Periodontology 2000, Vol. 66, 2014, 119–131 © 2014 John Wiley & Sons A/S.
y & Sons A/S. Published by John Wiley & Sons Ltd
Printed in Singapore. All rights reserved
Implant-assisted complete
prostheses
E L H A M E M A M I , P I E R R E -L U C M I C H A U D , I M A D S A L L A L E H & J O C E L Y N E S. F E I N E
Oral health status has long been reported as an
important determinant of morbidity and mortality in
the general population (1, 15, 20, 33, 39, 51, 62, 63, 68,
72, 78, 88, 91, 101, 102, 106, 108). An eminent compo-
nent of oral health is the number of remaining teeth,
with tooth loss resulting in partial or complete edent-
ulism as its consequence. Edentulism is considered as
the final marker of disease burden for oral health (23,
76, 77) and remains a major health problem world-
wide (16, 29, 66, 77). However, high levels of disability
can be reduced through new technologies and
health-promotion strategies. As replacing missing
teeth with conventional dentures cannot offer the
efficiency of natural teeth, the therapeutic paradigm
for the treatment of edentulism has shifted from con-
ventional dentures to osseointegrated implant-
assisted prostheses (42, 52, 97). Currently, there is a
great demand for dental-implant therapy (71). This
treatment modality has attracted the attention of
researchers, clinicians and patients because of
increased knowledge of its biological, functional,
esthetic and psychological benefits, as well as low sur-
gical morbidity.
In fact, edentate patients treated with implant-
assisted complete prostheses (a new terminology
encompassing all types of complete prostheses
retained or supported by implants) have reported an
improvement over conventional prostheses in several
outcomes (18, 19, 35, 64, 113). However, when consid-
ering the rehabilitation of edentulous jaws using
implant-assisted complete prostheses, an important
decision about prosthetic type must be made: fixed or
removable?
A review of the current literature has revealed a lack
of consistency in terminology. In fact, the wide array
of terms used to describe prosthesis types may lead
to misinterpretation (89). Accordingly, Simon &
Yanase (89) have proposed using the terms ‘implant-
supported overdenture’ or ‘implant-tissue-supported
PERIODONTOLOGY 2000
overdenture’ for an implant-assisted removable pros-
thesis and ‘implant fixed complete denture’ for an
implant-assisted fixed prosthesis. In this review, we
have attempted to summarize the existing terminol-
ogy in a way that will facilitate the use of the appro-
priate terms.
The fixed prosthesis could be porcelain fused to
metal, or a zirconia or a metal acrylic restoration (64)
(previously called hybrid restoration of denture,
teeth, acrylic and metal framework, but according to
the Glossary of Prosthodontics (93) the term ‘hybrid’
should not be used (Fig. 1)). The implant-assisted
fixed complete prostheses (fixed dentures) are totally
supported by implants and can only be removed
by clinicians (Figs 1–3), whereas implant-assisted
removable prostheses (implant-overdenture) are usu-
ally supported by implants and soft tissues, but can
be supported by implants alone, depending on the
superstructure used. They can also be removed by
the patients themselves (Fig. 4). Various terminolo-
gies have been used to differentiate these type of
prostheses: the terms ‘implant-retained overdenture’
or ‘tissue-supported overdenture’ are used when a
prosthesis relies on tissue support and retentive ele-
ments, such as ball or Locator, attached to implants
(120) (Figs 4A and 5A). In these cases, the tissue sup-
port is achieved by a hinging movement around the
superstructure; the term ‘tissue-implant-supported
overdenture’ defines the type of prostheses that get
their retention and anterior support from their super-
structures and their posterior support from mucosal
tissues (such as an ovoid/round bar with no cantile-
ver) (Fig. 5B), whereas ‘implant-supported overden-
tures’ (such as a rigid bar with a posterior bar
extension) provide retention and most of the support
(99, 120) (Fig. 6). Prostheses may also be classified by
arch, superstructure designs and splinting character-
istics, infrastructure (number and position of
implants) and prosthesis material (17, 89).
119
Emami et al.

A B

Fig. 1. Implant-assisted fixed pros-

theses.

A B

Fig. 2. Implant-assisted fixed pros-

theses.

A B

Fig. 3. Implant-assisted fixed pros-

theses.

A B

Fig. 4. Implant-assisted removable

prostheses. (A) Two Locators attach-
ments provide retention and ante-
rior support for the prosthesis. (B) A
long Dolder bar is used to provide
retention and most of the anterior
and posterior support for the pros-
thesis.

A B

Fig. 5. Simple attachments. (A)

Locator attachments. (B) Short Dol-
der bar attachment

Each prosthesis may have different long-term of outcomes, such as esthetics (lip support), implant
patient-reported or clinical outcomes, and wise treat- success/survival rates, prosthetics success rate, func-
ment planning should take into account a vast array tional ability, time to retreatment, maintenance,

120

A B
complications and cost, as well as psychological and
social benefits associated with choice of treatment
(119). Treatment decisions should be grounded in
evidence-based knowledge to assure quality and to
avoid negligent care. Hence, it would be useful to
review and compare the evidence available on vari-
ous treatments to assist both clinicians and patients.
The objective of this manuscript was to scope the lit-
erature on the efficacy of implant-assisted complete
prostheses in edentate jaws from the perspective of
both clinicians and patients in order to assist in the
diagnostic process and choice of treatment alterna-
tives for patients considering implant prostheses.
Therefore, the review was focused on answering the
following four questions: (i) What are the advantages
and disadvantages of fixed dentures and implant-
assisted overdentures compared with conventional
dentures? (ii) What are the indications for prescribing
fixed dentures? (iii) What are the indications for pre-
scribing implant-assisted overdentures? (iv) What are
the differences between fixed dentures and implant-
assisted overdentures in terms of patient-reported
and clinician-measured outcomes? Finally, knowl-
edge gaps and clinical recommendations were high-
lighted.
Advantages of implant-assisted
fixed or removable prostheses
compared with conventional
dentures
The results of several randomized controlled trials
with short- and long-term follow-ups confirm that
mandibular and maxillary implant-assisted complete
prostheses offer biologic and functional benefits to
edentate individuals and are more advantageous than
the rehabilitating effect of conventional dentures (10,
57, 69, 80, 82). These benefits include a decreased
bone-resorption rate, enhanced prosthetic retention
and stability, improved masticatory efficacy and
chewing ability, and decreased soft-tissue trauma (7,
21, 34, 75, 81, 112). Several research teams worldwide
Implant-assisted complete prostheses
Fig. 6. Long bar attachments. (A)
Long Dolder bar on four mandibular
implants with bilateral cantilevers
and a central Locator for anterior
retention. (B) Long bar on five maxil-
lary implants with unilateral cantile-
ver and four CEKA attachments for
retention.
have tested the impact of implant-assisted dentures
on satisfaction and quality of life (3, 7, 9, 44, 83, 107,
110). The evidence shows that individuals with man-
dibular implant-assisted dentures are more satisfied
and have a better oral health-related quality of life
than do those with conventional dentures, indepen-
dently of sociodemographic factors, anatomy, num-
ber of implants and type of superstructure (7, 9, 11,
26, 32, 35, 44, 58, 75, 80, 81, 107). However, increasing
the number of implants per denture decreases the
cost efficiency of treatment. This is why the mandibu-
lar two-implant overdenture has been recommended
as the minimal standard of care for edentate patients
(37, 94). A meta-analysis of eight randomized con-
trolled trials published since 2007 indicated that,
when compared with mandibular conventional com-
plete dentures, implant-supported overdentures were
rated to be more satisfactory at a clinically relevant
level (35). However, this meta-analysis questioned the
stability of the treatment effect and the magnitude of
the improvement in oral health-related quality of life.
This research question was recently addressed in a
follow-up study indicating that oral health-related
quality of life will improve following delivery of con-
ventional dentures or two-implant overdentures and
that the treatment effect for both was stable over time
(48). However, the magnitude of the treatment effect
was significantly larger for the overdenture group.
Recent effectiveness research has supported these
findings (84). Finally, some promising results appear
to favor the use of mandibular overdentures retained
by a single midline implant, showing comparable sat-
isfaction and maintenance vs. the two-implant over-
dentures (104).
Even though implant-assisted prostheses were
superior over conventional dentures for restoring
edentulous mandibles, the completely edentulous
maxilla is usually successfully restored with conven-
tional dentures because of greater retention and sta-
bility. In a crossover trial, de Albuquerque Jr et al.(26)
showed that patient satisfaction with maxillary
implant-assisted prostheses was not significantly
higher than for new conventional maxillary prostheses.
121
Emami et al.
In general, there is limited evidence available on the
benefits of maxillary implant-assisted complete pros-
theses over conventional dentures. Thus, no firm
conclusions can be made as to whether one is super-
ior to the other. However, the implant-assisted treat-
ments could be considered for dissatisfied patients
with advanced maxillary bone resorption, for those
who desire fixed prostheses, or as a preventive
approach to bone loss (26). These treatments are
more complex than those performed in the mandible,
and treatment success relies on the meticulous
assessment of several factors such as esthetics, pho-
netics, bone and soft-tissue quality/quantity and bio-
mechanical factors (64).
Indications for implant
overdentures
A successful prosthetic treatment relies on evidence-
based comprehensive treatment planning, in which
several elements should be considered, such as
patient preferences and needs, anatomic constraints
and prosthetic limitations.
Based on these factors, removable implant-assisted
prostheses could be the treatment of choice for a sig-
nificant proportion of patients. In terms of patient
preference, many patients desire an implant-assisted
denture but are financially limited. In such cases, the
presence of only one mandibular implant may make
overdenture treatment possible (104). Depending on
a patient’s chief reason for seeking implant treat-
ment, an implant overdenture may be the best alter-
native. For example, a patient complaining of stability
or retention issues could potentially benefit from this
treatment modality. Furthermore, additional surgery,
such as bone augmentation, may not be necessary as
a result of the use of implant overdentures and there-
fore the cost, morbidity and duration of treatment
could be reduced (28). For elderly patients who may
lack dexterity and/or have limited visual acuity, and
for patients with poor oral hygiene, the overdenture
may be preferable (13, 38, 43) because it can be
removed and is therefore easier to clean. This ability
to remove the overdenture prosthesis easily also
makes it a better option for people with acquired or
congenital oral and maxillofacial defects because it
can be easily removed by the oncologist during
check-up appointments or in the event of complica-
tions (28).
In a crossover trial it was found that patients did
not find implant overdentures to be a second-class
treatment compared with the fixed alternative (27,
122
38). Both were found to be equally satisfying, even
though the fixed counterpart was rated as more effi-
cient for chewing. Still, half of the patients decided to
keep the removable prostheses because of easier
hygiene and the fact that it could be removed at
night. The length of time that patients were com-
pletely edentulous did not appear to affect which type
of prosthesis they preferred, even though it would be
logical to think that this might be the case. However,
younger patients seemed to prefer the fixed-implant
prostheses, whereas patients over 50 years of age had
a tendency to favor the removable design (38). As the
ability to clean the prosthesis was the factor that had
the greatest influence on whether or not patients
chose the removable alternative, it has been sug-
gested that, during treatment planning, the clinician
should determine which patients consider cleanliness
as an important factor (38).
Some anatomic constrains could also hold great
importance on the treatment of choice. For example,
when the opposite arch is dentate or provided with
an implant-fixed prosthesis and there is potential for
parafunctional activity, an overdenture is recom-
mended because it can be removed at night (64). For
patients presenting with moderate to severe vertical
and horizontal atrophy, a concave and prognathic
profile, inadequate lip support or phonetic problems,
the implant-assisted overdenture would be preferable
(117, 118); this would allow the construction of labial
flanges to provide esthetic lip support and could
potentially improve the phonetics because of a better
seal and the possibility to add acrylic onto the lingual
aspect of the teeth when needed.
There are some prosthetic limitations that must be
taken into consideration during treatment planning
for an implant-assisted prosthesis. Overdentures
require more interarch vertical space to provide the
room necessary for superstructures such as a bar, the
clips and the overlying acrylic restoration (30). It has
been suggested that at least 12 mm (Locators) to
15 mm (bar) are needed between the soft tissues and
the occlusal plane (65, 96) to use implant-overden-
tures, but depending on the system used, as much as
20 mm could be needed. For an example, when using
a bar with Locator abutments on top of it (Fig. 6),
20 mm may be needed. The possibility of using
acrylic flanges also provides increased control of
esthetics by replacing lost hard and soft tissues. For
this reason, it is suggested that implant overdentures
should be used when the antero-posterior bone
resorption exceeds 10 mm (30). Overdentures are also
less sensitive to malpositioned implants, excessive
cantilevering and lateral offset of the occlusal surface

compared with the fixed designs (28, 32). Finally,
patients whose tongues cannot reach the palate (ton-
gue hypomobility) could also benefit from the short-
ened distance offered by the acrylic thickness of the
overdenture, and the use of a fixed prosthesis in these
cases could potentially cause speech problems.
Indications for implant-fixed
dentures
Implant-fixed dentures are often recommended for
younger edentate patients, those who psychologically
could not tolerate removable dentures and the sense
of tooth loss, those suffering from prosthesis-related
recurrent sores, and those with an excessive gag reflex
(28). Also, a larger denture-bearing area is covered
with a removable prosthesis. Therefore, patients with
high muscle attachments, sensitive mandibular ridges
or tori, or knife-edge ridges may be more satisfied
with fixed dentures (28). However, for a fixed denture,
a minimum of four implants is needed (12, 31, 40)
and therefore cost could be a limiting factor (65).
If there is no need to replace soft or hard tissues,
then a fixed prosthesis is the best option, as there
would then be no space to accommodate acrylic
flanges associated with overdentures. If only 8–
10 mm of vertical space is available, the treatment of
choice is a porcelain-fused-to-metal restoration (65).
With less than 8 mm, the outcome could have poor
esthetics as a result of very short crowns, and soft/
hard tissue remodeling should be considered (65). If
soft or hard tissues have to be replaced vertically by
the prosthesis, a fixed restoration consisting of acrylic
supported by a metallic Montre al bar (Figs 1,7) could
be used instead of a porcelain-fused-to-metal pros-
thesis. The advantage of this type of denture is that it
will lower the costs and allow the use of acrylic teeth
if required, although porcelain teeth could also be
used with this type of prosthesis. The optimal vertical
space for this type of restoration is 15 mm (65). If
using a fixed implant prosthesis, an intermaxillary
space of more than 15 mm could lead to esthetic
A B
Implant-assisted complete prostheses
problems, such as long and/or buccally flared teeth,
black triangles and visible abutments (60, 61), and
may also cause excessive air space and additional
speech problems (28). If soft or hard tissues have to
be replaced horizontally (e.g. for lip support), the
overdenture is still the better choice (30). However,
fixed dentures for the mandible produce fewer
esthetic complications because of reduced lip move-
ment and a need for lip support. Hygiene is more dif-
ficult with fixed prosthesis and this should be
discussed with the patient. Depending on the design
of the fixed prosthesis, ease of hygiene can vary
greatly (Figs 2B and 3B).
Differences between implant-fixed
dentures and implant-assisted
overdentures in terms of patient-
reported and clinician-measured
outcomes
Patient-reported outcome
Patient satisfaction and oral health-related quality
of life
In general, studies comparing patient satisfaction
with implant overdentures and fixed dentures
showed favorable outcomes for both treatments,
regardless of the characteristics of the rehabilitated
jaw (27, 79, 118). In a crossover clinical trial 20 years
ago, Feine et al. (38) compared mandibular fixed and
long-bar implant-supported overdentures using
patient-based outcomes of various aspects of the
prostheses. Almost equal numbers of study partici-
pants chose the fixed and the removable dentures.
Both groups rated stability and the ability to chew
some foods as significantly better with fixed dentures
than with removable dentures (27). There was a ten-
dency for the removable denture to be chosen by
older subjects (50 + years of age), who preferred its
ease of cleaning (2). Heydecke et al. (43) used the
same design for comparing maxillary fixed overdentures
Fig. 7. Montr
eal bars. (A) Occlusal
view (same bar as Figure 1). (B)
Front view of a second bar with
guide pins.
123
Emami et al.
with removable long-bar overdentures, both of which
were opposed by mandibular implant-supported
overdentures. Removable long-bar overdentures
received significantly higher ratings of general satis-
faction compared with fixed prostheses. In this study,
about two-thirds of the participants preferred to keep
the removable prosthesis. Heydecke et al. (45) also
examined the rate of speech errors with different
prosthetic designs. Subjects produced a significantly
higher percentage of correct sounds with the over-
dentures than with the fixed dentures. There were no
significant differences in error rates between the two
maxillary implant overdentures with and without pal-
atal coverage (45). Zitzmann et al. (118) compared
the patient’s perspective of fixed and removable
implant-supported restorations in the edentulous
maxilla. No statistically significant difference was
found between the patient’s denture assessments in
both groups. However, patients with removable den-
tures demonstrated greater improvement in esthetics,
taste and speech. In a 10-year follow-up of clinical
studies comparing fixed dentures with implant-sup-
ported overdentures, Quirynen et al. (79) showed
that patients were highly satisfied with both treat-
ment types. Patients with fixed dentures were slightly
more satisfied with chewing ability and general satis-
faction.
Although these results show a coherent pattern
of patient-based outcomes regarding fixed and
removable prostheses, a recent survey by Brennan
and co-workers (13) and a clinical two-year study
by Katsoulis et al. (53) got quite different results,
which suggest that we still need to investigate this
subject and identify the rationale behind these dif-
ferences. Katsoulis et al. (53) compared the oral
health-related quality of life of 41 patients with
maxillary implant overdentures with a gold bar,
computer-aided design/computer-aided manufac-
turing (CAD-CAM)-fabricated implant overdentures
with a titanium bar and CAD-CAM produced
implant-fixed dentures. This study showed good
oral health quality of life for the three groups, with
a tendency for better oral health-related quality of
life in the fixed group. Brennan and co-workers
(13) surveyed patients who wore overdentures
(mostly in the maxilla) over a 6-year period; they
found that these patients had poorer oral health-
related quality of life and were less satisfied in gen-
eral, specifically with chewing ability and esthetics,
compared with those wearing fixed prostheses. In
this study, the fixed group was less satisfied with
cost, clinician performance and hygiene factors,
but had significantly lower psychological discomfort
124
and psychological disability compared with the
overdenture wearers.
Our review found that the prosthetic ‘design effect’
and its impact on oral health-related quality of life,
especially for the maxillary jaw, is seldom assessed.
Clinical outcomes
Implant survival rate – success
Implant survival and success have been widely exam-
ined in implant research on fixed and removable
prostheses. Researchers have attempted to under-
stand these data by means of systematic reviews and
meta-analyses. A recent systematic review by Bryant
et al. (17) examined data from randomized clinical
trials and 5-year follow-up studies to determine the
effect of type of removable or fixed prosthesis on
implant survival and success. Descriptive analysis of
at least 60-month follow-up data indicated no type-
specific differences in relation to implant survival
rate. Implant survival varied between 71.3% and
97.0% in the maxilla and between 83.0% and 100% in
the mandible. The maxillary removable and fixed
prostheses had pooled 5-year implant-survival rates
of 76.6% and 87.7%, respectively. The mandibular
removable and fixed prostheses had pooled implant-
survival estimates of 95.7% and 96.7%, respectively. In
a systematic review of longitudinal studies with at
least 5 years of follow-up, Berglundh et al. (8) esti-
mated the rate of implant loss for different prosthetic
designs. They found that implant loss during func-
tion was higher for overdentures (range: 5.6–5.9%)
than for those supporting fixed prostheses (range:
2.7–3.1%), with the failures located primarily in the
maxilla.
In a 6-year prospective clinical study, Tinsely et al.
(95) reported 100% survival and 100% prosthetic suc-
cess, with interval success rates of 95% in the first 4
years; this dropped to 83% at 6 years for both the
fixed and removable groups. Following a 10-year per-
iod, Schwartz-Arad et al. (87) reported a total cumu-
lative implant-survival rate of 95.4% (maxilla 83.5%,
mandible 99.5%), with an overdenture success rate of
70.4% (maxilla 41.9%, mandible 80.8%). Van Steen-
berghe et al. (98) reported a 97.2% cumulative suc-
cess rate for mandibular two-implant overdentures.
In a long-term follow-up study performed by Attard
et al. (5), cumulative survival rates of over 90% for
mandibular overdentures were reported after
15 years of follow-up. Naert et al. (70), reported a
cumulative implant failure rate of 3% over 9 years in
207 consecutive patients who received mandibular
overdentures with Dolder bar attachments. Another

retrospective study, of 495 mandibular overdentures
on two implants, reported a survival rate of 95.5%
after 20 years of loading (100).
These results indicate that both removable and
fixed treatments are reliable in terms of success and
survival, but the mandibular fixed prosthesis may
have greater survival than the maxillary fixed prosthe-
sis, and greater implant failures were observed for
overdentures in the maxilla (47). This dissimilarity
could be explained by differences in bone quality and
quantity, loading conditions, selection bias and the
effect of treatment planning (36). In a retrospective
study by Widbom et al. (109), a group of 27 patients
wearing maxillary overdentures retained by a long
bar attachment were followed over 5 years and
divided in two groups, according to initial treatment
planning. The cumulative implant-survival rate after
5 years was 77% in the group planned for overden-
ture treatment and 46% in the group who were
planned for treatment with a fixed prosthesis, but
who received overdentures. Sadowsky (85) reviewed
maxillary implant overdenture outcomes and con-
cluded that there is a lack of solid evidence to support
guidelines on treatment planning for this modality of
treatment.
Sanna et al. (86) compared the clinical outcomes of
maxillary implants supporting ‘planned’ overdentures
with those supporting fixed prostheses. They found a
high cumulative survival rate of 99.3% when four to
six connected implants were used to support the
overdenture. In fact, different studies demonstrated
that implant survival with maxillary overdentures will
increase where bone quantity and quality are good
and loading characteristics are well evaluated (49, 74,
86, 87, 109, 114, 115).
Biologic complications
Implant-assisted treatment could result in a wide
range of biologic complications, including marginal
bone loss around implants, peri-implantitis, peri-mu-
cositis, tissue hyperplasia and residual ridge resorp-
tion (22, 116).
A limited number of studies have compared these
types of complication for implant-assisted fixed/
removable dentures. Berglundh et al. (8) systemati-
cally reviewed the incidence of biologic and techni-
cal complications in 51 longitudinal studies. In
general, soft-tissue complications were found to be
more prevalent in patients with overdentures than
in patients with fixed prostheses. In a recent prac-
tice-based study in Italy, a 3.9-year follow-up of bio-
logic complications of 159 patients with mandibular
bar-retained overdentures showed a prevalence of
Implant-assisted complete prostheses
46% of biologic complications. The most common
soft-tissue complication, especially with the use of
bars, is hyperplasia, which may be avoided with
careful oral hygiene (14, 50). Shrinkage of the tissue
has been observed if a change is made to a fixed
design (59).
A 10-year follow-up of 37 patients restored with
fixed prostheses and overdentures revealed no dif-
ference in the marginal bone level (79). The review,
by Esposito et al. (36), showed that late failures
caused by peri-implant infection are rare, in gen-
eral. According to Montes et al. (67), most failures
(88.2%) occur before loading, which may be a result
of local bone quality and quantity, instead of load-
ing factors and type of prosthesis. In his study, only
1% of the failed implants could be attributed to
peri-implantitis.
Regarding marginal bone loss, a meta-analysis of
eight observational studies on the impact of overden-
ture attachment types detected no bone loss around
mandibular implant overdentures (22). These find-
ings agree with numerous other studies demonstrat-
ing very limited marginal bone loss with the use of
overdentures (50, 56, 98).
Concerning residual ridge resorption, Wright et al.
(111) investigated the effect on residual ridge resorp-
tion of two implant-retained mandibular overden-
tures and fixed dentures on five or six implants in the
posterior mandibular up to 7 years after insertion.
They reported that patients rehabilitated with over-
dentures had low rates of residual ridge resorption,
whereas patients with fixed prostheses showed bone
apposition.
Maintenance
One important aspect of prosthetic care is long-term
maintenance. The type of prosthesis, as well as the
type of materials used, the dental or prosthetic status
of the antagonist jaw and the related loading factors
and occlusal forces, can all influence the magnitude
of the maintenance issues (24). Clinicians may
encounter complications, such as wear or fracture of
prosthetic components, loosening and wear of reten-
tive mechanisms, as well as the need to reline and/or
remake the prostheses (5, 24, 25).
Tinsely et al. (95) compared the maintenance
complications for fixed dentures and implant-sup-
ported overdentures. The long-term maintenance,
including the incidence of remakes, relines and gen-
eral adjustments, was higher for implant-supported
overdentures than for fixed dentures. Naert et al.
(70) reported the need for relatively low mainte-
nance care of mandibular implant overdentures
125
Emami et al.
supported by a Dolder bar over a 9-year period,
with a 23% need to reline, a 10% untightening of
the retention, 7% remakes and 7% fracture of
opposing dentures. According to the review by
Goodacre et al. (41), loosening of the overdenture
retentive mechanism was the most common after-
care need (33%), followed by need for relines (19%)
and overdenture clip/attachment fracture (16%).
A higher frequency of prosthetic complications was
also reported for maxillary implant-supported over-
dentures than for mandibular implant-supported
overdentures (4). Katsoulis et al. (53) compared the
2-year maintenance service of 41 patients wearing
maxillary implant overdentures with a gold bar,
CAD-CAM fabricated implant overdentures with a
titanium bar or CAD-CAM produced implant-sup-
ported fixed prostheses. Most complications
occurred in the first year, independent of prosthesis
design. Direct screw fixation of the superstructure,
having a fixed prosthesis and use of CAD-CAM tech-
nology appeared to reduce complications. They also
found a significant difference between gold and tita-
nium bars in some complications (e.g. matrix and
bar-extension fractures were found only in the group
with the gold bar, and 65% of these patients had tis-
sue hyperplasia compared with the absence of this
complication in the titanium group). Davis and co-
workers (24) examined the dental records, over a 5-
year period, of a limited number of patients (n = 37)
who wore a mandibular fixed prosthesis, which was
Table 1. Comparison between fixed and removable implant-assisted prostheses
Removable
Indications 12–20 mm of vertical space
Patients lacking dexterity
Oral/maxillofacial defects
Severe bone loss
Malpositioned implants
High nocturnal parafunction
Financially limited
Advantages Easier to clean
Phonetics
Provides lip support
Technically easier to make
Disadvantages More mucosal problems
Wear of components
126
opposed by a mix of dental or prosthetic conditions
in the maxilla. They reported a higher maintenance
rate for implant-fixed prostheses opposed by fixed
prostheses compared with those opposed by natural
teeth or complete dentures. Combining these results
with other study findings, Berglundh et al. (8) demon-
strated that the incidence of technical complications
in implant overdentures (1.9; 5-year mean) was about
3.5 times higher than for fixed dentures (0.54; 5-year
mean). This higher incidence of complications was
also noted for implant components. These data indi-
cate that, although overdentures are a more econom-
ical alternative to fixed prostheses, they may need
greater long-term maintenance, which would neces-
sarily increase cost.
Cost-effectiveness
Continuous increases in the cost of alternative
implant therapies have led to an expansion of cost-
effectiveness studies. Accordingly, different cost-
effectiveness assessment methods have been applied
to compare implant-assisted fixed prostheses, over-
dentures and complete dentures, as well as different
types of superstructures and attachments (6, 46, 54,
55, 90, 92, 103, 105, 118, 121, 122). Attard et al. (6)
conducted an economic analysis of fixed prostheses
and removable overdentures over a 15-year period.
According to their results, initial time and treatment
costs were significantly higher for the fixed group. In
fact, even taking into account long-term outcomes
Fixed
8–10 mm of vertical space (PFM)
15 mm of vertical space (metal-acrylic)
Younger patients
Psychological needs
Mild/moderate bone loss
No horizontal bone loss
Can be made of acrylic or porcelain
Esthetics
Higher bite force
Better stability/retention
More implants required
Accumulation of food posteriorly
More difficult and expensive to make, adjust and redo

and greater maintenance needs, mandibular implant-
assisted overdentures seem to be the best option in
terms of cost-effectiveness (6, 121).
In contrast to these results, a small study by Palmq-
vist et al. (73) indicated that clinical and laboratory-
work costs were relatively similar for 17 edentate par-
ticipants who randomly received three implant-fixed
prostheses (All-in-One concept) with varying num-
bers of implants or overdentures supported by a Dol-
der bar. However, these results are not in agreement
with the majority of studies, which concluded that
the implant-assisted overdentures are the most cost-
effective treatments (46, 122). Our review found that
the number of research studies in this field is still lim-
ited, and the majority of these few studies used a
short follow-up period (46, 92) and they did not com-
pare different designs of implant-assisted overden-
tures (64).
Table 1 presents a summary of comparison of these
two modalities of treatments.
Knowledge gaps: research implications
This review reveals that there is still a need to provide
data on the differences between fixed and removable
implant-assisted treatments on patient-based and
some clinical outcomes using robust research meth-
ods. These methods could include both quantitative
and qualitative approaches. Quantitative unbiased
research is hard to achieve, mainly because of the
high costs of conducting large randomized clinical tri-
als with long-term follow-up. One approach would be
to provide standard raw data, then aggregate these
data. This suggests that there is a need for an
extended collaboration of multidisciplinary teams of
oral scientists and research methodologists. Another
approach would be to encourage qualitative research
in the field of implant dentistry. Qualitative research
may help us to gain a better understanding of the per-
ceptions of patients about differences in the types of
treatment, their decision-making process and the
extent of the burden of unsuccessful treatment.
These results could promote more judicious oral-
health care and encourage clinicians to emphasize
cautious treatment planning so that patient dissatis-
faction and potential lawsuits can be avoided.
Conclusion and clinical
recommendation
When indicated, and depending on the patients’
needs, both removable and fixed implant-assisted
Implant-assisted complete prostheses
prostheses can be highly safe, reliable and satisfactory
treatment modalities for rehabilitation of edentulous
jaws. Careful and precise treatment planning would
assist the clinician in preventing potential prosthetic
failures and is highly recommended. Clinicians
should consider patient preferences, financial con-
straints, hygiene capacities and anatomic factors as
key elements in their decision-making process
regarding the choice of removable and fixed implant-
assisted prostheses.
Acknowledgments
We acknowledge Maha Masri and Nathalie Clairoux
for their assistance with the literature search. Figures
presented in this manuscript were reproduced by cour-
tesy of Drs Pierre Luc Michaud and Me lanie Menassa.
Dr Emami holds a Canadian Institutes of Health
Research (CIHR) Clinician Scientist’s Salary Award.
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