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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 5  |  Page : 669-674

Effects of attachment type and palatal coverage on oral perception and patient satisfaction in maxillary implant-supported complete denture patients


1 Department of Prosthodontics, Faculty of Dentistry, Erciyes University, Kayseri, Turkey
2 Department of Biostatistics, Faculty of Medicine, Erciyes University, Kayseri, Turkey
3 Department of Prosthodontics, Faculty of Dentistry, Yeni Yüzyıl University, İstanbul, Turkey

Date of Acceptance12-Feb-2019
Date of Web Publication15-May-2019

Correspondence Address:
Dr. K Kilic
Department of Prosthodontics, Faculty of Dentistry, Erciyes University, Kayseri
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_14_19

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   Abstract 


Aim: The effect of oral rehabilitation on the oral perception of implant-supported overdenture patients is a concern. This study evaluated the effects of the attachment type and palatal coverage on oral perception and patient satisfaction in maxillary implant-supported complete denture patients. Subjects and Methods: The correlation between oral perceptual ability (OPA) and patient satisfaction in three groups was investigated. Group I consisted of dentate individuals (n = 40), Group II consisted of maxillary implant-supported complete denture patients with bar attachments and palatal coverage (n = 12), and Group III of maxillary implant-supported complete denture patients with magnetic attachments and palatal coverage (n = 14). In addition, implant-supported maxillary overdentures with bar attachments, with (Group II; n = 12) and without (Group IV; n = 18) palatal coverage, were examined in terms of patient satisfaction and OPA. The relationship between OPA and patient satisfaction was assessed with the Turkish version of the Oral Health Impact Profile-14 (OHIP-TR-14) satisfaction survey. To compare oral sensory function among the groups, tactile awareness and pressure awareness were assessed. Results: There was no significant difference in OHIP-TR-14 scores between Groups II and III. In addition, there was no correlation between oral tactile function and patient satisfaction in Groups II and III. For patients with maxillary bar-retained implant-supported overdentures, palatal coverage did not affect the correlation between OPA and patient satisfaction, lateral pressure threshold, or tactile thickness threshold. Conclusion: According to the results of the study, whether maxillary implant-supported overdentures were made with a bar- or magnetic-type retainer, and whether bar-retained implant-supported overdentures had an open or closed palate did not affect the correlation between patient satisfaction and oral perception.

Keywords: Implant-supported prosthesis, lateral loading, oral perceptual ability, patient satisfaction, thickness perception


How to cite this article:
Kilic K, Kurtulus I L, Eraslan R, Zararsiz G, Kesim B. Effects of attachment type and palatal coverage on oral perception and patient satisfaction in maxillary implant-supported complete denture patients. Niger J Clin Pract 2019;22:669-74

How to cite this URL:
Kilic K, Kurtulus I L, Eraslan R, Zararsiz G, Kesim B. Effects of attachment type and palatal coverage on oral perception and patient satisfaction in maxillary implant-supported complete denture patients. Niger J Clin Pract [serial online] 2019 [cited 2019 May 27];22:669-74. Available from: http://www.njcponline.com/text.asp?2019/22/5/669/258263




   Introduction Top


In patients with edentulous jaws, mandibular overdentures supported by two implants and conventional maxillary dentures were reported to offer better results by enhancing comfort, providing adequate support, and contributing to retention compared to conventional complete dentures.[1],[2]

It was also possible to support maxillary implant overdentures by dental implants in patients who were not satisfied with the retention and stability of a conventional maxillary complete denture.[2] There have been many reports regarding patient satisfaction with mandibular overdentures supported by two implants.[3],[4],[5] However, several systematic reviews and studies concluded that there was a lack of data on implant-supported overdentures in the maxilla with respect to patient satisfaction, implant survival, and biological, technical, and prosthetic outcomes.[4],[5],[6] Thus, more clinical research is needed on the outcomes, including patient satisfaction, of implant-supported maxillary overdentures using both splinted and unsplinted dental implants.

Because patients who have lost all of their teeth do not have periodontal receptors, their oral perception is lower than that of individuals with natural teeth.[7],[8],[9] The rehabilitation of oral perception is as important as the restoration of chewing function.[10],[11] Oral perception includes taste perception and is closely related to prostheses.[8] Several researchers have studied perceptual differences between patients with natural teeth and those with implant-supported prostheses.[7],[9],[11],[12] However, debates are continuing about the oral perceptual ability (OPA) and sensitivity of patients treated with implants.

The literature includes studies evaluating the effects of retainer type, number of implants, and palatal coverage of maxillary dentures on patient satisfaction.[13],[14],[15],[16] However, all of these studies investigated oral perception and patient satisfaction separately and few have evaluated oral sensation, patient satisfaction, and oral sensory function simultaneously.[17]

In this study, the OPA was measured by OPA test in 26 patients with implant-supported overdentures with bar or magnetic attachments, and the correlation between patient satisfaction and oral perception was assessed using the Turkish version of the Oral Health Impact Profile-14 (OHIP-TR-14) test. In addition, differences between the thickness detection and lateral pressure thresholds were examined in these patients. Furthermore, in patients with a maxillary implant overdenture with an open or closed palate (total of 40 bar retainers), we determined whether there was a correlation between oral perception and patient satisfaction.

The null hypotheses of this study were

  • There is no correlation in maxillary implant-supported (with bar- or magnetic-type attachments) overdenture patients between OPA and patient satisfaction
  • In patients with bar-retained maxillary implant-supported complete dentures, there is no correlation between OPA and patient satisfaction according to palate status (open vs. closed).



   Subjects and Methods Top


In this study, OPA and satisfaction were compared between patients with natural teeth, those with maxillary implant-supported complete dentures with bar attachments, and those with maxillary implant-supported complete dentures with magnetic attachments. Group I consisted of dentate individuals (n = 40); Group II of 12 maxillary implant-supported complete denture patients with bar attachments and palatal coverage (n = 12); and Group III of maxillary implant-supported complete denture patients with magnetic attachments and palatal coverage (n = 14). Group IV consisted of 18 maxillary implant-supported complete denture patients with bar attachments and without palatal coverage (n = 18). Four dental implants were located in the lateral and first premolar regions for bar-retained overdentures, and two dental implants were located in the canine regions for magnetic-retained overdentures. The opposing arch for Group I was natural dentition; for Groups II and Group IV, it was a mandibular implant-supported overdenture with bar attachments; and for Group III, the opposing arch was a mandibular implant-supported overdenture with magnetic attachments.

The group selection criteria were as follows: no local inflammation/oral diseases/symptoms, no temporomandibular disorder, no high cigarette consumption (>10 cigarettes a day), no drug habits or life-threatening diseases, no excessive parafunctional activity owing to denture use, and fractures in the existing dentures.

This clinical prospective study was conducted at Erciyes University Faculty of Dentistry, Department of Prosthodontics, Kayseri, Turkey. Before commencing the study, ethics committee approval was obtained from the Erciyes University Clinical Research Council (no. 2014/510), and informed consent was obtained from all patients who participated in this study.

The study protocol proceeded as follows: selection of patients according to specific criteria; telephone contact with patients to make appointments and obtain informed consent; occlusion control by two prosthodontists, with adjustments made as necessary; application of OPA test; completion of the OHIP-TR-14 questionnaire; completion of the thickness threshold test; and completion of the lateral pressure threshold test.

The patients included in this study had used their dentures for 2 to 8 years. All included patients had been treated at Erciyes University, Faculty of Dentistry, Department of Prosthodontics.

The patients' dentures were evaluated by two prosthodontists. During this evaluation, occlusion, articulation, vertical dimension, interocclusal distance, vestibular and lingual flanges, retention, and stability were evaluated. Patient occlusion control was performed with the T-scan III computerized occlusal analysis system. Bilateral balanced occlusion was provided for all dentures. After all necessary adjustments had been made, the testing phase was initiated.

The OPA, OHIP-TR-14, thickness perception threshold, and lateral pressure threshold tests were performed as in a previous study that evaluated both oral perception and patient satisfaction.[17] Ten different test samples were used to assess OPA. The test samples were plastic with diameters of 5–10 mm. The patients' eyes were covered, and the small test specimens were placed on each patient's tongue with the aid of a tongue depressor, after which the patient was shown large duplicates of the pretest samples [Figure 1].[17] Later, the number of seconds it took for the patient to respond was measured using a stopwatch. All patients included in the study were subjected to this test without dentures first to ensure standardization.[17] Further, the test was repeated while the patients' dentures were in their mouths. The OHIP-TR-14 test was performed on all patients after completion of the OPA test. Articulation papers with a thickness of 8 μm were used to measure the thickness perception threshold of the patients.[17] The thickness at which the patient reported feeling the height of the papers was recorded as the thickness threshold. A horizontal load was applied to the labial or buccal surface of a natural or artificial tooth with a tension meter (Ohba Siki, Tokyo, Japan). The applied force was increased at 5 g/s, and the value at which the patient began to feel the force was recorded as the lateral pressure threshold.[17]
Figure 1: Oral perceptual ability test samples

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The normality of the data distribution was assessed with a histogram, q–q plots, and the Shapiro-Wilks test. The homogeneity of variance was assessed using Levene's test. The Chi-square analysis was used to compare categorical variables between groups. For all other group comparisons, a two-sided independent samples t test, paired t test, or one-way analysis of variance (ANOVA) was used. The Tukey test was applied for multiple comparisons. The Pearson test was used for correlation analysis. Analyses were conducted with R software (ver. 3.4.0; R Development Core Team, Vienna, Austria). A P value of less than 5% was considered statistically significant.


   Results Top


There was a statistically significant difference in age between the control group and Groups II and III (26.6, 59.5, and 61.8, respectively; P < 0.01) but not between Groups II and III (P > 0.05). There was no statistically significant difference in gender distribution among Groups I, II, and III (P = 0.642). When Groups II and IV were compared in terms of age (59.5 and 56.2 years, respectively) and gender distribution, no statistically significant difference was observed (P > 0.05).

The results of the OPA test for Groups I, II, and III are shown in [Table 1]. The Group I patients were significantly faster than the other groups in perceiving all perceptual ability test stimuli (circle, pyramid, window, smooth, 1-rill, 4-rill, and chessboard shapes) except for the cone, drop, and 2-rill shapes [Table 1]. When we compared Groups II and III, Group II patients perceived the circle shape significantly earlier (P < 0.001) [Table 1]. In addition, as shown in [Table 1], there was no significant difference between these groups in terms of OPA test performance either when the dentures were inserted or when the patients were toothless (for the complete denture and implant-supported complete-denture patients; P > 0.05) except in terms of the latency to perceive the circle shape among the implant-supported complete denture patients with magnetic attachments [Table 1]. The OPA test results of Groups II and IV were also compared. Group II perceived the window shape significantly earlier than Group IV did [Table 2]. In additional, as shown in [Table 2], there was no significant difference between these groups in terms of OPA test performance either when the dentures were inserted or when the patients were toothless (for complete denture and implant-supported complete denture patients; P > 0.05).
Table 1: The answer times of oral perceptual ability test between Group I, II, and III

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Table 2: The answer times of oral perceptual ability test between Group II and IV

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There was no significant difference in OHIP-TR-14 scores (Groups II and III: 17.6 for males and 16.9 for females; Groups II–IV: 17.7 for males and 17.3 for females) or between genders (P > 0.05).

There was no significant difference in the overall OHIP-TR-14 scores between Groups II and III (17.7 and 16.9, respectively) or between Groups II and IV (17.7 and 17.4, respectively; P > 0.05).

As shown in [Table 3], analysis of the lateral pressure and tactile thickness threshold values showed that Group I perceived the applied lateral and vertical forces significantly earlier relative to the other groups (P < 0.001). There was no statistically significant difference between Groups II and III in terms of the lateral pressure threshold or tactile thickness threshold (P > 0.05; [Table 3]). When the lateral pressure and tactile thickness threshold values of Groups II and IV were compared, no statistically significant difference was seen (P > 0.05, [Table 3]).
Table 3: The correlation results of patient satisfaction and oral perceptual ability level in Group II and Group III

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As shown in [Table 4] there was no correlation between OPA and patient satisfaction in any group.
Table 4: The correlation results of patient satisfaction and oral perceptual ability level in Group II and Group IV

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   Discussion Top


In our study, the OPA test was used to assess OPA. In addition, tactile sensitivity at the mandible and maxilla was calculated according to the thickness detection threshold and according to the lateral loading threshold at the tooth and prosthesis.

The shapes included in the OPA test are sufficiently difficult to perceive; in this study, the shape for which the latency to lowest detection was the circle, whereas the slowest recorded responses were those to the square figure.

For anatomical reasons, it is more difficult to maintain retention and stabilization in the mandible than in the maxilla; therefore, an implant-supported denture in the mandible is essential.[2] However, if retention cannot be achieved in the maxilla, or if the patient's expectations regarding restraint and stabilization are very high, an implant-supported overdenture in the maxilla represents a viable alternative.[2] A small number of reports have evaluated the correlation between patient satisfaction with an implant-supported maxillary overdenture and OPA.[13],[14],[17],[18],[19],[20],[21] Ikbal et al. found no correlation between patient satisfaction and OPA in patients with a complete denture or implant-supported overdenture.[17] Kuoppala et al. reported that patient satisfaction, retention type (bar, round bar, or stud attachment), and the number of implants had no effect on patient satisfaction, as indexed by the OHIP-14 questionnaire, in maxillary implant overdentures.[18] Alqutabi also reported that the retention type had no effect on patient satisfaction.[13] All of the articles cited herein included a follow-up period of at least 1 year for overdentures made with round bar, magnetic, and standard bar attachments. In another study that investigated patient satisfaction with implant-supported overdentures, high satisfaction was noted independent of the implant or attachment type; round bar, locator, and standard bar attachments were evaluated.[22]

In this study, there was no statistically significant difference in OHIP-TR-14 satisfaction scores between Groups II and III (P > 0.05) according to the retention type, in patients with an implant-supported overdenture. This result is consistent with those of previous studies.[13],[18],[22]

This study also included a patient group having implant-supported maxillary overdentures with a bar or magnetic attachment. When we examined the effect of retainer type on OPA test performance, it was found that the patients with bar retainers only perceived the circle and pyramid shapes significantly earlier (P < 0.05) than the other patients, with no significant difference in latency to detection seen for any other stimulus (P > 0.05). However, there was no significant difference in OHIP-TR-14 questionnaire scores between patients with bar-retained versus magnetic retaining-type overdentures (P > 0.05). Furthermore, no significant difference in the lateral perception or thickness perception threshold values was seen between the two attachment types (P > 0.05). The lack of difference in the thickness perception threshold between the two types of vertical retainers suggests that they confer similar OPAs.

In the control group, there was no correlation between the OPA test results and OHIP-TR-14 satisfaction scores in patients with implant-supported overdentures with bar attachments (and providing full palatal coverage) versus magnetic attachments. Thus, the first study hypothesis can be accepted.

This study also compared OPA results between implant-supported overdenture patients with maxillary and those with mandibular bar attachments. Whether the palate was open or closed had no impact on the latency to perceive the stimuli in the OPA test (P > 0.05). Thus, as reported by Calhoun et al., it can be concluded that the palate is as not as important as the tongue in oral sensitivity.[23]

In 2013, Zembic et al. examined 21 patients with maxillary implant-supported prostheses and two retainers conferring full palatal coverage.[15] The palatal coverage and OHIP scores of these patients were examined initially and, after 2 months, the palatal coverage was reduced and the OHIP re-administered. Patient satisfaction with the implant-supported overdentures did not vary according to whether the palate was closed or open; however, an open palate had a positive effect in terms of aesthetics and taste perception.

De Albuquerque et al. analyzed four implant-supported maxillary overdentures with bar attachments and found that the palate status (open vs. closed) had no significant association with overall satisfaction, stability, retention, comfort, aesthetics, or cleanability.[24]

In the present study, palate status also had no statistically significant association with patient satisfaction. These results are in agreement with similar studies investigating implant-supported (three to four implants) maxillary overdentures with open or closed palates.[14],[24],[25],[26],[27]

In this study, there was no difference in the OPA test results or OHIP-TR-14 satisfaction scores between patients with open- versus closed-palate maxillary implant-supported overdentures with bar attachments. Thus, the second null hypothesis can also be accepted.

When the open and closed palates of patients having an implant-supported overdenture with bar attachments were examined, there was no significant difference in either the lateral perception or thickness perception threshold value.

In this study, patients with natural dentition were included in the control group. Thus, there was a difference in age between the control group patients and those with the implant-supported overdentures with magnetic attachments. Furthermore, this study was conducted in a limited number of patients, so there is a need for further studies involving more patients.


   Conclusion Top


The results of this study indicated that there was no correlation between patient satisfaction and OPA in patients with implant-supported overdentures.

The palate status (open vs. closed) of the patients using implant-supported overdentures with bar attachments had no effect on the correlation between patient satisfaction and oral perception.

Whether the attachment was by bar or magnetic, and whether the palate was closed or open (in the case of bar-retained overdentures) had no significant effect on the lateral perception threshold or thickness perception threshold.

Abbreviations

OHIP-TR-14: Oral Health Impact Profile-Turkish-14

OPA: Oral perceptual ability

Acknowledgments

We would like to thank TUBITAK (The scientific and technological research council of Turkey) for supporting this project, and Meltem Unlusavuran from the department of Biostatistics at Erciyes University, Kayseri, Turkey for their assistance with the statistics in this study.

Financial support and sponsorship

This study was supported by Project No 214S587 by TUBITAK (The scientific and technological research council of Turkey).

Conflicts of interest

There are no conflicts of interest.



 
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Al-Zubeidi MI, Alsabeeha NH, Thomson WM, Payne AG. Patient satisfaction with maxillary 3-implant overdentures using different attachment systems opposing mandibular 2-implant overdentures. Clin Implant Dent Relat Res 2012;14:11-9.  Back to cited text no. 14
    
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de Albuquerque Junior RF, Lund JP, Tang L, Larivee J, de Grandmont P, Gauthier G, et al. Within-subject comparison of maxillary long-bar implant-retained prostheses with and without palatal coverage: Patient-based outcomes. Clin Oral Implants Res 2000;11:555-65.  Back to cited text no. 24
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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