April 26, 2018
Some recent publications have attempted to compare patient experiences or perceptions between those who receive over-dentures versus those who are fitted with fixed implant-supported prostheses.
The ITI, a reputable implant organisation linked to the Strauman implants brand, appears to have postulated following a review of 13 articles on the topic, that it is not entirely clear there is any kind of difference in patient perceptions whether the restoration is fixed or removable, …really? We can also postulate that a denture replacing a single tooth is preferred by the patient to an implant or a bridge, and if we look hard enough we can probably find an argument, …but seriously, who are we kidding?
The ITI will be publishing a consensus about this, and I very much look forward to reading this. Interestingly the result of that consensus appears to already be known, …before any arguments or evidence to the contrary are actually considered?
I like to follow evidence-based protocols in my practice, but tempted as I am to follow or even consider what is being postulated, the only thing that is not “entirely clear” to me in this case is the actual evidence. What is being suggested certainly does not represent my personal experience in an implant-exclusive practice and where patients experience has been a primary force driving the success of my own franchise.
Before I go ahead and spill the beans nestled within the insight of my 20 years implant experience, and portray a view that is a polar opposite, I do acknowledge that patient perceptions is an entirely different parameter to a quality of life, and whilst quality of life is not what is actually being measured, there is a high risk of clinicians (and patients) potentially confusing the two.
The problems with these kind of studies are as follows:
- No comparison: there is no way to adequately compare patient experiences or perceptions with both fixed AND removable implant restorations when they only had one OR the other;
- Technique sensitivity: The quality of the plan and execution of fixed restorations by the dentist has a far greater impact on a patients experience compared to a removable implant over-denture. With a poor fixed restoration a patient is “stuck with it” if its bulky, difficult to clean, etc. So in trying to compare the difference in experiences what we are actually comparing is the quality of dental care provided (planning and/or execution);
- Cost difference & patient bias: There is a substantial difference in cost between a fixed and removable options. Patients view any choices that they make (such as choosing the cheaper option) as their fault, so they will always try and find a positive spin to validate their own choices. On the flip side, if they preferred a fixed solution and there was no choice other than having to pay the dentist a lot of money for it, then they are likely to be far more scrupulous in their judgement and more inclined towards finding anything that is negative. Its just human nature! Though from my personal observations an improvement to a person’s confidence and quality of life is far more powerful than any inclination they might have to complain.
- Non-objective parameters: Satisfaction or lack thereof is a personal view and is highly subjective. The view may vary significantly depending on things like a patients mood, psychological factors, presence of pain or discomfort (regardless of of simple or difficult this might be to fix), whether different treatments were done by different practitioners with differences in rapport, etc. Comparing levels of satisfaction for different treatments, even for the one and the same patient, can be subject to all the above and has a potential for significant errors. Comparing the same between different patients has a probability of errors;
- Dentist Bias: Most implant dentists and specialists, even those with limited experience, can typically undertake implant over-deture treatments, but NOT many of those can plan or execute a satisfactory fixed restoration that is aesthetic, comfortable, AND easily cleanable. This can naturally, albeit often unassumingly, lead to operator bias;
- Manufacturer/organisational bias: All implants brands (those with 2-piece implants of 3mm diameter and above) are suited to a removable protocol, but NOT all can satisfy the requirements for a satisfactory full fixed bridge, especially the immediate kind. The potential for bias here is due to the common fact that such studies are often commissioned by manufacturers or brand-biased organisations considering a selective pool and for a specific purpose …to highlight the efficacy of treatment options that are (i) most suited to their own implants, and/or (ii) most suited to beginners so that more users can feel confident to place more implants.
My personal experience and data suggests the following:
- Of my estimated 200 over-denture cases that I personally treated many years ago, I have converted more than half (over 100) patients from removable implant over-dentures to fixed, including my mother. Over 70% of those were by choice due to various issues that could not be satisfactorily resolved in other ways, and the rest due to failures;
- I have also converted 28 cases from fixed back to a different kind of fixed with revision surgery by removing the original implants due to inadequacies in the original plan and/or implant placement resulting in bulkiness and poor hygiene. Two of those were my own cases and due to my own errors. The rest were originally done by others and offered no restorative space and/or the implants were very poorly positioned;
- Of the approximate 2000 cases that I personally treated with full arch fixed restorations, I have converted a total of 5 patients from fixed to removable (2 of which were originally treated by others), all were due to failures in poor bone or poor host, none were by choice, and all were on a temporary basis until I improve the conditions, or preconditions, for a revisionary fixed solution. It was my observation that these patients were miserable during the transition, and were happy to pay more money and accept more risks to go back to a fixed restoration;
It has also been my observation that:
- Most patients would only choose over-dentures because its cheaper, or because the dentist talks them into it or tells them it would be easier to clean (due to inexperience or a lack of insight?);
- The nature of most of the removable options is that there is still movement, which has the effects of (i) acting as a pump to trap food underneath and cause discomfort, and (ii) potentially still compressing fragile tissues or nerve structures;
- Many of the upper removable implant solutions are less well tolerated than even a standard denture;
- In order to accomodate the required components for a removable system, the denture often has to be bulky;
- Edentulous patients who go from full dentures to implant overdentures will certainly be happier (except in the case of an upper). Those who go from dentures (or overdentures) to adequately planned and delivered fixed restoration will simply be happy.
- Dentate patients who go from a terminal dentition to dentures or overdentures will often regret their decision. Those who go from the same to a fixed solution may complain about certain things, but they will not regret their decision.
Overall, its simply a matter of either the patients or dentists (or both) not actually knowing what they still don’t know in relation to the alternative possibilities, or the dentist not having the required insight/experience/skill-set. My associates and I follow case selection methods very similar to numerous other credible and valid ITI publications, and on occasion might even recommend a removable approach. However, whilst I am in full support of critical research efforts on case selection criteria, and I am also in full support of exploring all options by arming patients with adequate knowledge to make informed decisions based on their needs and budget, I am also equally opposed to a rhetoric that denies patients the option that suits their true desires or which aims to achieve the ideal.
Here is a video of an interview of one of my patients from a few years ago, which is typical of how patients who have had both fixed and removable compare the two treatments.