International Journal of Clinical Dentistry ISSN: 1939-5833

Volume 10, Number 4 © Nova Science Publishers, Inc.

TOOTH-IMPLANT-SUPPORTED REMOVABLE
DENTURE: A SYSTEMATIC REVIEW

Dario Melilli1,, DDS, PhD, Giuseppe Davì2, DDS,

Rodolfo Mauceri1, DDS, PhD, Pietro Messina1, MD,
and Giuseppe Alessandro Scardina1, DDS, PhD
1
Department of Surgical, Oncological and Oral Sciences,
University of Palermo, Palermo, Italy
2
Private Practitioner, Palermo, Italy

ABSTRACT
Purpose: The aim of this systematic review is to verify whether tooth-implant
supported removable dentures (TISRD) can really be proposed to patients as a successful
alternative to traditional prosthetic therapy.
Methods: This systematic review was carried out following the PRISMA guidelines
and the studies were selected by PubMed and Scopus. The keywords were “tooth-implant
connection,” “removable denture,” “removable dental prosthesis,” “tooth and implant
supported removable dentures,” “partial dentures,” and “overdenture.” The outcomes
sought in the potentially eligible studies were the survival rate of TISRD, the patient
satisfaction, presence of biological and technical complications; furthermore the bias risk
assessment was performed.
Results: Out of the 3108 citations found, 19 studies met the inclusion criteria. In the
included studies the enrolled participants were 615, the implant abutments were 1118 and
the residual teeth were 601. The behaviour of abutments was examined for a time range
between 6 and 180 months. The survival rate of TISRD ranged between 91.82 and
100%; as for complications, none of the authors reported intrusion and the most frequent
biologi.
Clinical significance: The tooth-implant connection seems to be an alternative and
beneficial treatment for the rehabilitation of partially edentulous patients, however the
evidence remains slight and unclear due to the shortage of controlled and randomized
clinical trials. Therefore, further studies with a higher level of evidence and more
representative samples are need.


Corresponding Author E-mail: dario.melilli@unipa.it
316 Dario Melilli, Giuseppe Davì, Rodolfo Mauceri et al.

INTRODUCTION
An oral health problem commonly encountered in the elderly is edentulism, which
greatly affects the quality of life. The rate of edentulism seems to have declined over the last
decades in many countries, a trend that will be maintained in the near future, as can be
deduced from the studies of Muller et al. [1] and Mojon et al. [2]. It is therefore possible to
foresee an increase in the percentage of partially edentulous individuals. Thus, the
management of partial edentulism will continue to be a major challenge in the foreseeable
future.
In literature, there are a lot of articles describing the possible rehabilitative solutions for
various states of edentulism, which consist of removable or fixed dentures, supported by teeth
or by implants. However, in recent years, an alternative approach to traditional rehabilitation
involving a connection between teeth and implants has started to be used as support for a
removable denture.
In a recent article [3] the features, the advantages and the complications of this type of
denture were described. In particular, two possible types were identified: implant supported
and implant assisted dentures [4, 5].
In the first case, implants embedded in the design of a removable partial denture
provide support by exploiting the healing abutment. Therefore, if the patient with distal
edentulism still has some anterior teeth that ensure a good retention of the denture, the
implants positioned in the distal portion of the edentulous ridge can serve to give greater
stability [6].
Intracoronal or extracoronal attachments can be used for dental abutment, but the former
would ensure that the tooth would endure less stress during chewing [7].
Instead, with regard to implant assisted partially removable dentures, the use of resilient
attachments (OSO attachments, o-rings or similar, or Locator®) is required, as in this case the
residual teeth do not guarantee optimal retention.
As for the choice of the insertion site of the implant, which will serve as an abutment for
the prosthetic device, some authors argue that placing the implant near the abutment tooth
allows for a better distribution of forces, reducing the stress placed on both the abutments and
the tissues [8-11].
The rationale behind this type of rehabilitation may seem superfluous. However, given all
the changes that the partially edentulous patient is subject to as a result of tooth loss and
considering also modern socio-demographic factors, it has become necessary to find
alternative solutions to allow an adequate rehabilitation of the stomatognathic system with
reduced biological and economic costs.
The study of the connection between teeth and implants as abutments for a fixed denture
is well documented in literature [12-15]. Instead, few studies have been carried out to
evaluate the effectiveness of removable dentures supported by teeth and implants and the
evidence that they have produced is slight.
The aim of this systematic review is to verify, through the analysis of the literature,
whether or not removable dentures supported by a connection between natural teeth
and implants can really be proposed to patients as a successful alternative to
traditional prosthetic therapy options on the basis of scientific articles published on the
subject.
 Tooth-Implant-Supported Removable Denture 317

MATERIALS AND METHODS

This systematic review has been carried out following the PRISMA guidelines, to
demonstrate whether the tooth- implant connection in the removable dentures can be a useful
and beneficial therapeutic tool to improve the quality of life of the population suffering of
partial edentulism. Only studies published in English since 1998 were considered eligible. In
addition, a number of inclusion criteria have been identified regarding the type of studies, the
participants, the treatments and the results.
Only studies whose participants were partially edentulous patients, with or without
removable denture, regardless of their sex or age, were considered potentially eligible.
In addition, the selected studies had to compare removable prosthetic devices with
tooth-implant connection to prosthetic devices that did not have such a connection, or
compare the advantages and disadvantages of the tooth-implant connection in removable
dentures.
Finally, the outcomes sought in the various potentially eligible studies were the
following: patient satisfaction, presence of biological or technical complications in the
prosthetic device or in the abutments that could compromise the survival of the teeth or the
implants themselves.
Instead, the exclusion criteria considered were the following: the study carried out was
not in the field of interest (studies based on tooth-implant connections in fixed prosthetic
devices), as well as studies with a limited level of scientific evidence (case reports or in vitro
studies).
The studies considered for this review were selected by searching through PubMed and
Scopus.
The keywords used were “tooth-implant connection,” “removable denture,” “removable
dental prosthesis,” “tooth and implant supported removable dentures,” “partial dentures,” and
“overdenture.” In order to optimize the search and identify the highest possible number of
eligible studies, keywords were combined in a definite order (Table 1).
The search started on 17/11/14, while the last search was done on 2/5/2016.
Subsequently, the search was extended to studies reported in the bibliographies of those
articles considered eligible in order to identify other relevant data.
From each of the included studies informations were extracted about: authors and year of
publication; number of participants and their state of edentulism; typology and methodology
of the prosthetic rehabilitation; survival rate of the abutments and the prosthetic structure;
biological and technical complications; the degree of patient satisfaction with the new
denture.
In this review, the bias risk assessment was performed by evaluating the criteria found in
Table 2 for each included study.
The choice of using these criteria was based on several works, [16-19] focusing
on the methodological evaluation of observational studies and, specifically, “case series”
studies.
For each criterion, a specific judgment was established: adequate, indicating a low
bias risk; not adequate, indicating a high bias risk; not clear, indicating an uncertain bias risk.
A further methodological investigation used to evaluate the overall quality of this review
is the AMSTAR (A Measurement Tool to Assess Systematic Reviews) questionnaire [20].
318 Dario Melilli, Giuseppe Davì, Rodolfo Mauceri et al.

Table 1. Search strategy

1. Tooth-implant connection
2. Tooth-implant connection AND removable denture
3. Tooth-implant connection AND partial removable denture
4. Tooth-implant connection AND overdenture
5. Tooth-implant supported removable denture
6. Implant and tooth supported removable dentures
7. Implant and tooth retained removable dentures
8. Implant and tooth supported overdenture
9. Implant and tooth retained overdenture

Table 2. Criteria for evaluating the risk of bias

A. Are the eligibility criteria clearly reported?

B. Have the participants the same health conditions at baseline?
C. Is the follow-up an adequate time?
D. Lost to follow up? (Do the authors report the reasons of drops-out during the follow-up?
Are the participants at the end of the follow up 90% at least?)
E. Are the outcomes evaluated through objective criteria?
F. Selective outcome reporting?

AMSTAR involves the compilation of a questionnaire consisting of 11 questions. In our

case, this was assigned to two external readers, so as to avoid a conflict of interest and to
obtain the most objective result possible.

Resources Selection

A total of 3,108 bibliographic citations were found in the electronic search. Most
of the citations were identified through the use of electronic databases such as PUBMED
(n = 1511) and SCOPUS (n = 1594), while only three citations were identified by
searching through expert forums. After removing duplicate results, the articles underwent
screening.
The first step in this screening involved reading titles and abstracts, so as to eliminate
from the list the duplicates and all those articles that did not reflect the previously established
eligibility criteria. Out of the initial number of citations found, only 26 articles appeared to
respect the eligibility criteria, so the “full texts” were acquired for further evaluation and for
additional screening.
After reading the full texts, 7 articles were discarded because they did not reflect
the inclusion criteria, given that they dealt with the tooth-implant connection in fixed
dentures.
All studies that met the inclusion criteria (n = 19) were then subjected to data extraction
and quality evaluation (Appendix A).
 Tooth-Implant-Supported Removable Denture 319

Search in literature

Database: PubMed, Scopus

Total references identified (n = 3108)

- Pubmed (n = 1511)
- Scopus (n = 1594)
- Other sources (n = 3)

Screening of titles or Studies excluded (n=3082)

abstracts - Not pertinent
- Duplicates
- Fixed prostheses
- Slight level of evidence
Studies included (laboratory studies, n = 8)
(n = 26)

Screening by reading Studies excluded (n = 7)

the full text - tooth-implant connection
in fixed prostheses

Studies included
(n = 19)

RESULTS
Among the 19 studies included, 10 were descriptive studies, [4, 6, 8, 21-27] 7 analytical
studies, [28-34] characterized by the presence of one or more comparison groups, and 2 were
multicentric studies [6-35]. All 19 were, however, observational studies.
Considering all the studies included, the enrolled participants were 615 in total. The
implant abutments studied were 1118 and the total number of residual teeth was 601. The
behaviour of these abutments over time was examined for a total time range of between 6 and
180 months. All the studies described the placement of implants in the edentulous ridge of the
participants in order to obtain a polygonal distribution of the abutments, a solution designed
to provide stable support for the final prosthetic device.
In addition, the anchoring systems studied were mainly ball attachments [4, 7, 8, 21, 23,
29-31] and telescopic crowns [22, 25-29, 32, 34]; but also healing caps, modified to act as a
support system, were considered [6, 35].
320 Dario Melilli, Giuseppe Davì, Rodolfo Mauceri et al.

Survival of the Abutments and Dentures

An adequate parameter for understanding the utility of the tooth-implant connection is the
survival rate, not only of the abutments, but also of the prosthetic structure, understood as
being the permanence of the tooth, of the implant and of the prosthetic structure throughout
the duration of the check-ups, in the presence of the adequate health of the periodontal and
peri-implant tissues, as well as the absence of significant resorption of bone tissue.
Of the 19 studies included in this work, only 14 quantitatively reported the results on the
percentage of dental and implant abutments which survived during the follow-up.
However, these studies show that the survival of implants in the case of removable
dentures supported by traditional anchoring systems (ball attachment or Locator®) is between
93.75% and 100%, considering a total of 243 implants [4, 7, 8, 21, 23, 31] while for the same
type of dentures, the survival rate of the teeth was only examined by Hug et al. in their
2006 study, [31] where a survival rate of 96.8% was reported after two years of check-ups
(Table 3).
As for removable dentures supported by telescopic systems, the studies reported a
survival rate of implants connected to teeth (n = 650) between 91.82% and 100%, while the
survival rate of teeth was between 85.19% and 100% [22, 29, 24-26, 32-34] (Table 4).
Instead, regarding the survival of the prosthetic structure, Hug et al. [31] studied 18 dentures
with combined support for 2 years and despite the occurrence of minor technical and
biological complications, none had to be remade.
For Kaufmann et al., [29] the survival rate of the 65 dentures with combined support was
100%. Bortolini et al. [21] studied 32 partially edentulous patients for 8 years. These had been
rehabilitated with tooth-implant supported dentures: despite some complications, such as the
loss of 4 implants, the prosthetic structures functioned correctly throughout the control period.
For Schwarz et al. [28] survival of the superstructure was of 93.3% after 2 years and
82.9% after 5 years. Other studies, such as Rinke et al. [24] and Frisch et al. [32] report a
survival rate of 100% after an average period of 5 and 6 years respectively.

Table 3. Studies analyzing the survival rate of implants and teeth in removable dentures
supported by traditional anchoring devices (ball-attachment or Locator®)

% implant % teeth Follow Patients Implants Teeth

Author
survival rate survival rate up (years) (n.) (n.) (n.)
Mijiritsky
100 / 15 20 42 /
et al. (2013) [4]
El Mekawy
95% / 2 20 40 /
et al. [7]
Grossman
95,5 / 10 23 44 /
et al. [8]
Bortolini
93,75 / 8 32 64 /
et al. [21]
Mijiritsky
100 / 7 15 33 /
et al. (2005) [23]

Hug et al. [31] 100 96,8 2 14 20 32

 Tooth-Implant-Supported Removable Denture 321

Table 4. Studies analyzing the survival rate of implants and teeth in removable dentures
supported by telescopic systems

% implant % teeth Follow up Patients Implants Teeth

Author
survival rate survival rate (years) (n.) (n.) (n.)
Krennmair
100 100 3,2 22 60 48
et al. [22]

Rinke et al. [24] 100 85,19 >5 14 24 27

Romanos
91,82 / 2-10 55 110 /
et al. [25]

Joda et al. [26] 100 100 2 10 28 28

Kaufmann
96,78 97,69 3 60 93 130
et al. [29]
63 (16 tooth-
Bernhart
100 100 2 implant supports 40 44
et al. [32]
denture)

Frisch et al. [33] 98,36 86,36 6, 12 ± 3,80 23 61 66

Rammelsberg
97,43 93,45 2,7 61 234 107
et al. [34]

Complications

Among the included studies the most common adverse events were phenomena of
“pitting of the healing abutment surface,” “abutment screw loosening” [4, 6, 8, 21, 23, 31]
and the relining of the denures, as reported by Bortolini et al. [21] (93 cases in 32 patients in 8
years, with an average relining every 2.75 years), but these can still be categorised as minor
technical complications.
However, with regard to complications concerning tissues, after a 2-year follow-up, Hug
et al. [31] reported that peri-implant bone loss, calculated at mesial and distal sites, was of
0.8 ± 1.1 mm, while at the level of the residual teeth, the bone loss was of 0.3 ± 0.9 mm.
Mijirstky et al. [4] after a control period of 15 years, reported that the probing depth
around the 42 implants was less than 5 mm without bleeding on probing, while the peri-
implant bone loss was between 0 and 2 mm.
Instead, the examination of studies that considered the use of telescopic crowns as an
anchoring system revealed that the most frequent technical complication was the loss of the
screw in the implant abutments, followed by chipping and relining [22, 26, 32]. These,
however, were all minor events that did not interfere adversely with prosthetic functionality.
In contrast, Schwarz et al. [28] reported 6 cases (out of 36 prostheses examined) of major
technical complications, specifically the breaking of the prosthetic superstructure.
The most frequent biological complication was the inflammation of the tissues supporting
the abutment, probably due to the patients’ inadequate oral hygiene.
With regard to biological complications, Kreinmair et al. [22] reported data of an average
peri-implant bone resorption of 2.2 mm (± 1 mm), while the average probing depth was 2.4
322 Dario Melilli, Giuseppe Davì, Rodolfo Mauceri et al.

mm (± 0.8 mm) and, with regard to the residual teeth, there was a slight increase in the
mobility of the teeth, calculated with the Periotest (6.8 ± 4.1 at zero time, 7.9 ± 5.7 at the last
check-up), as well as an increase in the probing depth (2.8 ± 0.9 mm at zero time, 3.2 ± 1.5 at
the last check-up); In both cases, however, the differences calculated at zero time and at the
end of the control period (9 years) were not considered statistically significant.
Other relevant results were those reported by Kaufmann et al. [29] in their 2009 study; in
more than 3 years of check-ups, there were 23 cases of biological complications, 8 of which
were cases of peri-implant inflammation, another 8 were cases of caries and 3 others cases of
periodontitis regarding the dental abutments. The same authors, with regard to technical
complications, recorded 317 cases of minor technical complications over 3 years; despite this
high number, all the dentures remained functional until the last check-up. Statistically, most
of the technical complications occurred during the first year. With regard to the biological
complications, the authors found that 36% of the maxillary implants showed > 1 mm bone
loss at mesial or distal levels; at the mandibular level 22% of the implants had <1 mm bone
loss.
In the study by Romanos et al. [25] 3/110 implants were considered to have clinically
failed as they had excessive mobility after two months of prosthetic placement, while 6/110
implants were considered to be failures after radiographic evaluation because they were
characterized by a bone loss that was greater than 2 mm. Instead, 9 teeth were lost because of
periodontal problems or deep caries.
Rammelsberg [34] reported in his study that 6 implants (2.6%) were removed because of
extensive bone loss; another 11 (4.7%) had peri-implantitis; instead, 12 (5.1%) showed
mucositis without bone loss; 4 teeth (3.7%) were extracted and another 3 (2.8%) had severe
complications (such as fractures or apical periodontitis).
In the Rinke’s study [24] 21% of the implants (n = 5) showed signs of mucositis and one
patient showed progressive bone loss (>2 mm) around an implant, considered by the authors
as failures after radiographic evaluation. The average peri-implant probing depth was 3.29 ±
0.94 mm. In addition, the authors identified crown fractures as being the predominant cause
of loss of teeth (n = 4). Despite this, only a small number of complications were observed,
and these did not alter the functioning of the denture in any way.
Frisch et al. [33] reported the loss of 9 teeth in 7 patients (13.64%) because of caries or
fracture (n = 1) after an average of 6.12 years. Out of 61 implants, only one failed due to peri-
implantitis during the observation period. The average peri-implant probing depth was 3.68 ±
0.76 mm.

Satisfaction of Patients

Using a system of a scale from 1 to 5, some authors tried to quantify the degree of patient
satisfaction, such as Mitrani et al. [6] who reported a value of 1.2 at zero time and 5 at the end
of the check-ups. A similar result was obtained by Bortolini et al. [21] with average
satisfaction of 1.31 at zero time and 4.59 after 1 year.
Grossmann et al. [8] also achieved excellent results, as 87% of the patients claimed to
have improvements in chewing, 78% of the participants were satisfied with the aesthetic
improvement, 65% of the patients defined the dentures as being comfortable, while only 13%
complained of some discomfort. The results of the questionnaires of Wismeijer et al. [35]
 Tooth-Implant-Supported Removable Denture 323

showed that the placement of the implants and the subsequent use of prostheses supported by
teeth and implants guaranteed an increase in patient satisfaction, as well as better prosthetic
stability and better chewing ability. Wolfart et al. [30] and Gonçalves et al. 2014 [27] also
highlighted in their studies a significant increase in patient satisfaction after the use of
dentures supported by teeth and implants.
Instead, Hug et al. [31] compared the degree of satisfaction of rehabilitated patients with
three different types of prosthetic rehabilitation. They found that general satisfaction was
greater when using denture supported only by implants; however, the use of dentures with
combined tooth-implant support guaranteed a greater degree of satisfaction compared to that
given by conventional dentures.

Bias Risk in the Included Studies and Additional Analysis

The evaluation of the possible presence of bias in the included studies was carried out by
looking for the parameters described below and summarized in Table 5.
A. Are the eligibility criteria clearly reported?
Among the included studies 11 [7, 8, 22, 24, 27-30, 33-35] explicitly stated the eligibility
criteria used to identify which patients could participate and which ones should be excluded,
while 8 [4, 6, 21, 23-26, 31] were considered inadequate.
B. At baseline, do the participants have the same health conditions?
The participants had the same characteristics at baseline, that is, the same degree of
edentulism, only in 4 studies [21, 25, 27, 35].
In 9 studies, [6, 8, 22, 26, 29-32, 34] participants had different degrees of edentulism.
Instead, in six studies [4, 7, 23, 24, 28, 33] it was not possible to determine the degree of
heterogeneity at baseline, due to a lack of information.
C. Is the length of follow-up adequate?
The follow-up was adequate in only 6 studies, [4, 21, 22, 23, 25 ,29] while for the
remaining 13 [6-8, 24, 26-28, 30-35] the control period was not long enough.
D. Lost to follow-up?
The loss of patients during the follow-up was not significant in 10 studies [4, 7, 8, 22, 25-
27, 29, 30,35], while for 3 studies, [24, 28, 33] the loss of participants may have adversely
affected the estimate of the final results. Finally, in 6 studies [6, 21, 23, 31, 32, 34] the lack of
information did not allow to assess the number of drop-out.
E. Are the results evaluated with objective criteria?
In 17 studies [4, 6-8, 21, 22, 24, 25, 27-35] the results were evaluated with criteria judged
to be appropriate, while in the study of Mijiristjy et al. of 2005 [23] these criteria were
considered inadequate and for the work of Joda et al. [26] it was not possible to assess which
criteria were used for the evaluation of the outcome.
F. Selective outcome reporting?
In 17 studies [4, 6, 7, 20-23, 26-34] the results for all the outcomes considered were
adequately reported, while the work of Romanos et al. [25] and Joda et al. [26] were judged to
be inadequate, as no significant outcome results were reported.
Finally, the scores of the AMSTAR survey were 8/11 and 7/11 respectively for the two
involved readers. The scores were obtained by counting each affirmative answer and
awarding each answer 1 point.
324 Dario Melilli, Giuseppe Davì, Rodolfo Mauceri et al.

Table 5. Risk of bias

A B C D E F
Mijiritsky et al. (2013) [4] - ? + + + +
Mitrani et al. [6] - - - ? + +
El mekawy et al. [7] + ? - + + +
Grossman et al. [8] + - - + + +
Botolini et al. [21] - + + ? + +
Kreinmair et al. [22] + - + + + +
Mijiritsky et al. (2005) [23] - ? + ? - +
Rinke et al. [24] + ? - - + +
Romanos et al. [25] - + + + + -
Joda et al. [26] - - - + ? -
Goncalves et al. [27] + + - + + +
Schwarz et al. [28] + ? - - + +
Kaufmann et al. [29] + - + + + +
Wolfart et al. [30] + - - + + +
Hug et al. [31] - - - ? + +
Benhart et al. [32] - - - ? + +
Frisch et al. [33] + ? - - + +
Rammelsberg et al. [34] + - - ? + +
Wismejer et al. [35] + + - + + +
A. Are the eligibility criteria clearly reported?
B. At baseline, do the participants have the same health conditions?
C. Is the length of follow-up adequate?
D. Lost to follow-up?
E. Are the results evaluated with objective criteria?
F. Selective outcome reporting?

DISCUSSION
In cases where a fixed denture is not suitable, the rehabilitation with a removable partial
denture can be a viable alternative. However, it is fairly common that removable partial
dentures have reduced stability and retention, especially if the patient has a large edentulous
area and an unfavourable distribution of the few residual teeth that should act as abutments. 23
Another limit of the traditional removable partial dentures is linked to its double support
(dental and osteomucosal) with a different degree of resilience [28].
Thus, in cases where the patient cannot be rehabilitated with a fixed denture, or where the
patient cannot adapt to the traditional removable denture, one possible alternative solution is
to use a limited number of implants placed in strategic positions in the patient’s ridges and
then to connect them to the patient's residual teeth. This review was conducted in light of this
consideration, and, exploiting the principles of the PRISMA statement, an attempt was made
to identify the studies that could provide the best possible evidence.
 Tooth-Implant-Supported Removable Denture 325

Indeed, none of the included studies is a randomized trial, which, among all the types of
study, represents the one that can provide the best possible evidence; few studies seem to
have a sufficiently long follow-up period to be able to observe significant events in the
behaviour of the abutments, teeth or implants, and in the prosthetic structures. Therefore, the
choice to also include “case series” in this review was dictated not only by the evident and
justified lack of randomized and controlled clinical trials, but also by the belief that the use of
studies with this particular design could strengthen the state of the evidence and at the same
time increase the credibility of emergent therapeutic approaches that have not yet been
studied to their full potential, [36] as for example the tooth-implant connection aimed at
supporting removable prosthetic devices.
Instead, with regard to determining the risk of bias in the included studies, the indicator
system of Cochrane Collaboration was initially taken into consideration for this purpose.
However, due to the type of studies, it is not possible to evaluate some types of bias, such as
selection bias, performance bias and detection bias, since the choice of participants is not
random. In addition, the allocation of these patients to groups will not be randomized or
concealed. Finally, both the participants and the healthcare professionals working in the study
are not in a blinded test, so probably the evaluation of outcomes was not totally objective.
Therefore, the system developed by Cochrane Collaboration does not seem to be the best
for this review. As a result, it was necessary to identify different systems to perform an
objective evaluation of the quality of the included studies.
There are several possible “tools” or “checklists” available in literature for assessing bias
in observational studies, but none of them enjoys unanimous consensus. Moreover, each of
them has both strengths and weaknesses. Therefore, for this review, the choice of using the
criteria analysed in the preceding paragraphs was not arbitrary, but the result of the
considered analysis of several works [16-18].
Thus, from the analysis of the results (Figure 1), it is evident that 57.9% of the included
studies clearly express the eligibility criteria used for the selection of the patient sample. In
addition, a fundamental parameter is represented by the homogeneity of the baseline
characteristics. However, only 21.05% of the studies has patients with homogeneous
characteristics. Consequently, the results of most studies (78.95%), which are inadequate or
not clear, could lead to a heterogeneity that could result in an altered or overestimated
interpretation of the results. Moreover, it could fail to guarantee a good standardization of the
result itself.
The 68.42% of studies had a control period of less than 5 years. Some authors such as
Carlsson et al., [37] studying the morphological changes in the mandible after extraction,
calculated that after a 5-year period the average loss of bone tissue was 6.7 mm. Therefore,
checking the patients and the prosthetic devices for a period less than the one established by
these authors could be insufficient for assessing the occurrence of episodes considered to be
possibly relevant and able to affect the vitality of the various components present in the
prosthetic rehabilitation.
In 52.63% of the studies, however, the patients came to all the scheduled check-ups, thus
enabling the abutments and prosthetic devices to be evaluated over time and to obtain
theoretically standardized results.
As for the last two criteria, regarding the methodology used to evaluate the outcome, we
can deduce that in most of the studies (89.47%) important outcomes were evaluated with
objective and appropriate criteria.
326 Dario Melilli, Giuseppe Davì, Rodolfo Mauceri et al.

In addition to the evaluation of the risk of bias, an additional analysis was carried out to
examine the methodological quality of this review using the AMSTAR questionnaire [20].
As stated, the questionnaire was filled in by two external readers whose results (8/11 and
7/11) were later compared to the AMSTAR classification in three separate quality categories:
0-3 low, 4-7 moderate, 8.11 high.

The indicators used for the evaluation of the bias in the included studies, are reported in order on the axis of
the ordinates, while on the axis of the abscissas are reported the percentage values.

Figure 1. Risk of bias in the studies.

The results of the AMSTAR questionnaires are therefore encouraging and also allow us
to deduce how this review has an objective and appropriate methodological quality.

Survival and Complications

The survival rate of dental and implant abutments, together with the rate of
complications, are adequate parameters to understand the real effectiveness of the tooth-
implant connection in removable dentures.
It is particularly difficult to draw definitive conclusions about this because of the
heterogeneity present in the studies, due to differences in the number and conditions of the
patients and to the temporal differences in the follow-ups. However, a series of deductions
can be made.
With regard to dental and implant abutments, the results of the included studies allow us
to affirm that when the teeth and the implants were interconnected by using a removable
denture, the implant’s longevity increased compared to the cases in which a fixed denture was
used. This is evidenced by a survival rate between 91.82 and 100% for removable dentures, in
comparison to a survival rate between 90% and 95% reported by Bragger et al. [15] and Naert
et al. [38] when tooth-implant connections were used for fixed dentures.
 Tooth-Implant-Supported Removable Denture 327

As for complications, none of the authors of the studies included in this review reported
intrusion, which is one of the major complications when teeth and implants are connected to
support a fixed denture [39-41].
In addition, with regard to the resinous components of the dentures, the evaluation of the
various studies shows that the frequency of complications due to these parts is minimal. This
could be explained by the fact that keeping the natural abutments could ensure the
conservation of tactile perception [42] and, consequently, this would ensure the preservation
of an adequate neuromuscular feedback so as to avoid excessive chewing force, which could
lead to a mechanical overload, especially on the resinous parts of the prosthesis.
Another consideration can be made regarding cases in which an alternative anchorage
system to the traditional one is used, such as the telescopic system. Would anything change in
the onset of technical or biological complications?
In the studies that examine the traditional anchoring system, [4, 6, 21, 31] the most
frequent phenomena were the “pitting of the healing abutment surface” and the relining of the
denture, while the most frequent phenomenon in the cases of dentures anchored by telescopic
system was the loss of the screw in the implant abutments [22, 24, 26, 32]. These, however,
were all minor events that could not interfere adversely with the functionality of the denture.
With regard to biological complications, the extent of bone resorption after two years is
about 0.8 ± 1.1 mm at the peri-implant level and 0.3 ± 0.9 mm at the level of the residual
teeth, according to the authors who used traditional anchoring systems, such as Hug et al. [31]
The average peri-implant resorption after three years was between 1 and 2.2 mm according to
other authors such as Kreinmair et al. [22] and Kaufmann et al., [29] who used dentures
anchored by telescopic systems in their studies.

Satisfaction of Patients

A key objective of any type of rehabilitation is to improve the quality of life of patients,
therefore one of the most reliable parameters that can be used to evaluate such improvement
is the degree of patient satisfaction.
Satisfaction means the subjective sensation that the patient perceives as a result of the
use of the prosthetic device; the subjective connotation of this sensation entails some
difficulty when it comes to measuring and classifying it, so several studies prefer to use
questionnaires.
These questionnaires are usually given to participants at different times: usually at zero
time, to understand what the initial situation is, and subsequently during the various check-
ups, so as to observe the possible changes that may occur over time.
Furthermore, following the attempt to quantify a parameter that by definition is
subjective, the responses to the questionnaires can be structured in the form of visual analog
scales (VAS) [27, 31, 35]. However, other authors use a system consisting of a scale from 1
to 5, where normally 1 represents the smallest value, usually indicating total dissatisfaction
with the denture, while 5 indicates the highest degree of satisfaction [4, 6, 21].
Authors such as Mijirtsky et al. [23] and Romanos et al. [25] describe an improvement in
patient satisfaction with the new dentures due to a better chewing function and the greater
stability of the device. However, these data have only an indicative value, as these authors do
not report the system they used to evaluate these parameters.
328 Dario Melilli, Giuseppe Davì, Rodolfo Mauceri et al.

A further drawback of this means of measurement is the potential systematic error due to
the fact that patients recruited in different studies are recruited because they are dissatisfied
with their original condition and are in need of a new prosthetic rehabilitation.
The reduced relevance of the parameter assessed at zero time aside, the true datum that
should be considered and which can provide useful evidence is the change in the rate, that is,
the change in the degree of satisfaction between time 0 and the last check-up.
To this regard, as shown by the data from the included studies and which have previously
been reported, a noticeable improvement in patient satisfaction through the use of removable
denture supported by teeth and implants. In particular, both Mitrani et al. [6] and Bortolini
et al. [21] reported an increase in patient satisfaction of about 5 times the value reported
at time 0.

CONCLUSION
Comparing these studies, it can be seen that all of them have reduced follow-up periods
(from 2 to 8 years) with the exception of Mijiristky’s study [4] (15 years).
The comparison between the various studies is made even more difficult by the limited
number of recruited patients, but also by the heterogeneity that these patients present at the
baseline, by the different types of prosthetic design and by the different anchoring systems
used and the number of residual teeth.
As a result of these limitations, it is difficult to draw certain and absolute conclusions
about the actual validity of using the tooth-implant connection.
However, from the assessment of the survival rates, we can deduce that by increasing the
number of abutments and using strategically placed implants, there is a tangible reduction in
the risk of failure or onset of other complications at the level of the implant and an
improvement in the prognosis of the teeth and prosthetic structure.
We can also deduce that the frequency with which complications occur in the case of
tooth-implant connections in the removable denture is minimal, and in any case acceptable if
considered with regard to the possible advantages. In addition, comparing the different studies
carried out on removable dentures, there is an absence of the typical complications that afflict
the tooth-implant connection in fixed dentures, such as intrusion of the dental abutment.
Although this approach may be an alternative and beneficial treatment for the
rehabilitation of partially edentulous patients, the evidence remains slight and unclear due to
the lack of controlled and randomized clinical trials.
Therefore, in order to confirm the validity of this rehabilitative solution, further studies
with a higher level of evidence and more representative samples are needed.

ETHICAL COMPLIANCE
The authors have stated all possible conflicts of interest within this work. The authors
have stated all sources of funding for this work. If this work involved human participants,
informed consent was received from each individual. If this work involved human
participants, it was conducted in accordance with the 1964 Declaration of Helsinki. If this
work involved experiments with humans or animals, it was conducted in accordance with the
related institutions’ research ethics guidelines.
 Appendix A

Risk of bias
At baseline, do
Are the
the participants
results
have the same Is the length Lost to Selective
Study Are the eligibility criteria evaluated
Author/Ref. Participants Intervention Outcomes characteristics of follow-up follow- outcome
design explicitly reported? with
with regard to adequate up? reporting?
objective
their state of
criteria?
health?
Adequate:
Clinical and
42 implants Results
radiographic Adequate:
inserted to regarding
20 partially conditions of Descriptive Not adequate: Inclusion Adequate: Adequate: Clinical and
Mijiritsky obtain a all the
edentulous periodontal/peri- study (case and exclusion criteria not Not clear Follow-up 15 No drop- radiographic
E. [4] symmetric outcomes
patients implant tissues; series). reported. years out examination,
distribution of considered
patient questionnaire
the abutments are
satisfaction
reported
The implants
were
positioned as Satisfaction of Not clear:
distantly as the patient; Probably
possible. Clinical no patient Adequate:
10 partially Group 1: the conditions dropped Results
edentulous implants (component Not adequate: Non out Adequate: regarding
Mitrani R Analytical
patients acted only as wear, peri- Not adequate: Eligibility Participants with adequate: during Clinical and all the
[6] cohort
(Kennedy occlusal implant gingival criteria not reported varying degree Follow-up of follow- radiographic outcomes
study
class I and stops; Group inflammation), of edentulism 12-48 months up, but examination considered
II). 2: the radiographic this is not are
implants were evaluation (peri- reported reported.
equipped with implant bone in the
anchoring loss). article.
systems (OSO
attachment).

(Appendix A continued on next page.)

 Risk of bias
At baseline, do the Are the
participants have results
Are the eligibility Is the length Lost to Selective
the same evaluated
Author/Ref. Participants Intervention Outcomes Study design criteria explicitly of follow-up follow- outcome
characteristics with with
reported? adequate up? reporting?
regard to their state objective
of health? criteria?
Adequate: Inclusion
Implant criteria: between 35
survival; and 45 years old, Adequate: Adequate:
20 partially clinical good state of general Clinical and Results
Adequate:
edentulous conditions health, without any Not adequate: radiographic regarding all
El Mekawy Descriptive 1/20
patients Overdentures (Plaque Index, history of local or Not clear Follow-up of examination, the
NH [7] study drop-out
(Kennedy PPD, BOP); general metabolic or 2 years densitometric outcomes
(5%)
class I). radiographic bone disorders, no and statistical considered
conditions bisphosphonates, analysis are reported
(bone loss). need of bilateral
distal implants.
Adequate:
43 implants Adequate: Inclusion
Adequate: Results
inserted to Patient criteria: partial Non adequate: Not adequate:
23 partially Descriptive Adequate: Clinical regarding all
Grossmann obtain a satisfaction, edentulism, no Participants with Average
edentulous study No drop- examination the
Y [8] stable abutment prosthesis prior to different degree of period 31.5
patients. (case series). out and outcomes
polygonal survival the study, good state edentulism months
questionnaire considered
support. of general health.
are reported.
3 groups
depending on
the degree of
Adequate:
their Patient Adequate: The
Adequate: Results
edentulism satisfaction; participants were
Not adequate: Adequate: Clinical and regarding all
Bortolini, S. 32 according to implant Retrospective divided into groups
Eligibility criteria Follow-up of Not clear radiographic the
[21] participants the Kennedy survival; study according to their
not reported 8 years examination. outcomes
classification: retention of degree of
Questionnaire considered
class I n = prosthesis edentulism
are reported
19, class II n
= 10, class III
n=3
 Risk of bias
At baseline,
do the Are the
participants Is the results
Lost to Selective
Are the eligibility criteria have the same length of evaluated
Author/Ref. Participants Intervention Outcomes Study design follow- outcome
explicitly reported? characteristics follow-up with
up? reporting?
with regard to adequate objective
their state of criteria?
health?
Clinical
conditions
(Plaque Index; Adequate:
Not adequate:
PPD, BOP) and Results
18 Adequate: Absence of Presence of Adequale: Adequate:
Krennmair radiographic Adequate: regarding
22 patients, overdentures Retrospective strategic abutments for the participants Follow- Clinical and
G. [22] conditions No drop- all the
and 4 partial study. polygonal support of with varying up of 9 radiographic
(bone loss), out outcomes
dentures dentures degree of years examination.
implant and considered
edentulism.
tooth survival, are reported.
retention of the
prosthesis
Patient
satisfaction,
Adequate:
33 implants retention of the Not adequate:
Results
to obtain a prosthesis¸ Adequate: The
15 partially Descriptive regarding
Mijiritsky favourable clinical Not adequate: Eligibility Range of evaluation
edentulous study Not clear Not clear all the
2005 [23] distribution conditions criteria not reported. follow-up criteria of the
patients (case series) outcomes
of the (mobility, 2-7 years. outcome are
considered
abutments. inflammation insufficient
are reported.
around teeth or
implants).

(Appendix A continued on next page.)

 Risk of bias
Are the
At baseline, do the
Is the results
Are the eligibility participants have the Lost to Selective
length of evaluated
Author/Ref. Participants Intervention Outcomes Study design criteria explicitly same characteristics follow- outcome
follow-up with
reported? with regard to their up? reporting?
adequate objective
state of health?
criteria?
Adequate. Inclusion
Clinical criteria: use of the same
Not Adequate:
Tooth- conditions and type of implants and of Not
adequate: Adequate: Results
18 partially implant radiographic Descriptive the same anchoring adequate:
Rinke S Range of Clinical and regarding all
edentulous supported conditions of study system; no more than Not clear 4/18
[24] follow-up radiographic the outcomes
patients partial the abutments; (case series). three teeth with reduced drop-out
3.01-12.21 examination considered
dentures. retention of periodontium; regular (22%)
years are reported
the prosthesis post-implant support
treatment (hygiene).
Implants
inserted in
Patient
order to Adequate:
satisfaction, Adequate: All the
55 partially obtain a Adequate: Adequate: No data
clinical and participants were
edentulous stable Not adequate: No Average Adequate: Annual regarding a
Romanos radiographic Retrospective Kennedy class I,
patients polygonal inclusion or exclusion period: No drop- clinical and significant
GE [25] conditions of study without signs of
(Kennedy support. criteria were reported 61.58 out radiographic outcome
the abutments, periodontal disease
class I). Telescopic months examination were
implant and or mobility.
anchoring reported.
tooth survival.
system was
used.
28 implants Not
Retention of Not clear.
and 28 Not adequate. No
the prosthesis; The criteria
natural teeth adequate. data
10 partially biological or Not adequate. Adequate. for
were used. Retrospective Not adequate: Inclusion Average regarding a
Joda T [26] edentulous technical Different degrees of No drop- evaluating
Anchoring study criteria not reported. period: significant
patients complications; partial edentulism. out the outcome
system: 26.3 outcome
abutment are not
telescopic months were
survival. reported.
crowns. reported.
 Risk of bias
At baseline,
do the Are the
Is the
participants results
Are the eligibility length of Lost to Selective
have the same evaluated
Author/Ref. Participants Intervention Outcomes Study design criteria explicitly follow- follow- outcome
characteristics with
reported? up up? reporting?
with regard to objective
adequate
their state of criteria?
health?
Joda T [26] 10 partially 28 implants and Retention of Retrospective study Not adequate: Not adequate. Not Adequate. Not clear. Not
edentulous 28 natural teeth the prosthesis; Inclusion criteria not Different adequate. No drop- The criteria adequate.
patients were used. biological or reported. degrees of Average out for No data
Anchoring technical partial period: evaluating regarding
system: complications; edentulism. 26.3 the outcome a
telescopic abutment months are not significant
crowns. survival. reported. outcome
were
reported.
Gonçalves 12 patients, Removable Patient Descriptive study Adequate. Inclusion Adequate. Not Adequate. Adequate. Adequate.
TM [27] partially partial dentures satisfaction, (case series). criteria: total maxillary The adequate. No drop- Clinical and Results
edentulous supported by clinical and edentulism and partial participants Range of out radiographic regarding
in the teeth and radiographic mandibular edentulism, were of follow- examination, all the
lower arch implants distally evaluations of with only canine teeth Kennedy up 2.8 questionnaire outcomes
(Kennedy positioned. the abutments and incisors. Residual class I. months considered
class I). Aanchoring bone crest of a height are
systems: hooks and thickness adequate reported
for the dental to consent the insertion
abutments and of implants. No history
ball attachments of mandibular or
for the implants. parafunctional
disorders.

(Appendix A continued on next page.)

 Risk of bias
At baseline, do
Are the
the participants
Is the results
Are the eligibility have the same Selective
length of Lost to evaluated
Author/Ref. Participants Intervention Outcomes Study design criteria explicitly characteristics outcome
follow-up follow-up? with
reported? with regard to reporting?
adequate objective
their state of
criteria?
health?
Schwarz S 55 patients 66 dentures: 30 Retention of Retrospective Adequate. Inclusion Not clear Not Not Adequate. Adequate.
[28] supported by 129 the dentures, cohort study criteria: edentulism adequate. adequate. Clinical Results
implants, while survival of the Average 12/55 examination regarding
the other 36 were superstructure period 3.4 patients lost and statistical all the
supported both by years during analysis outcomes
implants (n = 80) follow-up considered
and teeth (n = (21.8%) are
102). Anchoring reported
system: telescopic
crowns.
Kaufmann 60 partially Group 1 (n = 42): Biological and Cohort study. Adequate. No Not adequate. Adequate. 3 drop-outs: Adequate. Adequate.
R [29] edentulous implants placed in technical diabetes, no The participants Follow-up 2/48 in the Clinical and Results
patients . order to obtain a complications; bisphosphonates, had different of 8 years “planned” radiographic regarding
symmetrical and retention of radiotherapy or degrees of group examination all the
stable support for the prosthesis. chemotherapy, no edentulism. (4,16%); outcomes
the denture; the oral defect, either 1/18 in the considered
residual teeth acquired or “repair” are
prepared for the congenital, absence group, death reported
insertion of a of Sjogren’s (5,5%)
telescopic crown, Syndrome, no cardiac
while the implants problem in the last 12
had a ball months, the patients
anchoring system. with high blood
Group 2 (n = 18): pressure were not
During the excluded if under
observation treatment. 15% of the
period, when a participants were
patient lost some smokers.
 Risk of bias
At baseline, do
Are the
the participants
results
Are the eligibility have the same Is the length Selective
Study Lost to evaluated
Author/Ref. Participants Intervention Outcomes criteria explicitly characteristics of follow-up outcome
design follow-up? with
reported? with regard to adequate reporting?
objective
their state of
criteria?
health?
abutments, these
ones were then
substituted with
implants (n = 21),
so that the patients
could maintain their
original denture.
A total of 101 post-
copings with
precision
attachments were
used, 7 telescopic
crowns,
22 molars had
hooks.
Wolfart S 23 patients For each patient, the Patient Analytical Adequate. Inclusion Not adequate. Not Adequate. Adequate. Adequate.
[30] arches were divided satisfaction; study for a criteria: good state of Heterogeneity adequate. 1/24 drop- Questionnaire Results
into 4 sectors (from survival of prospective health (ASA at baseline Follow-up out (4,1%) OHIP regarding
the 3rd molar to the teeth and cohort classification, class I or of 2 years (oral health all the
1st premolar, from implants; study II). impact outcomes
the canine to the retention of Exclusion criteria: need profile) considered
central incisor); the prostheses. of bone grafts; presence are reported.
implants were of psychological
placed so that there disorders; presence of
was at least one craniomandibular
abutment (tooth or disorders; presence of

(Appendix A continued on next page.)

 Risk of bias
At baseline,
do the Are the
Is the
participants results
length of Lost to Selective
Study Are the eligibility criteria have the same evaluated
Author/Ref. Participants Intervention Outcomes follow- follow- outcome
design explicitly reported? characteristics with
up up? reporting?
with regard to objective
adequate
their state of criteria?
health?
implant) in each sector. addiction to illicit substances
Then, the implants
were connected to the
denture with ball
anchoring (complete
dentures) or telescopic
crowns (partial
dentures).
Hug S [31] 46 patients 3 groups: Group 1 (n = Patient Cohort Not adequate. Eligibility criteria Not adequate. Not Not Adequate. Adequate.
14) tooth-implant satisfaction, study. not reported Participants adequate. clear Clinical and Results
supported dentures; retention of with varying Follow- radiographic regarding
Group 2 (n = 17) tooth the degree of up of 2 examination, all the
supported dentures; edentulism years questionnaire, outcomes
overdentures; clinical statistical considered
Group 3 (n = 15) (Plaque analysis are
implant supported Index, BOP, reported
overdentures. PPD) and
Anchoring systems: radiographic
ball attachments. conditions;
survival of
teeth and
implants.
 Risk of bias
At baseline, do
Are the
the participants
results
Are the eligibility have the same Is the length Selective
Lost to evaluated
Author/Ref. Participants Intervention Outcomes Study design criteria explicitly characteristics of follow-up outcome
follow-up? with
reported? with regard to adequate reporting?
objective
their state of
criteria?
health?
Bernhart G 63 patients, 3 groups: Group 1 Clinical Cohort study. Not adequate. Not adequate. Not Not clear. Adequate. Adequate.
[32] (n = 19) implants conditions Eligibility criteria Heterogeneity adequate. The number Clinical and Results
supported dentures; (dental not reported among the Follow-up of of drop-outs radiographic regarding all
Group 2 (n = 28) mobility, participants at 24 months. is not examination, the
teeth supported PPD); the baseline specified. statistical outcomes
considered
dentures; retention of analysis.
are reported
Group 3 (n = 16) the
tooth-implant dentures.
supported dentures.
Frisch E 26 partially The treatment Clinical and Retrospective Adequate. Not clear Not Not Adequate. Adequate.
[33] edentulous consisted of at least radiographic cohort study. Inclusion criteria: adequate. adequate. Results
patients two abutments conditions age ≥ 18 years, Range of 3/26 regarding all
(only the (teeth or implants) of the post-implant follow-up, 2- patients lost the
upper in each side of the abutments; support, same 16 years during the outcomes
arch). upper maxillary retention of anchoring system, observation considered
arch. the denture; definitive device in period are reported
The primary crowns survival of function for at least (11.5%).
were cemented to teeth and 2 years.
the teeth and implants.
screwed to the
implants, while the
secondary crowns
were included in the
dentures.

(Appendix A continued on next page.)

 Risk of bias
Author/Ref. Participants Intervention Outcomes Study design Are the eligibility At baseline, Is the Lost to Are the Selective
criteria explicitly do the length of follow- results outcome
reported? participants follow- up? evaluated reporting?
have the same up with
characteristics adequate objective
with regard to criteria?
their state of
health?
Rammelsberg 61 patients. 34 implants supported Clinical and Cohort Adequate. Inclusion Not adequate. Not Not clear Adequate. Adequate.
P [34] dentures vs 39 tooth- radiographic study. criteria: prosthetic Heterogeneity adequate. Clinical and Results
implant supported conditions of device on implants or at baseline Average radiographic regarding
dentures. the abutments; on a combination of period examination, all the
survival of the teeth and implants, use 2.7 years statistical outcomes
considered
abutments, of telescopic crowns. analysis
are
biological and reported
technical
complications.
Wismeijer D 48 4 groups. 3 test groups Patient Prospective Adequate. Inclusion Adequate. Not Adequate. Adequate. Adequate.
[35] participants. each with 12 satisfaction multicentric criteria: maxillary Kennedy adequate. 4/48 Questionnaire Results
participants who were study. edentulism partial class I Follow- drop-out OHIP and regarding
provided with distal mandibular edentulism up of 3 (8,3%) statistical all the
implants so as to obtain (Kennedy class I), years analysis outcomes
considered
stable support for the aged between 25 and
are
future removable 80, residual bone crest reported.
denture, anchored both of adequate quality
to the natural residual and quantity for the
teeth and to implants. insertion of the
Control group (n = 12): implants.
traditional removable
partial denture.
 Tooth-Implant-Supported Removable Denture 339

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