CLINICAL EBOOK SERIES

POWERED BY

PROSTHODONTICS
FEBRUARY 2017

2 C E C R E D I T S

PROSTHETIC IMPLANT PROBLEMS

Common Prosthetic Implant

Complications in Fixed Restorations
Elyce E. Link-Bindo, DMD; James Soltys, DDS; David Donatelli, DDS; and Richard Cavanaugh, DDS

2 C E C R E D I T S

DENTURE ADAPTATION

Changes in Patient Satisfaction and Masticatory

Efficiency During Adaptation to New Dentures
Arcelino Farias-Neto, DDS, MSc, PhD; and Adriana da Fonte Porto Carreiro, DDS, MSc, PhD
 Learning Curve of Continuing Education in Dentistry

February 2017 | www.compendiumlive.com

W
PUBLISHER
Dental Learning Systems, LLC
of Continuing Education in Dentistry
hile implants have proven to be a MANAGING EDITOR
Melissa Tennen
game-changing innovation in den- mtennen@aegiscomm.com

tistry in recent decades, the fact BRAND MANAGERof Continuing Education in Dentistry
Amelia Falcone
remains that not every implant res-
EDITOR
toration is perfect—or at least not Bill Noone

every one remains perfect over time. Ranging from screw SPECIAL PROJECTS COORDINATOR
Angela Buziak
fractures, abutment loosening, and resin/veneer material CREATIVE
fractures, to loss of retention and peri-implantitis, prosthetic Claire Novo

implant problems can and do happen. As more and more
dentists are jumping into the fray and learning the practice
of dental implant restorations, it is helpful to know what
problems to look for and how to overcome them if and when
they do occur.
In our first of two continuing education articles in this spe-
cial supplement to Compendium, we feature an article that
focuses on complications commonly seen with fixed implant
EBOOK DESIGN
Jennifer Barlow
PROFESSIONAL RELATIONS
Mark Nelson
COVER
© AEGIS Communications, LLC
Copyright © 2017 by AEGIS Publications, LLC. All
rights reserved under United States, International and
Pan-American Copyright Conventions. No part of this
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system or transmitted in any form or by any means
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restorations. The authors provide strategies on how these dif-
ficulties can be averted and offer treatment options to handle
such challenging situations.
Our other CE focuses on a study regarding patient adapta-
PHOTOCOPY PERMISSIONS POLICY:
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Drive, Danvers, MA 01923. Per­mission is granted
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tion to new dentures. As the authors point out, successful

treatment with conventional dentures is highly dependent
on the patient’s ability to use the denture. Patients need time
to “learn” their new prosthesis and adapt to such chang-
ing factors as chewing, speech, retention, and comfort. The Chief Executive Officer
Daniel W. Perkins
article discusses the impact dentures have on the stomato- President
gnathic system and addresses the question of how long your Anthony A. Angelini
Chief Operating Officer
patients should consider waiting before opting for dental Karen A. Auiler
implant treatment. Corporate Associate
Jeffrey E. Gordon
We hope you find this supplement a valuable resource for
Subscription and CE information
your practice. For a whole host of clinical articles and CE Hilary Noden
877-423-4471, ext. 207
on the topic of prosthodontics, please visit Compendium’s hnoden@aegiscomm.com
comprehensive online library at www.dentalaegis.com/cced/
prosthodontics.

Sincerely,

Louis F. Rose, DDS, MD

Editor-In-Chief AEGIS Publications, LLC
104 Pheasant Run, Suite 105
lrose@aegiscomm.com Newtown, PA 18940

2 COMPENDIUM EBOOK SERIES February 2017

CONTINUING EDUCATION 1 PROSTHETIC IMPLANT PROBLEMS

Common Prosthetic
Implant Complications
in Fixed Restorations
Elyce E. Link-Bindo, DMD; James Soltys, DDS; David Donatelli, DDS; and Richard Cavanaugh, DDS

ABSTRACT: Many clinicians consider implants to be one of the most important in-
novations in dental care. Even so, over the past 40 years of implant dentistry, compli-
cations have been a constant struggle for restorative dentists, surgeons, and patients
alike. Implant-related problems can be particularly challenging and frustrating, es-
pecially given that an implant is thought to be a “lifetime” solution expected to yield
minimal difficulties. This, however, is not necessarily the case with prosthetic restora-
tions. With innovations in implant technology continuing to rapidly advance, main-
taining knowledge of all the latest developments can be challenging for clinicians. The
purpose of this article is to provide a basic understanding of the treatment, manage-
ment, and prevention of common prosthetic and technical implant complications seen
in the office of a restorative dentist.

LEARNING OBJECTIVES

• Recognize and diagnose • Identify and apply several • Discuss clinical treatment
common prosthetic implant ways to minimize future of common implant-related
complications prosthetic complications prosthetic problems

T
he evolution of implant dentistry
has brought improvements in tech-
niques and designs aimed at enhanc-
ing implant osseointegration while
avoiding potential complications.
However, even with such advances, problems
can and still do occur.1 Most of the literature on
prosthetic complications has focused on screw
loosening, screw fractures, abutment loosening,
abutment fractures, implant fractures, oppos-
ing prosthesis fractures, framework resin/ve-
neering material fractures, implant prosthesis
fractures, loss of retention, and overdenture
mechanical retention problems.1-3
DISCLOSURE: The authors had no disclosures to report.
Higher complication rates have generally
been reported in cases of full-arch rehabili-
tation, mainly consisting of fracturing/chip-
ping of the veneering material (33.3% at 5
years), prosthetic screw fracture and screw
loosening (10.4% and 9.3%, respectively, at 5
years), and hypertrophy/hyperplasia of soft
tissue (13% at 5 years).4 More recently, other
complications have been noted in the litera-
ture, including the opening of interproximal
contacts between adjacent implants and
natural teeth, and excess cement leading to
peri-implantitis. This article focuses on com-
plications commonly seen with fixed implant

www.compendiumlive.com February 2017 COMPENDIUM EBOOK SERIES 3

 CONTINUING EDUCATION 1 PROSTHETIC IMPLANT PROBLEMS

restorations and how to avoid such problems
and treat them when they do occur.
Fracture/Chipping of
the Veneering Material
With 5-year complication rates from 3.2%
to 25.5%,1 chipping of the veneering mate-
rial (Figure 1) is the most common technical
complication addressed in the literature.1,2
This can be minimized by designing the pros-
thesis before the final fabrication to ensure
optimal framework design and thickness of
the veneering material. Following basic oc-
clusal principles in implant prosthodontics
is essential. These include reduced cuspal in-
clination, narrow occlusal table, correction
of load direction, reduced nonaxial loading,
reduced length of the cantilever, and lighter
occlusal contacts on implants.5 Restorations
such as monolithic zirconia (Figure 2) and
lithium disilicate are also being used to mini-
mize chipping. However, long-term follow-up
information on these restorations is limited.
Screw and Abutment:
Loosening and Fracture
Screw loosening and fracture (Figure 3 and
Figure 4) have been consistent problems in
implant dentistry.6 Several adaptations have
been made to the screw and implant design
to minimize these issues, such as the transi-
tion from an external to internal connection
and changing both the screw composition
and coating. Implant manufacturers offer
various implant connection and screw de-
signs, and these designs are modified as new-

Fig 1. Fig 2.

Fig 3. Fig 4.

Fig 1. Chipping of veneering porcelain of porcelain-fused-to-gold full-arch fixed dental prosthesis.

Fig 2. Screw-retained monolithic zirconia crown cemented to a titanium base. Fig 3. Fractured abutment
screw. Fig 4. Bending of the abutment prongs as a result of motion caused by screw fracture.

4 COMPENDIUM EBOOK SERIES February 2017

 er and enhanced materials become available.
Even with these advances, screw loosening
and fracture are common. Five-year rates of
screw loosening have been 0% to 5.8%.1 Factors
that can contribute to this problem include a
framework that does not passively fit, biome-
chanical overload, improper implant position-
ing, repeated tightening of the screws, inad-
equate tightening of the screws, settling of the
screws, and improper screw design.7-9
One of the best methods to avoid screw and
abutment complications is to virtually plan the
prosthetic design of the implant crown(s) with
a prosthetically driven treatment approach us-
ing cone-beam computed technology beginning
at the time of surgery. Even with virtual plan-
ning, however, the implant may be placed at
an angle that is not in the axial direction of the
adjacent teeth or the direction of the occlusal
load. The direction of force and screw-access
location must also be taken into consideration.
The dentist must be diligent about verifying
the integrity of the screw and abutment and
ensuring that the prosthetic components are
appropriate for the implant being restored, ie,
a final screw is used rather than a laboratory
screw (Figure 5 and Figure 6).
The use of third-party vendors for prosthetic
components should be avoided.10 Third-party
components (Figure 7) typically do not fit to
the same standards as the manufacturer’s rec-
ommendations and can, thus, both weaken
the screw connection before the screw is even
placed in function and introduce micromotion
that may lead to fracture of the implant or the
screw/prosthesis, or crestal bone loss.11,12

Fig 8.

Fig 5.

Fig 9.

Fig 6. Fig 7.

Fig 5. Fractured implant crown following use of lab screw instead of

abutment screw. Fig 6. Radiograph following crown fracture. Fig 7.
Ill-fitting milled abutment obtained from a third-party vendor and not
from the manufacturer. Fig 8. Loss of restoration and subsequent tis-
sue overgrowth from broken abutment screw as shown in the radio-
graph (Fig 9). Fig 9. Radiograph depicting fractured screw inside of
Fig 10.
the implant. Fig 10. Fractured zirconia abutment with a titanium base.

www.compendiumlive.com February 2017 COMPENDIUM EBOOK SERIES 5

 CONTINUING EDUCATION 1 PROSTHETIC IMPLANT PROBLEMS

The implant crown should also be verified
with a stock analogue to determine the proper
seating and confirm that the abutment has not
been damaged. A new screw should also be
provided. When the crown is being adjusted
for fit intraorally, the number of times the
implant screw is torqued must be kept to a
minimum. Torqueing the screw more than 10
times can cause permanent elastic deforma-
tion, thus increasing the risk for screw loosen-
ing and fracture.13
If an implant crown does come loose, the
cause must be determined. A radiograph
should be exposed to establish that the prob-
lem resides with the prosthetic components
rather than with an implant failure. Various
techniques have been described in the litera-
ture for removing cement-retained restora-
tions. If the crowns have been cemented with
permanent cement or are otherwise not re-
trievable, one can check if the original implant
cast is available. If so, a guide can be made by

Fig 11. Fig 12.

Fig 13.

Fig 14. Fig 15. Fig 16.

Fig 11. Fractured all-zirconia abutment. Fig 12. Path of draw necessitates adjustment to adjacent tooth or
cement-retained restoration. Fig 13. Radiograph depicting peri-implantitis. Fig 14. Clear resin cement left
on the implant abutment. Fig 15. Implant abutment following cement removal. Fig 16. Radiograph depicting
closed contact at time of implant insertion.

6 COMPENDIUM EBOOK SERIES February 2017

 creating a stent over a duplicate of the final
restoration and retrofitting the stent over the
original cast to identify the screw-access hole
location.14,15 If the original cast is unobtain-
able, an access hole can be made by judging
the implant angulation on a radiograph.9 As a
last resort, the implant crown may have to be
sectioned. Several techniques have also been
developed to aid in crown retrieval such as lin-
gual retaining screws,16 applying stains to the
screw-access location,17 or using an angulated
screw-channel restoration.
Once the screw has been located, it should
be examined for damage under a microscope.
In cases with multiple units using prosthetic
screws such as fixed dentures (hybrids), the
screws are subject to galling (adhesive wear).
Screws located anterior to the fulcrum line
will wear and deform at a faster rate than
those posterior.18 As the screw preload (clamp-
ing force) is lessened, more adhesive wear of
the screw is observed. It should be noted that
the screw preload has been shown to decrease
over time.12 Clinicians may want to consider
retightening or replacing screws at the subse-
quent recall appointment following insertion
of the definitive prosthesis.19
Fractured screws are challenging to retrieve,
particularly when they are abutment screws.
If the screw head is accessible, a hemostat can
be used to remove it. However, when the screw
breaks inside the implant (Figure 8 and Figure
9), removal can be highly complicated in order
not to damage the implant’s internal threads.
Therefore, many implant manufacturers have
developed screw-retrieval kits. Because it is
critical to be able to visualize the area, magni-
fication using loupes and a surgical microscope
may be necessary.8 Additional methods can be
used to remove the fractured screw. A ¼ round
bur set on a high speed can be used by lightly
activating it, touching only the side of the screw.
After repeating this technique several times,
the screw may be able to be backed out with an
explorer tip. Ultrasonic tips with copious irri-
www.compendiumlive.com
gation may also dislodge the screw.7,20 In cases
in which this fails, a small slot can be made in
the head of the screw to back it out.21 If screw
threads have been damaged during retrieval,
they may be retapped using a tool obtained only
from the implant manufacturer.7
The increase in demand for esthetically
pleasing implant restorations has led clinicians
to embrace the use of all-ceramic abutments.
This has subsequently increased abutment
fractures (Figure 10 and Figure 11)22,23 and
decementation of the ceramic crown and cor-
responding abutment.24 Use of zirconia abut-
ments is relatively new in implant dentistry
and has limited long-term follow-up data. Time
will tell whether this technology is successful.
Excess Cement Leading
to Peri-implantitis
If all implant-supported crowns could be de-
signed for screw retention, no discussion of
excess cement would be necessary. However,
screw retention is not always possible de-
pending on the location of the access open-
ing and because of the unesthetic appearance
in anterior restorations or the mesial/distal
angulation of the implant compromising the
path of insertion (Figure 12). Residual cement
left after crown cementation on implants
can lead to peri-implant inflammation, peri-
implantitis, and eventual loss of the implant
(Figure 13 through Figure 15).25 The presence
of lingering excess cement can encourage the
development of bacterial colonization and
peri-implantitis. Conversely, when too little
cement is used, voids in the cement layer can
occur and the prosthesis can become loose.26
The deeper the implant crown margin, the
more difficult it is to remove excess cement.27
Radiopaque cements that contain zinc phos-
phate and zinc oxide (with and without eu-
genol) should be considered to help identify
excess interproximal cement; however, this
should be used secondarily to proper margin
height and careful removal of cement during
February 2017 COMPENDIUM EBOOK SERIES 7
 CONTINUING EDUCATION 1
cementation. Resin cements lack the same
opacity as zinc-containing cements and have
been shown to be the most difficult to re-
move.28 Often in the process of removing this
excess cement, the abutment surface becomes
scratched and damaged, potentiating further
plaque accumulation.29
Fig 17.
Fig 18.
Fig 19.
Fig 17. Open proximal contact between implant
and adjacent tooth 3 years post insertion. Fig 18. In
1999, teeth Nos. 8 and 9 had the same length with
even gingival margins. Fig 19. In 2016, downward
growth of tooth No. 8 could be observed with un-
even gingival margins of Nos. 8 and 9.
8 COMPENDIUM EBOOK SERIES February 2017
PROSTHETIC IMPLANT PROBLEMS
Several modifications in abutment design
and cementation have been suggested. Placing
vent holes in the abutment during fabrication
or leaving most of the screw-access chamber
open for access has reduced the amount of ce-
ment that expresses out into the sulcus.26 It is
also beneficial to extraorally express excess
cement on an abutment replica prior to final
crown seating to minimize complications. If
retrievability is desired with cementable im-
plant crowns, weaker cements (eg, zinc oxide
eugenol) should be used first and progressively
changed until the desired retention is achieved.
Open Proximal Contacts
During the initial planning phase for implant
therapy, the dental practitioner should not
assume that the existing position of the teeth
within the dental alveolus will remain station-
ary throughout the patient’s lifetime. Long-
term follow-up of implant restorations has
proven that often it does not remain stationary,
regardless of the age of the patient. Open con-
tacts have frequently been reported between
implants and adjacent teeth.30
Open proximal contacts between implants
and adjacent teeth have been attributed to
ongoing craniofacial growth31 and vector
forces mesializing tooth position (Figure 16
and Figure 17).32 These changes, particularly
in the esthetic zone, can contribute to differ-
ences in incisal edge position, gingival margin
height, and the facial contour and alignment
of the dental arch (Figure 18 and Figure 19).31
Jemt et al30 studied a population of 28 con-
secutive anterior implant crowns followed
for 15 years. During this time, only 8 patients
demonstrated no movement of the adjacent
teeth; 55% of adjacent teeth displayed palatal
tooth movement, predominately in the female
population.30 Shifting of teeth can contribute
to occlusal changes leading to uneven occlusal
load and distribution among the arch.31 Similar
to adjacent open contacts between teeth, any
open contact can lead to food impaction/ac-
 cumulation, pocketing, and inflammation of
the interdental tissue.
Greenstein et al32 made several suggestions for
the treatment of open interproximal contacts,
including discussing with the patient prior to
treatment the possibility that therapy may be
needed for the implant crown. Also, the need
for retrievability of the crown should be con-
sidered so that porcelain may be added to the
crown, and adjacent teeth should be modified to
include broad, flat contacts. In addition, in cir-
cumstances when the crown cannot be removed,
the contacts may be added to the adjacent teeth.
Conclusion
According to the complications consensus of
2014,33 prosthetic complications can be mini-
mized by planning appropriate implants and
prosthetic designs for each case, following the
manufacturers’ instructions for all prosthetic
components, carefully assessing and checking
for misfit of the framework, and monitoring
occlusal forces. In addition, greater caution
should be taken with ceramic abutments be-
cause long-term data on their use do not exist,
and clinicians should be aware of their specific
material requirements. Also, providing an ad-
equate framework can reduce the likelihood of
veneering materials chipping. Furthermore, the
full contour of the finished prosthesis should
be determined before completing the under-
lying framework to ensure adequate thickness
of the veneering material. Patients should
be monitored at regular recall appointments,
which should be increased in number depend-
ing on case complexity, and these appointments
should include a careful occlusal analysis.
In addition to these considerations, the clini-
cian must take into account future retrievabil-
ity as it has become increasingly apparent that
the craniofacial region is far from static. Screw-
retained restorations or careful cementation
with temporary cement should be considered.
In cases in which permanent cementation is
indicated, a radiopaque cement should be used
www.compendiumlive.com
and the master cast should be maintained if
future access to the screws is ever indicated.
ABOUT THE AUTHORS
Elyce E. Link-Bindo, DMD
Private Practice in Prosthodontics
Doylestown, Pennsylvania
James Soltys, DDS
Associate Professor
Eastman Institute for Oral Health
University of Rochester
Rochester, New York
Private Practice in Prosthodontics
Victor, New York
David Donatelli, DDS
Assistant Professor
Temple University Kornberg School of Dentistry
Philadelphia, Pennsylvania
Richard Cavanaugh, DDS
Adjunct Clinical Professor
Temple University Kornberg School of Dentistry
Philadelphia, Pennsylvania
Private Practice in Prosthodontics
Doylestown, Pennsylvania
Queries to the authors regarding this course may be submit-
ted to authorqueries@aegiscomm.com.
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Cement removal from restorations luted to titanium
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30. Jemt T, Ahlberg G, Henriksson, Bondevik O. Tooth
movements adjacent to single-implant restorations
after more than 15 years of follow-up. Int J Prostho-
dont. 2007;20(6):626-632.
31. Daftary F, Mahallati R, Bahat O, Sullivan RM. Life-
long craniofacial growth and the implications for os-
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2013;28(1):163-169.
32. Greenstein G, Carpentieri J, Cavaliaro J. Open
contacts adjacent to dental implant restorations:
Etiology, incidence, consequences, and correction. J
Am Dent Assoc. 2016;147(1):28-34.
33. Heitz-Mayfield LJ, Needleman I, Salvi GE, Pjeturs-
son BE. Consensus statements and clinical recom-
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biologic and technical implant complications. Int J
Oral Maxillofac Implants. 2014;29 suppl:346-350.
 CONTINUINGEDUCATION
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Common Prosthetic Implant

Complications in Fixed Restorations
Elyce E. Link-Bindo, DMD; James Soltys, DDS; David Donatelli, DDS;
and Richard Cavanaugh, DDS

THIS COURSE IS AVAILABLE ONLINE AT: COMPENDIUMLIVE.COM/GO/PROSTHODONTICS1.

ENTER PROMO CODE: PROS1

1. What are the 5-year complication rates for 6. Clinicians may want to consider retightening
chipping of the veneering material? or replacing screws at the subsequent recall
A. 1% to 2.5% appointment following:
B. 3.2% to 25.5% A. placement of adhesive cement.
C. 32% to 34% B. insertion of the provisional restoration.
D. 25.6% to 43% C. insertion of the definitive prosthesis.
D. hyperplasia of soft tissue.
2. Which of the following is an adaptation made
to cope with screw loosening and fracture? 7. What size should the round bur be for remov-
A. transition from an external to internal ing a fractured screw?
connection A. 1/4
B. changing the screw composition B. 1/2
C. altering the coating C. 3/32
D. All of the above D. 3/8

3. To avoid screw and abutment complications, 8. The increase in demand for what type of im-
the prosthetic design of the implant crown(s) plant restorations has led clinicians to embrace
can be virtually planned with a prosthetically the use of all-ceramic abutments?
driven treatment approach using: A. screw-retained
A. CAD/CAM. B. multi-unit
B. cone-beam technology. C. tissue-level
C. third-party components. D. esthetically pleasing
D. digital photography.
9. Resin cements lack the same opacity as zinc-
4. How many times can an implant screw be containing cements and have been shown to:
torqued before causing permanent elastic A. be the most difficult to remove.
deformation? B. be the most difficult to apply.
A. 5 C. be easily removed.
B. 6 D. not scratch abutment surfaces.
C. 7
D. 10 10. Open proximal contacts between implants
and adjacent teeth have been attributed to
5. Screws located anterior to the what will ongoing:
wear and deform at a faster rate than those A. uneven occlusal load.
posterior? B. craniofacial growth.
A. fulcrum line C. food impaction.
B. retaining screw D. inflammation of interdental tissue.
C. mental foramen
D. occlusal table

Course is valid from 8/1/2016 to 8/31/2019. Participants

must attain a score of 70% on each quiz to receive credit. Par-
ticipants receiving a failing grade on any exam will be notified
and permitted to take one re-examination. Participants will
receive an annual report documenting their accumulated
credits, and are urged to contact their own state registry
boards for special CE requirements.
AEGIS Publications, LLC, is an ADA CERP Recognized
Provider. ADA CERP is a service of the American Dental Approval does not imply acceptance
Association to assist dental professionals in identifying quality
by a state or provisional board of
providers of continuing dental education. ADA CERP does not
approve or endorse individual courses or instructors, nor does
dentistry or AGD endorsement. The
current term of approval extends from
it imply acceptance of credit hours by boards of dentistry.
1/1/2017 to 12/31/2022.
Concerns or complaints about a CE provider may be directed
to the provider or to ADA CERP at www.ada.org/cerp. Provider #: 209722.

www.compendiumlive.com February 2017 COMPENDIUM 11

 CONTINUING EDUCATION 2 DENTURE ADAPTATION

Changes in Patient
Satisfaction and Masticatory
Efficiency During Adaptation
to New Dentures
Arcelino Farias-Neto, DDS, MSc, PhD; and Adriana da Fonte Porto Carreiro, DDS, MSc, PhD

ABSTRACT: Because adapting to new conventional dentures is highly variable, there

is uncertainty as to how long dissatisfied patients should wait before choosing a treat-
ment with dental implants. The authors investigated whether changes in patient satis-
faction and masticatory efficiency may be observed between 3 and 6 months after the
insertion of new conventional complete dentures. The study included 24 edentulous
patients requiring new complete dentures. Masticatory efficiency and patient satis-
faction were evaluated at 3 and 6 months post-insertion. Masticatory efficiency was
evaluated through the colorimetric method, with the beads as the artificial test food.
A method for quantifying overall satisfaction of complete-denture wearers was used.
Subjects were asked to respond to questions with three-grade answers concerning 12
factors: chewing, tasting, speech, esthetics, pain, fit, retention, and comfort (maxillary
and mandibular evaluations were done for each of the last four factors). The results of
patient satisfaction and masticatory efficiency at 3 and 6 months post-insertion were
compared using the paired-samples t test (α = 0.05). Significant reductions in man-
dibular pain (P < 0.05) and improvements in mandibular fit (P < 0.05) were observed
at 6 months. No difference was found for patient overall satisfaction, chewing, tasting,
speech, maxillary pain, esthetics, maxillary fit, retention, comfort, and masticatory
efficiency. The authors concluded that reduction in pain and improvements in adapta-
tion of the lower denture may be observed between 3 and 6 months after insertion of
new conventional complete dentures. This period of adaptation should be considered
before choosing a treatment with dental implants.

LEARNING OBJECTIVES

• Discuss the impact the
insertion of new dentures can
have on the stomatognathic
system
• Describe how to execute a
masticatory efficiency test
using the colorimetric method
• Discuss the length of time
patients dissatisfied with new
conventional dentures should
wait before choosing dental
implant treatment

DISCLOSURE: The authors had no disclosures to report.

12 COMPENDIUM EBOOK SERIES February 2017

R
ehabilitation of edentulous pa-
tients remains one of the most
challenging treatment modali-
ties. Successful treatment with
conventional complete dentures
depends to a great extent on patients’ abil-
ity to use the denture. The problem is how to
identify, through oral examination, which pa-
tients exhibit suitable conditions for denture
use.1 Several studies have failed to show strong
correlations between either patient satisfac-
tion with their dentures and their quality or
denture satisfaction and the quality of the
denture-supporting tissues.2,3
The insertion of new dentures greatly im-
pacts the stomatognathic system. Changes
may take place in chewing, speech, tasting,
swallowing, salivary flow, and esthetics. A pe-
riod of 6 to 8 weeks has been regarded as nec-
essary to assess satisfactory use with the new
dentures, as this period has the potential to
establish new memory patterns for the masti-
catory muscles.4 In a previous study, although
approximately 60% of experienced denture
wearers were able to eat and speak satisfacto-
rily within a week after replacement dentures
were fitted, another 20% of these patients re-
quired up to 1 month to become proficient.5
Occasionally, edentulous patients go without
dentures for long periods and experience in-
creased difficulty in learning to masticate with
new dentures, and the time for adjustment will
likely be extended.6
Although most edentulous patients appear
to benefit from complete denture treatment
and report satisfactory oral and masticatory
function with their use,7 a minority of patients
seems to never adapt to any conventional com-
plete denture.8 In these cases, significant in-
crease in patient satisfaction and oral health–
related quality of life may be observed with
implant-retained dentures.9 Improvement in
masticatory function has been given as the
most common reason for choosing dental im-
plant prosthesis, and 82% of patients reported
www.compendiumlive.com
improved subjective chewing experience after
implant treatment.10
Since adaptation to new conventional den-
tures is highly variable, it is not known how long
dissatisfied patients should wait before opting
for a treatment with dental implants. Therefore,
the purpose of this study was to investigate
whether changes in patient satisfaction and
masticatory efficiency may be observed be-
tween 3 and 6 months after the insertion of new
conventional complete dentures. The research
hypothesis is that a period of 6 to 8 weeks may
not be sufficient to achieve optimal use, but fur-
ther improvements in denture adaptation may
be observed for up to 6 months.
Materials and Methods
Study Design, Sampling Procedures, Study
Subjects, and Ethical Considerations
The sample used for the present study derived
from a previous crossover trial that compared
bilateral balanced and canine-guided den-
tures.11 In that study, patients were divided into
two groups with different treatment sequences
to avoid bias. Since no difference was found be-
tween occlusal concepts,11 data were coupled
and analyzed in the present study for changes
in masticatory efficiency and patient satisfac-
tion after the insertion of new dentures.
The study was approved by the Research
Ethics Committee of the institution (Protocol
# 001/08). Edentulous patients visiting the
Clinic of Prosthodontics at Federal University
of Rio Grande do Norte, Natal, Brazil and re-
quiring new conventional complete dentures
were invited to participate in this follow-up
study. After a preliminary examination, pa-
tients were excluded if they exhibited symp-
toms of temporomandibular disorders, xe-
rostomia, orofacial motor disorders, severe
oral manifestations of systematic diseases, or
psychological or psychiatric conditions that
could influence their response to treatment.
The sample was composed of 24 patients with
a mean age of 59.7 years. All patients were di-
February 2017 COMPENDIUM EBOOK SERIES 13
 CONTINUING EDUCATION 2
agnosed as Class II (Prosthodontic Diagnostic
Index)12 and had previously worn conven-
tional complete dentures. At 3 and 6 months
post-insertion, data were collected regarding
patient satisfaction and masticatory efficiency.
Denture Construction
The dentures were fabricated in accordance
with traditional techniques and in coopera-
tion with the undergraduate dental students.
Preliminary impressions were made using
stock edentulous trays (Tecnodent, www.
tecnodent.com) and irreversible hydrocolloid
impression material (Jeltrate®, DENTSPLY,
www.jeltrate.com). The final impression for
the complete dentures was taken with a cus-
tom tray, with border-molded impression
compound (Impression Compound, Kerr
Dental, www.kerrdental.com), followed by
a zinc oxide/eugenol impression (Horus,
DENTSPLY, www.dentsply.com). Master
casts were mounted on a semi-adjustable ar-
ticulator with a common arbitrary ear–face-
bow instrument. Dentures were made in cen-
tric occlusion and anatomically shaped acrylic
teeth with a cuspal inclination of 33º (Trubyte
Biotone, DENTSPLY).
Patient Satisfaction
A validated method for quantifying overall
satisfaction of complete denture wearers was
used. Subjects were asked to respond to ques-
tions with three-grade answers (well satisfied,
satisfied, and dissatisfied) concerning 12 fac-
tors: chewing, tasting, speech, pain (maxillary
and mandibular), esthetics, fit (maxillary and
mandibular), retention (maxillary and man-
dibular), and comfort (maxillary and mandib-
ular). Then, the three grades were turned into
scores according to the degree of contribution
of each factor as previously established.13
Masticatory Efficiency Test
Masticatory efficiency was performed through
the colorimetric method. The beads were the
14 COMPENDIUM EBOOK SERIES February 2017
DENTURE ADAPTATION
artificial test food used to measure the mastica-
tory efficiency.11 They were obtained by iono-
tropic jellification of an aqueous dispersion of
2% pectin containing 50% solids and fuchsine
dye in a 1.0 M calcium chloride solution. After
preparation, the beads were coated with a 5%
Eudragite solution (Eudragit® E100, Evonik
Industries, http://eudragit.evonik.com) in a
solvent mixture of 10% acetone in absolute eth-
anol. Then, 250 mg of the beads were packed
in polyvinyl acetate capsules in a rectangular
0.70-inch x 0.51-inch form and sealed.
For application of the masticatory test, sub-
jects seated on a chair with a back and with both
feet resting on the ground were asked to chew
the beads in their habitual manner, without be-
ing given any additional instruction on how to
chew, in an effort to best replicate habitual mas-
tication. The test was stopped after 20 seconds,
and the beads were collected into a container
identified by subject and test number. This test
was repeated two more times. In no case was the
polyvinyl acetate capsule shell damaged, so no
beads’ interiors were allowed to escape.
After chewing, the capsule shell was cut
and the content of the beads was placed in a
20-ml test tube, dissolved in 5 ml of distilled
water, and shaken mechanically in a rotary
shaker (Certomat® MV, B. Braun Biotech
International, USA, www.bostonlabco.com)
for 30 seconds. The solution was then filtered
through qualitative filter paper, and the ex-
tracted dye was quantified in nanometers
(nm) with a Beckman DU-640 UV-Visible
Spectrophotometer (Ultrospec 2100 pro UV/
Visible Spectrophotometer®, GE Healthcare,
USA, www3.gehealthcare.com). It allowed the
measurement of masticatory efficiency on the
basis of the concentration of extracted fuch-
sine, which was expressed in absorbance (abs).
Statistical Analysis
Data were collected by a single examiner to
avoid interexaminer variability. The mastica-
tory efficiency of each subject was calculated
 TABLE 1: DATA FOR MASTICATORY EFFICIENCY (ABS) AND PATIENT OVERALL SATISFACTION (SCORE)
Factors 3 Months 6 Months
Masticatory efficiency 0.185 (± 0.037) 0.169 (± 0.026)
Overrall satisfaction 89.24 (± 8.2) 88.95 (± 5.8)
Means did not differ significantly at P < 0.05. Abs = absorbance

TABLE 2: DATA FOR THE 12 FACTORS THAT CONTRIBUTED TO OVERALL PATIENT SATISFACTION
Factor 3 Months 6 Months
DISSATISFIED SATISFIED WELL SATISFIED DISSATISFIED SATISFIED WELL SATISFIED

Chewing ability 4 (16.7%) 13 (54.2%) 7 (29.1%) 3 (12.5%) 10 (41.7%) 11 (45.8%)

Tasting 2 (8.3%) 6 (25%) 16 (66.7%) 1 (4.2%) 7 (29.1%) 16 (66.7%)
Speech 0 (0%) 7 (29.1%) 17 (70.9%) 0 (0%) 7 (29.1%) 17 (70.9%)
Maxillary pain 0 (0%) 11 (45.8%) 13 (54.2%) 0 (0%) 12 (50%) 12 (50%)
Mandibular pain* 5 (20.8%) 10 (41.7%) 9 (37.5%) 0 (0%) 10 (41.7%) 14 (58.3%)
Esthetics 0 (0%) 5 (20.8%) 19 (79.2%) 0 (0%) 5 (20.8%) 19 (79.2%)
Maxillary fit 0 (0%) 6 (25%) 18 (75%) 0 (0%) 8 (33.3%) 16 (66.7%)
Mandibular fit* 4 (16.7%) 15 (62.5%) 5 (20.8%) 0 (0%) 14 (58.3%) 10 (41.7%)
Maxillary retention 1 (4.2%) 5 (20.8%) 18 (75%) 0 (0%) 7 (29.1%) 17 (70.9%)
Mandibular retention 1 (4.2%) 14 (58.3%) 9 (37.5%) 1 (4.2%) 13 (54.2%) 10 (41.7%)
Maxillary comfort 0 (0%) 6 (25%) 18 (75%) 0 (0%) 5 (20.8%) 19 (79.2%)
Mandibular comfort 5 (20.8%) 9 (37.5%) 10 (41.7%) 2 (8.3%) 12 (50%) 10 (41.7%)
* significantly different at P < 0.05

as the mean value for the three tests. The re-
liability of the masticatory test was analyzed
by one-way ANOVA with Tukey test as post-
hoc test (P < 0.05). Data were processed with
SPSS software (V 17.0 for Windows, SPSS Inc.,
www-01.ibm.com). Differences regarding pa-
tient satisfaction and masticatory efficiency
between 3 and 6 months post-insertion were
compared using the paired-samples t test.
Shapiro-Wilk and Levene tests were used to
observe normality and variance homogeneity,
respectively. Confidence level was set at 95%.
Results
Data for masticatory efficiency and patient
overall satisfaction are presented in Table 1.
No difference for patient overall satisfaction
and masticatory efficiency between 3 and 6
months after the insertion of new dentures
was observed. Table 2 presents the data for the
12 factors that contributed to patient overall
satisfaction. Significant differences for man-
dibular pain (P < 0.05) and mandibular fit
(P < 0.05) were observed (P < 0.05).
Discussion
The results of this study support the research
hypothesis that a period of 6 to 8 weeks may
not be sufficient to achieve optimal use with
new conventional dentures. Further improve-
ments in denture adaptation were observed
for up to 6 months. It is supposed that dis-
satisfied patients should take into account
this period of adaptation before opting for a
treatment with dental implants. In the pres-
ent study, dentures were delivered and weekly
appointments were scheduled during the first
month for clinical adjustments. After that, pa-
tients returned at 3 and 6 months for clinical
examination and data collection, but no ad-

www.compendiumlive.com February 2017 COMPENDIUM EBOOK SERIES 15

 CONTINUING EDUCATION 2
justments were made. During clinical exami-
nation at 3 and 6 months, neither ulcers nor
sore points were found. Interestingly, greater
satisfaction relative to mandibular pain and
mandibular fit were observed at 6 months
(P < 0.05). Data were collected only at 3 (base-
line) and 6 months post-insertion to avoid the
influence of the initial period of adaptation
and clinical adjustments and the improve-
ment in patient satisfaction that is to be ex-
pected during this period.
The results of this study suggest that some
patients may take up to 6 months to achieve
optimal use with their new mandibular den-
tures. It is hypothesized that the improve-
ments in pain and fit observed in this study
may be related to changes that may occur
slowly in the mandibular residual ridge (bone
remodeling) and mucosal covering to adapt to
the intaglio surface of the new dentures. Also,
it is hypothesized that patients may assume
that some degree of discomfort is to be ex-
pected in their situation, so they complain less
during the time period. The period of 6 to 8
weeks regarded as necessary to establish new
muscle memory patterns is probably related
to the domains of mastication, speech, and
retention, which did not present any change
during this study. Actually, there is no consen-
sus about the amount of time that dissatisfied
denture wearers should wait before choosing
a treatment with dental implants.
Despite increased satisfaction for reduced
mandibular pain and improved mandibular
fit at 6 months, no difference was found for
patient overall satisfaction. This is probably
related to the methodology used. In the pres-
ent study, patients were asked to respond to
questions with three-grade answers (well sat-
isfied, satisfied, and dissatisfied) concerning 12
denture factors. Then, the three grades were
turned into scores according to the degree
of contribution of each factor as previously
established by Sato et al.13 The contribution
of each grade of the 12 factors to the over-
16 COMPENDIUM EBOOK SERIES February 2017
DENTURE ADAPTATION
all satisfaction was determined by multiple
regression analysis, and seven factors were
found to be highly correlated with the overall
satisfaction (chewing, speech, maxillary pain,
esthetics, maxillary fit, mandibular retention,
and maxillary comfort). Based on the level of
contribution by these seven significant fac-
tors, which did not include mandibular pain
and mandibular fit, patient overall satisfaction
was calculated.
It has been shown that patients usually com-
plain less about comfort and retention of the
maxillary than of the mandibular denture.8
The results of this study are in agreement
with that, since improvements in pain and fit
were limited to the mandibular denture. It is
supposed that immediate satisfaction with
new dentures is lower for the mandible due
to its anatomical characteristics, and patients
need more time to adapt to mandibular than to
maxillary dentures. A previous study investi-
gated how patients’ ratings of their prosthesis
changed over time.12 Patients were asked to
rate their dentures in varying domains at in-
sertion, 3 months, and 2 years. Chewing ability
and comfort of the mandibular denture in-
creased over time. According to the authors,
habituation to dentures may continue over
2 years to overcome gradual deterioration of
denture quality that might reasonably be ex-
pected over 2 years after denture insertion.14
No difference was found for masticatory
efficiency and patient satisfaction regarding
chewing ability, tasting, speech, esthetics, re-
tention, and comfort. These results suggest the
reestablishment of these domains at 3 months
post-insertion of new dentures. The muscles
of the tongue, cheeks, and lips must be trained
to retain the dentures in position on the re-
sidual ridges during mastication.6 According
to Zarb and Bolender,4 6 to 8 weeks are neces-
sary to establish new memory patterns for the
muscles of mastication. In addition, salivary
excess may impair comfort and make chewing
and speech difficult during the initial period
 of denture wearing.4 Speech may also be in-
fluenced by tongue positioning necessary to
stabilize the lower denture.4 Taste sensitivity
may be reduced when an upper denture covers
the hard palate due to the fact that a smooth
acrylic denture surface may modify the sense
of touch within the oral cavity.6 Finally, pa-
tients must understand that their appearance
with new dentures will become more natural
with time. A repositioning of the oral and fa-
cial muscles and a restoration of the former
facial dimension and contour by the new den-
tures may seem like too great a change in the
patient’s appearance.6
In the present study, the masticatory effi-
ciency was measured with the beads.11 In this
method, the test material is promptly evaluated
and has stable physical properties. Since the
beads are packed in the capsules, the material
is fully obtained from the mouth, with no dan-
ger of being swallowed nor dissolved by saliva.
Laboratory processing is fast and effective and
allows precise determination of the patient’s
masticatory efficiency. The capsules are not
torn or ripped during mastication, and thus the
granules are kept inside the capsule. All granule
components are listed in the Brazilian pharma-
copoeia and can be reproduced.
To summarize, the results of this study
showed that further improvements in pain
and fit of the mandibular denture may be
observed between 3 and 6 months after the
insertion of new dentures. While a period of
6 to 8 weeks may be sufficient for muscle ad-
aptation and satisfactory control of the new
dentures during functional activities,4 some
patients may require more time to achieve
optimal use with their new mandibular den-
tures. Actually, there is no consensus about
the amount of time patients dissatisfied with
their new conventional dentures should wait
before choosing a treatment with dental im-
plants. The results of this study suggest that
a period of 6 months should be considered. It
is crucial that realistic expectations of den-
www.compendiumlive.com
tures are created with the patient before treat-
ment is actually started. Patients should be
informed that new dentures require a period
of adjustment, which is highly variable and
depends on their anatomic, psychological, tis-
sue tolerance, and oral conditions.6
Conclusion
Reduction in pain and improvements in fit of
the mandibular denture may be observed be-
tween 3 and 6 months after the insertion of
new conventional complete dentures. This pe-
riod of adaptation should be considered before
choosing a treatment with dental implants.
ABOUT THE AUTHORS
Arcelino Farias-Neto, DDS, MSc, PhD
Professor, Health School
Potiguar University – Laureate International Universities,
Natal, Brazil
Adriana da Fonte Porto Carreiro, DDS, MSc, PhD
Professor
Department of Dentistry
Federal University of Rio Grande do Norte
Natal, Brazil
Queries to the authors regarding this course may be submit-
ted to authorqueries@aegiscomm.com.
REFERENCES
1. Wright CR. Evaluation of the factors necessary
to develop stability in mandibular dentures.
J Prosthet Dent. 2004;92(6):509-518.
2. Heydecke G, Klemetti E, Awad MA, et al. Re-
lationship between prosthodontic evaluation
and patient ratings of mandibular conventional
and implant prostheses. Int J Prosthodont.
2003;16(3):307-312.
3. Carlsson GE. Critical review of some dogmas in
prosthodontics. J Prosthodont Res. 2009;53(1):3-10.
4. Zarb GA, Bolender CL, Eckert SE, et al, eds.
Prosthodontic Treatment for Edentulous Patients
– Complete Dentures and Implant-Supported Pros-
theses. St. Louis, MO: Mosby; 2003.
5. Bergman B, Carlsson GE. Review of 54 com-
plete denture wearers. Patients’ opinions 1
year after treatment. Acta Odontol Scand.
1972;30(4):399-414.
6. Shigli K. Aftercare of the complete denture pa-
tient. J Prosthodont. 2009;18(8):688-693.
7. Carlsson GE, Omar R. The future of complete
dentures in oral rehabilitation. A critical review.
February 2017 COMPENDIUM EBOOK SERIES 17
 CONTINUING EDUCATION 2
J Oral Rehabil. 2010;37(2):143-156.
8. Critchlow SB, Ellis JS. Prognostic indicators for
conventional complete denture therapy: a review
of the literature. J Dent. 2010;38(1):2-9.
9. Assunção WG, Barão VA, Delben JA, et al. A
comparison of patient satisfaction between treat-
ment with conventional complete dentures and
overdentures in the elderly: a literature review.
Gerodontology. 2010;27(2):154-162.
10. Grogono AL, Lancaster DM, Finger IM. Dental
implants: a survey of patients’ attitudes. J Pros-
thet Dent. 1989;62(5):573-576.
11. Farias Neto A, Mestriner Junior W, Carreiro Ada
F. Masticatory efficiency in denture wearers with
18 COMPENDIUM EBOOK SERIES February 2017
DENTURE ADAPTATION
bilateral balanced occlusion and canine guidance.
Braz Dent J. 2010;21(2):165-169.
12. McGarry TJ, Nimmo A, Skiba JF, et al. Clas-
sification system for complete edentulism. The
American College of Prosthodontics. J Prostho-
dont. 1999;8(1):27-39.
13. Sato Y, Hamada S, Akagawa Y, et al. A method
for quantifying overall satisfaction of complete den-
ture patients. J Oral Rehabil. 2000;27(11):952-957.
14. Fenlon MR, Sherriff M. Investigation of new
complete denture quality and patients’ satisfac-
tion with and use of dentures after two years.
J Dent. 2004;32(4):327-333.
CONTINUING EDUCATION 2 QUIZ 2 Hours CE Credit

Changes in Patient Satisfaction and Masticatory

Efficiency During Adaptation to New Dentures
Arcelino Farias-Neto, DDS, MSc, PhD; and Adriana da Fonte Porto Carreiro, DDS, MSc, PhD

THIS COURSE IS AVAILABLE ONLINE AT: COMPENDIUMLIVE.COM/GO/PROSTHODONTICS2.

ENTER PROMO CODE: PROS2

1. The insertion of new dentures greatly 6. Results of this study showed that significant
impacts the: differences were observed for:
A. endocrine system. A. maxillary pain and maxillary fit.
B. cardiovascular system. B. maxillary retention and maxillary fit.
C. stomatognathic system. C. mandibular pain and mandibular fit.
D. nervous system. D. mandibular retention and esthetics.

2. A period of how long has been regarded as 7. The results of this study suggest that some
necessary to assess satisfactory use with new patients may take how long to achieve optimal
dentures? use with their new mandibular dentures?
A. 6 to 8 days A. up to 6 months
B. 2 to 3 weeks B. no less than 9 months
C. 6 to 8 weeks C. 12 months
D. 2 to 3 years D. a minimum of 24 months

3. The most common reason that has been given 8. The period of 6 to 8 weeks needed to establish
for choosing dental implant prosthesis is: new muscle memory patterns is probably
A. to overcome speech impediments. related to the domains of:
B. improvement in masticatory function. A. mastication.
C. to increase salivary flow. B. speech.
D. improved ability to taste. C. retention.
D. All of the above
4. Adaptation to new conventional dentures is:
A. virtually the same for all patients. 9. The muscles of the what must be trained to
B. highly variable. retain the dentures in position on the residual
C. achieved through masticatory efficiency ridges during mastication?
testing. A. tongue
D. always pain-free. B. cheeks
C. lips
5. The testing performed in this study allowed D. All of the above
the measurement of what on the basis of the
concentration of extracted fuchsine? 10. Due to the fact that a smooth acrylic denture
A. masticatory efficiency surface may modify the sense of touch within
B. ease of swallowing the oral cavity, what might be reduced when an
C. esthetic improvement upper denture covers the hard palate?
D. reduced mandibular comfort A. salivary flow
B. taste sensitivity
C. mandibular retention
D. All of the above

Course is valid from 3/1/2015 to 3/31/2018. Participants

must attain a score of 70% on each quiz to receive credit. Par-
ticipants receiving a failing grade on any exam will be notified
and permitted to take one re-examination. Participants will
receive an annual report documenting their accumulated
credits, and are urged to contact their own state registry
boards for special CE requirements.
AEGIS Publications, LLC, is an ADA CERP Recognized
Provider. ADA CERP is a service of the American Dental Approval does not imply acceptance
Association to assist dental professionals in identifying quality
by a state or provisional board of
providers of continuing dental education. ADA CERP does not
approve or endorse individual courses or instructors, nor does
dentistry or AGD endorsement. The
current term of approval extends from
it imply acceptance of credit hours by boards of dentistry.
1/1/2017 to 12/31/2022.
Concerns or complaints about a CE provider may be directed
to the provider or to ADA CERP at www.ada.org/cerp. Provider #: 209722.

www.compendiumlive.com February 2017 COMPENDIUM EBOOK SERIES 19