SYSTEMATIC REVIEW

Placement of a distal implant to convert a mandibular removable Kennedy class I to an implant-supported partial removable Class III dental prosthesis: A systematic review Karla Zancopé, DDS, PhD,a Gizella M. Abrão, DDS, MSc,b Frederick K. Karam, DDS,c and Flávio D. Neves, DDS, PhDd

INTRODUCTION

ABSTRACT

A bilateral distal extension partial removable dental prosthesis (PRDP) replaces the most distal tooth or teeth on each side of 1 arch of the mouth. Consequently, the masticatory ability decreases compared with fixed rehabilitations.1 During mastication movements, poorly adapted prostheses cause excessive pressure and bone resorption beneath the denture base.2 This resorption may cause the displacement of the PRDP, overloading the abutment tooth. To avoid this situation, which can cause periodontal breakdown, regular recall is recommended.3 Since the 1990s, the placement of a distal implant associated with a PRDP has been reported to make this rehabilitation more stable.4 This option could resolve such intrusion movements5 of the

Statement of problem. A number of authors have reported the placement of a distal implant associated with a partial removable dental prosthesis (PRDP) to make this rehabilitation more stable. This strategy may represent an option for resolving the problem of the intrusive movements of the PRDP and for reducing treatment costs. Purpose. The purpose of this systematic review was to evaluate the current evidence about the placement of a distal implant associated with a mandibular PRDP to improve patient satisfaction and the clinical performance of the abutment tooth and distal implant. Material and methods. Two independent prosthetic specialist reviewers conducted this systematic review. The search was performed using selected clinical studies with PRDP associated with distal implants published in English up to May 2014 from the PubMed and Cochrane Library databases. A data extraction form was developed to collect general information: authors, title, year of publication, aim of study, level of evidence, number of participants, number of implants used, implant system, implant length and diameter, abutment type, masticatory performance, patient satisfaction, implant mean bone loss, abutment tooth mean bone loss, prosthetic complications, follow-up period, and implant survival rate. The quality of the selected studies and the risk of bias were also reported. Results. The initial electronic search identified 231 studies, and the manual process identified 15 studies (total of 246 studies). After the title and abstract reading and the removal of duplicates, the full texts of 43 studies were obtained. The articles that did not meet the inclusion criteria were excluded (28 studies), and the data from 15 studies were extracted. Seven were retrospective studies, 1 a crossover pilot study, 2 case series, 2 paired clinical studies, and 3 case reports, demonstrating that a high number of the selected studies were of low methodological quality. Nevertheless, the high survival rates for PRDP associated with dental implants have been described. Conclusions. The use of a PRDP associated with dental implants to convert a Kennedy class I to class III dental prosthesis benefits patients by improving their satisfaction and masticatory abilities without decreasing implant survival rates. Considering the abutment tooth survival rate, clinical studies with comparable methodology are still lacking to define protocols regarding the use of distal implants associated with PRDP. Long-term, prospective clinical trials are still needed to understand which implant abutments increase abutment tooth survival rate. (J Prosthet Dent 2015;-:---)

a

Postdoctoral Research Fellow, Department of Occlusion, Fixed Prostheses and Dental Materials, Federal University of Uberlândia, Minas Gerais, Brazil. Private practice, Uberlândia, Minas Gerais, Brazil. c Postgraduate student, Department of Occlusion, Fixed Prostheses and Dental Materials, Federal University of Uberlândia, Minas Gerais, Brazil. d Associate Professor, Department of Occlusion, Fixed Prostheses and Dental Materials, Federal University of Uberlândia, Minas Gerais, Brazil. b

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Clinical Implications The use of a partial removable dental prosthesis (PRDP) associated with dental implants to convert a Kennedy class I to class III denture does not decrease the implant survival rate and may ultimately benefit a patient’s satisfaction and masticatory abilities. This treatment could represent an option for resolving the problem of the intrusive movements of the PRDP and for reducing treatment costs.

PRDP while reducing treatment costs, ultimately allowing patients with limited financial resources to access this treatment.6-8 Clinical6-17 and in vitro18,19 studies have been performed to assess the use of distal implants with resilient devices or healing abutments; however, because they only stabilize the PRPD, these devices do not actually convert Kennedy class I or II to Kennedy class III PRDPs. Previous systematic reviews have been performed,20,21 but no data reported the survival rates of the abutment tooth in PRDPs associated with distal implants. Understanding the influence of this treatment on the abutment tooth is important to clarify the predictability of the proposed treatment. A previous study3 reported the deterioration of the probing depths and tooth mobility; a distal implant could minimize these symptoms. Furthermore, because the PRDP already used by the patient can be converted to a replacement PRDP, the economic advantages of this rehabilitation protocol must be considered. The only additional cost will be of 1 implant and 1 abutment, side by side, representing either an interim11 or definitive treatment. In patients with adequate bone, partial fixed implant prostheses, including the addition of 1 or 2 implants, should be planned.12 The aim of this systematic review was to evaluate the evidence supporting the placement of a distal implant associated with a PRDP to improve patient satisfaction and the clinical performance of the abutment tooth and distal implant. MATERIAL AND METHODS A systematic review was conducted by following the PRISMA statement.22 The review question was formulated by following PICO (patient population, intervention, comparison, and outcome) framework23: patient/population, partially edentulous jaw patients; intervention, mandibular bilateral dental implant; comparison, partial removable dental prosthesis; and outcome: clinical performance, patient satisfaction, and clinical follow-up. THE JOURNAL OF PROSTHETIC DENTISTRY

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A focused question was formulated: Does the placement of a distal implant to convert a partial removable dental partial Kennedy class I to an implant-supported removable partial class III denture affect patient satisfaction and the clinical performance of abutment tooth and implants? A literature search of PubMed and Cochrane Library databases up to May 2014 was conducted. The search strategy was based on the use of the following MeSH terms and search terms combination: “Jaw, Edentulous”[Mesh] OR “Edentulous Jaw” OR “Edentulous Jaws” OR “Jaws, Edentulous”; AND “Dental Implants”[Mesh] OR “Dental Prosthesis, Implant-Supported”[Mesh] OR “Implants, Dental” OR “Dental Implant” OR “Implant, Dental” OR “Dental Prostheses, Surgical” OR “Dental Prosthesis, Surgical” OR “Surgical Dental Prostheses” OR “Surgical Dental Prosthesis” OR “Prostheses, Surgical Dental” OR “Prosthesis, Surgical Dental”; AND “Denture, Partial, Removable”[Mesh] OR “Removable Partial Denture” OR “Denture, Removable Partial” OR “Dentures, Removable Partial” OR “Partial Denture, Removable” OR “Partial Dentures, Removable” OR “Removable Partial Dentures.” The authors did not use the RCT filter because there were no randomized controlled trials. A manual searching process was applied based on the bibliographies of selected articles. Two prosthetic specialist reviewers (K.Z. and G.M.A.) independently ran the described search and listed the selected abstracts. The lists were then compared, and a definitive consensus regarding the inclusion of articles was reached by discussing each individual article. Selection criteria Prospective controlled clinical studies and clinical studies reporting a comparison of patient satisfaction and clinical performance (marginal bone changes on the abutment tooth and distal implants) of Kennedy class I PRDPs associated with distal implants were selected. The English language literature published up to May 2014 was selected. All types of human clinical studies with PRDP Kennedy class I associated with distal implants were included. No restriction on the length of the follow-up period was applied. Duplicated and published studies that did not meet the inclusion criteria were excluded from this systematic review. A data extraction form was developed by the authors to collect general information: authors, title, year of publication, journal, impact factor, aim of study, level of evidence, number of participants, number of implants used, implant system, implant length and diameter, abutments used, masticatory performance, patient satisfaction, implant mean bone loss, abutment tooth mean bone loss, prosthetic complications, follow-up period, and implant survival rate. The level of evidence of the Zancopé et al

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selected studies was defined,24 according to Table 1. The Newcastle-Ottawa (NOS) scale was used to report any potential risk for bias. This scale is based on 4 specific components that define the quality of the studies and assess the risk of bias. The criteria used were the following: patient selection, comparability, exposure, and outcome. Two prosthetic specialist reviewers (K.Z. and G.M.A.) evaluated all of the selected studies. After the evaluation process, the study considered a score of 6 or greater out of a total of 9 to have a high risk of bias. Based on the systematic review objectives, inferential statistics were not performed. The selected studies did not provide all of the necessary general information, and sometimes the information was only provided in narrativey. Performing a complete metaanalysis was impossible because of the lack of information and the heterogeneity of the selected studies. RESULTS An initial electronic search identified 231 studies (Fig. 1), and the manual searching process identified 15 studies (total of 246 studies). After the titles and abstracts had been read and all duplicates removed, the full texts of 43 studies were obtained. The articles that did not meet the inclusion criteria (Table 2) were excluded20-21,25-50 (28 studies), leaving a total of 15 studies6-9,11-17,51-54 for data extraction (Supplemental Table 1). Description of studies Seven studies were retrospective, 1 was a crossover pilot study, 2 were case series, 2 were paired clinical studies, and 3 were case reports, demonstrating that a high number of the selected studies were of low methodological quality. Three studies did not accumulate 6 points after using the NOS, revealing a high risk of bias. This systematic review included studies that analyzed 163 individuals and revealed an implant survival rate of 99.13% for mandibular PRDP Kennedy Class I associated with a distal implant. The follow-up period was heterogeneous, ranging from 2 weeks to 120 months. Considering only studies with at least 36 months of follow-up,55 98 participants received 196 implants for an implant survival rate of 99.44%.6,8,11,12,14 The marginal bone loss around the implants ranged between 0 and 1.4 mm. The periodontal condition and the abutment tooth survival rate were not described. The visual analog scale is the most common instrument used to evaluate patient satisfaction and was applied in 4 studies6,7,11,12 for a total of 65 individuals. These studies described an improvement in patient satisfaction after the placement of the distal implants associated with the PRDP. Other studies described an improvement in patient satisfaction, but only narratively.9,17,52-54 Masticatory abilities generally improved Zancopé et al

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Table 1. Hierarchy of evidence Level of Evidence

Study Design

I

A systematic review of randomized controlled trials

II

A randomized controlled trial

III-1

A pseudorandomized controlled trial (i.e., alternate allocation or some other method)

III-2

A comparative study with concurrent controls: nonrandomized, experimental trial Cohort study Case-control study Interrupted time series with a control group Systematic reviews of such comparative studies

III-3

A comparative study without concurrent controls: historical control study Two or more single arm study Interrupted time series without a parallel control group

IV

Case series

Electronic search N=231

Manual search N=15

References without duplication; only human studies and criteria inclusion and exclusion N=43

Full-text articles evalued for eligibilty N=15

Full-text articles excluded N=28 (Table 2)

Studies included in quantitative and qualitative syntheses N=15 (Supplemental Table 1) Figure 1. Flow chart for search strategy.

after the placement of a distal implant to support a PRDP. However, only 3 studies quantified masticatory performance by means of a food test13,15 or questionnaire.54 In the selected studies, the described prosthetic complications included pitting on the surface of the healing abutment, abutment loosening, and fractured framework. The implant complications described were severe inflammation and at-rest rupture of a clasp assembled around an abutment tooth. Only 1 study8 described abutment tooth loss, but whether this tooth was associated with a PRDP Kennedy class I or II was not clear. THE JOURNAL OF PROSTHETIC DENTISTRY

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Table 2. Exclusion of 27 full-text articles based on predetermined exclusion criteria Exclusion Criteria Applied

Article Excluded

Other types of treatment

Chikunov et al23 (2008) Minoretti et al24 (2009) 25 Andreiotelli and Smeekens (2009) Zitzmann et al26 (2009) 27 Chronopoulos et al (2008) Priest28 (1999) 29 Patras and Sykaras (2012) 30 Wolfart et al (2013)

Do not describe specifically a Kennedy class I situation

Turkyilmaz31 (2009) 32 Mijiritsky et al (2005) George33 (1992) Giffin34 (1996)

Systematic or literature review

de Freitas et al (2012) Shahmiri et al19 (2010) 35 Mijiritsky (2007)

Do not correlate PRD and dental implants

Petricevic et al (2012) Wenz et al37 (1998) 38 Haltermann et al (1999) Kapur39 (1991) 40 Tanigawa et al (2012)

Describe single implants

Kumar et al

18

36

41

(2011)

42

Describe maxillary rehabilitations

Mahn (2011) 43 McAndrew (2002) 44 Grossmann et al (2008) Bortolini et al45 (2011) 46 Fugazzotto & Lightfoot (2010)

Do not present the implant survival rate of Kennedy class I associated with distal implants

Senna et al47 (2011) 48 Strong (2012)

Healing abutments and resilient abutments were described by the selected studies as providing support for the PRDP. One study11 described the rehabilitation in 2 stages, using both types of abutment. Others randomly allocated the participants to 2 groups.6,14 Still others15,16,54 rehabilitated the participants first with the placement of only the distal implant and later with further implants and a partial fixed dental prosthesis. DISCUSSION The use of a distal implant to modify a Kennedy class I arch configuration seems to be a favorable treatment. When this treatment is performed, patient satisfaction and comfort increase. The use of only 2 implants and the associated lower cost make this treatment more accessible,7,8 and the association between retention systems and PRDPs can improve patient satisfaction. A study of the masticatory and nutritional aspects of fixed and PRDP demonstrated that the more retentive and stable the prosthesis, the more effective is the masticatory process.51 Elsyad et al14 concluded that, for the residual ridge, it is better to support the PRDP with a healing abutment rather than a resilient attachment. However, no consensus has been reached as to the better abutment, whether resilient or rigid. Subjective evaluations of masticatory function and patient satisfaction were often quantified by using a questionnaire based on a visual analogue scale.6,7,11,12,16 THE JOURNAL OF PROSTHETIC DENTISTRY

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This method can detect potentially important clinical differences with respect to masticatory ability.16 The Optocal food test was used in 2 studies13,15 as an objective, convenient, and reliable method of evaluating mastication. Nutritional tests were described in only 1 study,13 and no changes were found in the nutritional behaviors of patients with a distal implant to retain the PRDP. The authors concluded that the time was too short for eating habits to have changed after implant placement. Therefore, the authors propose proper chewing conditions for the patient and resources for healthier eating behaviors. More clinical studies with larger follow-up periods are still needed. Several in vitro studies18,19 have demonstrated that the association of a distal implant and a PRDP could improve such mechanical behaviors. Clinically, healing and resilient abutments are used to support or to retain a PRDP. The type and size of the implant evaluated had high heterogeneity. Lengths ranged from 6 to 13 mm and diameters from 3.3 to 6 mm. Three implants and only 1 abutment tooth were lost. The mean implant survival rate was 99.13% out of all studies. The follow-up period was heterogeneous. However, according to a previous study,55 the greatest incidence of implant loss occurred during the first year after prosthesis placement. This incidence decreased in the second year of function and become rare by the third year after prosthesis placement. Considering only studies with at least 36-month followup, the implant survival rate was 99.44%, suggesting that the placement of a distal implant to support/retain a PRDP does not negatively affect the implant survival rate. The marginal bone loss around the implants ranged between 0 and 1.4 mm. No bone loss around the abutment tooth or periodontal damage was described. Nevertheless, this treatment seems to present predictable long-term results.12 The most described location for the implant placement was as posterior as possible in the hope of providing maximum stability17; however, this location could lead to the placement of the implant at the third molar area, unnecessarily generating a higher stress at the abutment tooth. Three units of mastication (short dental arch) are sufficient to create an improvement in the masticatory performance. The authors understand that the placement of the implant at the first or second molar area, considering the bone quality and quantity, already solves that problem. Implant location should be well planned to enable future rehabilitation with an implant-fixed restoration.12 None of the described prosthetic complications were directly related to the type of rehabilitation. One study7 described an abutment tooth loss, but the study did not describe whether that loss was associated with a resilient abutment or the implant site. Zancopé et al

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Three studies9,52,54 accumulated fewer than 6 points on the NOS,56 indicating a risk of bias when considering these studies. The authors believe that the risk of bias is directly related to the low methodologic quality of the selected studies, similar to other revisions presented.20,21 No randomized clinical trials exist about partial removable dental prostheses associated with dental implants.

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15. 16. 17. 18.

CONCLUSIONS The following conclusions can be drawn from this systematic review: 1. The use of a partial removable dental prosthesis associated with a dental implant to convert a Kennedy class I to class III dental prosthesis increases patient satisfaction and masticatory performance and does not impair implant survival rates. 2. Clinical studies with comparable methodology are still lacking to define protocols about the use of distal implants associated with PRDP that consider the abutment tooth survival rate. 3. Long-term, prospective clinical trials are still needed to understand which implant abutments increase abutment tooth survival rate. REFERENCES 1. Mendonca DB, Prado MM, Mendes FA, Borges T de F, Mendonca G, do Prado CJ, et al. Comparison of masticatory function between subjects with three types of dentition. Int J Prosthodont 2009;22:399-404. 2. Carlsson GE. Responses of jawbone to pressure. Gerodontology 2004;21: 65-70. 3. Kern M, Wagner B. Periodontal findings in patients 10 years after insertion of removable partial dentures. J Oral Rehabil 2001;28:991-7. 4. Hmam K, Käyser AF, Hertel R, Battistuzzi PGF. Distal extension removable partial dentures supported by implants and residual teeth: considerations and case reports. Int J Oral Maxillofac Implants 1993;8:208-13. 5. Rocha EP, Luersen MA, Pellizzer EP, Del Bel Cury AA. Distaleextension removable partial denture associated with an osseointegrated implant. Study by the finite element method. J Dent Res 2003;82:B-254. 6. Mitrani R, Brudvik JS, Phillips KM. Posterior implants for distal extension removable prostheses: a retrospective study. Int J Periodontics Restorative Dent 2003;23:353-9. 7. Ohkubo C, Kobayashi M, Suzuki Y, Hosoi T. Effect of implant support on distal-extension removable partial dentures: in vivo assessment. Int J Oral Maxillofac Implants 2008;23:1095-101. 8. Grossmann Y, Nissan J, Levin L. Clinical effectiveness of implant-supported removable partial dentures: a review of the literature and retrospective case evaluation. J Oral Maxillofac Surg 2009;67:1941-6. 9. Kuzmanovic DV, Payne AG, Purton DG. Distal implants to modify the Kennedy classification of a removable partial denture: a clinical report. J Prosthet Dent 2004;92:8-11. 10. Liu R, Kaleinikova Z, Holloway JA, Campagni WV. Conversion of a partial removable dental prosthesis from Kennedy class II to class III using a dental implant and semiprecision attachments. J Prosthodont 2012;21:48-51. 11. Wismeijer D, Tawse-Smith A, Payne AG. Multicentre prospective evaluation of implant-assisted mandibular bilateral distal extension removable partial dentures: patient satisfaction. Clin Oral Implants Res 2013;24:20-7. 12. Mijiritsky E, Lorean A, Mazor Z, Levin L. Implant tooth-supported removable partial denture with at least 15-year long-term follow-up. Clin Implant Dent Relat Res 27 Dec 2013. http://dx.doi.org/10.1111/cid.12190. 13. Campos CH, Gonçalves TM, Rodrigues Garcia RC. Implant retainers for freeend removable partial dentures affect mastication and nutrient intake. Clin Oral Implants Res 2014;25:957-61. 14. ELsyad MA, Habib AA. Implant-supported versus implant-retained distal extension mandibular partial overdentures and residual ridge resorption: a

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Cunha LD, Pellizzer EP, Verri FR, Falcon-Antenucci RM, Goiato MC. Influence of ridge inclination and implant localization on the association of mandibular Kennedy class I removable partial denture. J Craniofac Surg 2011;22:871-5. de Freitas RFCP, Dias Carvalho K, Carreiro AFP, Barbosa GAS, Ferreira MAF. Mandibular implant-supported removable partial denture with distal extension: a systematic review. J Oral Rehabil 2012;39:791-8. Shahmiri RA, Atieh MA. Mandibular Kennedy class I implant-tooth-borne removable partial denture: a systematic review. J Oral Rehabil 2010;37: 225-34. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 2009;151:264-9. Miller SA, Forrest JL. Enhancing your practice through evidence-based decision making: PICO, learning how to ask good questions. J Evid Based Dent Pract 2001;1:136-41. National Health and Medical Research Council. How to use the evidence: assessment and application of scientific evidence. Canberra: Australian Government; 2000. Available at: http://www.nhmrc.gov.au/_files_nhmrc/file/ publications/synopses/cp69.pdf. Last accessed March 17, 2015. Chikunov I, Doan P, Vahidi F. Implant-retained partial overdenture with resilient attachments. J Prosthodont 2008;17:141-8. Minoretti R, Triaca A, Saulacic N. The use of extraoral implants for distalextension removable dentures: a clinical evaluation up to 8 years. Int J Oral Maxillofac Implants 2009;24:1129-37. Andreiotelli M, Smeekens S. Treatment planning of a partially edentulous case. Eur J Esthet Dent 2009;4:234-48. Zitzmann NU, Rohner U, Weiger R, Krastl G. When to choose which retention element to use for removable dental prostheses. Int J Prosthodont 2009;22:161-7. Erratum in: Int J Prosthodont 2009;22:286. Chronopoulos V, Sarafianou A, Kourtis S. The use of dental implants in combination with removable partial dentures: a case report. J Esthet Restor Dent 2008;20:355-64. Priest G. Single-tooth implants and their role in preserving remaining teeth: a 10-year survival study. Int J Oral Maxillofac Implants 1999;14:181-8. Patras M, Sykaras N. Esthetic and functional combination of fixed and removable prostheses. Gen Dent 2012;60:e47-54. Wolfart S, Moll D, Hilgers RD, Wolfart M, Kern M. Implant placement under existing removable dental prostheses and its effect on oral health-related quality of life. Clin Oral Implants Res 2013;24:1354-9. Turkyilmaz I. Use of distal implants to support and increase retention of a removable partial denture: a case report. J Can Dent Assoc 2009;75:655-8. Mijiritsky E, Ormianer Z, Klinger A, Mardinger O. Use of dental implants to improve unfavorable removable partial denture design. Compend Contin Educ Dent 2005;26:744-6. George MA. Removable partial denture design assisted by osseointegrated implants. J Calif Dent Assoc 1992;20:64-6. Giffin KM. Solving the distal extension removable partial denture base movement dilemma: a clinical report. J Prosthet Dent 1996;76:347-9. Mijiritsky E. Implants in conjunction with removable partial dentures: a literature review. Implant Dent 2007;16:146-54. Petricevic N, Celebic A, Rener-Sitar K. A 3-year longitudinal study of qualityof-life outcomes of elderly patients with implant- and tooth-supported fixed partial dentures in posterior dental regions. Gerodontology 2012;29:e956-63. Wenz HJ, Lehmann KM. A telescopic crown concept for the restoration of the partially edentulous arch: the Marburg double crown system. Int J Prosthodont 1998;11:541-50. Halterman SM, Rivers JA, Keith JD, Nelson DR. Implant support for removable partial overdentures: a case report. Implant Dent 1999;8:74-8. Kapur KK. Veterans Administration Cooperative Dental Implant Studyd comparisons between fixed partial dentures supported by blade-vent implants and removable partial dentures. Part III: Comparisons of masticatory scores between two treatment modalities. J Prosthet Dent 1991;65:272-83. Tanigawa Y, Kasahara T, Yamashita S. Location of main occluding areas and masticatory ability in patients with implant-supported prostheses. Aust Dent J 2012;57:171-7.

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43. Kumar AB, Walmsley AD. Treatment options for the free end saddle. Dent Update 2011;38:382-4. 387-8. 44. Mahn DH. Stabilizing and securing an RPD with a single implant. Dent Today 2011;30. 124,126. 45. McAndrew R. Prosthodontic rehabilitation with a swing-lock removable partial denture and a single osseointegrated implant: a clinical report. J Prosthet Dent 2002;88:128-31. 46. Grossmann Y, Levin L, Sadan A. A retrospective case series of implants used to restore partially edentulous patients with implant-supported removable partial dentures: 31-month mean follow-up results. Quintessence Int 2008;39:665-71. 47. Bortolini S, Natali A, Franchi M, Coggiola A, Consolo U. Implant-retained removable partial dentures: an 8-year retrospective study. J Prosthodont 2011;20:168-72. 48. Fugazzotto PA, Lightfoot WS. Maximizing treatment outcomes with removable partial prosthesis through the inclusion of implants and locator attachments. J Mass Dent Soc 2010;59:20-2. 49. Senna PM, da Silva-Neto JP, Sanchez-Ayala A, Sotto-Maior BS. Implants to improve removable partial denture retention. Dent Today 2011;30:118. 120-1; quiz 121,113. 50. Strong SM. Implant-retained removable partial dentures. Gen Dent 2012;60: 374-8. 51. Gonçalves TM, Campos CH, Rodrigues Garcia RC. Implant retention and support for distal extension partial removable dental prostheses: satisfaction outcomes. J Prosthet Dent 2014;112:334-9. 52. Suzuki Y, Ohkubo C, Kurtz KS. Clinical application of stress-breaking ball attachment for implant overdenture. J Prosthodont Res 2013;57:140-4.

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53. El Mekawy NH, El-Negoly SA, Grawish Mel-A, El-Hawary YM. Intracoronal mandibular Kennedy Class I implant-tooth supported removable partial overdenture: a 2-year multicenter prospective study. Int J Oral Maxillofac Implants 2012;27:677-83. 54. Praveen M, Chandra Sekar A, Saxena A, Gautam Kumar A. A new approach for management of Kennedy’s class I condition using dental implants: a case report. J Indian Prosthodont Soc 2012;12:256-9. 55. Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. Clinical complications with implants and implant prostheses. J Prosthet Dent 2003;90: 121-32. 56. Wells GA, Shea B, O’Connell D, Peterson J, Welch V, Losos M, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Available at http://www.ohri.ca/programs/clinical_ epidemiology/oxford.asp. Last accessed March 17, 2015.

Corresponding author: Dr Flávio Domingues das Neves Av Pará, 1720 Bloco 4LA sala 4LA-42 Campus Umuarama Uberlândia, Minas Gerais, 38405-320 BRAZIL Email: [email protected] Copyright © 2015 by the Editorial Council for The Journal of Prosthetic Dentistry.

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Supplemental Table 1. Data from 15 definitive studies

Authors

Title

Year of Publication

Journal (Impact Factor)

Aim

Level of No. of Evidence Participants

Total No. of Placed Implants

Implant System

Implant Length (mm)

Gonçalves TMSV, Campos CH, Rodrigues 16 Garcia RCM

Mastication and jaw motion of partially edentulous patients are affected by different implant-based prostheses

2014

Journal of Oral Evaluated the influence of Rehabilitation three different prosthetic treatments over the (1.934) mandibular ability and mandibular movements

III-2

12

Not reported

Titamax, Neodent, Curitiba, Brazil

Not reported

Gonçalves TM, Campos CH, Rodrigues 51 Garcia RC

Implant retention and support for distal Implant retention and support for distal extension partial removable dental prostheses: satisfaction outcome

2014

Journal of Prosthetic Dentistry (1.913)

Evaluated the use of distal implants to retain and support partial removable dental prostheses and assessed the outcomes with respect to specific aspects of patient satisfaction

III-2

12

Not reported

Titamax, Neodent, Curitiba, Brazil

Not reported

Mastication improvement after Gonçalves TM, Campos partial implant-supported prosthesis use CH, Gonçalves GM, de Moraes M, Rodrigues 15 Garcia RC

2013

Journal of Dental Research (4.144)

Evaluated if the increased retention and stability provided by implants would be predictive of masticatory improvements and could affect muscle thickness

III-2

12

48

Titamax; Neodent, Curitiba, Brazil

Not reported

Suzuki Y, Ohkubo C, 52 Kurtz KS

Clinical application of stressbreaking ball attachment for implant overdenture

2013

Journal of Prosthodontic Research (1.299)

Case Described a clinical report, with the use of stress-breaking report ball attachment for implantsupported overdentures

1

2

Nobel Replace (Nobel Biocare, Belgium)

Not reported

Mijiritsky E, Lorean A, Mazor Z, Levin L12

Implant tooth-supported removable partial denture with at least 15-year long-term follow-up

2013

Clinical Implant Dentistry and Related Research (2.796)

Described the long-term follow-up of cases treated with implant tooth-supported removable partial denture (ITSRPD) after at least 15 years

III-3

12

Zimmer and 10 to 13 MIS

Campos CH, Gonçalves TM, Rodrigues 13 Garcia RC

Implant retainers for free-end removable partial dentures affect mastication and nutrient intake

2013

Clinical Oral Implants Research (2.796)

Measured swallowing threshold parameters and nutrient intake in Kennedy class I patients

III-2

8

16

Titamax; Neodent, Curitiba, Brazil

Wismeijer D, Tawse-Smith A, Payne AG11

Multicentre prospective evaluation of implant-assisted mandibular bilateral distal extension removable partial dentures: patient satisfaction

2013

Clinical Oral Implants Research (2.796)

Compared the levels of patient satisfaction in Kennedy class I patients before and after the placement of a distal implant

III-2

48

96

SLA Not (Straumann) reported

El Mekawy NH, ElNegoly SA, Grawish MelA, El-Hawary YM53

Intracoronal mandibular Kennedy class I implant-tooth supported removable partial overdenture: a 2-year multicenter prospective study

2012

International Journal of Oral and Maxillofacial Implants (1.491)

Assessed clinical status and radiographic and densitometric periimplant tissue changes as parameters for the success or failure of 40 mandibular implants supporting intracoronal mandibular Kennedy class I

III-2

Praveen M, Chandra Sekar A, Saxena A, Gautam Kumar A54

A new approach for management of Kennedy’s class I condition using dental implants: a case report

2012

Journal of Indian Prosthodontic Society (0.000)

Described the fabrication of a mandibular RPD supported by existing anterior teeth and 2 distal single implants with ball attachments

Elsyad MA, 14 Habib AA

Implant supported versus implant-retained distal extension mandibular partial overdentures and residual ridge resorption: a 5-year retrospective radiographic study in men

2011

International Journal of Prosthodontics (1.185)

Grossmann Y, Nissan J, Levin L8

Clinical effectiveness of implant-supported removable partial dentures: a review of the literature and retrospective case evaluation

2009

Journal of Oral and Maxillofacial Surgery (1.359)

20 (only 6 Kennedy Class I)

20 (19 were 40 (38 were evaluated) evaluated)

6.0, 7.0, 9.0, or 11.0

BEGO

11.5

Case report

1

2

UNITI

13

Examined posterior mandibular ridge resorption under implant-supported and implant-retained distal extension partial overdentures in men

III-3

34

68

Dyna

Not reported

Described the concept of implant-supported RPDS (ISRPDs) and the clinical guidelines for placing implants for ISRPDs, and evaluate case series results

III-3

6

10

Zimmer Not Dental, 3i reported Implant Innovations, and MIS Implants Technologies (continued on next page)

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Supplemental Table 1. Data from 15 definitive studies (continued)

Authors

Year of Publication

Title

Journal (Impact Factor)

Aim

Ohkubo C, Kobayashi M, Suzuki Y, 7 Hosoi T

Effect of implant support on distal-extension removable partial dentures: in vivo assessment

2008

International Evaluated implant supported Journal of Oral distal-extension removable partial dentures and Maxillofacial Implants (1.491)

Kuzmanovic DV, Payne AG, Purton DG9

Distal implants to modify the Kennedy classification of a removable partial denture: a clinical report

2004

Journal of Prosthetic Dentistry (1.913)

Described the fabrication of a mandibular ISRPD with a combination of bilateral single implants

2003

International Journal of Periodontics and Restorative Dentistry (1.007)

Presented a follow-up clinical evaluation consisting of patient satisfaction, radiographic examination, and soft tissue health

1993

International Described 2 case reports Journal of Oral about the association of an RPD and distal implants and Maxillofacial Implants (1.491)

Mitrani R, Posterior implants for distal Brudvik JS, extension removable 6 Phillips KM prostheses: a retrospective study

Keltjens HM, Kayser AF, Hertel R, Battistuzzi 17 PG

Distal extension removable partial dentures supported by implants and residual teeth: considerations and case reports

Implant Diameter (mm)

Implant Abutment (Attachment)

Masticatory Performance

Patient Satisfaction

Total No. of Placed Implants

Level of No. of Evidence Participants

Implant System

III-1

5

10

Branemark TU MK III

Case report

1

2

ITI

IV

IV

Abutment Teeth Mean Implant Mean Bone Loss Bone Loss

10 (6 on mandible)

Prosthetic Complications

4

8.5-11.5

12

16 (did not Branemark specifiy witch ITI implants ones were installed in Kennedy class I patients)

2

Implant Length (mm)

Not reported

IMZ Implant, 10.0 and Dyna 10.5 implant

Follow-up Period

Implant Survival Rate

Not reported

Ball abutments and miniabutments

Not reported Subjective evaluation of masticatory function (VAS) improved after implant placement

Not reported

Not reported

Not reported

2 mo

100%*

Not reported

Ball abutments and miniabutments

Improved after implant placement (questionnaire)

Not reported

Not reported

Not reported

4 mo with resilient attachments; 2 mo with partial fixed prosthesis

100%*

Not reported

Ball abutments and miniabutments

Maximum bite force (MBF), Not reported food comminution index (FCI) improved after implant placement

Not reported

Not reported

Not reported

2 mo

100%*

Not reported

Stress-breaking ball attachments

The patient’s masticatory function improved by the implant with the stress-breaking ball attachment

The patient’s satisfaction Not reported improved by the implant overdenture with the stress-breaking ball attachment

Not reported

Not reported

Not reported

100%*

3.7 to 5

Ball attachments

Not reported

The patient’s satisfaction Improved after the placement of a distal implant

6.0, 4.0, or 3.75

Ball abutments

After the placement of distal Not reported implants, patients presented better mastication and increased nutrient intake

4.1

Healing caps; ball Not reported attachments after 6 mo

3.75

Healing caps

4.3

Ball attachments

VAS assessment was significantly greater after the placement of the distal implant

Ranged Not between 0 and reported 2 mm (mean 0.64 ± 0.6 mm)

One rest rupture 24e84 mo of a clasp assemble around a natural mandibular tooth

100%

Not reported

Not reported

Not reported

2 mo

100%*

Participants in the test groups showed significant improvement on the oral health impact questionnaires scores

Not reported

Not reported

Not reported

36 mo

100%*

Not reported

Not reported

0.1 ± 0.01 mm Not reported at T0; 0.4 ± 0.24 mm at T24

Not reported

24 mo

95% (2 failures)

Improved masticatory efficiency

The patient was satisfied Not reported about the treatment

Not reported

6 mo

Not reported

100%*

(continued on next page)

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Supplemental Table 1. Data from 15 definitive studies (continued) Implant Diameter (mm)

Implant Abutment (Attachment)

Masticatory Performance

Patient Satisfaction

Abutment Teeth Implant Mean Mean Bone Loss Bone Loss

Prosthetic Complications

Follow-up Period

Implant Survival Rate

Not reported

Not reported G1: healing abutment; G2: ball abutment

Not reported

Not reported

Not reported

Not reported

60 mo

100%*

Not reported

Locator Attachment (Locator, Zest), O-ring attachment (Zimmer dental), bar and clip

Increased satisfaction in all patients,

Not reported

Not reported

Not reported

12-90 mo

100%

3.75

Healing abutment Improvement in and mastication healing cap

Patient’s satisfaction Improved

Not reported

Not reported

Not reported

3 wk

100%*

4.1

Patrices

Not reported

Not reported

Not reported

Not reported

24 mo

100%*

Not reported

Group 1: modified Not reported healing abutment Group 2: Resilient attachment [OSO, Attachments International; Zaag, Preat; Hader Bar and Clip, Attachments International; or extracoronal resilient attachment (ERA),-Sterngold

Increased patient satisfaction

Not reported

Pitting Screw loosening Framework fracture Hyperplastic tissue

12-48 mo

100%

3.0 and 3.3

Case 1: Implant Not reported provided support: Implant rounded head Case 2: Dyna magnet

Increased patient satisfaction

Not reported

Repeated relining

24 mo

100%

Improvement in mastication (87%)

Not reported

0.63 mm

Not reported

*The implant survival rate as considered as 100% because no implant loss was described.

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