Changes in the edentulous maxilla in persons wearing implant-retained

mandibular overdentures
Timo O. Närhi, DDS, PhD,a Mariëlle E. Geertman, DDS, PhD,b Miluska Hevinga, DDS,c Hanan Abdo,
BDS,d and Warner Kalk, DDS, PhDe
Institute of Dentistry, University of Turku, Turku, Finland, University of Nijmegen, Nijmegen, The
Netherlands, and University of Groningen, Groningen, The Netherlands
Statement of problem. It has been suggested that risk for severe resorption in the anterior maxilla is
increased in persons wearing mandibular implant-retained overdentures. However, little information is
available about the changes in the edentulous maxilla after mandibular implant treatment.
Purpose. This study determined the possible changes in the width of the maxillary residual ridge 6 years
after receiving mandibular implant-supported or implant-mucosa–supported overdentures and evaluated the
association between the anatomic changes and subjective complaints with maxillary complete dentures.
Methods and material. The subjects for this study (n = 55), enrolled among the participants of a
prospective clinical trial, were randomly assigned into 3 groups treated with: (a) implant-supported over-
dentures on a transmandibular implant system (n = 21); (b) implant-mucosa–supported overdentures on
2 IMZ implants (n = 20); or (c) conventional complete dentures (n = 14). A lingual contact occlusion con-
cept with anterior open bite was used for tooth arrangement in all subjects. Diagnostic casts were made at
baseline, and again at the 6-year follow-up. Most prominent points perpendicular to the crest of residual
ridge were located in the incisor, canine, and premolar regions, after which the width of the ridge was
recorded at these points with a Boley gage. Subjects’ opinions on their dentures were evaluated with a ques-
tionnaire.
Results. Significant reduction in the width of the ridge was found in all measurement areas (mean differ-
ence = 0.4 to 0.6 mm; P<.0001). However, changes were small and not associated with the type of pros-
thetic restoration in the mandible. In subjects with implant-mucosa–supported overdentures, complaint of
loose maxillary denture correlated with the decrement of residual ridge width.
Conclusion. The width of residual ridge decreases with time, despite the type of mandibular prosthetic
restoration. (J Prosthet Dent 2000;84:43-9.)

CLINICAL IMPLICATIONS
Treatment with implant-supported or implant-mucosa–supported mandibular over-
dentures does not increase residual ridge width reduction in the edentulous maxilla.

I mplant-retained overdentures may be considered

either implant-supported or implant-mucosa–support-
ed, depending on the number of implants and type of
superstructures used to retain the prostheses. In this
article, the term implant-retained overdenture is used
to describe both of the overdenture constructions.
Distinction between the 2 overdenture type is made
when needed.
aAssistant
Professor, Department of Prosthodontics, Institute of Den-
tistry, University of Turku.
bAssistant Professor, Oral Function and Prosthetic Dentistry, Uni-
versity of Nijmegen.
cAssistant Professor, Oral Function and Prosthetic Dentistry, Univer-
sity of Nijmegen.
dStudent, Oral Function and Prosthetic Dentistry, University of
Most persons wearing implant-retained overden-
tures are satisfied with the treatment results.1,2
Improved chewing function and increased bite forces
have also been recorded after the implant treatment.3,4
Furthermore, improved retention and function of a
denture may have favorable psychological effects. A
person’s social life has been reported to become more
active after conventional complete dentures have been
replaced with implant-retained overdentures.1,2,5
Severe resorption is frequently seen in edentulous
anterior maxilla in those with shortened dental arch in
the mandible. This so-called combination syndrome is
a result of occlusal load caused by excessive anterior
function.6 According to previous studies, persons
wearing implant-retained prostheses may create bite

Nijmegen.
forces comparable to those performed by natural den-
eProfessor and Head, Department of Prosthodontics, University of tition,7 and it has been suggested that the risk for com-
Groningen. bination syndrome increases in persons wearing

JULY 2000 THE JOURNAL OF PROSTHETIC DENTISTRY 43

THE JOURNAL OF PROSTHETIC DENTISTRY
Table I. Study population
Mandibular dentition n Men
Implant-mucosa–supported overdenture (IMZ) 20 4 16
Implant-supported overdenture (TMI) 21 4 14
Complete denture 14 4 10
mandibular implant-retained prostheses opposed to
maxillary complete dentures.8,9
Patients’ satisfaction with prostheses decreases over
time.10 However, it has been speculated that satisfac-
tion with maxillary dentures may also decrease because
of the increased resorption caused by mandibular
implant treatment.11 Anatomic changes in the edentu-
lous maxilla have been evaluated in several studies that
used diagnostic casts,12-15 panoramic radiographs,16-18
or computerized methods.19-21 However, no published
randomized clinical trials have evaluated the changes in
the edentulous maxilla after mandibular implant treat-
ment; the information available is based on retrospec-
tive evaluations of successfully treated patients.
The aim of this longitudinal study was to evaluate
the changes in the edentulous maxilla and patients’
satisfaction with maxillary dentures, after wearing
mandibular implant-supported or implant-mucosa–
supported overdentures or a new set of conventional
complete dentures for 6 years.
MATERIAL AND METHODS
The subjects for this study were enrolled among the
participants of prospective clinical trial on implant-
retained mandibular overdentures carried out at the
University of Nijmegen since 1989.2 The original study
group consisted of persons who had persistent problems
in wearing conventional complete dentures (n = 89).
Subjects were randomly assigned for an overdenture
group and a control group treated with conventional
complete dentures. In the overdenture group subjects
received an implant-supported overdenture on 5 bars
retained by a transmandibular implant (Krijnen Medical
BV, Beesd, The Netherlands) or they were treated with
implant-mucosa–supported overdenture on a single bar
retained by 2 IMZ implants (Friedrichdfeld AG,
Mannheim, Germany). Treatments were carried out
according to a specific protocol and all subjects received
new maxillary dentures. Porcelain teeth (Optiform,
ENTA-Lactona, Bergen op Zoom, The Netherlands)
were used for all treatment groups and tooth setup was
performed according to the lingual contact occlusion
concept.11,22,23 The study protocol was approved by the
hospital ethical committee of the University of
Nijmegen and the subjects were enrolled in the study
after signing the informed consent.
The group consisted of 55 subjects who were suc-
44
NÄRHI ET AL
Maxilla Number of dentures
Women Mean age edentulous in the maxilla
59.8 ± 7.2 28.8 ± 9.7 3.0 ± 1.4
61.4 ± 9.2 31.6 ± 8.6 3.7 ± 2.2
65.7 ± 10.3 25.1 ± 9.8 3.9 ± 1.4
cessfully treated according to the original treatment allo-
cation and agreed to participate in the 6-year follow-up
(Table I). Of the original study group, 34 subjects could
not be included: 4 subjects died, 3 dropped out before
the 1-year follow-up, 10 refused to participate in the 6-
year follow-up, and 4 subjects could not be contacted as
they had moved without leaving any information on
their current place of residence. Poor quality of either
the baseline or the follow-up diagnostic casts prevented
the cast evaluations in 13 subjects. In addition to routine
annual examination, the following items focusing on the
edentulous maxilla were evaluated.
Occlusion and articulation
Occlusion was evaluated using guided closure and
was considered as: good, if centric relation (CR) coin-
cided with centric occlusion (CO); moderate, if minor
(<0.5 mm) deviation was observed between CR and
CO; poor, if clear (>0.5 mm) deviation was observed
between CR and CO. Articulation was considered as
good when it was fully balanced during lateral move-
ments performed from CO, otherwise it was consid-
ered poor.24 Presence or absence of frontal contact in
CO was also noted.
Retention and stability
Retention of the maxillary complete denture was
examined using the following scores: (1) good = good
resistance to vertical pull, and sufficient resistance to
lateral forces; (2) satisfactory = slight to moderate
resistance to vertical pull, and little or no resistance to
lateral forces; and (3) poor = no resistance to vertical
pull and lateral forces; the denture falls out of place.
Stability was determined with the following criteria:
(1) good = slight or no rocking on denture-supporting
structures when under pressure; (2) moderate = mod-
erate rocking on supporting structures under pressure;
and (3) poor = extreme rocking on supporting struc-
tures under pressure.24
Oral mucosa
The presence of the following mucosal changes was
recorded and their location was illustrated in the
World Health Organization evaluation form for oral
mucosal changes25: (1) decubitus ulcers; (2) localized
hyperemia; (3) hyperplasia; (4) denture stomatitis; (5)
flabby ridge; and (6) lichenoid changes.
VOLUME 84 NUMBER 1
NÄRHI ET AL THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 2. Measurement of width of residual ridge with Boley

cage.

Table II. Mean magnitude of error (mm) in the 3 measure-

Fig. 1. Most prominent points of buccal wall with their ref- ment sites
erence points on palatal side marked on model (see text).
Measurement
area* n Mean SD SE

Incisor Left + right 20 0.4 0.7 0.1

Model examination
Canine Left + right 20 0.5 0.5 0.1
Irreversible hydrocolloid impressions (CA37 fast set Molar Left + right 20 0.6 0.6 0.1
Dustfree, Cavex, Haarlem, Holland) were made for *Absolute values of left and right sides were used to calculate the mean
the diagnostic cast models. The scar line26 was used to value for each measurement site.

aid in locating the top of the residual ridge that was

marked on the baseline and follow-up models. The
palatal edge of the incisive papilla was located after
which a line was drawn along the midline of the palate.
The canine-papilla line (CPC line27) was drawn and
the canine regions were marked on the models. The
distance between canines was measured, and one third
the distance mesial from the canines represented the
location of lateral incisors. Total length of maxilla was
then determined by measuring the distance between
the palatal edge of the incisive papilla and the fovea.
The midpoint of the line was marked on the models
and used to locate the molar regions.
Most prominent points on the buccal wall of the
residual ridge were located from incisor, canine, and
molar regions and marked on the models. A palatal ref-
erence point was selected from recognized landmarks
on the same level (Fig. 1), after which the thickness of
the ridge was measured by placing the Boley cage per-
pendicular to the scar line (Fig. 2). Measurements were
made simultaneously from the baseline and follow-up
models. To evaluate repeatability of cast measurements
10 models (9% of all models evaluated) were randomly
selected for reevaluation 2 weeks after the original
recordings were made. Mean measurement error was
calculated for each of the 3 measurement sites.
Subjective opinion about the dentures
Subjective opinion about the dentures was obtained
using the set of questions in which the denture complaints
were expressed on a 4-point scale.2,28 The overall func-
tional complaint score was calculated by summing up the
scores of 3 items describing the looseness of maxillary den-
ture. The scores for pain sensation while eating food with
various consistencies formed the overall pain complaint
score. Satisfaction with maxillary and mandibular dentures
was expressed on a 10-point rating scale (1-10).
Statistical analysis
Statistical analysis was performed by the means of
StatView SE+ Graphics program (Abacus, Berkeley,
Calif.). The existence of systematic error in cast evalu-
ations was detected with paired t test. Magnitude of
change in the ridge width that could have been detected
with the sample size for the 3 groups was calculated with
the following scale:


SD2(Z1 – α/2 + Z1 – β/2)
δ=
n
where δ = minimal detectable difference (critical dif-
ference); SD = standard deviation of the mean residual
ridge width at baseline; 1–α = 90% probability for the
critical δ value (1–β = 0.90; β =.1); and α = level of sig-
nificance 5% (α=.05). Z values were obtained from the
normal distribution table.
Comparisons of the 3 groups at each measurement

JULY 2000 45
THE JOURNAL OF PROSTHETIC DENTISTRY NÄRHI ET AL

Table III. Clinical findings related to the function of maxillary complete dentures in the 6-year follow-up
Maxillary denture: ISO IMSO CD Total
clinical findings (n = 21) (n = 19) (n = 13) (n = 53) P value

Retention NS
Good 72% 47% 62% 60%
Moderate 28% 47% 38% 38%
Poor 0% 6% 0% 2%
Stability NS
Good 81% 63% 92% 77%
Moderate 19% 31% 8% 21%
Poor 0% 5% 0% 2%
Frontal contact in CO 19% 22% 54% 29% NS
Mucosa
Ulcers 5% 5% 0% 4% NS
Localized hyperemia 38% 26% 23% 30% NS
Stomatitis 0% 0% 8% 2% NS
Hyperkeratosis 10% 5% 0% 6% NS
Hyperpasia 10% 5% 0% 6% NS
Statistical valuation with Chi square. ISO = Implant-supported overdenture; IMSO = implant-mucosa–supported overdenture; CD = complete denture;
NS = not significant; CO = centric occlusion.

site were made in a repeated measures multivariate
analysis of variance (MANOVA) model. Clinical
examinations were successfully completed for 53 sub-
jects. Two subjects whose data was incomplete were
excluded from statistical analysis concerning the clin-
ical findings. Subjective opinion on the dentures was
obtained from 50 subjects; 5 subjects did not return
the questionnaire and they were excluded from the
statistical analyses. Association of clinical findings and
the type of mandibular restoration was analyzed with
Chi-square test.
Differences in complaint scores among the groups
were analyzed with Kruskal-Wallis test. Associations
between subjective complaints and changes in the
width of the residual ridge were demonstrated by use
of Spearman correlation. Pairwise comparisons in sat-
isfaction scores among the 3 groups were made by
Fisher’s least significant difference method, after the
F test for equal means from an ANOVA was found to
be significant at the 5% level.
RESULTS
Magnitude of change in the ridge width that could
have been detected with the sample size in the incisor
area was 1.0 mm for implant-mucosa–supported over-
dentures, 1.1 mm for implant-supported overden-
tures and 1.3 mm for complete dentures. In canine
area, the figures were 0.9, 0.9, and 1.0 mm, and in
molar area they were 1.6, 1.6, and 1.9 mm, respec-
tively. No systematic measurement error was found
(paired t test). Depending on the site, mean measure-
ment error varied between 0.4 and 0.6 mm (Table II).
The evaluation of denture function showed that the
occlusion was good in all the subjects and the articula-
tion was considered moderate for only 6 subjects.
None of the subjects had frontal contact in centric
occlusion. Retention and stability of maxillary com-
plete denture was good or moderate for almost all the
subjects, with no significant association with the type
of mandibular restoration (Chi-square). Oral mucosal
changes related to maxillary denture were relatively
rare, except for localized hyperemia that was found in
16 participants (Table III).
The width of residual alveolar ridge decreased sig-
nificantly during the 6-year follow-up in all measure-
ment sites. However, no significant differences
between the genders or among the 3 treatment
groups were found (Table IV). In the incisor area in
77% of the subjects decrement of the residual ridge
width exceeded the critical value for the sample size.
In canine and in molar regions, the percentages were
50% and 30%, respectively. Position of incisive papilla
in relation to the top of the residual ridge remained
relatively stable. The position was the same in 74% of
the subjects as 6 years earlier, whereas in 22%, it
moved anteriorly.
Functional complaints with maxillary complete
dentures were rare. One third of the subjects had occa-
sionally noticed looseness of the maxillary denture
when eating or opening the mouth wide, whereas 20%
had occasionally noticed pain when eating hard or
rough food (Table V). No significant differences in the
complaint scores were found amount the 3 groups
(Kruskal-Wallis test).
For those with implant-mucosa–supported over-
dentures subjective looseness of maxillary denture
correlated with residual ridge width reduction in the
incisor (r=0.44, P<.01) and canine areas (r=0.36,
P<.03; Spearman correlation). No correlations with
functional complaints and residual ridge width reduc-

46 VOLUME 84 NUMBER 1
NÄRHI ET AL THE JOURNAL OF PROSTHETIC DENTISTRY

Table IV. Changes in the width of maxillary residual ridge during 6-year follow-up
Incisor* Canine Molar
Mandibular Measurement
dentition sites (n) BL F-U Change BL F-U Change BL F-U Change

ISO 42 8.4 ± 1.8 7.8 ± 1.7 –0.6 ± 1.0 8.0 ± 1.5 7.5 ± 1.3 –0.5 ± 0.8 12.1 ± 3.5 12.2 ± 3.2 –0.1 ± 1.6
IMSO 40 8.1 ± 1.3 7.8 ± 1.4 –0.3 ± 0.9 8.0 ± 1.1 7.4 ± 1.3 –0.7 ± 0.8 12.4 ± 2.8 11.9 ± 2.5 –0.5 ± 1.7
CD 28 7.4 ± 1.4 7.0 ± 1.3 –0.3 ± 0.8 7.8 ± 1.3 7.2 ± 1.4 –0.6 ± 0.8 12.0 ± 2.9 11.6 ± 2.5 –0.4 ± 1.6
Total 110 8.0 ± 1.6 7.6 ± 1.5 –0.4 ± 0.9† 8.0 ± 1.3 7.4 ± 1.3 –0.6 ± 0.8† 12.2 ± 3.1 11.9 ± 2.8 –0.3 ± 1.6
BL = Baseline; F-U = follow-up; ISO = implant-supported overdenture; IMSO = implant-mucosa–supported overdenture; CD = complete denture.
*Significant association between the residual ridge width and type of mandibular restoration (P<.03; MANOVA).
†Significant decrement in the residual ridge width (P<.0001; MANOVA).

Table V. Maxillary denture complaints in mandibular overdenture wearers and controls 6 years after the treatment
Complaint Score* ISO (n = 19) IMSO (n = 18) CD (n = 13) Total (n = 50)

1. Denture comes loose while eating 1 15 10 10 35

2 4 6 3 13
3 0 2 0 2
4 0 0 0 0
2. Denture comes loose while speaking 1 17 15 12 44
2 1 3 1 5
3 0 0 0 0
4 1 0 0 1
3. Denture comes loose while opening wide 1 13 7 10 30
2 4 10 1 15
3 1 1 2 4
4 1 0 0 1
4. Denture causes pain while eating hard food 1 17 14 12 43
2 1 3 1 5
3 0 0 0 0
4 1 0 0 1
5. Denture causes pain while eating soft food 1 18 16 12 46
2 1 2 1 4
3 0 0 0 0
4 0 0 0 0
6. Denture causes pain while eating craggy food 1 15 14 11 40
2 4 1 2 7
3 0 2 0 2
4 0 1 0 1
ISO = Implant-supported overdenture; IMSO = implant-mucosa–supported overdenture, CD = complete denture.
*1 = Never; 2 = occasionally; 3 = often; 4 = constantly.
Mean scores among groups not significant (Kruskal-Wallis).

tion were found in those with implant-supported over-
dentures or complete dentures.
Subjects with implant-supported overdentures were
more satisfied (satisfaction score 8.7 ± 0.8) with their
mandibular and maxillary prostheses than were those
with implant-mucosa–supported overdentures (7.8 ±
1.0; P<.05) or complete dentures (7.5 ± 1.3; P<.01).
DISCUSSION
The patterns of resorption in the maxilla differ from
those in the mandible, and are most pronounced the first
years after the loss of teeth. In contrast to the edentulous
mandible, maxillary resorption is frequently seen as grad-
ually decreasing the width of the residual ridge.12,15
Jacobs et al17 used panoramic radiographs for ret-
rospective evaluation of maxillary bone resorption
after the treatment with conventional complete
dentures, implant-mucosa–retained mandibular
overdentures or fixed implant-supported mandibu-
lar prostheses. They concluded that the resorption
was most pronounced in complete denture wearers
and slightly higher annual resorption was observed in
the subjects with implant-supported fixed prostheses
than in the overdenture wearers. However, continu-
ing bone resorption was found in all groups of sub-
jects. Although the reproducibility of the method
Jacobs et al16 used for radiographic evaluation was
very high, it may have underestimated the amount of

JULY 2000 47
THE JOURNAL OF PROSTHETIC DENTISTRY
vertical bone loss as the reference area used for calcu-
lating anterior and posterior maxillary ratios obvious-
ly decreases with bone loss. In our study, panoramic
radiographs were made as a part of routine annual
examinations, but standardized radiographs were not
possible to obtain. The head positioning for panoram-
ic radiography affects vertical measurements18; thus,
direct measurements from nonstandardized radi-
ographs are not reliable. Although model analysis does
not give information on bone resorption directly, it
demonstrates morphologic changes in denture-bearing
area more accurately than the analysis based on non-
standardized panoramic radiographs. Ridge mapping
has been used to evaluate the thickness of the soft tis-
sues. However, because of the porous construction of
maxillary bone, ridge mapping may not always give
reliable information on the actual width of the residual
ridge.19 The use of ultrasound overcomes the problem
and sonographic imaging seems to be the most accu-
rate evaluation method currently available.19 Unfortu-
nately, it was not possible to evaluate the thickness of
the soft tissues from our subjects.
Diagnostic casts have frequently been used to eval-
uate the changes in the edentulous maxilla, because
several anatomic landmarks can be located from the
casts to aid the evaluation.12-15 Three-dimensional
computerized analysis has recently been developed for
the evaluation of the maxillary casts.20 In our study,
changes in the width of the residual ridge were mea-
sured in the areas in which the most pronounced
reduction of residual ridge width was expected to
occur. Variability from sources such as pressure applied
during the impression may lead to variability in soft tis-
sue points.21 Therefore, assessment of the reliability of
measures should have included a series of multiple
impressions and casts from the same persons at one
time. On the other hand, longitudinal studies with
extensive evaluations can be stressful for the subjects.
In our study, to keep the number of dropouts as few as
possible, all efforts were made to decrease the chairside
time. This caused some limitations to the study design
and reliability assessment, for example, could not be
performed.
Subjects who were not included in the cast evalua-
tions were those who refused to participate in the 6-
year follow-up or those whose diagnostic casts could
not be used for the measurements. It is unlikely that
the characteristics of these subjects could have had sig-
nificant impact on the results. Because of a large vari-
ability in residual ridge width, especially in the molar
area, the power of the method we used was relatively
poor. Increasing the size of the study population
would have improved the power, but because of the
nature of the study, it was not possible.
It must be also noted that the differences we found
were only slightly higher than the mean magnitude of
48
NÄRHI ET AL
measurement error. Cast evaluations involved both
soft and hard tissues, and it is not known how much of
the ridge reduction is due to bone resorption and what
role does the changes in soft tissue anatomy play. Fur-
thermore, additional error is likely to occur in cast
evaluation, but it is unknown, because there was no
evaluation of error introduced by impression and cast-
related procedures.
This study appears to be the first prospective ran-
domized clinical trial on objective and subjective
changes in the edentulous maxilla after the treatment
with mandibular implant-retained overdentures. A ret-
rospective case report has previously shown increased
anterior maxillary bone loss in persons wearing
implant-retained mandibular overdentures.9 However,
no control group was included in that study and the
follow-up period was relatively short. The findings of
continuous residual ridge reduction is in agreement
with a previous study,16 although in our study the
reduction was not associated with mandibular pros-
thetic status.
To preserve anterior maxillary bone, an occlusal
concept with anterior open bite has been recommend-
ed for implant-retained mandibular prostheses.23 In
our study, all subjects were treated with lingualized
occlusion concept without anterior tooth contact in
maximal occlusion. If anterior contact was noticed
during the annual recall examination, the occlusion
was adjusted to relieve the pressure from the anterior
maxilla. Lehner and Mammen9 reported that patients
might loosen contacts between the posterior teeth,
which subsequently increases the anterior guidance.
Their study and our findings demonstrate the impor-
tance of occlusal design in implant-retained prostheses.
Sensation of a loose maxillary denture, as was found
in those with implant-mucosa–supported overden-
tures, is a logical consequence of the residual ridge
width reduction. The previous assumption that
patients’ complaints of a loose maxillary denture is
associated with an increased residual ridge reduction in
the maxilla caused by mandibular implant treatment
was not confirmed by our study.
The reason for higher satisfaction score in persons
wearing implant-supported overdentures than in those
with implant-mucosa–supported overdentures or com-
plete dentures is not known. Implant-supported over-
dentures may retain the occlusal plane better than do
the implant-mucosa–supported overdentures or com-
plete dentures, and morphologic changes in the max-
illa are not readily noticed. Changes in the plane of
occlusion with different types of overdentures would
be an interesting topic for future studies. It must be
remembered, however, that the satisfaction score eval-
uated not only the maxillary denture but also the sub-
jects’ opinions on their prostheses in general. There-
fore, differences in the subjects’ experiences with their
VOLUME 84 NUMBER 1
NÄRHI ET AL
mandibular dentures had obviously a significant
impact on their scorings.
CONCLUSIONS
Within the limitations of this study, the following
conclusions were made:
1. Residual ridge width of an edentulous maxilla
decreases gradually in incisor and canine areas.
2. The decrease in residual ridge width is small and
not associated with the type of mandibular restoration.
REFERENCES
1. Wismeijer D, Vermeeren JI, van Waas MA. Patient satisfaction with over-
dentures supported by one-stage TPS implants. Int J Oral Maxillofac
Implants 1992;7:51-5.
2. Geertman ME, van Waas MA, Van’t Hof MA, Kalk W. Denture satisfac-
tion in a comparative study of implant-retained mandibular overden-
tures: a randomized clinical trial. Int J Oral Maxillofac Implants 1996;
11:194-200.
3. Geertman ME, Slagter AP, van Waas MAJ, Kalk W. Comminution of food
with mandibular implant-retained overdentures. J Dent Res 1994;73:
1858-64.
4. Carlsson GE, Lindquist LW. Ten-year longitudinal study of masticatory
function in edentulous patients treated with fixed complete dentures on
osseointegrated implants. Int J Prosthodont 1994;7:448-53.
5. Kent G, Johns R. Effects of osseointegrated implants on psychological
and social well-being: a comparison with replacement removable pros-
theses. Int J Oral Maxillofac Implants 1994;9:103-6.
6. Kelly E. Changes caused by a mandibular removable partial denture
opposing a maxillary complete denture. J Prosthet Dent 1972;27:140-50.
7. Stafford D, Glantz PO, Lindqvist L, Strandman E. Influence of treatment
with osseointegrated mandibular bridges on the clinical deformation of
maxillary complete dentures. Swed Dent J Suppl 1985;28:117-35.
8. Barber HD, Scott RF, Maxson BB, Fonseca RJ. Evaluation of anterior max-
illary alveolar ridge resorption when opposed by the transmandibular
implant. J Oral Maxillofac Surg 1990;48:1283-7.
9. Lechner SK, Mammen A. Combination syndrome in relation to osseoin-
tegrated implant-supported overdentures: a survey. Int J Prosthodont
1996;9:58-64.
10. Van Waas MAJ. Determinants of dissatisfaction with dentures: a multiple
regression analysis. J Prosthet Dent 1990;64:569-72.
11. Denissen HW, Kalk W, van Waas MA, van Os JH. Occlusion for maxil-
lary dentures opposing osseointegrated mandibular prostheses. Int J
Prosthodont 1993;6:446-50.
12. Klemetti E, Lassila L, Lassila V. Biometric design of complete dentures
related to residual ridge resorption. J Prosthet Dent 1996;75:281-4.
13. Likeman PR, Watt DM. Morphological changes in the maxillary denture
bearing areas. A follow up 14 to 17 years after tooth extraction. Br Dent
J 1974,136:500-3.
14. Brehm TW, Abadi BJ. Patient response to variations in complete denture
JULY 2000
THE JOURNAL OF PROSTHETIC DENTISTRY
technique. Part IV: residual ridge resorption—cast evaluation. J Prosthet
Dent 1980;44:491-4.
15. Roraff AR. Arranging artificial teeth according to anatomic landmarks. J
Prosthet Dent 1977;38:120-30.
16. Tallgren A, Lang BR, Walker GF, Ash MM Jr. Roentgen cephalometric
analysis of ridge resorption and changes in jaw and occlusal relationships
in immediate complete denture wearers. J Oral Rehabil 1980;7:77-94.
17. Jacobs R, van Steenberghe D, Nys M, Naert I. Maxillary bone resorption
in patients with mandibular implant-supported overdentures or fixed
prostheses. J Prosthet Dent 1993;70:135-40.
18. Xie Q, Soikkonen K, Wolf J, Mattila K, Gong M, Ainamo A. Effect of head
positioning in panoramic radiography on vertical measurements: an in
vitro study. Dentomaxillofac Radiol 1996,25:61-6.
19. Mailath G, Ulm CW, Ertl U, Matejka M. Sonographic imaging of the soft
tissues of the edentulous maxilla. Int J Oral Maxillofac Implants 1991;6:
70-4.
20. Kawahata N, Kamashita Y, Nishi Y, Hamano T, Nagaoka E. Analysis of
residual ridges and ridge relationship by three-dimensional reconstruc-
tion method. J Oral Rehabil 1998;25:110-6.
21. McGivney GP, Haughton V, Strandt JA, Eichholtz JE, Lubar DM. A com-
parison of computer-assisted tomography and data-gathering modalities
in prosthodontics. Int J Oral Maxillofac Implants 1986;1:55-68.
22. Becker CM, Swoope CC, Guckes AD. Lingualized occlusion for remov-
able prosthodontics. J Prosthet Dent 1977;38:601-8.
23. Lang R, Razzoog ME. Lingualized integration: tooth molds and an
occlusal scheme for edentulous implant patients. Implant Dent 1992;
1:204-11.
24. Nevalainen MJ, Rantanen T, Närhi T, Ainamo A. Complete dentures in
the prosthetic rehabilitation of the elderly persons: five different criteria
to evaluate the need for replacement. J Oral Rehabil 1997;24:251-8.
25. Kramer IR, Pindborg JJ, Bezroukov V, Infirri JS. Guide to epidemiology
and diagnosis of oral mucosal diseases and conditions. World Health
Organization. Community Dent Oral Epidemiol 1980;8:1-26.
26. Watt DM, Likeman PR. Morphological changes in the denture bearing area
following the extraction of maxillary teeth. Br Dent J 1974;136:225-35.
27. Watt DM, MacGregor AR. Designing complete dentures. 2nd ed. Bristol,
United Kingdom: Wright; 1986.
28. Vervoorn JM, Duinkerke AS, Luteijn F, van de Poel AC. Assessment of
denture satisfaction. Community Dent Oral Epidemiol 1988;16:364-7.
Reprint requests to:
DR TIMO O. NÄRHI
DEPARTMENT OF PROSTHODONTICS
INSTITUTE OF DENTISTRY
UNIVERSITY OF TURKU
LEMMINKÄISENKATU 2
SF-20520 TURKU
FINLAND
FAX: (358)2-333-8356
E-MAIL: timo.narhi@utu.fi
Copyright © 2000 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2000/$12.00 + 0. 10/1/107113
doi:10.1067/mpr.2000.107113
49