, and B3) based on the arch type (mxl; mdl)
and design (CAN and SAD) as shown in Tables 1 and 2.
When the 2nd premolar position could serve as the site for the
last abutment tooth or implant, the 1st molar served as a single
CAN tooth for CAN DC-RDP placement (unilaterally or bilater-
ally). The CAN design involved the Co-Cr cast framework with
extension supporting composite resin pontic teeth without flang-
es. When bone support in the 2nd premolar/1st molar region was
deemed to be inadequate and the patient declined augmentative
surgery, implants were placed up to the 1st premolar position and
the two posterior teeth were replaced (unilaterally or bilaterally).
In this case, the distal framework extension parts were designed as
cast meshwork to support an acrylic base with prefabricated den-
ture teeth in the free-end SAD area resting on the residual founda-
tional tissue of the alveolar ridge.
Impressions were recorded using an open-tray technique with
polyether impression material (Impregum; 3M ESPE, St. Paul,
MN, USA). Natural teeth received cast-gold PrCs, and implants
received system-specific UCLA customized implant abutments
(CIAs). PrCs and CIAs were fabricated with a convergence angle
of 2° and cast using a gold alloy (Portadur P4, 68.50% gold; Wieland
Dental, Pforzheim, Germany) and served as primary telescopes
(PrTEs). Electroformed 0.25-mm-thick gold copings (Auro Gal-
vano Crowns [AGCs], Galvano gold, >99.9% gold; Wieland Den-
tal) were fabricated for all abutments and served as SecCrs. Frame-
work castings were constructed in Co-Cr-Mo alloy (Ankatit; An-
katit-Anka Guss, Waldaschaff, Germany).
At try-in, PrTEs and SecCrs were transferred and positioned on
abutments. Consequently, frameworks were placed over the Sec-
Crs and verified with occlusal records. The jaw relationship was
re-recorded with a central tracing device and facebow mounted on
a semi-adjustable articulator (SAM 2P; SAM Praezisionstechnik,
Gauting, Germany) and occlusion adjusted as required. Frame-
works were veneered with a micro-ceramic composite (Ceramage;
Shofu, Ratingen, Germany). Veneering of free-end SADs was
made using an autopolymerizing acrylic resin base material
(PalaXpress Ultra; Heraeus-Kulzer, Hanau, Germany) and prefab-
ricated acrylic teeth (SR; Ivoclar Vivadent, Ellwangen, Germany).
Finally, restorations were tried-in before finishing and polish-
ing. The PrCs were luted to abutment teeth with zinc phosphate

Outcomes of Telescopic Implant and Med Princ Pract 2023;32:61–70 63

Tooth-Implant Prostheses DOI: 10.1159/000529154
 Table 2. Restoration characteristics and abutments used

Group Restorations, Restorations’ Implant abutments, Teeth abutments, Total abutments,

N (%) design N/mean (range) N/mean (range) N/mean (range)

A1 – mxl 16 (15) CAN I-RDP 95/5.9 (5–6) NA 95/5.9 (5–6)

A2 – mxl 16 (15) SAD I-RDP 86/5.4 (4–6) NA 86/5.4 (4–6)
A3 – mdl 15 (14) CAN I-RDP 90/6.0 (6–6) NA 90/6.0 (6–6)
A4 – mdl 10 (9) SAD I-RDP 52/5.2 (4–6) NA 52/5.2 (4–6)
Total group A 57 (52) – 323/5.6 (4–6) NA 323/5.6 (4–6)
B1 – mxl 21 (19) CAN TI-RDP 75/3.6 (3–5) 79/3.8 (3–6) 154/7.3 (6–9)
B2 – mxl 19 (17) SAD TI-RDP 73/3.8 (2–5) 43/2.5 (2–4) 116/6.1 (5–8)
B3 – mdl 13 (12) CAN TI-RDP 37/2.8 (2–5) 31/2.4 (2–4) 68/5.2 (4–7)
Total group B 53 (48) – 185/3.5 (2–5) 153/3.0 (2–6) 338/6.4 (4–9)
TRA: 110 (100%) NA NA NA
Total mxl: 72 (65%) NA NA NA
Total mdl: 38 (35%) NA NA NA

TRA, total restored arches; NA, not applicable; TI, tootth implant; I, implant; RDP, removable dental prosthesis;
CAN, cantilever (unilateral/bilateral); SAD, saddle (unilateral or bilateral).

cement (Harvard; Harvard Dental, Hoppegarten, Germany), and Maintenance

the CIAs were torqued to 35 Ncm. SecCrs were placed on the
PrTEs, and the supra-construction was luted with a self-curing
compomer cement (AGC Cem; Wieland Dental) and allowed to
set for 3–4 min. Occlusion was re-evaluated and restorations were
finished, polished, and delivered.
Complications
Gingivitis and mucositis were treated with debridement and
oral hygiene improvement. Lost teeth and implant abutments were
replaced with implants only when no distal adjacent abutments
were present. Periodontal disease was classified according to Ar-
mitage [21]. Periodontal pockets with probing pocket depths
(PPDs) ≤5 mm and/or attachment loss (AL) ≤3 mm (periodontitis
1) were treated with scaling/root planning. Otherwise, periodontal
surgery was performed (periodontitis 2). Peri-implant mucositis
and peri-implantitis were diagnosed according to Mombelli and
Lang [15] and Lindhe and Meyle [22]. Areas with vertical bone loss
affecting up to 50% of the implant length (peri-implantitis 1) were
treated with augmentative surgery. When vertical bone loss >50%
of the implant length (peri-implantitis 2) was observed, implant
removal and subsequent augmentation of the bone defect were
undertaken. Artificial tooth loss, veneer fractures, and free-end
SAD fractures were repaired in the dental laboratory. In the cases
of implant failure, the DC-RDPs continued to function after the
SecCrs were filled with resin. In the cases of tooth loss, the teeth
were replaced with implants.
After DC-RDP delivery, PE patients were enrolled in support-
ive periodontal care (SPC), comprising quarterly annual follow-up
appointments, wherein restorations were polished and oral hy-
giene was assessed and reinforced. Additionally, patients’ abut-
ments and DC-RDPs were examined for technical or biological
complications.
Data Analysis
Comparisons were made between groups A and B and among
subgroups, with analyses performed at the patient level. Continu-
ous variables were assessed for normality using the Shapiro-Wilk
test. Categorical variables are presented as numbers with percent-
ages and compared using the Pearson’s χ2 test. Outcome variable
data were included in the survival analyses over the follow-up pe-
riod. Hazard ratios (HRs) were calculated to compare complica-
tion and recession risks between groups, among subgroups, and
according to distal extension and implant types. The assumption
of proportional hazards was validated using a log-log plot. Time
intervals from loading to each outcome, capped at the previous
follow-up, were calculated. Kaplan-Meier analysis was used to es-
tablish the cumulative proportions of groups for which the target
outcome had occurred at various follow-up timepoints, using the
patient as the unit of analysis. Cox regression was used to compare
outcomes between patient subgroups and to examine the associa-
tion of complications with recession (from a baseline assumption
of 0). Statistical analyses of the data were conducted using Stata
software (v. 15.1; StataCorp LLC, College Station, TX, USA). The
sample size of this study was determined based on previous similar
studies [9, 30] comparing I-DC-RDPs with TI-DC-RDPs. A post

64 Med Princ Pract 2023;32:61–70 Zafiropoulos/Abuzayeda/Murray/Baig

DOI: 10.1159/000529154
 Color version available online
0.20 0.20
Proportion with natural tooth loss

Proportion with implant failure

0.15 0.15

0.10 0.10

0.05 0.05

0 0
0 5 10 15 0 5 10 15
a Time, years b Time, years

0.40 0.40
I-RDP

Proportion with biological complication

Proportion with technical complication

TI-RDP

0.30 0.30

0.20 0.20

0.10 0.10

0 0
0 5 10 15 0 5 10 15
c Time, years d Time, years

Fig. 1. Kaplan-Meier plots. a Time to natural tooth loss. b Time to implant failure. c Time of appearance of a
technical complication. d Time of appearance of a biological complication.

hoc power analysis based on the differences between the abutment 95.4–99.9%), and 3 of 508 implants (peri-implantitis 2, [2
(implants and teeth) and prostheses survival rates, in terms of the Straumann and 1 Camlog]) failed, yielding a 10-year im-
number of complications observed with the two main modalities
(I-DC-RDPs and TI-DC-RDPs), confirmed 90% power for the
plant survival rate of 99.3% (95% CI: 97.5–99.7%). Ten-
study [31]. year survival rates for Straumann and Camlog (n = 9)
implants were 99.3% and 98.8%, respectively. The esti-
mated rates of implant failure and natural tooth loss at 15
years were 3% (95% CI: 1–9%) and 2% (95% CI: 0–7%),
Results respectively (Fig. 1).
Frequencies of technical and biological complications
The distribution of DC-RDPs by group-subgroup and and recession rates are reported in Table 3. Notably, no
patient-related demographic characteristics are shown in framework or abutment fractures, abutment screw loos-
Table 1. The distribution of 110 DC-RDPs according to ening, or tooth intrusions were observed. Overall, nearly
the arch and distal extension restoration design is pre- one-fifth of patients experienced technical complications,
sented in Table 2. In total, 153 natural teeth and 508 im- while approximately a third of patients experienced bio-
plants (421 Straumann and 87 Camlog) were used as logical complications. Periodontitis and gingivitis oc-
abutments (Table 2). Two out of 153 teeth were lost, curred more commonly in group B than in group A (Ta-
yielding a 10-year tooth survival rate of 99.3% (95% CI: ble 3). Conversely, mucositis and peri-implantitis oc-

Outcomes of Telescopic Implant and Med Princ Pract 2023;32:61–70 65

Tooth-Implant Prostheses DOI: 10.1159/000529154
 Table 3. Summary of key study outcomes (N [%])

Type of Statistic I-RDP TI-RDP All patients

complication (N = 57) (N = 53) (N = 110)

Technical Total complications 8 (7.27/14.03a) 12 (10.90/22.64b) 20 (18.18)

Artificial teeth lost 3 (2.72/5.26a) 3 (2.72/5.660b) 6 (5.45)
Veneering fracture 1 (0.90/1.75a) 5 (4.54/9.43b) 6 (6.36)
Loss of friction 4 (3.63/7.01a) 1 (0.90/1.88b) 5 (4.54)
Free-end SAD acrylic’s fractures 0 3 (2.72/5.66b) 3 (2.72)
% 5 years (95% CI) 4 (1, 13) 13 (7, 26) 8 (4, 15)
% 10 years (95% CI) 14 (7, 27) 23 (14, 37) 18 (12, 27)
% 15 years (95% CI) 17 (9, 32) 23 (14, 37) 20 (13, 30)
Biological Total complications 17 (15.45/29.82a) 20 (18.18/37.73b) 37 (33.63)
Natural tooth loss 1 (0.90/1.75a) 1 (0.90/1.88b) 2 (1.81)
Periodontitis 1c 1 (0.90/1.75 )a
6 (5.45/11.32 ) b
7 (6.36)
Periodontitis 2d 0 6 (5.45/11.32 ) b
6 (5.45)
Gingivitis 0 2 (1.81/3.77b) 2 (1.81)
Mucositis 7 (6.36/12.28a ) 2 (1.81/3.77 )b
9 (8.18)
Peri-implantitis 1e 6 (5.45/10.52a) 2 (1.81/3.77b) 8 (7.27)
Peri-implantitis 2f 2 (1.81/3.50a) 1 (0.90/1.88b) 3 (2.72)
% 5 years (95% CI) 14 (7, 26) 23 (14, 36) 18 (12, 27)
% 10 years (95% CI) 31 (20, 45) 38 (26, 52) 34 (26, 44)
% 15 years (95% CI) 31 (20, 45) 38 (26, 52) 34 (26, 44)
Recessions Total number 52 44 96
1–3 mm 37 29 66
>3 mm 15 15 30
% 5 years (95% CI) 49 (38, 63) 47 (35, 61) 49 (40, 58)
% 10 years (95% CI) 95 (86, 99) 85 (73, 93) 90 (83, 95)
% 15 years (95% CI) 95 (86, 99) 85 (73, 93) 90 (83, 95)
Median years (95% CI) 6 (4, 6) 6 (4, 7) 6 (5, 6)
a% of the total I-RDP. b % of the total TI-RDP. c PPD ≤5 mm, clinical attachment loss (CAL); 3 mm. d PPD > 5 mm;
CAL > 3 mm. e ≤50% (no implant failure). f >50% (implant failure). For abbreviations, please refer to Table 2.

curred more commonly in group A than in group B
(Table 3). Recessions were observed in 87% of restora-
tions (Table 3). Recessions were more common than
technical or biological complications, being observed in
nearly half of the arches within each group by the 5-year
follow-up and affecting nine-tenths of all patients at 10
years (Table 3). The median durations of recession occur-
rence were similar in groups A and B. In the total sample,
recession was observed in more restorations than techni-
cal or biological complications.
Generally, complications occurred within 10 years.
Technical and biological complications were more fre-
quent with TI-RDPs than with I-RDPs. The percentage of
technical complications increased from 5 to 15 years (in

66 Med Princ Pract 2023;32:61–70 Zafiropoulos/Abuzayeda/Murray/Baig

DOI: 10.1159/000529154
 Table 4. Comparison of key study outcomes between patient groups

Type of complication Variable Category Complication, n/N Hazzard ratio (95% CI) p value

Technical Group I-RDP (group A) 8/57 1 0.23

TI-RDP (group B) 12/53 1.74 (0.71, 4.25)
Group A subgroup A1/A3 5/31 1 0.64
A2/A4 3/26 0.71 (0.17, 2.96)
Group B subgroup B1/B3 4/34 1 0.02
B2 8/19 4.40 (1.32, 14.6)
Distal end Bilateral CAN 0/13 a

Unilateral CAN 3/17

0.16
Bilateral SADs 8/35
Unilateral SADs 5/16
Implant type Straumann 18/93 1
0.55
CAMLOG 2/17 0.64 (0.15, 2.75)
Biological Group I-RDP (group A) 17/57 1
0.41
TI-RDP (group B) 20/53 1.31 (0.69, 2.51)
Group A subgroup A1/A3 10/31 1
0.54
A2/A4 7/26 0.74 (0.28, 1.94)
Group B subgroup B1/B3 14/34 1
0.51
B2 6/19 0.73 (0.28, 1.89)
Distal end Bilateral CAN 3/13 0.82 (0.22, 3.08)
Unilateral CAN 7/17 1.60 (0.58, 4.41)
0.71
Bilateral SADs 12/35 1.30 (0.53, 3.19)
Unilateral SADs 7/16 1.73 (0.63, 4.78)
Implant type Straumann 30/93 1
0.55
CAMLOG 7/17 1.29 (0.57, 2.94)
Recessionsb Group I-RDP (group A) 52/57 1
0.48
TI-RDP (group B) 44/53 0.87 (0.58, 1.29)
Group A subgroup A1/A3 29/31 1
0.05
A2/A4 23/26 0.57 (0.32, 0.99)
Group B subgroup B1/B3 27/34 1
0.43
B2 17/19 1.28 (0.70, 2.35)
Distal end Bilateral CAN 13/13 0.95 (0.49, 1.83)
Unilateral CAN 12/17 0.51 (0.26, 1.41)
0.21
Bilateral SADs 31/35 0.77 (0.46, 1.29)
Unilateral SADs 12/16 0.55 (0.28, 1.10)
Implant type Straumann 83/93 1
0.88
CAMLOG 13/17 1.05 (0.58, 1.88)
Technical None 9/23 1
1–3 mm 7/58 2.02 (0.55, 7.39) 0.47
>3 mm 4/29 2.24 (0.52, 9.60)
Biological None 33/46 1
1–3 mm 3/45 0.26 (0.08, 0.87) 0.02
>3 mm 1/19 0.27 (0.04, 1.98)

a Unable to calculate hazard ratios due to no complications in one category; analysis using log rank test. b Findings related to recessions occurring

before a complication only; for abbreviations, please refer to Table 1.

Outcomes of Telescopic Implant and Med Princ Pract 2023;32:61–70 67

Tooth-Implant Prostheses DOI: 10.1159/000529154
group A: 4%, 14%, and 17% and in group B: 13%, 23%,
and 23%; at 5, 10, and 15 years, respectively; Table 3). The
percentage of biological complications also increased
(group A: 14%, 31%, and 31%; group B: 23%, 38%, and
38%, at 5, 10, and 15 years, respectively; Table 3). The cu-
mulative rates of DC-RDPs free of technical complica-
tions were 86% (CI 95%: 73–93%) for I-RDPs and 77%
(CI 95%: 63–86%) for TI-RDPs. There were no significant
differences (p > 0.05) in technical and biological compli-
cations between the two main groups A (I-DC-RDPs)
and B (TI-DC-RDPs) (Table 4). The differences were also
insignificant between the different cantilevered and sad-
dled prosthesis designs for I- and TI-DC-RDPs (p > 0.05),
except for the technical complications between I- and TI-
RDPs, where there were significant differences noted (p <
0.05) (Table 4). The technical complications were 4 times
more frequent in the mxl group B SAD restorations (B2)
compared with the mxl group B CAN (B1) or mdl CAN
(B3) restorations (Table 4). Overall, the risk of developing
a technical complication over the follow-up period was
similar between the A and B groups and across implant
types and prosthetic designs (Table 4; Fig. 1). The risk of
technical complications could not be compared between
subgroups defined by distal extension type due to the lack
of such complications in one group (Table 4). Table 4 also
illustrates that biological complication risk values did not
differ across groups or subgroups, distinguished by distal
extension or implant type. The Kaplan-Meier plots
(Fig. 1) further depict the time-related differences in
complications for both I- and TI-DC-RDPs.
The risk of gingival recession occurrence was similar
in groups A and B (Fig. 1) and for the different subgroups
in group B. The differences were also not significant be-
tween different distal end variations and implant types.
The frequency of gingival recession was about 0.57 times
in groups A2 and A4 compared with groups A1 and A3
(p = 0.05; Table 4).
Discussion
In this private practice-based, non-randomized retro-
spective study, clinical data from 110 nonsmoking patients
receiving DC-RDPs based on I or TI abutments for a period
of up to 16 years were assessed to determine abutment and
prosthesis survival rates and complication types and rates.
No significant differences were found in terms of technical
and biological complications between the two main treat-
ment modalities, I-DC-RDPs and TI-DC-RDPs, thus af-
firming the first null hypothesis of the study. There were
68 Med Princ Pract 2023;32:61–70
DOI: 10.1159/000529154
significant differences found in technical complication
rates between the CAN and SAD designs for the TI-DC-
RDPs, hence rejecting part of the second null hypothesis.
However, the differences in complication rates between the
CAN and SAD I-DC-RDPs and the biological complication
rates of TI-DC-RDPs were not significant, hence the other
part of the second null hypothesis failed to get rejected.
The primary reasons for DC prosthesis selection in this
study included anatomical and/or financial consider-
ations. Two prosthesis designs were tested in this study
with regards to the use of different combinations of mate-
rials and tissue coverage. The CAN design had the com-
posite resin bonded to the cast Co-Cr framework, with
CAN framework extensions supporting composite resin
pontic teeth without flanges. In the SAD design, the frame-
work extensions in the distal extension parts were de-
signed as denture retentive elements continuous with the
metal-composite resin RDPs to support an acrylic denture
base with prefabricated denture teeth in the free-end SAD
area. The hybrid design thus compensated for the soft and
hard tissue deficit, which were difficult to fill with the pon-
tic teeth alone, in addition to the extended span length. To
the authors’ knowledge, these design combinations have
not been examined and compared in the past with I- and
TI-DC-RDPs; hence, the outcomes of this study could not
be meaningfully compared with other similar papers with
regards to the impact of design differences.
The 10-year tooth abutment survival rate (98.7%) in
this study was higher than previously reported [1, 9, 14,
18]. The 10-year implant abutment survival rate (IaSR)
was high in the present study. Previous studies reported
IaSR in the range of 82.3% [5] to 97.4% [18], and a recent
review revealed cumulative IaSRs for DC-RDPs (TI,
98.72%; I, 98.83%) [1]. Koller et al. [13] in their system-
atic reviewing survival of TI- and I-DC-RPDs reported a
survival rate of 100% for teeth-implant-supported pros-
theses in the maxilla, as well as for tooth-supported RDPs.
Furthermore, they reported survival rates of 97–100% for
implant-supported prostheses in the mandible.
The slightly higher complication rate with Straumann
implants compared with Camlog implants may be due to
the more frequent placement of Straumann implants. No
lost implant was replaced in an area with sinus augmenta-
tion. Technical complication rates were significantly
higher for SAD TI-RDPs in the maxillary arch than for
CAN prostheses in both arches; however, there were no
statistical differences between the CAN and SAD I-RDPs.
The variations may be related to the differential mobility
between teeth and implant abutments, causing acrylic
resin free-end SAD and veneer fractures [20].
Zafiropoulos/Abuzayeda/Murray/Baig
 The incidence of complications tended to increase
over the first 10 years, but not significantly. More bio-
logical complications occurred in the group A (PE) with
TI-RDPs than in the group B (CE) with I-RDPs. Occur-
rence of peri-implantitis has been reported, ranging be-
tween 4.3% and 10% [11, 15, 22–24]. In our study, the
higher occurrence of peri-implantitis in patients with I-
RDPs than in those with TI-RDPs is in concordance with
previous studies demonstrating patient-based peri-im-
plantitis and implant loss more frequent in patients with
I-DC-RDPs [9, 18, 25, 26]. Although limited data eluci-
dates the reasons for higher peri-implantitis risk with I-
RDPs, the preservation of natural teeth with TI-DC-RDPs
may allow for the maintenance of functional oral proprio-
ception, enabling wearers to limit stress loading on den-
tures and supporting implants and thereby reducing the
risk of implant failure due to peri-implantitis [9]. The low
rates of mucositis in this study may be attributed to the
patients’ compliance to supportive periodontal care [3, 4,
18, 24, 27, 28]. Detailed descriptions of the occurrence of
gingivitis and periodontitis in patients with DC-RDPs are
scarce. Both conditions were observed more frequently in
patients with TI-RDPs than in those with I-RDPs in this
study. CE arches (group A) demonstrated similar rates of
periodontitis 1 and 2. However, Rinke et al. [23] and Frit-
sch et al. [11] observed no periodontitis in patients with
TI-RDPs [11, 20]. Recession occurred slightly more fre-
quently in the CE arches (group A) than the PE ones
(group B) at a median timepoint of about 6 years in this
study. At all other follow-up timepoints, the 2 groups
showed similar risk of recession development. Memon et
al. [28] observed recession within 5 years in a majority of
PE arches with conventional RDPs but not in arches with
DC-RDPs and suggested it may be attributed to reduced
retention and stability. In our study, fewer recessions
were observed among patients with SAD I-RDPs com-
pared with CAN I-RDPs and the reverse occurred for TI-
RDPs.
The restoration survival rate (rSR) for groups of DC-
RDPs was 100%. Schwarz et al. [29] observed rSRs of
93.3% and 100% (I-DC-RDPs and TI-DC-RDPs, respec-
tively). Frisch et al. [11] reported rSRs for TI-DC-RDPs
of 100% for a mean period of 6 years [17]. Rammelsberg
et al. [9] observed 5-year rSRs of 85% and 92% (for I-DC-
RDPs and TI-DC-RDPs, respectively). In this study, 5
(4.5%) DC-RDPs were repaired due to biological compli-
cations and 20 (1.8%) DC-RDPs were repaired due to
technical complications. The DC-RDPs continued to
function in the 3 cases of implant failure and in the 2 cas-
es of tooth loss.
Outcomes of Telescopic Implant and
Tooth-Implant Prostheses
Although the present study had a large sample size, the
distribution among different groups and subgroups was
not uniform and may not have been adequate to elicit
clinically significant differences between different groups.
Second, information on the opposing arch/es has not
been included in this study, and this factor might have af-
fected the clinical outcomes. Furthermore, follow-up ra-
diographic records could not be acquired for analyses due
to country-specific radiological assessment regulations.
Conclusions
The 10- and 15-year abutment and prosthesis survival
rates determined in this study indicate that I-DC-RDPs
and TI-DC-RDPs could be recommended for restoration
of PE and CE arches. Regarding the RDP design, CAN
prostheses produced significantly fewer technical com-
plications than SAD designs.
Statement of Ethics
Required ethical approvals were obtained from the Dental
Council North-Rhine, Germany (No.: RA 232.20 AK-cls), for con-
ducting and publishing the results of this study.
Conflict of Interest Statement
The authors declare that there is no conflict of interest.
Funding Sources
There were no funding resources for this work.
Author Contributions
Gregor-Georg Zafiropoulos designed the study, performed all
clinical procedures, and contributed to the writing of the manu-
script. Moosa Abuzayeda performed statistical analysis and con-
tributed to the interpretation of the results. Colin Alexander Mur-
ray selected and reviewed the scientific literature and edited the
final manuscript. Mirza Rustum Baig contributed to the analysis
and interpretation of the results and wrote the manuscript. All au-
thors contributed equally to discussing the results and reviewing
the manuscript before submission.
Data Availability Statement
Data are not available for sharing.
Med Princ Pract 2023;32:61–70 69
DOI: 10.1159/000529154
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