Oral health‐related quality of life of patients rehabilitated with fixed and removable implant‐supported dental prostheses

1The models for restoring edentulous patients have changed in recent decades because of the high predictability of oral implants. Historically, dental implants were installed in fully edentulous patients with the aim of increasing the stability of full denture prostheses. However, with increasing predictability of implant treatment, various dental implant‐loading protocols have been proposed, expanding the range of implant rehabilitation protocols for partially edentulous patients., Today, the majority of implants are used to rehabilitate partially edentulous patients, who represent up to 90% of all implant patients., The development of appropriate augmentation techniques and the introduction of novel implant surfaces has resulted in acceptable treatment outcomes, even where esthetics are a priority. In this respect, surgical and prosthetic procedures have led to improved esthetic outcomes for the teeth to be replaced.,,

2From the patients’ perspective, an excellent esthetic outcome is perceived as a satisfactory final solution to cope with their dental problems. However, it is well known that biologic complications can arise with dental implant placement, and infections may develop that require a complex, protracted, and costly treatment of peri‐implant infections. Again, the patient is usually unaware of the risks associated with implant placement in terms of biologic complications.

3In this context, patients’ perceptions and psychological parameters are becoming more and more significant in evaluating treatment outcomes in implant dentistry., This is reflected in an increasing number of recent publications on patient‐reported outcome measures. In implant dentistry, patient‐reported outcome measures were proposed at the 8th European Federation of Periodontology Consensus Conference with the aim of focusing on patients’ perspectives and evaluating oral health‐related quality of life.

4The aim of this narrative review was to summarize the current evidence on oral health‐related quality of life of fully and partially dentate patients rehabilitated with fixed and removable implant‐supported dental prostheses. Special emphasis was given to oral function, esthetic outcomes, and cost‐related aspects.

5A comprehensive electronic search of the MEDLINE–PubMed database was performed for articles published in English up to 2021, applying the following free text terms: "PROMS" or "Oral health related quality of life" or "patient related outcome measures" or "patient satisfaction" or "esthetics" or "function" or "cost‐effectiveness" or "patient happiness" and "dental implants" or "implant dentistry". Moreover, the reference lists from the retrieved publications were screened to identify any additional relevant studies.

6Oral health‐related quality of life is an established and relevant instrument with which to describe patient satisfaction. It was developed with a psychometric and social survey background and encompasses multiple dimensions of life, ranging from impairment (which is closely linked to clinically defined health status) to social function, and to more global constructs such as “opportunity.” These dimensions have been linked to conceptual models, in which the effects of impairment on disability or reduced opportunity are mediated by intervening with personal and environmental factors. This makes it difficult to summarize oral health‐related quality of life in a single term. In fact, there is still a lack of consensus on the plethora of terms used in the literature for oral health‐related quality of life. Moreover, the instruments used to analyze oral health‐related quality of life remain unstandardized and rather heterogenic in nature. Nevertheless, there are many standardized questionnaires and scales employed to assess the impact of dental interventions upon oral health‐related quality of life, and a selection of these questionnaires are listed and explained in Table 1.

7The visual analog scale is defined as the distance on a horizontal line between two anchoring points representing the minimum and the maximum perception. The anchoring points are usually 10 cm apart, and the scale on the line is in millimeters or other units. In order to quantify a parameter on a visual analog scale, the evaluator will present a mark on the line. Thus, the distance from the mark to the anchoring point may be calculated., The scale is often used as answer modality in standardized questionnaires (Table 1).

8The Likert scale is named after its inventor. Likert was a psychologist and he used the scale as a technique for evaluation of people's attitudes. The scale contains five points on a horizontal line with a maximal distance between each. Each point is tagged with a descriptor. The patient is summoned to highlight the most accurate description according to their opinion. Today, the scale is widely used in research and it has undergone many adaptations., The scale is employed as a component of several standardized questionnaires (Table 1).

9In the last 3 decades, a variety of standardized questionnaires have been proposed and propagated. The questionnaires usually comprise different areas.

10Prior to the conference on oral health‐related quality of life in North Carolina, there was no consensus regarding how to evaluate oral health‐related quality of life. At that conference, efforts were made to standardize health questionnaires. The questionnaires were analyzed in terms of reliability, validity, and precision. Following the conference, further questionnaires were introduced. A detailed table of the questionnaires, with descriptions of the dimensions evaluated, as well as the number of questions and answering modalities, is listed in Table 1. One questionnaire in particular is emphasized because it is frequently used in the publications cited in this review: the oral health impact profile. The oral health impact profile assesses the dimensions of function, pain, physical disability, social disability, and handicap. The patient is asked to answer 49 standardized questions with answering modalities in five categories. A shorter version applying 14 standardized questions has also been validated and propagated.

11The methods for the judgment of the esthetics by clinicians are depicted in Table 2.

12The evaluation of oral health‐related quality of life of patients rehabilitated with dental implants can be summarized in three domains: the aspect of function, esthetics, and cost‐effectiveness. Furthermore, the functional aspect was subdivided into fully edentulous, partially edentulous patients, and the topic of implant‐supported vs tooth‐supported fixed dental prostheses. An overview of the results is summarized in Table 3.

13The functional aspect of oral health‐related quality of life is not only important in the field of dentistry. Oral health‐related quality of life also affects the overall well‐being of the individual. In other words, oral health‐related quality of life correlates to general health‐related quality of life. In terms of rehabilitation with dental implants and the different surgical protocols, it appears that immediate loading protocols achieved the highest patient satisfaction.

14The majority of studies dealing with implant placement and oral health‐related quality of life has been performed in edentulous patients. Edentulism may be associated with functional impairment, which includes chewing ability, bite force, swallowing mechanism, differences in salivary flow, phonetics, and oral sensory function in general. Moreover, cleansability, as well as social behavior, are included. Ill‐fitting and unstable prostheses are a particular source of distress and reduced self‐esteem. Therefore, implant placement in edentulous patients severely impacts on their functional well‐being.

15Fonteyne et al evaluated patients receiving new fully removable dentures during different stages of treatment. The assessments were conducted by speech therapists. Interestingly, despite existing articulation and oro‐myofunctional impairments following treatment, patients were very satisfied with their oral health‐related quality of life and their speech. Similarly, Dellepiane et al assessed 25 patients at different stages (ie, before treatment, during the healing phase, and after the final reconstruction). At the final evaluation, 4 months after rehabilitation, 92% of patients did not indicate any difficulty in eating. Overall, oral health‐related quality of life revealed a significant improvement in terms of quality of life, and the patients only reported phonetic impairment in the immediate aftermath of surgery. Two prospective studies indicated that implant‐supported prostheses improved the oral health‐related quality of life significantly., It has been shown that the support of a full dental prosthesis supplemented by two implants improves the retention and stability of the prosthesis significantly. A total of 45 edentulous patients receiving implant‐supported mandibular overdentures reported a strong improvement in oral health‐related quality of life in the first 3 years. Similar results were reported in another prospective study including 67 patients over 5 years. New complete mandibular dentures led to significant improvements in patient‐reported outcome measures. Implant‐supported mandibular dentures yielded the best results, as reflected by reduced functional complaints, complaint frequency, and intensity of complaints. Overall patient satisfaction correlated negatively with technical complications. An International Team for Implantology consensus report evaluated patient‐reported outcome measures of fixed and removable implant‐retained prostheses in edentulous patients. In the 13 studies included, fixed and removable implant‐retained prostheses were rated similarly. Only cleansability was rated differently. Consequently, whether to restore an edentulous patient with either fixed or removable implant prostheses cannot be solely answered by assessing the oral health‐related quality of life. Oral rehabilitation of edentulous patients with both implant‐supported fixed and removable prostheses yielded similar patient‐reported outcome measures, as reported in a systematic review. However, fixed prostheses displayed a trend for higher patient acceptance than removable prostheses. Overall, there is a large body of evidence that implant‐supported overdentures, especially in the edentulous mandible, lead to improved satisfaction in terms of oral health‐related quality of life compared with conventional prostheses. A 5‐year prospective study including 30 patients rehabilitated with single‐implant mandibular overdentures revealed significant increases in comfort, stability, and the ability to masticate for all evaluation periods. This is in agreement with a systematic review comparing conventional complete dentures and implant‐retained overdentures. Implant‐retained overdentures received higher ratings in terms of overall satisfaction, comfort, stability, psychological comfort, chewing function, and ability to speak.,, In a randomized trial including 118 patients, comfort, stability, and retention, as well as chewing function, were reported as being superior for implant‐supported overdentures compared with conventional dentures. However, where speech or cleaning ability were concerned, patients reported similar results., Furthermore, patients reported an improvement in social as well as in couple activities. Concerning functional aspects, cleaning, speaking, and pronunciation, overall comfort and stability were evaluated as superior for maxillary implant‐supported overdentures compared with conventional dental prostheses.

16The question arises as to whether bone atrophy has an impact on the oral health‐related quality of life of patients treated with implant‐retained overdentures, foremost in the mandibular region. A 3‐year prospective study compared patients treated with implant‐retained mandibular overdentures with and without atrophic mandibles and, interestingly, did not reveal any statistical significant differences. More recent studies support the finding that retention and therefore better stability of prostheses appears to be an important factor for patients’ oral health‐related quality of life., A 3‐year prospective study assessed the impact of four implant‐supported overdentures in the maxilla in terms of oral health‐related quality of life and speech. Twenty‐one patients were examined preoperatively and following the connection to an implant bar. The design of the conventional denture before surgery was with palatal coverage. The implant‐supported overdenture after treatment was designed without palatal coverage. All seven domains improved oral health‐related quality of life for implant‐supported overdentures compared to conventional dentures. By contrast, a recent prospective study failed to show significant differences between the aforementioned treatment modalities. Nevertheless, implant retention of overdentures does appear to be an important driver of patient satisfaction. The connections between implants and the denture are diverse. The different attachment modalities (ie, magnetic, locator, or ball attachments) were assessed in recent studies.,, The results indicated stable 5‐year outcomes and improved oral health‐related quality of life for both locators and balls. Although locators required more maintenance and resulted in lower retention in one study, another retrospective study (including a total of 122 patients) reported higher patient satisfaction for locators compared with ball attachments. Oral health‐related quality of life was significantly increased for patients receiving implant‐assisted removable partial dentures with magnetic attachments compared with rehabilitation without magnetic attachments. However, no difference in terms of oral health‐related quality of life was discerned between bar attachment and magnetic attachment.

17With rehabilitations using implants, there is always a risk of peri‐implant diseases. An interesting cross‐sectional study, including 109 geriatric patients, revealed a statistically significant correlation between total oral health impact profile‐14 score, plaque index, and gingival index. These results suggest that peri‐implant health also affects patient satisfaction.Another aspect to be taken into consideration is the effect of preoperative patient expectations on oral health‐related quality of life. This question was addressed in a randomized controlled study including three experimental groups of edentulous patients requesting replacement of their conventional complete dentures. The first group of 20 patients had been edentulous for a mean time of 23.1 (range 3‐40) years, had worn a mean of 6.7 (3‐12) sets of complete dentures, and requested implants to stabilize their conventional prosthesis in the mandible. They received mandibular implant‐supported fixed partial dentures. In the second group, 20 patients requested an implant‐stabilized prosthesis but did not receive this treatment. Instead they received conventional complete dentures. They had been edentulous for a mean time of 19.9 (2‐35) years and had worn a mean number of 4.9 (1‐12) sets of complete dentures. In the third group, 35 patients requested and received conventional complete dentures. They were treated according to their wishes. In this group the subjects had been edentulous for a mean time of 27.1 (3‐40) years and had received a mean number of 3.4 (1‐12) sets of complete dentures. The results from the oral health impact profile questionnaire indicated that patient satisfaction improved, even in the group of patients who preferred implant‐stabilized prostheses but were instead treated with conventional prostheses. But the extent of patient satisfaction was higher in patients who received their desired treatment. It was concluded that patient expectation is not a good predictor of treatment outcome.

18In conclusion, there is increasing evidence that the use of dental implants to support either fixed or removable dental prostheses in fully edentulous patients significantly improves overall patient satisfaction when focusing on functional ability, especially in the lower jaw.

19Replacing missing single teeth with dental implants has become a routine procedure for the rehabilitation of partially edentulous patients, although the lack of a periodontal ligament may have an impact on chewing sensation. The number of missing teeth is reflected in the oral health‐related quality of life, assessment, demonstrating that tooth loss per se affects patients psychologically. Recently, it was reported that tooth loss had a negative impact on eating in public and forming close interhuman relationships.

20Kurosaki et al compared the long‐term performance of three different prosthetic reconstruction types—implant‐supported fixed denture, fixed partial denture, and removable partial denture—in terms of prosthetic survival and oral health‐related quality of life. Concerning survival, the 6‐year cumulative survival rates of the implant‐supported fixed dentures, fixed dentures, and removable partial dentures were 94.7%, 77.4%, and 33.3%, respectively. The oral health‐related quality of life scores for the implant‐supported fixed denture group immediately after treatment and 6 years after treatment were significantly higher than those observed before treatment. However, there was no improvement in the oral health‐related quality of life scores in the fixed partial denture or removable partial denture groups compared with before treatment.

21According to a questionnaire‐based survey, only 15.3% of patients receiving single implants considered masticatory function as their major concern. A total of 8.6% were most worried about food impaction and another 4.5% about pronunciation, occlusion, and swallowing. Functional limitations, along with psychological discomfort, significantly decreased in patients who had received implant‐supported single crowns or fixed partial dentures over a period of 3 years following implant installment.

22A systematic review with a meta‐analysis, including different questionnaires such as oral health impact profile‐49, oral health impact profile‐14, geriatric oral health assessment index, oral impacts on daily performances, and ad hoc satisfaction, indicated that not only the number of teeth lost, but also the location and distribution of missing teeth, affect the reduction in oral health‐related quality of life. Furthermore, the extent and severity of impairment appears to be context‐dependent (eg, cultural background).

23An evaluation of implants and their contralateral teeth clinically, alongside patient satisfaction by oral health impact profile‐14, confirmed that patients with implants were highly satisfied with their oral health‐related quality of life. The majority (72.8%) felt that they were never limited in function. Moreover, they indicated satisfaction with their dietary consumption (69.5%). Nearly half of the patients (48.9%) had encountered phonetic problems pretherapy and had become more self‐confident through implant treatment.

24Comparing the oral health‐related quality of life pre‐ and post‐implant placement revealed that, prior to surgery, patients reported functional problems, specifically eating (78%), but also speaking and smiling, which when considered together were a cause of general embarrassment (53%). After implant placement, the oral health‐related quality of life changed in many aspects. Besides those functions directly related to tooth replacement, such as eating, speaking, or oral sensory function, oral health‐related quality of life increased in general terms. Going out or meeting others, communication, smiling, and showing teeth without discomfort became natural and enjoyable. Interestingly, patients reported that becoming upset, in general, as well as job‐related activities, significantly improved after implant placement.

25A recent review suggested that in partially dentate patients there was insufficient evidence that implant‐supported fixed dental prostheses yielded better oral health‐related quality of life scores than tooth‐supported fixed dental prostheses. In partially dentate patients, the consensus of oral health‐related quality of life studies is that treatment with implant‐supported fixed dental prostheses improved oral health‐related quality of life. However, all of these studies need to be interpreted with caution. First, it is clear that all these patients had an edentulous gap or a provisional prosthesis before treatment. It is well known that fabrication of new definitive prostheses positively influences oral health‐related quality of life. Thus, it remains plausible that the prosthetic replacement rather than the implants per se were responsible for the improved oral health‐related quality of life. Second, patients restored with implants usually have higher levels of education and income, which may affect their satisfaction scores.

26To date there is limited evidence for partially dentate patients that implant‐supported fixed dental prostheses are superior in terms of patient perception than conventional fixed dental prostheses.

27Loss of teeth, particularly in the anterior region, is associated with esthetic impairment and reductions in oral health‐related quality of life. In fact, a prospective study with 238 participants investigated patients with loss of anterior teeth and their satisfaction before implantation and following crown delivery. The results showed that oral health‐related quality of life, assessed with the oral health impact profile‐14 questionnaire, increased significantly after crown insertion, and the effect appeared to be longlasting. A cross‐sectional study including a total of 95 patients revealed high satisfaction in terms of esthetics and function with implant‐supported restorations, even 10 years after they had received their implants.

28For many years, the evaluation of esthetic outcomes of care was obscure and not standardized in the dental literature. However, in 2005, two esthetic assessment methods were proposed and validated, namely, the pink esthetic score80 and the implant crown esthetic index. Both systems were successfully used in subsequent reports on esthetic outcomes in implant dentistry (Table 2). It has to be kept in mind, however, that both systems require the ability to compare the implant reconstruction with a contralateral or control tooth. Nevertheless, the index systems helped clinicians to objectively assess the esthetic aspects of newly placed and reconstructed implants. However, esthetic assessment by means of the index system described is significantly affected by the paradigms of the respective specialties. In a validation study, prosthodontists were the most critical evaluators and yielded the lowest mean rank scores regardless of the index, while dental assistants and periodontists had significantly better ratings than other specialties.

29Hence, it has to be realized that esthetic scores are dependent on the professional experience of the examiners, irrespective of the esthetic index system utilized. In that respect, a recent review applied objective and subjective criteria for clinicians and patients to evaluate esthetic outcomes. In that review, the oral health impact profile and oral health‐related quality of life questionnaires were used for esthetic evaluation (Table 2). These standardized and validated questionnaires allowed comparisons. A comparison of the objective and subjective assessments yielded a discrepancy between subjective patient‐related criteria and objective prosthodontist‐related evaluations.

30An important aspect to be mentioned is that professionals were more critical than patients when subjective patient‐evaluation was used. In one study, five prosthodontists were asked to evaluate the esthetic outcome of single implant‐supported crowns based on intra‐oral and extraoral photographs. A total of 41 implants were placed in the maxillary anterior region of 29 patients. In 89% of cases, the clinicians correctly located the single implant‐supported crown. The form of the crown and surrounding soft tissue were the most important parameters for the clinicians’ satisfaction. However, regression analysis failed to reveal any statistically significant agreement when the patient's view was taken into consideration, as patient satisfaction was higher for all variables compared with clinicians’ satisfaction.

31A further study on subjective and objective evaluations of esthetic outcomes in implant dentistry involved 30 patients treated with dental implants. Preoperative and postoperative images were graded using a visual analog scale. At the same time the images were shown to 10 independent clinicians using the same visual analog scale. The same outcome was reported and agreement between patients' and clinicians' evaluations was poor.

32A systematic review summarizing the existing evidence on esthetic oral health‐related quality of life of implant‐ and tooth‐supported fixed dental prostheses yielded no significant differences between the ratings for soft tissue‐level implants compared with those for bone‐level implants. The review encompassed 16 publications with a total of 19 relevant study cohorts, covering 816 implant‐supported reconstructions to be analyzed by patients. Despite the high heterogeneity among studies, the authors concluded that the esthetics of implant‐supported fixed dental prostheses are more highly rated by patients than by professionals.

33All‐ceramic and metal‐ceramic restorations were compared in a prospective study. A total of 59 patients with tooth agenesis were treated and followed up for 3 years. Finally, a total of 98 implant‐supported single unit crowns were evaluated. Materials used for crowns were either all‐ceramic or metal‐ceramic. Zirconia, titanium, and gold alloys were used for abutments, which retained these crowns. Patient‐reported and professionally reported esthetic outcomes were assessed with the oral health impact profile‐49 questionnaire and the Copenhagen index score, respectively. The professionals reported significantly superior color match of all‐ceramic over metal‐ceramic crowns. Patient reports for esthetic outcomes did not show a significant discrepancy between restoration materials after 3 years.

34It is important to understand that esthetic outcomes should be evaluated separately for partially and fully edentulous patients. It is clear that patients in need of a single unit crown in the frontal region of the maxilla may have higher expectations than fully edentulous patients in need of implant‐supported overdentures. Obviously, patient priorities will be driven by individual differences in their perceived need. In addition, the patient is confronted with proportionally higher costs for a single crown compared with those for an implant‐supported overdenture. It is, therefore, important to understand patient satisfaction scores in conjunction with cost‐effectiveness, which is analyzed in the following section.

35Introducing oral implants as a treatment for partially edentulous patients to improve their quality of oral health was usually accompanied by an increased cost compared with traditional removable prosthetic treatment., In relation to economic factors encountered with a specific treatment, and in comparison with the benefits of such treatments, cost‐utility analyses have been performed. Cost‐utility analysis is a specific model, in which costs are expressed in monitory units, and outcomes of the treatment are assessed as a combination of health improvements in terms of oral health‐related quality of life. A systematic review indicates the increasing interest of the profession in this topic. It was reported that 60% of the studies in the final analysis (n = 14) had been published during 2011‐2016. Among several different dental conditions analyzed (ie, oral cancer, dental prostheses, caries prevention, periodontitis), oral prosthetic rehabilitation was investigated in 26% of cases (six publications), highlighting its relevance in terms of cost‐related parameters. Costs related to implant‐supported dental prostheses have been a focus of discussion for many years. When conventional dentures were compared with fixed prostheses on five implants, a 17‐fold higher cost was found for the fixed overdentures. When fixed dentures on five implants were compared with two implant‐supported removable overdentures, the costs doubled for the fixed solution. A recent study conducted on 30 partially edentulous patients rehabilitated with conventional removable partial dentures and implant‐supported removable partial dentures included the oral health‐related quality of life aspect in the cost analysis. When a patient was willing to pay > €80 per oral health impact profile point gained, then the implant‐supported removable partial dentures were cost‐effective; however, it also depended on the chosen outcome measure and the financial marginal value. A randomized prospective study aimed to evaluate the cost‐efficacy of implant‐supported fixed prostheses and conventional dentures retained by a Dolder bar system in the edentulous mandible. Several parameters were considered, namely, treatment results, clinical working hours, laboratory working hours, and laboratory costs (including materials). It was concluded that no significant differences in costs were found between both groups. A comparison of the cost‐effectiveness of different fixed treatment modalities to rehabilitate posterior partial edentulous spaces with computer‐guided implant placement has recently been performed. However, whether or not computer‐guided implant placement will result in higher oral health‐related quality of life standards remains controversial, even although there were significant differences in favor of the nonguided implant placement group for the initial costs. Moreover the long term prosthetic complications and the total costs out‐weighed the differences. A long‐term retrospective study evaluated the performance of 2‐3 bone‐level implants supporting either three nonsplinted crowns, three splinted crowns, or a three‐unit implant‐supported bridge over two implants. Comparing the three‐unit implant‐supported bridge with one implant less with either the nonsplinted or splinted crowns yielded a reduction in initial costs of 16%. Furthermore, this reduction increased over the duration of the study because the complications were substantially higher in the nonsplinted crowns group.

36Despite the increasing levels of evidence in this field of dental research, adjunctive costs‐ related analyses should be encouraged, focusing particularly on the costs related to biologic and technical complications.

37Oral health‐related quality of life has become an important parameter for the assessment of treatment outcomes following implant therapy. However, there is no consensus on the definitions and standardization of this evaluation tool. The discrepancies in the terms, questionnaires, and scales presented in recent decades render a comparison of data challenging. Consequently, further studies with standardized questionnaires are necessary in the future. Nevertheless, the current evidence on function, esthetics, and cost‐effectiveness indicates that: There is evidence that implant‐supported reconstructions have substantially improved the retention and stability of conventional dentures and, hence, enable better chewing and speaking ability of the patient.The connection of implants to prostheses with either locators or balls indicated high oral health‐related quality of life.Patient expectation is not a good predictor of treatment outcome.There is no convincing evidence that oral health‐related quality of life is improved by implant therapy compared with conventional bridge work.In general, there is poor agreement between patients' perceptions and clinicians' objective assessments of esthetic outcomes.There are no significant differences found between the esthetic oral health‐related quality of life ratings for soft tissue‐level implants compared to those for bone‐level implants.Comparison of all‐ceramic and metal‐ceramic restorations showed no significant differences in patients' perceptions in terms of esthetic outcomes.Depending on the choice of outcome measure and financial marginal value, supporting a conventional removable partial denture with implants is cost‐effective when the patient is willing to pay more for achieving a higher level of oral health‐related quality of life.

38There is evidence that implant‐supported reconstructions have substantially improved the retention and stability of conventional dentures and, hence, enable better chewing and speaking ability of the patient.

39The connection of implants to prostheses with either locators or balls indicated high oral health‐related quality of life.

40Patient expectation is not a good predictor of treatment outcome.

41There is no convincing evidence that oral health‐related quality of life is improved by implant therapy compared with conventional bridge work.

42In general, there is poor agreement between patients' perceptions and clinicians' objective assessments of esthetic outcomes.

43There are no significant differences found between the esthetic oral health‐related quality of life ratings for soft tissue‐level implants compared to those for bone‐level implants.

44Comparison of all‐ceramic and metal‐ceramic restorations showed no significant differences in patients' perceptions in terms of esthetic outcomes.

45Depending on the choice of outcome measure and financial marginal value, supporting a conventional removable partial denture with implants is cost‐effective when the patient is willing to pay more for achieving a higher level of oral health‐related quality of life.

46The following clinical case illustrates how the replacement of the missing tooth 46 with an implant‐supported single unit crown increased the patient’s quality of life (Figures 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11). (Treatment: Dr. Ho‐Yan Duong, Department of Periodontology, University of Bern, Switzerland).

47A 58‐year‐old female, systemically healthy patient was referred for treatment of advanced periodontal disease. Following the initial clinical and radiographic examination, the following diagnoses were made: generalized periodontitis: stage III, grade Bbruxismtrauma from occlusionendo‐periodontal lesion with root damage

48generalized periodontitis: stage III, grade B

49bruxism

50trauma from occlusion

51endo‐periodontal lesion with root damage

52Tooth 46 had to be extracted before steps 1 and 2 of periodontal therapy because of a large endo‐perio lesion. A re‐evaluation was performed at 3 and at 6 months after step 2 of periodontal therapy (ie, full‐mouth subgingival scaling and root planing). Before implant placement, no probing depths exceeding 5 mm were recorded. Thereafter, the missing tooth 46 was replaced with an implant‐supported restoration by accommodating a soft tissue‐level implant (Straumann: TL, SP, ø 4.1 mm, SLActive, 8 mm, Roxolid) followed by transmucosal healing. The patient did not receive any provisional prosthesis during the healing period of 3 months. After 3 months, the implant was loaded with a full zirconia screw‐retained crown. Tooth 45 did not show any pathologic symptoms during the entire treatment. Periodontal chart of final examination is depicted in figure 12.

53After prosthetic restoration, the patient was asked to compete the oral health impact profile‐14 questionnaire (Table 4).

54According to Slade & Spencer, the responses are coded 0 = never, 1 = hardly ever, 2 = occasionally, 3 = fairly often, and 4 = very often. The coded responses can be subdivided into seven dimensions (functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability, and handicap). Within each dimension, coded responses were multiplied with specific weights. The result of the response was 0, showing the highest possible score for quality of life according to this questionnaire and this treatment modality.

55The following clinical case illustrates how the replacement of the missing tooth 46 with an implant‐supported single unit crown increased the patient's quality of life (Figures 13, 14, 15, 16, 17, 18, 19, 20). (Treatment: Dr. Ho‐Yan Duong, Department of Periodontology, University of Bern, Switzerland).

56A 41‐year‐old male, systemically healthy patient was referred for treatment of advanced periodontal disease. Following initial clinical and radiographic examination, the following diagnoses were made: generalized periodontitis: stage III, grade Bendo‐periodontal lesion without root damagecaries

57generalized periodontitis: stage III, grade B

58endo‐periodontal lesion without root damage

59caries

60Tooth 46 had to be extracted before steps 1 and 2 of periodontal therapy because of the extension of caries into the furcation. A re‐evaluation was performed at 3 months and at 6 months after step 2 of periodontal therapy (ie, full‐mouth subgingival scaling and root planing). Before implant placement, no probing depths exeeding 5 mm were recorded. Thereafter, the missing tooth 46 was replaced with an implant‐supported restoration by accommodating a soft tissue‐level implant (Straumann: TL, SP, ø 4.8 mm WN, SLActive, 8 mm, Roxolid) followed by transmucosal healing. The patient did not receive any provisional prosthesis during the healing period of 3 months. After 3 months, the implant was loaded with a full zirconia screw‐retained crown. After prosthetic restoration, the patient was asked to complete the oral health impact profile‐14 questionnaire (Table 5).

61According to Slade & Spencer, the result of the response was 0, showing the highest possible score for quality of life according to this questionnaire and this treatment modality (Table 5).