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A 1-year prospective cohort study on mandibular overdentures retained by

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Article in European Journal of Oral Implantology · December 2012

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 CLINICAL ARTICLE ! 367

Miodrag Šćepanović, Jose Luis Calvo-Guirado, Aleksa Marković, Rafael Delgado-Ruiz,

Aleksandar Todorović, Biljana Miličić, Tijana Mišić

A 1-year prospective cohort study on mandibular

overdentures retained by mini dental implants

Miodrag Šćepanović
Key words lower complete denture, lower overdenture, mini dental implants, patient satisfaction, Assistant Professor, Clinic for
Prosthodontics, Faculty of
quality of life Dental Medicine, University
of Belgrade, Serbia

Aim: The aim of this 1-year prospective cohort study was to evaluate the outcomes and complica- Jose Luis
tions of immediately loaded mini dental implants used for stabilizing mandibular overdentures in Calvo-Guirado
Senior Lecturer of Gen-
edentulous patients wearing conventional complete dentures. eral and Implant Dentistry,
Faculty of Medicine and
Materials and methods: Thirty patients received mandibular conventional complete dentures that Dentistry, University of
were subsequently retained by 4 immediately loaded mini dental implants placed in the interforamin- Murcia, Spain

al region. Overdenture success, implant success and biological and prosthetic complications were Aleksa Marković
evaluated after the first year of service. Quality of life using the Oral Heath Impact Profile (OHIP)- Professor, Clinic for Oral
Surgery, Faculty of Dental
EDENT test, satisfaction with dental prosthesis and chewing efficiency using questionnaires and a Medicine, University of
Visual Analogue Scale (VAS) were evaluated twice: after they had received mandibular complete Belgrade, Serbia

dentures, and again after they had received mandibular overdentures. Rafael Delgado-Ruiz
Results: After 1 year, no overdenture failed and 2 implants did not osseointegrate, resulting in a Lecturer of Restora-
tive Dentistry, Faculty of
98.3% success rate for loaded implants and 95.9% for total implants used (3 out of 123 were not Medicine and Dentistry,
University of Murcia, Spain
loaded due to fracture). A flap surgical approach was performed in 7 patients, 3 implants fractured
during insertion, 3 overdentures fractured, occlusion balancing was necessary for 11 dentures and Aleksandar Todorović
Professor, Clinic for
relining for 8. Implant rehabilitation provided significant improvement in quality of life, stability, Prosthodontics, Faculty of
comfort, chewing and speaking ability while no significant differences were found in quality of main- Dental Medicine, University
of Belgrade, Serbia
tenance of hygiene and for aesthetics.
Conclusions: Mini dental implant retained overdentures can be a successful therapeutic procedure Biljana Miličić
Professor, Department
for treating mandibular edentulism that improves quality of life, patient satisfaction and chewing of Medical Statistics and
ability in patients wearing maxillary dentures. Longer follow-ups are needed to validate this therapy Informatics, Faculty of Den-
tistry and Dental Medicine,
in the medium and long-term. University of Belgrade,
Serbia

Conflict-of-interest statement: This study was sponsored by the School of Dentistry at Belgrade Tijana Mišić
PhD student, Clinic of Oral
University, 3M ESPE (Seefeld, Germany) and Nuova Dentale (Belgrade, Serbia) under registration Surgery, Faculty of Dental
number: 1564/1. Medicine, University of
Belgrade, Serbia

Correspondence to:
Prof José Luís
! Introduction speaking1. Treatment of this chronic condition is Calvo-Guirado,
palliative with the aim to improve function, qual- School of Medicine and
Dentistry, University of
Completely edentulous patients meet the World ity of life and patient satisfaction2. The type of Murcia, Mozart No. 1. 1ºG,
30002 Murcia, Spain
Health Organization’s criteria for being handi- dental prosthesis as well as its stability and reten- Tel.: +34 96 826 8353
capped due to their limited ability to perform tion have an impact on quality of life and patient Fax: +34 96 826 8353
Email: joseluis.calvo@um.es
two of the most essential tasks of life: eating and satisfaction3.

Eur J Oral Implantol 2012;5(4):367–379

368 ! Šćepanović et al Mini implant retained overdentures
Complete dentures, the traditional treatment of
edentulism, despite technological progress in their
production, make 10 to 45% of patients dissatisfied
with regard to nutrition, speech and appearance in
public4-6. This dissatisfaction and reduced quality of
life is especially emphasised in mandibular complete
denture wearers7,8.
Mini dental implants (i.e. solid one-piece
implants with a diameter ranging from 1.8 mm to
2.4 mm inserted by single-stage flapless procedure)
allow for an alternative treatment of edentulism.
When first introduced, they were considered as a
transitional device for stabilising provisional pros-
theses during implant healing, but now they are
used as an alternative to conventional implants for
long-term prosthesis function, though long-term
data are scarce9. Treatment of difficult anatomic
conditions such as a thin buccolingual bone dimen-
sion is simpler when using mini dental implants due
to the lack of additional augmentation procedures
and their associated risks, which is important es-
pecially in elderly patients with chronic diseases10.
Additional benefits of mini dental implants as
retainers of overdentures are: good stability of the
dental prosthesis, the possibility of immediate load-
ing and an economically feasible treatment11. The
survival rate of mini dental implants as retainers of
mandibular complete dentures is in the range of
81% to 97.4%9,11-15.
A number of studies16-19 have compared the
quality of life and satisfaction of patients with
standard implant retained overdentures and com-
plete dentures, while only a few case reports11,12,20
have considered mini dental implants. Although
the results of these case reports are promising, ran-
domised controlled trials are needed to determine
the true effect of mini dental implants on quality of
life and patient satisfaction.
Despite certain advantages that mini dental im-
plant retained overdentures offer, complete dentures
are still widely used likely because of their cost effec-
tiveness and simple design.
The aim of this 1-year prospective cohort study
was to evaluate the outcome of immediately loaded
mini dental implants used for stabilising mandibular
overdentures in patients wearing conventional
complete dentures. The present article is reported
according to the STROBE statements (http://
Eur J Oral Implantol 2012;5(4):367–379
www.strobe-statement.org/)21 in order to improve
the quality of cohort study reports.
! Materials and methods
! Study population
This 1-year prospective cohort study was approved
by the Ethics Committee (no. 36/5) and was con-
ducted at the Clinic of Prosthodontics and Clinic of
Oral Surgery, School of Dentistry, University of Bel-
grade from January 2010 to June 2011. The inclu-
sion criteria were:
t
patients younger than 65 years (in order to form
a uniform group, since patients above 65 years
should have a different treatment and some
pre-tests regarding understanding the question-
naires)
t
patients edentulous in both jaws
t
little or non-resorbed mandible (shape A or B
according to the classification of the residual
edentulous ridge proposed by Lekholm and
Zarb22) with at least 15 mm of bone height in
the interforaminal region as well as a minimum
width of 5 mm measured by a caliper
t
presence of skeletal Class I
t
ability to understand and answer the question-
naires and scales used in this study.
The exclusion criteria were:
t
proven signs of osteoporosis and/or autoimmune
diseases
t
psychological or psychiatric conditions that could
affect a participant’s reaction to the treatment.
Patients were recruited to participate in the study
through advertisements in three widely read daily
newspapers. People younger than 65 years, edentu-
lous in both jaws, with or without previous denture
experience, who wanted prosthetic rehabilitation
free of charge were invited to apply by telephone.
Patients who responded to the call received detailed
explanations about the study through an informa-
tion session. Potential participants were clinically
and radiographically (using an orthopantomogram)
examined to assess for eligibility. All recruited partici-
pants signed an informed consent form.
 Šćepanović et al Mini implant retained overdentures ! 369

! Surgical and prosthodontic procedures Fig 1 a) A mandibu-

lar edentulous alveolar
ridge. b) Orthopanto-
In the first phase of the study, patients received mogram of the same
patient. c) The complete
maxillary and mandibular complete dentures made dentures in the mouth.
according to the protocol of the Clinic for Prosthetic
Dentistry, School of Dentistry in Belgrade (Fig 1).
All dentures were compression molded with a long
polymerization cycle (SRIvocap, Ivoclar Vivadent,
Schaan, Principality of Liechtenstein) with SR
a
Vivodent (Ivoclar Vivadent) acrylic teeth, and made
by the same team of specialists in prosthodontics and
dental technicians. All of the dentures were arranged
in conventional balanced occlusion. Prostheses were
revised several times until patients were completely
satisfied with the functional and aesthetic aspects of
the complete denture.
After 15 weeks, each patient received four
1.8 × 13 mm ‘O Ball’ mini dental implants (3M ESPE
MDI®, St. Paul, MN, USA – formerly IMTEC®, OK, b
USA) in the interforaminal mandibular region (Fig 2).
A flapless surgical technique followed by an imme-
diate loading protocol is the standard approach for
mini dental implants23. All implants were inserted
by an experienced oral surgeon, following the pro-
tocol specified by the manufacturer. In most cases,
implants were inserted using the flapless technique
and a flap was raised only in case of technical dif-
ficulties or complications. One hour prior to the sur-
gical intervention, a single dose of 2 g of amoxicillin
(Amoksicilin®, Hemofarm, Serbia) or 0.6 g of clinda- c
mycin (Clindamycin-MIP®, MIP Pharma, Innsbruck,
Austria) in case of penicillin allergy, was administered
to each patient24. The surgical field was infiltrated A soft diet, cold compresses and avoidance of
with 8 ml of articaine with 1:100,000 adrenaline. A smoking were recommended for 7 days. Analgesics
1.1 mm-diameter pilot drill was used (at 1200 rpm, (nimesulide 0.1 g) were prescribed to be taken if
with intermittent motion and under copious irriga- needed. When placed, sutures were removed after
tion using sterile, chilled saline at 5°C) only to perfo- 7 days.
rate the cortical plate (no longer than ½ the threaded Within 24 hours after surgery, the complete
length of the implant) in order to provide good pri- denture was adapted to snap onto the mini dental
mary implant stability. Due to their self-tapping cap- implants, which were immediately loaded (Fig 3).
acity, further implant insertion was performed using The overdenture attachment system consisted of
a finger driver followed by a winged thumb wrench metal housings with O-rings (3M ESPE MDI®) that
and adjustable torque wrench. An insertion torque were embedded in the denture base and coupled
of at least 35 Ncm was required for immediate im- with the O-ball heads of the mini dental implants
plant loading. If less than 35 Ncm of insertion torque (Figs 2 and 3).
was achieved upon final insertion, the implant was Patients received postoperative instructions
removed and replaced with a larger diameter implant about oral hygienic protocol. They were advised to
to obtain sufficient primary stability. maintain hygiene of overdentures and mini dental

Eur J Oral Implantol 2012;5(4):367–379

370 ! Šćepanović et al Mini implant retained overdentures
Fig 2 Four mini dental implants placed in the interforamin-
al region through a flapless approach. O-ball abutments
remain above gingival tissue and provide mandibular den-
ture stabilisation.
Fig 4 Orthopantomogram of immediately loaded mini
dental implants. After 1 year of function, no radiolucency
around the implants is present.
implants as well. The use of a specially designed
ACCESS™ toothbrush (3M ESPE) with curved bris-
tles and waterpick was recommended for cleaning the
abutment surfaces and surrounding soft tissues with
the denture removed. Patients were asked to follow
the instructions and were instructed to remove the
overdentures starting the first day. They were recalled
every 3 months for overdenture maintenance.
The following outcome measurements were
analysed in this cohort study: overdenture success,
mini dental implant success, complications (both
biological and prosthetic), quality of life, patient
satisfaction and chewing ability.
! Overdenture success evaluation
The criteria of prosthesis failure25 used in this study:
t
an overdenture that could not be placed or if the
patient was not using it
t
overdenture failure secondary to implant failures.
Eur J Oral Implantol 2012;5(4):367–379
Fig 3 Intaglio surface of the mini implant overdenture.
Removable O-rings were placed inside metal housings
embedded in the base of the overdenture.
! Implant success evaluation
All patients were clinically and radiographically (using
an orthopantomogram, Fig 4) followed up at least 1
year after the overdenture had been delivered. Each
implant was monitored as an independent unit of
observation.
The criteria of implant success26 set for this study
were:
t
absence of mobility
t
absence of persistent subjective complaints (pain,
foreign body sensation and/or dysaesthesia)
t
absence of a continuous radiolucency around the
implant
t
absence of a recurrent peri-implant infection with
suppuration.
! Surgical and prosthetic complication
evaluation
The presence of the following surgical complications
was evaluated: infection, intraoral haemorrhage,
postoperative pain, lack of primary implant stability,
inadvertent penetration of mandibular cortical bone
plate, neurosensory disturbances, tissue emphy-
sema, fracture of the implant or surgical instrument,
aspiration or ingestion of surgical instruments.
The following prosthetic complications were
recorded if present: loss of retention, debonded/
fractured artificial teeth, fracture in the denture
base, fracture of metal housings, loosening of the
o-rings, denture stomatitis, epulis fissuratum or
decubitus.
 Šćepanović et al Mini implant retained overdentures ! 371

Table 1 Questions and weights for the OHIP-EDENT questionnaire.

Domain Weight Question

FL 1.253 1. Have you had difficulty chewing any foods because of problems with your dentures?

FL 1.181 2. Have you had food catching in your dentures?

FL 1.213 3. Have you felt that your dentures have not been aligning properly?

P1 0.998 4. Have you had constant pain in the mouth?

P1 1.264 5. Have you felt discomfort when eating any foods because of problems with your dentures?

P1 1.472 6. Have you had sore spots in your mouth?

P1 1.002 7. Have you had uncomfortable dentures?

P2 2.006 8. Have you been concerned about problems with your dentures?

P2 1.902 9. Have you been aware of your situation related to the dentures?

D1 1.266 10. Have you had to avoid eating your food because of problems with your dentures?

D1 1.351 11. Have you had to interrupt your meal due to problems with your dentures?

D1 0.952 12. Have you been unable to eat with your dentures because of problems with it?

D2 1.393 13. Have you been upset because of problems with your dentures?

D2 1.437 14. Have you been embarrassed due to problems with your dentures?

D3 1.572 15. Have you been less tolerant of your partner or family because of problems with your dentures?

D3 2.555 16. Have you been irritable with other people because of problems with your dentures?

D3 2.236 17. Have you avoided going out because of problems with your dentures?

H 1.545 18. Have you been unable to enjoy other peoples company as much because of problems with your dentures?

H 1.567 19. Have you enjoyed life less because of problems with your dentures?

FL: functional limitations; P1: physical pain; P2: psychological discomfort; D1: physical disability; D2: psychological disability; D3: social disability;
H: handicap.

! Quality of life analysis
For the quality of life analysis, the OHIP-EDENT
test developed by Allen and Locker27 in 2002 and
adapted to edentulous patients was used. Patients
completed the OHIP-EDENT test twice: first, 15
weeks after they had received conventional com-
plete dentures (baseline scores) and again 15 weeks
after mini dental implants had been inserted (while
blinded to their baseline scores).
The OHIP-EDENT test consists of seven domains:
functional limitations, physical pain, psychological
discomfort, physical disability, psychological disabil-
ity, social disability and handicap (Table 1). Every
item has six possible answers: never, rarely, some-
times, often, very often and always. The categories
are marked gradually on a six-point Likert scale,
where 1 means never and 6 means always, with
the lower score indicating a better result (improved
quality of life).
The score for each domain was then calculated
by multiplying each score by its weighting and add-
ing the scores together to form the domain score.
The overall score was obtained by adding all domain
scores together.
! Patient satisfaction
For psychometric measurement of patient satisfac-
tion with the dental prosthesis and chewing effi-
ciency, the questionnaires proposed by Awad and
Feine28 and Awad et al29 were used. During this
phase, the patients evaluated their impressions of
comfort, stability, speaking ability, ability to maintain
hygiene, aesthetics and general chewing ability. The
question about patients’ general satisfaction with

Eur J Oral Implantol 2012;5(4):367–379

372 ! Šćepanović et al Mini implant retained overdentures
dentures was left out from the original questionnaire
because patients completed a questionnaire with a
new prosthesis.
Patients rated their responses on a scale of
100 mm, where the beginning of the scale was
labelled as ‘completely dissatisfied’ and ended with
‘completely satisfied’. The values marked on the VAS
scale were rounded up to the nearest integer value.
The patients rated their satisfaction with pros-
theses twice: first, 15 weeks after they had received
conventional complete dentures (baseline scores)
and again 15 weeks after mini dental implants had
been inserted (while blinded to their baseline scores).
! Chewing ability
Ability to chew was evaluated at the same intervals
as quality of life and patient satisfaction. It was also
rated on the VAS scale including six types of food
such as carrots, apples, cheese, bread, sausages and
lettuce. Patients were given different food samples
and asked to mark their impression of chewing on
a scale. The beginning of the scale was labelled
‘impossible to chew’ and ended with ‘not hard to
chew at all’.
Several efforts have been made in order to address
potential sources of bias in this study. When par-
ticipants rated their quality of life, satisfaction with
prostheses and chewing ability a second time (after
rehabilitation with implants), they were blinded to
their baseline scores. Data collectors who assisted
in completing the questionnaires were not informed
whether or not participants had already undergone
implant rehabilitation. Data divided into two groups
(A and B) were analysed by a statistician blinded
to treatment allocated to the group of data. Two
researchers assessed control orthopantomograms
simultaneously.
! Statistical analysis
The required sample size was calculated by the soft-
ware StudySize® (CreoStat HB., Frolunda, Sweden)
for a significance level of 0.05 and a power ! =
80% (type II error) on the basis of a pilot study of
the same design which included 15 participants. The
difference in the overall OHIP-EDENT scores before
and after implant treatment was 20.12 (SD = 13.81).
Eur J Oral Implantol 2012;5(4):367–379
Thirty participants were needed for a significance
level of 0.05 and power of the study of ! = 80%.
For statistical analysis of data, the present authors
used the statistical software package SPSS 18.0 for
Windows (SPSS, Chicago, IL, USA). Scores from the
questionnaires and VAS scale were described using
measures of central tendency (mean and median)
and measures of dispersion (standard deviation,
minimum, maximum). The differences between pre-
implantation and post-implantation mean domain
OHIP-EDENT scores as well as in mean overall
OHIP-EDENT scores, and furthermore values from
the VAS scale regarding patient satisfaction as well
as chewing efficiency were analysed using the Wil-
coxon signed rank test. The level of significance was
set at 0.05.
! Results
Out of 60 potential participants who were exam-
ined for eligibility, 35 met inclusion criteria. Of these
35 eligible participants, 5 were not recruited since
4 were not able to attend check-ups in proposed
observational periods and 1 patient had unrealistic
expectations of the treatment. Therefore, 30 par-
ticipants (16 females and 14 males) aged from 45 to
63 years, who met inclusion criteria, were enrolled
in the study and all of them completed the 1-year
evaluation period.
Participants were recruited and treated from Jan-
uary to June 2010. The follow-up period covered the
time from conventional complete denture delivery to
1 year after immediate loading of overdentures. The
last overdenture retained by mini dental implants
was delivered in June 2010 and the last 1-year
check-up was performed in June 2011. The total
follow-up time of this cohort study was 18 months.
Ten participants were affected by hypertension,
2 participants suffered from controlled diabetes mel-
litus type 2, 3 had thyroid dysfunction, 2 suffered
from asthma, 1 from coeliac disease and spondylitis,
and 12 participants had an inconspicuous medical
history. Enrolled participants were generally adaptive
patients. Twenty out of 30 participants were com-
plete denture wearers before the study. The other
10 participants had untreated edentulism and no
previous experience with dentures.

No participant dropped out of the study dur-
ing the 1-year follow-up period and statistical ana-
lysis was performed using data from all participants.
There were no deviations in the protocol or missing
data.
! Overdenture success
The 1-year prosthesis success rate was 100%, since
implant loss (2 implants in 2 patients) did not jeop-
ardize overdenture function because the remaining
3 implants in the mandible of each of the 2 patients
were sufficient for overdenture stabilisation and
retention.
! Dental implant success
Two implants did not osseointegrate, whereas 118
implants fulfilled the predefined criteria of suc-
cess. This corresponded to a 1-year success rate of
98.3% for loaded implants and 95.9% for the total
number of implants used (3 out of 123 were not
loaded due to intraoperative fracture). Implant fail-
ure occurred in 2 patients in the second and sixth
postoperative week. Patients reported pain around
mentioned implants and the following day, implants
were explanted by the patients themselves when
removing the overdentures to which they remained
attached. Failed implants were not replaced since
the remaining implants were sufficient for overden-
ture stabilisation and retention. All other sites healed
uneventfully.
! Surgical and prosthetic complications
A flap surgical approach was performed in 7
patients because of limited anatomical conditions
(narrow alveolar ridge) for flapless surgery, in order
to prevent accidental perforation of the lingual cor-
tical plate with the risk of sublingual hematoma, a
potentially life-threatening complication. During
the surgical phase of implant placement, 3 implants
fractured in the medial part of the mandibles of
2 patients (Fig 5). Fractured parts were left in
the bone and new implants were placed. Those
patients left the operating room with 4 implants
as retainers of mandibular complete dentures. A
total of 120 mini dental implants were used for
Šćepanović et al Mini implant retained overdentures ! 373
Fig 5 Periapical
radiograph obtained
after surgery show-
ing two fractured mini
dental implants in the
mandible.
stabilization of 30 mandibular overdentures in 30
patients. Their postoperative course was normal
with minimal discomfort. All implants achieved an
insertion torque of at last 35 Ncm, allowing for
immediate loading.
During the 1-year period of observation, 3
overdentures fractured in the area of the metal
housings, likely due to a thin layer of resin. Frac-
tured overdentures were repaired and reinforced,
and no further complications were reported. Loos-
ening of the o-rings or fracture of metal hous-
ings did not occur. Relining of the dentures was
performed in 8 patients whereas minor occlusion
balancing was necessary for 11 dentures. No com-
plication related to the surrounding soft tissues
was observed.
! Between-treatment differences in
OHIP-EDENT scores
Following the delivery of mini dental implant
retained overdentures, the patients reported sig-
nificantly lower OHIP-EDENT scores in all domains
compared with previous scores related to the con-
ventional complete denture (Table 2). The great-
est mean paired difference was reported in the
psychological discomfort domain, while the social
disability domain reported the least improvement
following implant rehabilitation. The post-implan-
tation overall OHIP-EDENT score was significantly
lower compared with the pre-implantation one,
indicating general improvement in quality of life
(Table 2).
Eur J Oral Implantol 2012;5(4):367–379
374 ! Šćepanović et al Mini implant retained overdentures

Table 2 Difference between pre-implantation and post-implantation OHIP-EDENT scores.

OHIP-EDENT score Paired differences

Mean Median SD Min Max Mean ± SD Pa value
(median)
FL * 13.05 12.64 3.67 6.27 21.07 3.52 ± 3.75 (5.60) P < 0.001
FL ** 9.53 9.81 2.91 3.91 16.51
P1 * 11.43 10.09 4.75 5.48 25.86 3.53 ± 4.55 (2.74) P = 0.001
P1 ** 7.90 6.95 3.71 4.48 17.12
P2 * 14.55 14.53 5.37 3.91 23.45 5.70 ± 5.33 (5.60) P < 0.001
P2 ** 8.84 7.82 4.55 3.91 21.44
D1 * 9.79 9.36 3.21 3.57 19.20 4.20 ± 3.63 (3.84) P < 0.001
D1 ** 5.59 5.31 1.92 3.57 10.31
D2 * 7.59 6.38 4.47 2.83 15.59 2.36 ± 3.62 (1.39) P = 0.001
D2 ** 5.23 4.22 3.25 2.83 12.80
D3 * 10.54 9.21 4.48 6.36 23.22 1.81 ± 4.42 (1.57) P = 0.017
D3 ** 8.73 6.36 4.45 6.36 21.06
H * 7.11 6.25 3.65 3.11 15.56 2.33 ± 3.83 (1.57) P = 0.003
H ** 4.78 4.68 2.16 3.11 10.90
Overall * 74.07 74.16 19.9 35.5 117.8 23.46 ± 17.77 (23.21) P < 0.001
Overall ** 50.61 44.77 17.7 29.4 95.62

FL: functional limitations; P1: physical pain; P2: psychological discomfort; D1: physical disability; D2: psychological disability;
D3: social disability; H: handicap
*Pre-implantation; **Post-implantation; Paired differences = pre-implantation – post-implantation; aWilcoxon signed rank
test

! Between-treatment differences in ! Discussion

patient satisfaction
In terms of patient satisfaction, mandibular mini den-
tal implant retained overdentures were rated sig-
nificantly better than complete dentures, with the
greatest improvement in stability followed by com-
fort, chewing ability and speaking ability. Quality of
maintenance of hygiene and aesthetics did not differ
significantly (Table 3).
! Between-treatment differences in
patient chewing ability
After rehabilitation with mini dental implants, chew-
ing ability was significantly improved for all types
of foods tested. The greatest improvement was in
the ability to chew hard and sinewy food particles
(Table 4).
Data from a Cochrane systematic review by Esposito
et al30 revealed a high rate of prosthesis success
after 1 year of function for mandibular overden-
tures retained by immediately loaded implants ex-
cept in 1 trial31, where a high failure rate (42% or
25% depending on the success criteria adopted)
was observed probably due to the limited experi-
ence of the surgeon. Cannizzaro et al25 reported
no prosthesis failure after 1 year of function for
mandibular overdentures supported by two flapless
inserted implants and immediately loaded. A com-
parable 1-year prosthesis success rate of 100% was
observed in the present study.
In the present study, the success rate of imme-
diately loaded mini dental implants in the 1-year
observation period was higher (98.3% for loaded
implants and 95.9% for the total number of implants
used since 3 out of 123 were not loaded due to intra-
operative fracture) than that reported in previous

Eur J Oral Implantol 2012;5(4):367–379

 Šćepanović et al Mini implant retained overdentures ! 375

Table 3 Between-treatment differences in patient satisfaction.

Patient satisfaction Scores (mean ± SD (median))

Pre-implantation Post-implantation Difference Pa Value
Comfort 5.40 ± 0.33 7.53 ± 1.46 -2.13 ± 2.88 P = 0.001*
(5.00) (8.00) (2.00)
Stability 5.27 ± 2.35 8.30 ± 1.26 -3.03 ± 2.71 P < 0.001*
(6.00) (8.00) (3.00)
Speaking ability 6.97 ± 2.36 8.63 ± 1.65 -1.67 ± 2.61 P = 0.002*
(8.00) (9.00) (1.00)
Hygiene 7.20 ± 2.44 7.53 ± 2.13 -0.33 ± 3.05 P = 0.603
(8.00) (8.00) (0.00)
Aesthetic 8.43 ± 1.90 8.70 ± 1.21 -0.27 ± 1.89 P = 0.451
(9.00) (9.00) (0.00)
Chewing ability 5.50 ± 2.40 7.57 ± 1.45 -2.07 ± 2.61 P < 0.001*
(5.5) (8.00) (1.5)

aWilcoxon signed rank test; *Statistically significant; Difference = pre-implantation – post-implantation

Table 4 Between-treatment differences in chewing efficiency.

Chewing efficiency Scores (mean ± SD (median))

Pre-implantation Post-implantation Difference Pa Value
Carrot 5.40 ± 3.26 7.03 ± 2.09 1.63 ± 3.32 P = 0.016*
(6.00) (8.00) (1.00)
Apple 5.90 ± 2.67 8.10 ± 1.47 -2.20 ± 2.83 P = 0.001*
(5.5) (8.5) (1.00)
Cheese 7.07 ± 2.48 8.60 ± 1.33 -1.53 ± 2.53 P = 0.005*
(7.5) (9.00) (0.5)
Bread 5.87 ± 2.59 8.33 ± 1.54 -2.47 ± 2.86 P < 0.001*
(6.00) (9.00) (2.00)
Sausages 5.43 ± 2.70 8.40 ± 1.28 -2.97 ± 2.58 P < 0.0010*
(5.5) (9.00) (2.00)
Lettuce 6.20 ± 2.87 8.07 ± 1.48 -1.87 ± 2.90 P = 0.003*
(6.5) (8.00) (0.00)

aWilcoxon signed rank test; *Statistically significant; Difference = pre-implantation – post-implantation

reports on mini-implants. Ahn et al13 have studied
a very small sample of 27 mini-implants, with a suc-
cess percentage of 96.2%, while Bulard and Vance9
recorded a success rate of 70 to 94%. Elsyad et al15
have published their 3-year prospective study on
112 MDIs used as retention elements for mandibular
complete dentures. All implants were loaded in the
interforaminal region of the mandible using flapless
surgical technique and the success rate was 96.4%.
Griffitts et al11, in their prospective study on 116 mini
dental implants, reported a success rate of 97.4%.
Shatkin et al12 analysed their experience with MDIs
for the retention of complete dentures. The paper
presents a retrospective study of 2514 MDIs placed
in 531 patients with a 5-year observation period. Of
the total number of loaded implants, only 23% were
intended for the retention of a mandibular denture
and their success rate was 95.1%. The high success

Eur J Oral Implantol 2012;5(4):367–379

376 ! Šćepanović et al Mini implant retained overdentures
rate recorded in the present study could be attributed
to consistent adherence to surgery instructions pro-
vided by the manufacturer, allowing for adequate pri-
mary implant stability (high value of insertion torque)
to be achieved as a key prerequisite for a success-
ful immediate loading procedure30. In the literature,
success rates in range of 70 to 94% for mini dental
implants have been reported depending on compli-
ance with manufacturer’s instructions9. In addition,
the present high success rates might be related to
producing new complete dentures for all participants
who received the mini dental implants, which is in
agreement with Shatkin et al32,33 who found a better
success rate in patients who received new complete
dentures compared to patients who had an existing
prosthesis retained to mini dental implants.
In this study concerning 123 mini dental implants,
3 implants fractured during placement into mandi-
bles of two patients, which represented a fracture
rate of 2.44%. A potential cause of implant fracture
could have been surgical technique that was not
adjusted to the characteristics of the local bone. Most
often, the surgical protocol involves only a perfor-
ation of the cortical bone layer using a pilot drill to
achieve sufficient primary implant stability. In dense
bone (type D122, which is often present in the medial
part of the mandible), an extended penetration as
well as wider osteotomy diameter that would allow
decreased insertion torque may be required to reduce
the possibility of implant fracture. The greater prox-
imity between insertion and fracture torque values
due to the reduced diameter of mini dental implants
highlights an increased fracture risk34. In the final im-
plant placement phase, a fracture torque level could
be rapidly achieved when the implant tip reaches the
undrilled apical cortical bone layer35,36. An insertion
torque of 35 Ncm as an indicator of sufficient pri-
mary stability would allow immediate implant load-
ing, while insertion torque values exceeding 45 Ncm
may result in implant fracture. The surgical technique
should be adjusted to bone quality to achieve suffi-
cient insertion torques but avoiding implant fractures.
Whenever possible, mini dental implants should be
placed using the torque wrench and strictly adhere to
the manufacturer’s recommendations37.
Although implant retained overdentures in the
mandible provide predictable results, they appear
to be associated with some prosthetic complications
Eur J Oral Implantol 2012;5(4):367–379
related to denture adjustment, problems with reten-
tion necessitating a change of retainers, loose or
lost abutments, replacement of retentive housings
and fractured denture bases. Most of the complica-
tions occur within the first year of service, leading to
expensive and time-consuming repair procedures38.
In the present study, fractured denture bases were
reported for 3 patients, 8 dentures required relin-
ing, and 11 dentures required occlusion balancing,
but the retentive systems with rubber O-rings were
without any problems over the 12-month observa-
tion periods. The area of the metal housings has
been revealed as a locus minoris resistentiae, likely
due to the thin layer of resin.
The present study has evaluated quality of
life, chewing efficiency and patient satisfaction of
patients treated with mandibular dentures who
were subsequently rehabilitated with mini dental
implant retained overdentures. Previous studies
have shown a difference between patients’ satis-
faction with their dental prostheses and clinicians’
assessments of patients’ oral condition39-42. This
discrepancy was more often present in mandibular
complete denture wearers. In contrast to the clin-
ical assessment of the anatomical condition of the
mouth based on the form of the crest, tissue attach-
ments and tissue quality together with type of
occlusion, patients’ satisfaction with their dentures
is affected by their own perceptions of their ability
to perform oral functions successfully. This indicates
that clinical assessments of dentures are not valid
predictors of patient satisfaction39. Highly sensi-
tive instruments for assessment and comparison of
oral health quality of life, chewing efficiency and
patients’ satisfaction in wearing various types of
prostheses are necessary to generate high-quality
and conclusive results. In this study, oral health
related quality of life was evaluated using OHIP-
EDENT due to its proven validity39. The second
reason for measuring quality of life using the OHIP-
EDENT test was the recommendation of the test
from the European Agency for Global Oral Health
as the specific instrument for edentulous patients43.
To the best of the present authors’ knowledge, this
is the first study in which the OHIP-EDENT test
has been used for patients who received mini den-
tal implants as retainers for a complete mandibular
denture. Patients evaluated quality of life related

to investigated treatment options after a period
of 15 weeks, allowing for optimal neuromuscular
adaptation44. Results of this study indicate that mini
dental implant retained overdentures improve qual-
ity of life, patient satisfaction and chewing ability
compared with conventional complete dentures.
Behavioural aspects in the treatment of eden-
tulism are a major issue. Complete denture wearers
experience decreased self-confidence and decreased
social contact that reduces quality of life and patient
satisfaction45. The present results of the OHIP-
EDENT test indicate a significantly higher possibility
of socialisation and decreased psychological discom-
fort for patients rehabilitated with mini dental im-
plant retained overdentures.
The patients in the present study noticed the
greatest improvement in the stability of the pros-
thesis after it was retained by mini dental implants.
This improvement in stability is the consequence of
additional retention provided by implants and bear-
ing tissue, contrary to complete dentures that only
have tissue support. In agreement with the present
results, Griffitts et al11 noted that a mini dental im-
plant retained overdenture provides a significant
level of patient satisfaction in terms of comfort,
chewing ability and speech, but the category with
the greatest improvement was stability. Additionally,
in the multi-clinic study of Bulard and Vance9, all
patients (with a total of 1,029 mini dental implants)
reported a substantial increase in the stability and
function of their respective prosthesis once the mini
dental implants were placed.
One of the most common complaints of complete
denture wearers is their inability to comminute vari-
ous textures of food27. Oliviera and Frigerio46 found
a high risk of malnutrition for elderly wearing com-
plete dentures. The present study revealed significant
improvement in chewing ability for food of various
consistencies following implant rehabilitation. In the
literature, chewing ability has been evaluated through
subjective and objective methods47. In the present
study, the time of chewing cycles was not relevant
since the evaluation was performed completely as a
subjective assessment, in contrast to objective assess-
ments where time of chewing and food particle size
is much more important48. Our results indicate that
overdentures retained by mini dental implants signifi-
cantly increase patients’ chewing ability, approaching
Šćepanović et al Mini implant retained overdentures ! 377
the physiological value that is 6 times greater than the
value attributed to complete dentures49,50.
The study of Awad and Feine28 revealed that the
largest percentage of patients considers comfort and
chewing ability as the most important factors in patient
satisfaction. In the current study, stability and com-
fort were rated as the most important factors in the
pre- and post-implantation difference. Patients sig-
nificantly improved their masticatory performance in
terms of both sinewy and hard foods. In the present
study, respondents did not perceive a significant dif-
ference in the quality of maintenance of hygiene or
in aesthetics when comparing the mini dental im-
plant retained overdentures and complete dentures,
likely due to their similar design. The question about
patients´ general satisfaction with dentures was left out
from the original questionnaire because, in the present
study, patients completed a questionnaire with a new
prosthesis. In the study of Misch and Misch51, 79%
of patients responded positively to the aforemen-
tioned question, while the responses to the remaining
questions seemed negative. The result suggests that
patients may respond positively to the above question
only when they are satisfied with the new prosthe-
sis, neglecting the influence of mini-implants.
The reported outcome of immediately loaded
mini dental implants used for stabilising mandibular
overdentures in this study might be limited to middle-
aged individuals with mild or moderate alveolar ridge
resorption (shape A or B according to the classification
of the residual edentulous ridge proposed by Lekholm
and Zarb22) and an interforaminal bone height of at
least 15 mm, indicating convenient conditions for im-
plant treatment. Also, in all patients from the study,
maxillary edentulism was rehabilitated using conven-
tional complete dentures. These characteristics of the
recruited participants could reduce the generalisability
(external validity) of the study results.
! Conclusions
The results of the present study suggest that mini
dental implant retained mandibular overdentures
significantly improve the quality of life, patient satis-
faction and chewing ability in patients wearing max-
illary dentures. Longer follow-up periods are needed
to confirm the outcome of this short-term study.
Eur J Oral Implantol 2012;5(4):367–379
378 ! Šćepanović et al Mini implant retained overdentures
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Erratum to
‘The impact of the type and configuration of
abutments and their (repeated) removal on the
attachment level and marginal bone’
In the special issue of EJOI devoted to ‘Marginal
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‘The impact of the type and configuration of abut-
ments and their (repeated) removal on the attach-
ment level and marginal bone’ by Eric Rompen (Eur
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to the confounding factors present in most clinical
studies on platform switching. Misled by a radio-
graph in the quoted papers of Canullo et al (2009)
the author wrote ‘radiographs seem to show that
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non-biocompatible materials were used at trans-
mucosal levels’ while in fact the shadow on the
radiograph were remnants of the Bio-Oss Collagen
graft material.
Additionally, it was mentioned that in these stud-
ies, the number of abutment disconnections was dif-
ferent from Cappiello et al and Vigolo & Givani’s
work, while in all the mentioned articles the number
of abutment disconnections was identical.
Eur J Oral Implantol 2012;5(4):367–379