JADA Continuing Education
Cleansability of and patients’ satisfaction with implant-retained overdentures
A retrospective comparison of two attachment methods
ALBERTO J. AMBARD, D.D.S., M.S.,
JU-CHUN FANCHIANG, D.D.S.,
LEONARD MUENINGHOFF, D.D.S. and
ANANDA P. DASANAYAKE, B.D.S., M.P.H., Ph.D.
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ABSTRACT
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Background. Two important factors in the use of implant-retained overdentures are cleansability and patients’ satisfaction. Limited research has been published concerning the cleansability of these overdentures. On the other hand, studies have compared patients’ satisfaction with conventional dentures and various designs of implant overdentures. However, no studies have compared overdentures retained by Hader bars (Sterngold, Attleboro, Mass.) and direct ERA attachments (Sterngold) in terms of both cleansability and patients’ satisfaction.
Purpose. The authors’ aim was to determine the cleansability of and patients’ acceptance of overdentures retained by direct ERA attachments and overdentures supported by a Hader bar with distal ERA attachments and a Hader clip.
Materials and Methods. Two groups of 10 subjects each were evaluated: Group A, consisting of patients with overdentures retained by direct ERA attachments, and Group B, consisting of patients with overdentures retained by Hader bars. The authors evaluated the subjects between 18 and 24 months after the delivery of the overdentures by means of a questionnaire and a clinical examination to score each patient on gingival, plaque and calculus indexes.
Results. Group A exhibited better results than Group B on calculus, plaque and gingival indexes, but the difference was not statistically significant. The authors found no significant difference between the two experimental groups in satisfaction.
Conclusions. When evaluated in terms of subjects’ satisfaction and calculus, plaque and gingival index scores, implant-retained overdentures supported by direct ERA attachments were similar to those supported by a Hader bar.
Clinical Implications. The two types of overdentures studied are equally satisfactory and easy to clean. Other factors such as biomechanics, patients’ preference and previous experience may be more critical when selecting the retention design for an overdenture supported by four implants.
When two alternative treatments are equally indicated, the patient’s opinion plays an important role in establishing a treatment plan. Studies of patients’ satisfaction provide information regarding the general opinion of a specific population about a treatment modality.
Wismeijer and colleagues1 compared patients’ satisfaction with implant overdentures retained by ball attachments and with those retained by bars, and found no difference. In a similar study, Burns and colleagues2 could not find a significant difference between patients’ satisfaction with overdentures retained by magnets and those retained by O-rings. Naert and colleagues3 published an article comparing overdentures retained with bars and overdentures retained with unsplinted magnets. They could not find a significant difference between the two groups when comparing satisfaction, but the magnet group scored lower on questions related to retention and chewing comfort.
The two types of overdentures studied are equally satisfactory and easy to clean.
The Sterngold ERA (Sterngold, Attleboro, Mass.) and Hader Bars (Sterngold) are retentive devices commonly used for implant-retained overdentures. However, there are no published studies comparing patients’ satisfaction with implant-retained overdentures using these two types of attachments.
A patient’s ability to perform oral hygiene is critical to the maintenance of healthy periodontal tissues. Any prosthetic device should be designed to permit easy access for cleaning. Cune and colleagues4 reported that inflammation of the peri-implant tissues and poor oral hygiene are the primary complications that can be observed with implant-retained overdentures. den Dunnen and colleagues5 suggested that patients using implant-retained overdentures require professional hygiene care, adjustment and treatment of complications. However, there are no clinical studies comparing the effect of various attachments on the ease of cleansability for implant-retained overdentures.
We undertook a study to rate implant overdentures retained by ERA attachments and implant overdentures retained by Hader bars, according to the patient’s acceptability and the cleansability of the implant overdenture.
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MATERIALS AND METHODS
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We conducted the study at the University of Alabama at Birmingham School of Dentistry. After we obtained approval from the institutional review board, we recruited patients from the school’s graduate prosthodontics clinic. The study population was required to meet the following criteria:
- – Subjects must have four Steri-Oss implants (Nobel Biocare USA Inc., Yorba Linda, Calif.) placed in the anterior mandible (positions 21, 23, 26 and 28) by the university’s periodontology clinic.
- – Subjects must have a mandibular implant-retained overdenture using either direct ERA attachments or a Hader bar with distal ERAs and a Hader clip in the midline.
- – The antagonist must be a conventional denture with resin teeth.
- – Residents of the graduate prosthodontics program must have fabricated the overdentures in lingualized occlusion following the same treatment protocol (Figures 1
through 4).
- – The final restorations must have been delivered no later than 18 months before the start of the study, so the investigators would be able to perform the clinical evaluations between 18 and 24 months after delivery.
- – Patients must have had no periodontal recall visit six months before the clinical evaluation in the study.
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Figure 2. Implant-retained overdenture with white distal ERAs (Sterngold, Attleboro, Mass.), yellow Hader bar clip (Sterngold) at the midline and metal housings.
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Figure 4. Overdentures with direct white ERA attachments (Sterngold, Attleboro, Mass.) and metal housings.
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Fourteen patients in the bar group and 13 patients in the ERA group matched the parameters. The investigators contacted the patients by phone and by mail. Twelve patients in the abr group and 10 patients in the ERA group were willing to participate in the study. Two patients in the bar group were removed from the study because they had received prosthodontic treatment from a private practitioner after the delivery of the prosthesis. Thus, we divided the subjects into two groups of 10 each: subjects with direct ERA attachments in Group A and subjects with Hader bars in Group B. The subjects’ mean age was 61.1 years in Group A and 62 years in Group B. This difference was not statistically significant (P = .71). Group A consisted of seven women and three men. Group B consisted of five men and five women. The frequency distribution between the two groups was not significant (Fisher exact test, P = .65). Each group included one black subject and nine white subjects. The racial distribution between the two groups was not statistically significant (Fisher exact test, P 
1.0).
We measured patients’ satisfaction by means of a questionnaire (Figure 5) developed in consideration of the most important aspects used to evaluate overdentures: esthetics, function, retention, stability, comfort and phonation. Our evaluation of questionnaires previously published by Ettinger and Jakobsen6 and Guckes and colleagues7 also affected the design of the questionnaire. Patients ranked the overdentures from 1 to 3 in each category: 1 = not satisfied, 2 = satisfied, 3 = very satisfied. We gave the questionnaire to the subjects after they signed the informed consent form and related paperwork. Subjects were left alone to complete the questions and were instructed to call the investigator when finished. We instructed them to leave a question blank if they did not understand it; then, when he or she had completed the rest of the questionnaire, he or she could call the investigator to request clarification concerning the unanswered question(s). The investigators did not read the results of the questionnaires until all clinical data from all subjects in the study were collected.
We evaluated cleansability by using gingival, plaque and calculus scores. Two clinicians (A.J.A. and J.-C.F.) evaluated the patients after they had finished the questionnaire. To perform the evaluation, the clinicians used a dental mirror, a plastic probe and cotton rolls to gently dry the area without eliminating plaque. Each clinician did not know the results of the other when performing the examination. They used the gingival and plaque scores developed by Löe8 and the Ramfjord9 calculus index.
We used the nonparametric statistical method and the Fisher exact test to evaluate the group differences in race, age and sex. We calculated the Spearman correlation coefficient to determine the relationship between the variables. We analyzed the results by taking the group mean of each variable and testing the difference in the mean using nonparametric analysis of variance.
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RESULTS
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Table 1 shows the results of the questionnaire. Both groups had a score higher than 2 in all individual aspects of the overdentures as well as overall. In terms of appearance, ability to speak, and retention and stability when eating soft food, there was no difference between the groups’ scores. The ERA group (Group A) rated the over-dentures better than the bar group (Group B) when comparing the ease of performing oral hygiene. However, this result did not reach statistical significance. Group B rated all the other aspects of the overdentures higher than did Group A. This includes retention and stability when eating hard food as well as speaking, ease in removing the overdentures, general comfort, comfort when sleeping without the overdentures and overall satisfaction. However, none of these results was statistically significant.
Table 2 shows the correlation between the two examiners. We obtained these data to determine if the clinicians differed significantly in their clinical observations. We found no statistical significance between them. Table 3 shows the results of the clinical examination. Group A performed better in all parameters evaluated, although the results did not reach statistical significance.
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DISCUSSION
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When evaluating patient satisfaction, we found no statistical difference between the two groups. This is consistent with the findings of other studies that have compared implant overdentures retained by various attachments and bars.1–3 Discussing their results, Burns and colleagues2 concluded that simple implant treatment, such as an overdenture retained by two ball attachments, is sufficient. In our clinical experience, a patient’s satisfaction is directly related to his or her expectations and previous denture experiences.
There was no significant difference between the two groups when we compared retention and stability when eating soft or hard food. These results are interesting, considering that overdentures retained by Hader bars are more retentive than those retained by direct attachments.10,11 Retention and appearance are the most important factors for patients using overdentures.6 Studies designed to have patients wearing both types of overdentures (Hader bars and direct ERA attachments) for certain periods are needed so that comparisons can be made.
Direct ERA attachments met with better acceptance than did bars in terms of the ease of performing oral hygiene, although the results were not statistically significant. This result is important because the subjects’ opinions matched their scores on the plaque, gingival and calculus indexes. These results also are important if we consider periimplantitis as one of the major causes of implant failure.
Subjects using ERA attachments had better results in terms of gingival, plaque and calculus scores than did patients with bars. However, the results did not reach statistical significance. We could not find any published study of cleansability or ease of performing oral hygiene when using any type of implant-retained overdentures. Therefore, our results, even though limited owing to the small population size, may be important for future reference.
In this study, subjects had not received a dental prophylaxis in the six months immediately preceding the clinical examination. Our intention with stipulating this was to eliminate a variable that could influence score results. Patients had received oral hygiene instructions on the day of prosthesis delivery by means of a practical demonstration. However, an individual patient’s compliance with and skills in performing oral hygiene may have influenced the results.
The study’s small population size was a significant limitation. There are obvious tendencies in the results that may reach significance in a larger population size. Also, we designed the study after the treatment for all subjects was completed. This may have influenced our population and may have introduced undesired variables.
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CONCLUSIONS
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Within the limitations of our study, we can draw the following conclusions:
- – When evaluating patients’ satisfaction and scores on the gingival index, plaque index and calculus index, we found no significant difference between overdentures retained by a midline Hader bar clip with distal ERA attachments and overdentures retained by four direct ERA attachments.
- – Future studies with a larger population size are needed to compare the tendencies of these results.
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When this study was conducted, Dr. Ambard was a prosthodontic resident, University of Alabama at Birmingham, School of Dentistry. In October, he will be in private practice in Portland, Ore. Address reprint requests to Dr. Ambard at 30 S. Ellsworth St., Naperville, Ill. 60540, e-mail "aambard{at}mac.com".
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When this study was conducted, Dr. Fanchiang was a prosthodontic resident, University of Alabama at Birmingham, School of Dentistry. She now is a fellow in maxillofacial prosthodontics, University of Alabama at Birmingham, School of Dentistry.
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Dr. Mueninghoff is a professor and the director, Graduate Prosthodontics and Continuing Dental Education, Department of Prosthodontics and Bio-materials, The University of Alabama at Birmingham, School of Dentistry.
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FOOTNOTES
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Dr. Dasanayake is an associate professor, Department of Epidemiology and Health Promotion, New York University College of Dentistry.
The findings of this study originally were presented as a table clinic at the American College of Prosthodontists’ annual session in Kona, Hawaii, Nov. 16, 2000.
The authors wish to acknowledge the research committee of the American College of Prosthodontists for selecting this project as one of the six to receive the 1999–2000 American College of Prosthodontists/ESPE Fellowship in Geriatric Prosthodontics.
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REFERENCES
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- Burns DR, Unger JW, Elswick RK Jr, Giglio JA. Prospective clinical evaluation of mandibular implant overdentures, part II: patient satisfaction and preference. J Prosthet Dent 1995;73:364–9.[Medline]
- Naert I, Gizani S, Vuylsteke M, van Steenberghe D. A 5-year prospective randomized clinical trial on the influence of splinted and unsplinted oral implants retaining a mandibular overdenture: prosthetic aspects and patient satisfaction. J Oral Rehabil 1999;26:195–202.[Medline]
- Cune MS, de Putter C, Hoogstraten J. A nationwide evaluative study on implant-retained overdentures. J Dent 1997;25(supplement 1):S13–9.
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- Ramfjord SP. Indices for prevalence and incidence of periodontal disease. J Periodontol 1959;30:51–9.
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ABSTRACT
MATERIALS AND METHODS
