Journal of Oral Rehabilitation
Journal of Oral Rehabilitation 2010 37; 143156
Review Article
The future of complete dentures in oral rehabilitation.
A critical review
G. E. CARLSSON* & R. OMAR *Department of Prosthetic Dentistry, Institute of Odontology, The Sahlgrenska Academy,
University of Gothenburg, Goteborg, Sweden and Department of Restorative Sciences, Faculty of Dentistry, Kuwait University, Kuwait
SUMMARY Based on available investigations and cur-
rent trends in oral rehabilitation published in the
dental literature, an attempt is made to describe the
possible future role of complete dentures. For
edentulous patients, complete dentures have for
long been the only prosthodontic treatment option.
Whereas a large number of edentulous patients
report satisfaction with denture usage, a smaller
number are unable to adapt; for such patients,
sophistication of clinical and technical processes or
quality of denture-supporting tissues, appear to
have little influence on patient-perceived outcomes.
Since the 1980s, osseointegrated dental implants
have dramatically improved the therapeutic possi-
bilities, especially so for maladaptive patients. Those
able to access such treatment can expect significant
improvements in oral functional status and quality
of life. While there is a downward trend in edent-
ulism in several countries, it is region-specific, con-
firming the overriding influence of socio-economic
Introduction
Although complete dentures cannot be considered a
substitute for natural teeth, they have been, and
remain, the staple treatment for edentulous patients.
Over the course of the past one hundred years, there
have been significant advances made in the science and
art of complete denture prosthodontics. One of the
major reasons for this has been the evolution of clinical
biomaterials and biological research. In the earlier part
of this period, developments in the sciences of dental
materials and dental technology essentially steered
progress, but few would disagree that the impact of
2009 Blackwell Publishing Ltd
factors on health status. In most societies, despite
ageing populations, the need for complete dentures
is not likely to reduce in the near future. Whereas a
two- or even a one-implant overdenture for the
edentulous mandible is increasingly regarded as a
minimum standard of care in many developed
countries, its routine prescription for the majority
in the world who are disadvantaged is unrealistic;
for them, even low-tech therapies like conven-
tional dentures are beyond their reach. Improving
the conventional management of edentulous pa-
tients is a necessity and requires a keener focus by
researchers, educators and clinicians in the devel-
oped world on the needs of populations with fewer
resources.
KEYWORDS: decision-making, dental implants, edent-
ulism, epidemiology, implant overdentures, preva-
lence, quality of life, treatment choice
Accepted for publication 14 November 2009
osseointegration in the last 30 years has been nothing
short of momentous (1, 2). Prostheses supported
and or retained by osseointegrated implants have
proven to be an indisputably positive treatment for
many edentulous (and partially dentate) patients for-
tunate enough to receive them. For the great majority
of edentulous patients, however, the only treatment
option is with complete dentures.
Most edentulous patients appear to have benefited
from complete denture treatment and report satisfac-
tory oral and masticatory function with their use (35).
However, not all complete denture wearers are able to
adapt to their dentures, even if the dentures fulfil all
doi: 10.1111/j.1365-2842.2009.02039.x
144 G. E. CARLSSON & R. OMAR

conventional prosthodontic criteria. Several studies
have failed to show strong correlations between either
patient satisfaction with their dentures and their quality
or denture satisfaction and the quality of the denture-
supporting tissues (68). The possible reasons for this
disparity have been the subject of several investiga-
tions. Aside from prosthetic, dental and oral factors that
may lead to prosthesis incompatibility (e.g. mechanical,
thermal, biological and chemical or allergic irritation of
the mucosa), psychogenic factors, for example, the
relationship between patient and dentist (8, 9) as well
as cultural factors (10), may be important.
The breakthrough of implant-supported and or
-retained prostheses has revolutionized treatment pos-
sibilities for edentulous patients. Whereas prostheses
stabilized by implants have helped many complete
denture wearers towards improved oral function, for
those patients regarded as maladaptive, the transfor-
mation in oral functional status has been dramatic (1, 2,
1113). So successful have the clinical outcomes with
implant treatment been that many clinicians have come
to believe that implants can solve all problems related
to tooth loss. This is, of course, not true, confounded as
it is by a number of non-dental factors. Of these, the
greatest obstacle is undoubtedly economic (14).
In many countries, notably industrialized ones, the
rate of edentulism has been falling, and reflects the
most recognizable and evident improvement in the oral
health of the adult populations of these countries. The
implications of such changes for future patterns of
treatment provision and dentist training would seem to
be obvious (1518), with the future of complete
dentures in oral rehabilitation seemingly easy to predict
in a long-term perspective. However, any kind of
prognostication must necessarily be based on realities,
which, as far as they are currently known with respect
to complete denture prosthodontics, are diverse (19).
For one, when considering the future demand for
supported and or -retained prostheses. In so doing, it
is intended to highlight the nature of the relation-
ship that currently exists between the varied and
changing needs for complete denture services at the
population level on the one hand, and on the other, the
direction of professional developments. A case is
made for the importance of greater synergism between
these two pivotal factors if equitability in complete
denture services is to be realized at some point in the
future.
Materials and methods
The literature on complete dentures was searched using
the PubMed, Scopus and Cochran Library databases. In
addition to searching for complete dentures as an
embracing term, various combinations of complete
dentures, edentulism, edentulous jaw, future,
prevalence, implants, implant overdenture, deci-
sion making, treatment choice, teaching, dental
education, oral health-related quality of life and
patient satisfaction were used to search the databases
for identification of articles relevant for the review. A
large number of titles and abstracts were identified
through the electronic searches in PubMed (Table 1),
most of which overlapped with those in Scopus. The
last update of electronic searches was carried out on 13
August 2009.
As a first step in the process of inclusion of articles,
titles were screened according to the following criteria:
review articles and studies related to developments in
the prevalence of edentulism, satisfaction with com-
plete dentures and implant prostheses for edentulous
jaws, quality of life in edentulous subjects with various
Table 1. Results of search in PubMed for articles related to
complete dentures

complete denture services, the effects of ageing popu-

Number Number
lations cannot be overlooked. While predictions cannot, Terms used of articles of reviews
therefore, be clear-cut, identifying and honing in on
some key areas may improve the chances of doing so. Complete dentures (CD) 10 911 327
CD and patient satisfaction 454 31
It is the aim of this study to assess the future role of
CD and prevalence 342 20
complete dentures in oral rehabilitation based on a CD and quality of life 142 12
critical review of the literature. The review focuses CD and future 100 16
particularly on current trends in the epidemiology of Edentulous jaw and treatment choice 94 12
edentulism, and the available evidence regarding the Edentulism and decision-making 12 4
Edentulism and implants 189 30
impacts on patient satisfaction and oral health-related
Edentulism and implant overdenture 40 6
quality of life of complete dentures versus implant-

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types of oral rehabilitation and choices of treatment for
the edentulous jaw. The next step was to review the
abstracts of the selected articles focusing on their
relevance as regards the future of complete dentures
in oral rehabilitation.
None of the abstracts definitively addressed, or was
able to fully answer, the central question about the
future of complete dentures. However, 112 were of
possible interest, and the full articles were read. Of
these, 85 met the inclusion criteria and were used in
the review. Older articles that were cited in more recent
systematic reviews were not included if they did not
provide information of specific interest. The Cochran
Library contained several reviews on implants and one
on complete dentures, but none were of direct rele-
vance for the present purpose. An additional hand
search of references cited in the included articles and in
various textbooks yielded 10 more references, resulting
in a total of 95 articles for the review.
Prevalence of edentulism and complete dentures
Edentulism is generally considered to be the result of
removal of all teeth because of caries and periodontal
disease. However, tooth loss is an outcome of a complex
interaction between disease and non-disease entities,
the latter including biological and patient-related fac-
tors (20). Economy, oral healthcare system, availability
of dental services, dental awareness, cultural tradition,
education and other psychosocial factors can potentially
strongly influence the decision to remove all remaining
teeth as a final clearance. It is hardly surprising then
that the prevalence of edentulism varies widely across
regions and countries, as well as over time and with
respect to age differences between the samples inves-
tigated (21).
A very rapid overall decline in the rate of edentulism
has occurred over the last three decades in several
countries. For example, the prevalence of edentulism in
70 year-old women living in Goteborg, Sweden, was
55% in 1971 and 7% in 2001 (Fig. 1) (22). National
surveys in Sweden have demonstrated a similarly
dramatic decrease in edentulism between 1975 and
1996. Specifically, the prevalence of edentulism among
60 -year-old Swedish women declined from 47% in
1975 to 3% in 1996 and is extrapolated to be <1% in
2015 (15). National surveys in Australia have reported
similar downward trends, with the prevalence of
edentulism having at least halved between 1979 and
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FUTURE OF COMPLETE DENTURES 145
60
W tot edent
50
W edent 1 jaw
M tot edent
40
M edent 1 jaw
30
%
20
10
0
I II III V VI
Fig. 1. Percentage distribution by gender (W = women,
M = men) of prevalence of edentulism in both jaws (totally
edentate) and in one jaw (1 edentulous jaw) in five cohorts of 70-
year-old subjects examined from 1971 (cohort I) to 2001 (cohort
VI). (From reference 22, with permission.)
2002. In cohorts born after 1915 and up to about 1950,
it is suggested that the practice of exceptionally high
historical rates of extraction may account for the high
edentulism seen in the contemporary elderly. In con-
trast, changes in extraction practices in subsequent
cohorts may explain the lower levels of edentulism that
they experience (23). Fewer people today suffer from
the severe levels of oral disease of the past, with
perhaps a greater conviction among patients and their
dentists to retain some natural teeth for as long as
possible. Thus, todays 50 year-olds who will be 70 in
20 years time are likely to be different from the 70 -
year-olds of today.
Although representative data on rates of edentulism
are available from relatively few countries in the world,
some broad observations can be made. According to an
extensive review for the period 19852000, there was
very wide variation among 35 countries, ranging from
0% to 715% for the 6574-year-old age group (21). A
remarkable finding in the review was that the rate of
edentulism was neither associated with the countries
economy nor with the number of dentists per capita
(Figs 2 and 3). More recently, while the prevalence of
complete tooth loss varied greatly across different states
in Mexico, no simple association between edentulism
and socio-economic and socio-demographic indicators
was found (24). Marked ethnic disparities in edentu-
lism and tooth loss have, however, been demonstrated
in various parts of the world (25). A recent study from
New Zealand found that Maori women were five times
146 G. E. CARLSSON & R. OMAR
Fig. 2. Edentulous rate of 70 -year-old subjects and gross domes-
tic products for selected countries in the year 2000. (From
reference 21, with permission.)
Fig. 3. Edentulism and the correlation to the dental workforce
(dentists and dental therapists) in selected countries. (From
reference 21, with permission.)
more likely than women of European descent to be
edentulous (26). Elsewhere, a comparison of trends in
the absolute prevalence difference in edentulism
between people from low and high socio-economic
groups in the United States revealed no change in the
size of the disparity over a 30-year period (the differ-
ence remaining at approximately 11% more edentu-
lousness in low compared to high socio-
economic groups in 1972 and 2001) (27).
A review of 55 studies performed between 1960 and
2001 in 14 countries largely confirmed the extremely
wide differences in prevalence of edentulism (380%)
in people aged 60 or older (28). It needs to be
considered, however, that the very rapid changes
observed in oral health over the last half century in a
number of countries means that data from even a
decade ago should be interpreted with caution as they
may not be directly valid for the situation at present. It
is also the case that in most countries a lack of reliable
epidemiological data means that conclusions cannot
easily be drawn either about current oral health status
or about the future development of the prevalence of
edentulism in their populations.
When focusing on people of working age, edentulism
is rare according to recent studies from several Euro-
pean countries, suggesting that the situation has
improved considerably over the last few decades (18).
The review also concluded that available results indi-
cate that the incidence, i.e. new cases of edentulism in a
given time period, is low, albeit with geographical
variation (02% per year). Further, incidence varies
between age groups, and there is a decreasing trend
over time. Taken together with the surveys mentioned
earlier about edentulism in older age groups, it would
seem reasonable to conclude that the prevalence of
edentulism is falling in all age groups in industrialized
countries. Similar analyses from the less industrialized
countries do not seem to be represented in the available
literature. However, it cannot be disputed that in many
countries there are still large numbers of edentulous
individuals who are in need of treatment, particularly
among the elderly. An indication of its extent is the
finding in a recent study that almost 60% of 365
patients attending a dental school prosthodontic clinic
in India were edentulous, and the remaining ones were
partially dentate (29).
The declining prevalence of edentulism would seem
to indicate a reduction in the number of people in need
of complete dentures. Reliable data to corroborate such
a conclusion is so far available from only a few
countries. Analyses from Finland, Sweden and the
United Kingdom conclude that the need for complete
denture production will fall despite changing age
demographics (17). However, conflicting results have
been published from the United States, which conclude
that when epidemiological and demographic data are
combined, those in the population with one or two
edentulous jaws will increase from 34 million in 1991
to 38 million in 2020 despite a decline in edentulism of
approximately 10% per decade (16). The explanation
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given by the authors is that a large increase in the
number of the elderly will counteract the diminishing
rate of edentulism. Two points can be mentioned in
relation to this predicted increase in the denture
market: first, the yearly decline in edentulism was
assumed to be at a rate of 1% (viz. an estimate from
surveys carried out between 1958 and 1974 (30) which
clearly does not reflect the present situation); secondly,
it was assumed that all edentulous jaws were to be
treated by provision of complete dentures, with
implants not even mentioned as an option. In mitiga-
tion of the latter point, this may have been because
edentulous people belong predominantly to the poorest
segment of the population and would be unlikely to
afford implant treatment not even in the worlds
richest country! Based on later population studies in the
United States, a recent review concluded that it does
not appear that the necessity for complete denture
therapy will disappear over the next 4 or 5 decades. The
faltering global economic conditions may even lead to a
growing need (20).
Viewed in a global perspective, poverty is still
extremely widespread, and rising even in many
industrialized counties (31). Certainly, most edentulous
people will never be candidates for any type of implant
therapy. For poor people, complete dentures will be the
sole option, and indeed, even this may be overstating
the case, because there are many edentulous people for
whom any type of dental treatment is neither attainable
nor available. However, a fuller discussion of this socio-
political dimension is outside the present remit. Suffice
it to say that whereas prosthodontics has been able to
provide excellent oral rehabilitation for many edentu-
lous patients, this is certainly not the case for all,
perhaps not even for most. Among an elderly Indian
edentulous population, almost half were not wearing
dentures (32). It follows that when complete dentures
are the only option, and are possible, it would be
desirable that the cost of treatment is affordable. In this
regard, if accepted levels of quality control can be
agreed by the profession, such as eliminating steps in
the fabrication process that have been shown to be
unnecessary for improving clinical outcomes, a mini-
mum standard of care might be assured (33) but
clearly not at the expense of sound prosthodontic
principles. The urgency with which the profession
decides to take up this challenge may not be predict-
able, but it needs to be recognized that the construct of
clinical practice cannot remain as it has.
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FUTURE OF COMPLETE DENTURES 147
Satisfaction with complete dentures
Studies published over several decades have reported as
many as 6590% of edentulous patients to be satisfied
with their complete dentures (3, 34). On the other
hand, the finding of almost 50 years ago that there was
a poor correlation between dentists assessments of
denture quality and patients satisfaction with the
treatment (35) surprised many dentists. Technical
perfection has for long, quite emphatically been taught
in dental schools to be a prerequisite for achieving a
successful outcome for any prosthodontic therapy.
Increasingly, compelling evidence from a number of
more recent studies has questioned this dogma. For
example, there is no evidence that a more complex
fabrication technique, including face-bow registration,
results in a better clinical outcome. Further, variations
in materials and techniques appear to have only minor
influence, if any, on the clinical end result (36).
Similarly, no strong correlation has been shown to
exist between the quality of the denture-supporting
tissues and the outcome of complete denture treatment.
One such study concluded that clinicians assessments
of the quality of denture-supporting tissues are poor
predictors of patient satisfaction with mandibular pros-
theses (7). If associations between the supposed ana-
tomical and technical prerequisites for successful
treatment and patient satisfaction with complete den-
tures are weak or lacking, there would seem to be a
convincing case that other factors, notably psychogenic
ones may be important. In this regard, studies have
indicated that the presence, or establishment, of a good
relationship between dentist and patient seems to be
more important to achieving patient satisfaction than
providing dentures that have as their foremost objective
the meeting of all technical specifications (8, 3739).
Furthermore, cultural factors, particularly in develop-
ing countries with strongly religious and or patriarchal
societies, may have an influence on expressed satisfac-
tion with dentures in a similar way as are expressed
attitudes to tooth loss influenced by patients societal
role (10, 40, 41).
Despite the high mean level of satisfaction with
complete dentures, there are edentulous people who
cannot adapt to them. Predicting those who suffer from
the affliction of chronic intolerance to complete den-
tures is still far from reliable. During the 1970s and
1980s, 1015% of 70 -year-old Swedes did not use their
complete dentures, although this figure was much
148 G. E. CARLSSON & R. OMAR
lower in 2001 (22). According to representative studies
conducted in the United States and in Spain, 10% of
edentulous subjects did not have dentures (41, 42). In a
large Italian community-based cohort of 65 -year-
olds, the rate of edentulism was 44%, among whom
175% wore no prostheses (43). The prevalence of
edentulism in a Brazilian population of people aged
60 years was 63%, among whom 15% required
maxillary and 38% mandibular dentures (44). Further,
institutionalized individuals have, in general, poorer
oral health than community-living subjects of the same
age. Large proportions of institutionalized edentulous
subjects either have no dentures or do not use their
complete dentures (18).
Historically, some edentulous subjects who had
difficulties adapting to their prostheses were treated
by means of an approach that aimed to improve the
foundations on which complete dentures are supported
using a variety of soft tissue and ridge augmentation
techniques. However, such techniques do little to
nothing to improve the patients skill in controlling
their dentures, a difficulty that implants easily over-
come (2, 45). Thus, for those maladaptive patients who
are able to access such care, implant-retained and or
-supported prostheses have vastly improved their
quality of life (4649). Nevertheless, implant treatment
will remain an unrealistic option for the vast majority of
edentulous subjects. Based on claims of market share by
the largest commercial implant entity, if it is conserva-
tively assumed that 10% of the worlds population of
6 billion is partially or totally edentulous, the propor-
tion of those who have had implant treatment would be
17%. But this is pure conjecture as there were at the
time that this estimation was made no reliable epide-
miological data on dental implants (34). The paucity of
such data remains. A 2007 review found only a few
studies from the preceding decade, all indicating low
rates of implant-treated patients, the highest ranging
between 2% and 4% in Germany, Sweden and Swit-
zerland (50).
Implant prosthodontics
The introduction of osseointegrated dental implants
has revolutionized prosthodontics, and a plethora of
scientifically robust articles have given implant-
supported and or -retained prostheses a significant
evidence base as a treatment for edentulous jaws. It is
suggested that the demand for solutions other than
conventional removable dentures for the management
of the edentulous predicament runs increasingly in
parallel with improved standards of living (51). This is
supported by some recent studies from Sweden (22,
52). It would not be unrealistic to suppose that such a
development is also occurring in other countries,
driven as it appears to be by commercial interests
and increasing consumerism among more informed
patients.
Severe problems with adaptation to complete den-
tures were the main indication for implant treatment
during the first period of the osseointegration era. The
original protocol for treatment of the edentulous jaw
suggested a fixed implant-supported reconstruction (53,
54). The survival rate for this therapy is >90% after
10 years (55). Even after 15 years, and beyond
20 years, similar survival rates have been demonstrated
in follow-up studies both for mandibular and maxillary
fixed implant-supported prostheses (56, 57).
The two-implant overdenture has gained consider-
able popularity since its introduction, and based on
compelling evidence, has been proposed as the first line
of treatment for the edentulous mandible (58). The
recommendation has quickly gained wide support as a
standard of care, although several prosthodontists have
suggested that the recommendation be limited to
patients with severe denture adaptation problems.
The choice between a fixed prosthesis and an
overdenture when treating the edentulous mandible
with implants shows wide variation both within and
between countries. According to a questionnaire survey
of prosthodontists in 10 countries, the overdenture
option was more strongly favoured by those in the
Netherlands (93%) than those in Sweden (12%), with
the trend reversed for the fixed prosthesis option for the
countries surveyed (59). Many factors are involved in
the decision to choose one or the other option,
economy and tradition probably being among the most
important. As a case in point, the Dutch National
Health Service reimburses most of the costs of implant
overdentures whereas there is no reimbursement for
fixed restorations. In Sweden, on the other hand, there
is no difference in reimbursement between removable
and fixed implant restorations (59). The Belgian gov-
ernment has recently announced that it will pay for
mandibular 2-implant overdentures for its edentulous
population (Professor Naert I, personal communication,
February 2009) based upon, among other things, the
consensus recommendations of an international
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workshop (58). Such initiatives by funders will
undoubtedly make implant treatment more attainable
and so probably heighten the prospect that implant
overdentures will replace conventional dentures as the
preferred mode of rehabilitation of edentulous mandi-
bles. In this regard, the advent of implants has been
shown to influence the profile of prescriptive patterns
for partially dentate patients according to recent Japa-
nese and Australian studies (60, 61).
Quality of life in relation to edentulism, complete dentures
and implant overdentures
The fundamental diagnosis that underlies prosthodon-
tic treatment is impaired oral function. Oral function is
multifaceted, ranging from the facility for adequately
harmonious mandibular movements to patients satis-
faction with their appearance, feelings of self-esteem
and social wellbeing. According to several studies,
impaired oral health is related to a poorer quality of
life (6264).
Edentulism is considered a handicap with impacts on
quality of life and nutrition. Provision of new complete
dentures improves oral health-related quality of life
(65, 66). Implant-retained overdentures have shown
superiority over complete dentures in several ways,
including patient satisfaction, comfort, chewing ability,
social and sexual activities and quality of life (4648,
6569). On the other hand, food selection was not
influenced by the method of rehabilitation according to
a randomized controlled trial of complete dentures and
implant overdentures (70). A recent review of studies
comparing patient satisfaction with complete dentures
and implant overdentures identified 90 articles, of
which 27 met the inclusion criteria. Most studies found
mandibular implant overdentures to be superior to
complete dentures as regards patient satisfaction and
quality of life (71). It seems fair to suggest that the
growing body of evidence of the multidimensional oral
functional benefits for edentulous patients that im-
plant-supported fixed prostheses and implant overden-
tures provide are in many ways superior to those of
complete dentures and will impact strongly on clinical
decision-making in the future.
Choice between complete dentures and implant prostheses
For dentists who have had positive clinical experiences
with providing their patients with implant prostheses,
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FUTURE OF COMPLETE DENTURES 149
advising an edentulous patient of the benefits of
implant treatment will seem natural. However, there
are several obstacles to the implant option, an essential
one being economic (14, 52). On the other hand,
among a group of patients who were offered free
implants for mandibular overdentures, 36% refused the
offer. The most common reasons for refusal were a fear
of surgical risks and a belief that implants were
unnecessary as their complete dentures functioned
well (72). It would seem that, for some patients, cost
is not the sole reason for not seeking implant treatment.
In Sweden, the interest in implant treatment increased
dramatically over a 10-year period according to con-
secutive questionnaire studies: 92% of all those sur-
veyed who did not express a desire for implants in 1989
had changed their minds 10 years later, resulting in a
large swing of 94% becoming positive towards im-
plants. However, the interest in implant treatment was
smaller among edentulous individuals: only 42%
answered the question and among them only 38%
changed to a more positive attitude towards implants
10 years later (52, 73). It should be noted that the
responses to the second (follow-up) questionnaire were
collected in 1999, i.e. 10 years ago, and further changes
in opinions in favour of implants are likely to have
occurred.
Implant overdentures cost between two and three
times that of complete dentures, with the differential
influenced by materials used, clinical setting, country,
dental healthcare system and type of insurance (74
76). Clearly, for many patients, the higher initial fee
would be a prohibitive factor. A more interesting
question, however, may be whether implant treatment
represents value for money spent, and the answer may
vary according to a number of personal and background
factors. A Swiss study compared the cost-effectiveness
of complete dentures with two types of implant over-
dentures. It was concluded that, over an assumed time
horizon of 10 years, the cost-effectiveness of implant
overdentures makes it the treatment of choice (77). A
Canadian study similarly showed that approximately
half (46%) of a group of edentulous elders were willing
to pay three times the current cost of conventional
dentures to have implant prostheses. Their interest
increased considerably (to 77%) if they could pay for
the implant treatment in monthly instalments (78).
Cost analysis for implant treatment for an edentulous
jaw will, of course, include the number of implants to
be used. On the basis of initial cost, the overdenture
150 G. E. CARLSSON & R. OMAR
option which requires fewer implants than a fixed
prosthesis would be more favourable. The trend over
the last several years has been to use fewer implants
than the six that were originally recommended for a
fixed implant-supported mandibular prosthesis (79). In
the interests of cost reduction, the use of three implants
for an implant-supported fixed prosthesis (which
increases the cost only moderately over that of a two-
implant overdenture) has been assessed in a 1-year
study. It was concluded that, if the early survival results
prove to be long-lasting, the choice between a fixed and
a removable prosthesis need no longer be a matter
solely of economy (74). One other aspect of cost
analysis relates to in-service maintenance, which
has been shown to be less expensive for the mandib-
ular implant overdenture than the fixed implant
prosthesis (80).
The possibility of reducing the number of implants to
one for stabilization of an overdenture has been
successfully tested in a few studies, demonstrating
favourable results (81, 82). A recent 1-year randomized
clinical trial demonstrated comparable patient satisfac-
tion with a mandibular overdenture retained by a single
midline implant compared to one with two implants
(83). This one-implant option deserves consideration as
an alternative to the standard two-implant overdenture
because it is a relatively more economic, as well as
surgically and prosthodontically simpler technique for
improving the functionality of a complete denture.
Even if successful 5-year results have been reported in
an observational study (81), longer observation periods
are needed for confirming the short-term results.
While the question of economy is certainly a sine qua
non in most cases, treatment decisions will also be
influenced by the edentulous situation (viz. morpho-
logical considerations), age, gender, cultural and
educational background, as well as a host of other
socio-economic and psychological factors (84).
Complete dentures and the future of dental education
and research
In spite of declines in edentulism, there are still millions
of edentulous people worldwide who need treatment
for a condition that can represent considerable disabil-
ity. The great majority of them, in many countries
across the world, will have to rely on complete
dentures. Providing patients with complete dentures
will, therefore, continue to be an important prostho-
dontic task for many more decades. Most of this care
will continue to be provided by general dental practi-
tioners. However, some older edentulous people will
require specialist care and to meet these needs it is
important to have in place a framework of specialist
backup in the form of specialists with an interest in
older people.
The implications for undergraduate dental education,
and postgraduate and specialist training, as well as for
research in the future are, therefore, evident. While it is
easy to assume that the decline in edentulism implies a
reduced need for emphasis in the undergraduate
curriculum on learning skills in complete denture
prosthodontics, the reality is more complex, with effects
felt at the level of undergraduate training. Dental
schools in many countries have reported difficulties in
finding suitable undergraduate teaching material, with
fewer complete denture cases being completed by
students prior to graduation and the time devoted to
the teaching of compete denture prosthodontics reduc-
ing. In the future, many younger clinicians may well be
not sufficiently equipped to diagnose, plan and effect
the needed treatment for edentulous patients.
Effects will be felt at the level of dental practice too,
with dentists likely to see too few cases to maintain
their skills and confidence, let alone to develop them
(85, 86). Dentists may become increasingly uncomfort-
able about treating difficult denture cases, and their
management may be transferred to the minority of
dentists who maintain a sufficient level of interest in
this area of prosthodontics to retain the required
expertise (87). Provision of complete dentures that
not so long ago was considered a simple treatment that
all dentists could perform, has in many places become
such an infrequent therapy that it has been upgraded to
the specialist level (88). This study was performed
almost 2 decades ago, and the situation is likely to be
even worse now in many countries.
When viewing the challenges that are occurring in
dental education along with the rapidly reducing
journal space taken up by research articles on com-
plete denture prosthodontics (89), the academic impor-
tance that this subject needs to maintain would seem to
be at risk. A UK study indicated that the journal space
devoted to complete denture prosthodontics had fallen
by more than the percentage of people becoming
edentulous in the United Kingdom (90).
As has already been elaborated, implants are not an
option for the majority. This raises questions about how
2009 Blackwell Publishing Ltd

the necessary level of education and training in
conventional complete denture prosthodontics can be
appropriately apportioned in increasingly congested
undergraduate curricula to maintain the needed level
of competence in the area. On another track, the
philosophy of appropriatech has been described as one
that harnesses the available evidence on the clinical
and technical parameters that influence complete den-
ture functionality for achieving more cost-effective
treatment (14). The same author goes on to propose
that a minimum acceptable protocol be set out for the
purpose of realizing greater consistency of outcomes
(33). Several studies have demonstrated that simplifi-
cation of the ideal technique for fabricating complete
dentures is possible without loss of denture quality and
patient satisfaction (8, 9193). One study comparing a
traditional and a simplified technique for producing
complete dentures concluded that the quality of
complete dentures does not suffer when manufacturing
techniques are simplified to save time and materials.
Dental educators should consider these findings when
redesigning prosthodontic training programs. (92). The
suggestion is consistent with the concept of appropria-
tech, viz. To provide treatment for the many, cost-
effective conventional treatment is required, but with
adequate quality control (14).
Discussion
The literature search conducted for this review iden-
tified no publications that were specifically related to
the future of complete dentures in oral rehabilitation.
This might not be surprising given the strong down-
ward trend in publications on complete dentures since
the mid-1980s (89). A number of articles did, how-
ever, meet the inclusion criteria derived from the
authors interpretation of the scope of the topic. This
does not imply that the search terms selected are fully
inclusive, but in an exercise such as this some
boundaries need to be set to manage the potential
content and size of the review. There may be inter-
esting areas that might have been included, such as
applications of technology to low-tech therapies, but
these would be largely speculative and in any case
lacks documentation at the present time. On the other
hand, and on a less serious note, an article from 1977,
with the promising title The future of complete
prosthodontics, dealt solely with a new impression
material (94).
2009 Blackwell Publishing Ltd
FUTURE OF COMPLETE DENTURES 151
In a global perspective, the available data on tooth
loss in general and edentulism in particular are neither
sufficiently consistent nor reliable. It is clear, however,
that there are wide variations between different coun-
tries making it extremely difficult to draw firm conclu-
sions about global trends (17, 18, 21). The data are
quite compelling, however, about declining rates of
edentulism in a number of the worlds industrialized
countries. This reflects the positive outcomes of dental
health education and prevention among these popula-
tions. In the United Kingdom, for example, while the
1998 Dental Health Survey showed about 12% of the
sample becoming edentulous in the preceding decade,
projections show that 5% of the UK population will be
edentulous by 2018 and 4% by 2028 (87). This
translates into a projected 2 million complete denture
wearers in 2018. It is clear that current and future
trends for the United Kingdom contrast strikingly with
the 37% of the population who were edentulous in
1968 (95).
The picture is complicated by emerging population
demographic trends, again partly the result of advances
in healthcare and socio-economic profiles in the
industrialized countries. Projections by the UK Gov-
ernment Actuarys Department are that people aged
65 will increase from 159% of the population in 2001
to 193% in 2020, and include increases in the number
of very old people (96). Population ageing is a fact in
both developed and developing countries, and the
future implications of these changes not only for
dentistry need more serious consideration than pres-
ently seems to be the case (97). In the context of this
review, the need for a complete denture service, in spite
of the lowering effect of declining rates of edentulism,
will remain substantial for a long time to come, not
only in developing but also in industrialized countries.
Even though most of this need for complete dentures
will be among old people, there will also be a not
insignificant number of late middle-aged in need of
such services (87).
As discussed in a previous review (19), the challenges
for prosthodontics are further aggravated by differences
in oral health that exist both between and within
countries. Specifically, tooth loss is not solely a function
of disease, but also reflects socio-economic conditions,
individual and cultural differences, and the nature of,
and peoples access to oral healthcare, with economic
disparities disadvantaging low-income groups (15, 20,
27). Whereas differences in oral health status have
152 G. E. CARLSSON & R. OMAR
frequently been explained along racial lines, they may
be more realistically viewed in the context of the
underlying social and behavioural variations that result
from the structural conditions that operate, or operated,
in society (19, 26).
There is consensus that a large majority of complete
denture wearers are satisfied with the benefits that
their dentures give them. There is also a significant
group, not so much in their proportion of the total
number of denture wearers, but in the challenges they
pose to clinicians because they cannot adapt to con-
ventional dentures. Contrasting with this group, there
are also the millions, representing a large proportion of
edentulous people, who simply have no denture at all.
There are wide variations in the way the subject is
taught and practised around the world. The vast
majority of complete dentures are provided by general
practitioners who tend to use clinical and laboratory
protocols that can be viewed as simple compared to the
ideal techniques that they would have learnt as dental
students. The evidence so far suggests that patients are
satisfied with less than ideally fabricated prostheses
(36). It is, therefore, reasonable to propose that the
dental curriculum should include simplified methods
for complete denture construction, as has recently been
suggested (33, 92, 93, 98). That this is an issue under
consideration in the profession was evident by a
discussion about the possibility of a 3-visit complete
denture technique at the recent conference of the
International College of Prosthodontists (99).
Even though the techniques employed by denturists in
some countries also seem to show acceptable outcomes
(100102), the concept of clinical dental technicians is,
and probably will remain a controversial issue among
dentists. Nevertheless, as long as simplicity does not
detract from denture acceptability for the many, it seems
clear that a minimum accepted protocol would benefit
patients and improve cost-effectiveness (33). This would
also likely open the door for the large number of
edentulous people who simply have no dentures.
Looking ahead, the future of complete denture
treatment is intimately linked on the one hand to
likely developments within the profession, and on the
other hand to a need for services that is in the process of
changing. The first, developments within the profes-
sion, may be viewed from two almost opposite per-
spectives. For one, the huge possibilities offered by
implants as a viable support and retentive element in
oral rehabilitation, has established the method as a gold
standard. Secondly, there is the still relatively unex-
plored clinical track of a minimum acceptable protocol
using a globally agreed standard of care that could
potentially serve as a realistic benchmark for rehabil-
itation with complete dentures (33). The contribution
of biotechnology to the evolution of implants into the
enviable position it holds today is evident. The potential
of technology for adding value to lower-end prosth-
odontic solutions must surely exist and should be
pursued with the same vigour as is being carried out for
high-tech treatments.
The second consideration, the need for services, is
probably much more complex, influenced as it is by
several factors. The relationship between socio-eco-
nomic conditions and dental disease levels, patterns of
tooth loss, and population demographics seems to be
crucial to reconciling the supply of appropriate services
with the huge need that undoubtedly exists. The
evidence that implants define a realistic standard of
care for individual edentulous patients is compelling
(19, 51, 58). What is less clear is a population-based
treatment recommendation that could guide policy for
the majority of the worlds disadvantaged who also
happen to be edentulous (98). How the profession
chooses to deal with the challenge will be important,
but whatever route it takes, the socio-political imped-
iments must be factored in.
Conclusions
The literature search revealed several potentially rele-
vant articles, although none could fully answer the
question of the future role of complete dentures in oral
rehabilitation. This review is, therefore, the authors
interpretation of the available literature, with the
following conclusions drawn:
1 Despite a declining prevalence and low incidence of
edentulism in countries where reliable epidemiolog-
ical data exist, in a global perspective large numbers
of edentulous individuals, particularly among the
elderly, are in need of rehabilitation.
2 Given the demographic data on population ageing, it
is likely that the need to rehabilitate edentulous
patients will remain considerable for many more
decades.
3 Complete dentures are and will remain the mainstay
of treatment for the vast majority of edentulous
patients; most are satisfied with their dentures but
some others are unable to adapt.
2009 Blackwell Publishing Ltd

4 While there is compelling evidence that implant-
retained and or -supported prostheses are in many
ways superior to conventional complete dentures and
would represent the standard of care for edentulous
individuals, the majority of them are poor and will
never be candidates for implant therapy; at the very
best, they can hope for well-functioning complete
dentures.
5 Several earlier studies found that a large majority of
edentulous individuals showed little interest in
implant treatment because they were satisfied with
their complete dentures; more recently, there is
increasing interest in implants (albeit less so among
edentulous than dentate subjects) and a decreasing
level of satisfaction with complete dentures.
6 Complete dentures will continue to play a central
role in the rehabilitation of edentulism; thus,
research, teaching and specialist training in complete
denture prosthodontics must continue, and in fact be
intensified rather than reduced.
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Correspondence: Gunnar E. Carlsson, Department of Prosthetic
Dentistry, Institute of Odontology, The Sahlgrenska Academy, Uni-
versity of Gothenburg, PO Box 450, SE 405 30 Goteborg, Sweden.
E-mail: g.carlsson@odontologi.gu.se
2009 Blackwell Publishing Ltd
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