CHAPTER ONE

1. INTRODUCTION AND LITERATURE REVIEW
1.1 INTRODUCTION:
Throughout the history of dentistry, there is an open debate between the clinicians and their patients regarding the optimum treatment options used for replacing missing teeth. Many treatment options were considered including acrylic dentures, metal framework removable dentures, fixed partial dentures and implant supported prosthesis. (1-2)
Defects that are congenital or acquired caused by trauma and ablative tumor resection surgery, can result in severe esthetic deformities and many functional disorders, which may lead to some sort of psychological trauma. (3) The incapacitating nature of the defect makes the reconstruction of both maxilla and mandible challenging. (4)
Maxillofacial defects can be repaired with surgical techniques or prosthetic devices, depending on the site, size, age, etiology, severity, and patient preference. (5-6) Many surgical techniques have been developed to reconstruct oral and maxillofacial defects such as skin grafts, local skin transposition, mucosa and/or muscle flap,regional flaps, free vascularized flaps and bone grafting procedures. (7) Surgical reconstruction may be limited by the age and the medical condition of the patient,insufficient residual tissue, the regular need to monitor tumor recurrence, vascular compromise subsequent to radiation, the inadequacy of the donor sites,and lastly the patients preference and choice. In these situations, prosthetic rehabilitation becomes the preferred treatment. (8)
However, there is a huge improvement in the surgical management of oral and facial defects. It is evident that significant defects cannot be satisfactorily repaired by plastic surgery alone. The need for maxillofacial prosthetic devices for rehabilitation of patients with congenital or acquired defects to improve patient quality of life has intensified in the recent years (9), and the success of the prosthesis is directly related to the amount of bone and soft tissues remaining and prosthesis retention. (10-11) The retention of maxillofacial prostheses can be provided using adhesives, anatomic undercuts, clasps, or connection to eyeglasses,but many problems commonly encountered and reported with these methods of retention. (12-13) The use of implants for maxillofacial prostheses enhances both retention, stability, improving the patient’s confidence and sense of security.(14) It also reduces the need to involve adjacent teeth and eliminates the necessity for a conventional ?xed prosthesis supported by natural teeth. (15)
At this time of specialization and diversification, an integrative view of patient demands, history and desires is crucial. That is why the final prosthodontic result should be the main idea throughout the treatment program. It was found that the quality of life of patients with maxillofacial defects is to some extent compromised even when a surgical reconstruction or prosthesis is provided. (6, 16-18) Ideally, the entire concept should be focused on aesthetics, phonetics, and mastication to be achieved, if possible, by fast and minimally invasive procedures as patients usually ask for fixed teeth which function immediately. (19)
Several implant systems are at present available for ”routine” treatment purposes. However, in many instances, when implant treatment performed according to the ”routine” protocols, usually the treated patients used various types of transitional removable prostheses during parts of the clinical handling. Also, an appropriate volume and quality of bone should be provided for the placement of osseointegrated implants. (10)
The basal implant is one of the implant systems that can be used in maxillofacial patients. These implants are placed transosseously and anchored into the basal, cortical bone. (20) The primary amount of crestal and spongeous bone is unimportant for this implant pattern to become fixed since the primary stability is gained through cortical engagement of the base-plate. (21) This qualifies this system to be used in patients with maxillofacial defects including patients with marginal mandibulectomy. However, there is a gap of knowledge when considering the outcome of using this system as a regular treatment modality in patients with marginal mandibulectomy in the Sudan.
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1.2 LITERATURE REVIEW: –
Removable complete and/or partial dentures were the traditional methods that commonly used for replacing missing teeth. Their main function is to improve the ability of patients to eat, speak and to have a normal appearance. (22)
Wearing a removable denture has many consequences including accelerated bone resorption in the edentulous region. Patients wearing removable partial dentures exhibit greater mobility on the abutments; greater plaque retention; increased bleeding on probing; and more incidences of caries. Also, patients are not always satisfied with the function of removable dentures, and the number and condition of the remaining teeth might prevent the use of fixed prosthesis. (23)
A Quilino et al. (23) reported a 44% abutment tooth loss within ten years in patients wearing removable partial dentures. Therefore the need for an alternative therapy that improve oral conditions and maintain the remaining bone is often warranted.
Osseointegrated dental implants have offered an alternative treatment option since the 1970s. They are surgically inserted into the bones of the jaws to support a dental prosthesis. (22) Dental implants have been one of the most significant scientific break throughs in dentistry over the past 30 years,and many implant systems are now available.
The Glossary of Prosthodontic Terms defines an implant as “a prosthetic device or alloplastic material implanted into the oral tissues beneath the mucosal or/and periosteal layer, and/or within the bone to provide retention and support for a fixed or removable prosthesis.” (24)
Many implant protocols were developed according to the surgical procedure and the occlusal loading of the prosthesis. Regarding the implant surgical protocol, it can be either one or two stage implant surgical protocol. (25)
Branemark has established the two-stage surgical protocol, to accomplish osseointegration. It consists of several fundamentals, including: countersinking the implant below the crestal bone; then obtaining and maintaining a soft-tissue for covering the implant for about 3 to 6 months, and finally providing and maintaining a minimally loaded implant environment for 3 to 6 months. The main reasons cited for the submerged surgical approach of implant placement were to reduce and minimize the risk of bacterial infection, also to prevent apical migration of the oral epithelium along the body of the implant, and to decrease the risk of early implant loading during bone remodeling. (25)
After this procedure, a second-stage surgery is done to uncover these implants and place a prosthetic abutment. A long-term, clinical rigid fixation has been reported after this protocol in both completely and partially edentulous patients. (25-26)
When implant treatment was performed according to the”routine” protocols,transitional removable prostheses were used. (27) This may be a psychologically traumatic experience for many individuals, as stated by Schnitman. (28) However,the treated patients may not be able to handle with the removable prostheses during healing phases, due to poor retention of the provisionals prosthesis and most of the patients usually ask for an immediate treatment solution due to socioeconomic reasons. Consequently, there has been a need or at least a wish for the development of an implant protocol that eliminates or just decreases the healing periods before loading the inserted implants. (29)
During the last 15 years, several studies (25, 30-32) have reported that root-from implants may osseointegrate, even though they extend through the soft tissues and above the bone during early bone remodeling. This surgical approach has been called a non-submerged or one-stage implant procedure because it eliminates the second-stage implant uncovering surgery. As a result, this technique eliminates the discomfort and inconvenience of the time required by the surgery and suture removal. In addition, the soft tissue will become matured before fabricating a final prosthesis. (25)
Another important protocol that should be considered in implant treatment is the loading protocol. Loading protocols were originally developed by Branemark and associates. He stated that the implant prosthesis can be either delayed loaded or immediately loaded. (25-26)
Misch (25) proposed the following definitions: Immediate occlusal loading is to load the implant within two weeks after implant insertion, early occlusal loading, is to apply an occlusal load to an implant between two weeks and three months after implant placement and delayed occlusal loading is to load an implant restoration more than three months after implant insertion. The delayed occlusal loading protocol can be either 1- or 2-stage surgical approach. The immediate loading restoration can be either; non-functional immediate loading restoration or functional immediate loading restoration. The Non-functional immediate restoration is described as an implant prosthesis in an edentulous patient delivered within two weeks of implant insertion with no direct occlusal load. (25)
Recently, Wang et al. (11) proposed the following definition of immediate implant loading, based upon the International Congress of Oral Implantologists (ICOI) meeting in May 2006 at Naples (Italy):Immediate implant loading is defined as an implant-based surgical technique in which the “implant supported restoration is placed into occlusal loading within at least 48 hours after implant placement.”This should not be confused with the concept of “Immediate Esthetics,” or “Non-functional loading,” because the provisional or final restoration in the last two concepts used to be placed in the absence of occlusal contacts. So, immediate loading of dental implants not only implies the use of a non-submerged, one-stage surgery technique, but also the loading of the recently inserted fixtures with a prosthetic restoration, either provisional or definitive, that allows adequate occlusal function.
The delayed occlusal loading protocol has been evaluated for more than 30 years by some clinical settings and situations. (26, 30, 33) It was found that in some patient conditions, the delayed healing process could cause psychologic, social, speech, and/or function problems. Many treatment options considering the initial hard and soft tissue healing is available today.Immediate restoration of a patient after implant surgery is considered one of these alternatives.(33)
High success rates from immediately loaded implants in humans were ?rst documented in the middle 1980s when the 1-stage implant protocol gained popularity. (33) Babbush et al.(34) reported a success rate of 88% when 1739 TPS implants were immediately loaded. Subsequently, many authors considered the possibility of loading implants immediately. (35-49)
Over the last ten years, the usage of immediate loading has expanded and slowly gained acceptance among the scientific researchers as well as clinicians. Under the indicated conditions and with a careful selection of the case and proper management of occlusion and prosthesis design, and thanks to the improvement of implant materials, surface coating, and thread designs, immediate implant loading can now be regarded as a clinical procedure as reliable as those reported in traditional delayed techniques. (49-50)
1.2.1 Advantages of immediate loading: –
Some of the advantages with immediate protocols are that; it shortens the treatment time, minimizes surgical trauma and cost less.
Lekholm (27) stated that immediate implant restoration with functional loading provides better patient comfort, allows quick masticatory function and esthetics. In addition, it also eliminates the discomfort and complications encountered with the second surgery approach for placement of transepithelial abutments.This result in early soft tissue healing and so early stabilization of the peri-implant mucosa to ensure higher implant survival.
Misch (33) stated that the immediate load concept includes all the advantages of the one -stage surgical approach. In addition, the splinted implants could decrease the risk of overload to each implant because of the increased surface area and improvement of the biomechanical distribution of the masticatory force. The patient does not need to wear a removable restoration during initial bone healing, which greatly increases patient’s comfort, function, speech, and stability and enhances patient’s psychology. (25, 28, 39, 43, 51-52)
1.2.2. Contraindication of immediate loading:
A benefit/risk ratio must be considered and carefully assessed for each patient’s condition to determine whether immediate occlusal loading is an excellent and a wise alternative. The greater the benefit and/or the lower the risk, the more likely immediate loading is to be considered.For example the compromised patients who are unable to undergo implant surgery due to impaired local or systemic medical conditions, such as; Diabetes mellitus, osteoporosis, blood dyscrasias, acquired immunodeficiency syndrome, morbid obesity, alcoholism, and smoking habits are some of the medical conditions that may determine or interfere with the outcomes of any implant-based treatment, regardless of the loading protocol followed.Clinicians should consider the drawbacks and risks associated with these groups of patients and compare it with the benefits prior to the planning of immediate loading. It has been advocated that the application of immediate loading techniques may be of special help in these medically compromised patients since this technique requires no further interventions by the elimination of the second surgery, which can significantly reduce the risk of morbidity that may occur in subsequent surgeries. (27, 53)
However, some consider that immediate implant loading is contraindicated in case of the medically compromised patients, drug and alcohol addiction and in patients in whom bone grafting protocols have been performed. There is a relative contraindication where there is vitamin D-dependent rickets, osteoporosis, Sjogren’s syndrome and if the patient is a smoker. (27-28, 54)
Potential risks for immediate implant loading seem to be present in connection with soft bone jaw sites, patients with bruxism, patients with ongoing pathology (including infections) within the jaws, irradiation of the surgical region and lack of patient compliance. (27)
1.2.3. Factors that influence the outcomes of immediate loading:
According to the review conducted by Gapski in 2003 (49), factors that affect the outcomes of immediate implant loading can be divided into four categories:
1) Surgery-related factors, involving the primary implant stability and a non-traumatic surgical technique;
2) Host-related factors, usually related to bone quantity and quality (density) and proper bone healing environment.
3) Implant-related factors, associated with the influence of macro- (thread) and micro- (surface coating) structure of the implant.
4) Occlusion-related factors, focusing on the importance of the occlusal forces and prosthetic design.
Oral hygiene/patient compliance may also need to be added to the section of host-related factors, as it undoubtedly is a determining factor for the long-term success of any implant treatment. (49, 55)
El Attar et al. (54) stated that the factors that may influence the success of immediate loading include five factors: patient selection; type of bone quality; the required implant length, the implant design and surface characteristics; the operator surgical skill; and finally a traumatic surgical technique.
1.2.3.1 Surgery-Related Factors in immediate loading:
? Surgical Technique:
Gentle surgical implant placement is a key element for implant success regardless of the applied treatment protocol. (49)
Alveolar and residual alveolar bone both have a cortical and trabecular component that may be modified by modeling or remodeling. Remodeling, or bone turnover, permits the mechanism of bone repair after trauma or allows the bone to respond to its local mechanical environment. Most often the bone is lamellar but during the repair process may become woven bone so that it may react more rapidly to the surgical trauma. Lamellar bone and woven bone are the primary bone tissue types found around a dental implant. Lamellar bone is organized, highly mineralized, it is the strongest bone type, with the highest modulus of elasticity, so it is called load-bearing bone. In contrast, woven bone is unorganized, less mineralized, is of lower strength, and is more flexible (lower modulus of elasticity). Woven bone form at a rate up to 60 microns per day, whereas lamellar bone forms at a slower rate of about 10 microns per day. (33, 56)
The two-stage surgical approach to implant dentistry permits 3 to 6 months’ separation between the surgical repair of the implant’s preparation site and the early loading response. Both implant osteotomy and implant insertion cause a regional accelerated phenomenon of bone repair around the implant interface. As a consequence of this, the organized, highly mineralized lamellar bone in the preparation site becomes unorganized, less mineralized woven bone (repair bone) next to the implant. At four months, the bone is still only 60% mineralized, organized lamellar bone.(57) However, this has proven to be sufficient for implant loading in most bone types and clinical situations. Therefore, a rationale for immediate loading is to reduce the risk of fibrous tissue formation (which results in clinicalfailure) and to promote lamellar bone maturation to sustain a continued occlusal load. The immediate implant loading challenges the conventional implant protocol that is characterized by a healing time of 3 to 6 months without loading. The risks of this procedure used is often during the first week after the implant insertion surgery. In reality,the bone in the macroscopic thread design is stronger on the day of implant insertion compared with the three months later, since there is more mature lamellar bone in the threads of the implant. (33) However, the cellular connection at the implant surface does not yet exist. On the day of surgery, there is residual cortical and trabecular bone all around the implant. So, when the implant is inserted, it has some contact with this prepared bone. Early cellular repair is triggered by the surgical trauma and begins to form an increased vascularization and repair process to the injured bone. Woven bone start to form by appositional growth as early as the second week after insertion. The implant-bone interface is weakest and usually at highest risk of overload approximately 3 to 5 weeks after implant insertion, since the implant-bone interface is least mineralized and unorganized during this time frame. A clinical report by Buchs et al. (56) ,found that immediate loaded-implant failure occurred primarily between 3 to 5 weeks postoperative from mobility without infection. (25, 33, 56-60)
Roberts (25, 57) showed how a zone of a non-vital bone of around 1 mm is formed after surgical trauma. This area was observed to be progressively remodeled and substituted after six months by a vital, functional bone, with the peaks of activity within the very early stages after implant placement. Interestingly, some authors have proposed that immediate loading can be useful to stimulate the early formation of lamellar bone around the implant body. This is in line with the concept of the regional acceleratory phenomenon (RAP) described by Frost. (25, 57, 61) Hence, it can be speculated that this RAP, along with the stimulation of the peri-implant bone via the immediate loading, might lead to an enhanced bone turnover around the implant, which in turn may result in a more organized lamellar bone supporting implant. (25, 57, 61) Excessive surgical trauma and thermal injury may lead to osteonecrosis and result in ?brous encapsulation of the implant. (49)
The heat that is generated during drilling without adequate cooling is associated with bone damage. It has been shown that a temperature over 47ºC for 1 min causes heat necrosis in the bone. Without irrigation, drill temperatures above 100ºC can be reached within seconds, and a temperatures above 47ºC are measured several millimeters away from the implant osteotomy. (49, 58-60)
Sharawy et al. (60) reported that the amount of heat generated in the bone next to the implant drill was dependent on the design and revolution of the drill. The temperature next to the drill found to be ranged from 38°C to more than 41°C from a 37°C baseline and required 34 to 58 seconds to return to baseline.
Avila et al. (62) reported that aggressive, inadequately irrigated drilling may cause a bone interface not suitable for the placement of implant fixation, especially those planned to be loaded immediately. This trauma can be minimized by using proper irrigation, sharp drill, and controlled surgical technique consisting of progressive vertical preparation of the receptor area.
In addition, it is critical for the success of endosseous root form implant that adequate load should be placed on the drill during the preparation of osteotomies. It has been demonstrated that independently increasing either the speed or the load caused an increase in temperature in bone. Interestingly, increasing both the load and the speed together permitted more efficient cutting with no signi?cant increase in temperature. (49, 63)
Other factors related to the amount of heat generated include the amount of bone prepared, drill design, (47, 58-59) and variation in cortical bone thickness. (64) Implant surgery generates microfractures in the surrounding bone, especially when press-?tting is intended. These fractures usually heal according to the following cascade: angiogenesis, osteoprogenitor cell migration, woven bone scaffold formation, deposition of parallel ?bered or lamellar bone, and secondary bone remodeling. (49, 64)
Cochran et al. (65), studied how the bone respond to implant insertion.They stated that after implant insertion the bone comes into direct contact to the implant surface. This results in immediate osseointegration of the implant that is recognized as a direct bone-to-implant contact when analyzed under the light microscope. Firstly, the bone at the osteotomy site is cut to a dimension equal to the implant drill resulting in cleaved edges. When an implant is placed into the preparation, especially if the implant has a slightly larger diameter than the implant drill, the implant is press-fitted along the cut bone edges and the implant contacts the bone, i.e. well osseointegrated. These areas of bone contact with the implant surface are referred to as primary bone contact. (49)
Kopp S. (19) considered that basal implants undergo a dual type of integration: the areas which were in direct contact with the native bone may undergo primary integration through bony remodeling. In addition, spaces left after insertion will be filled with blood which is transformed into woven bone and undergoes remodeling later. The fact that the amount of vertical bone needed for placement of basal implants is only 2–3 makes their use advisable in cases of severe bone loss. (19)

Primary Stability: –
Primary stability is the most important factor of immediate implant loading. It must be obtained at the time of the implant insertion before any load is applied. Primary stability involves securing the implant within host bone with sufficient rigidity to preclude any significant micromotion. (66)
The degree of primary stability depends up on the bone type, implant design, patient’s characteristics, and the surgical technique. (67)
Inorder to achieve osseointegration functional loading should be placed on an immobile implant. Consequently, if the implant is placed in a soft spongy bone with poor initial stability, it often results in connective tissue encapsulation, similar to the pseudo-arthrosis observed in an unstabilized fracture site. (49, 68)
Cochran (69) suggested that the crucial factor for successful osseointegration was the stability of the implant during the healing phase “such that any motion at the bone-to-implant interface should be below a certain threshold”. Other studies (67-68) also suggested that for osseointegration to occur, the mobility of the implant must be maintained below a certain critical amount. This indicates that the timing of the implant loading (immediate loading or not) is not as important as the ability to reduce the motion during the healing process. (67-68) Micro movements of more than 100 microns are suf?cient to jeopardize healing with direct Bone-implant contact (BIC). (49, 68) Szmukler-Moncler et al reported the same observation.(68) They considered that micro motions at the bone–implant interface beyond 150 microns not result in osseointegration instead ?brous integration was persent. (49)
Insertion Torque: –
Control of an adequate insertion torque has been suggested as a suitable strategy to minimize the implant failure associated with a lack of primary stability of immediately loaded implants. (62, 70) The implant should be non- mobile upon insertion, but excess strain within the bone from additional torque and space filling may also increase the risk of microdamage at the interface. (27, 45, 71)
Some reports (25, 27, 33, 49, 72) mentioned that if an initial stability rate of 30–40 Ncm is achieved, the implants can be immediately loaded. while other reports in immediate loading has shown an increase in the required insertion torque to 45 to 60 Ncm. (27, 45)
A study by Avila (62) evaluated immediate occlusal loading in edentulous mandibles using insertion torque to assess implant primary stability. In this study, out-comes of 151 implants inserted in 27 patients and that were immediately loaded for occlusal function with splinted, fixed implant prostheses (15 cement-retained, 12 screw-retained) on the day of implant placement, were assessed. Primary implant stability was at least 30 Ncm (insertion torque). The implants were evaluated for primary clinical stability and radiographic bone apposition to implants. After 18 months, results showed cumulative survival rates of 98.0% and 100% for implants and prostheses, respectively. (62)
Ottoni (73) carried a similar study in single-tooth immediately loaded implants and reported conclusions similar to those described by Dragoo and Lazzara.(62,70) Basically, to achieve osseointegration, an insertion torque above 32 Ncm was necessary.
Furthermore, a study by Neugebauer (63) showed that an insertion torque > 35 Ncm resulted in an increased bone-implant contact (BIC) than the implants with insertion torque 4 mm (less than1/2 of implant body).
4) Probing depth >7 mm.
5) May have exudates history.
IV. Failure (clinical or absolute failure). Any of following:
1) Pain on function.
2) Mobility.
3) Radiographic bone loss >1/2 length of the implant.
4) Uncontrolled exudates.
5) No longer in the mouth.
Goodacre et al. (165) performed a Medline and an extensive hand search to identify both implant and prosthesis complications usually associated with endosseous implants. They found that the complications were divided into the following six categories: surgical complications, implant loss, bone loss, peri-implant soft tissue, mechanical, and esthetic/phonetic complications.The mechanical complications included many factors such as; veneer fracture of ?xed partial prosthesis , opposing prosthesis fracture, metal framework fractures and implant fractures. (165)
Studies on immediately loaded implant-supported prostheses in completely edentulous patients have been reported, showing high success rates comparable to conventionally loaded implants. (166-169) These studies emphasized that careful patient selection and treatment planning are still as important as, or even more important than, the treatment itself. (166-170)
The main goal of dentistry is not only to eliminate oral disease, but also to improve the patient oral health quality of life and to increase the patient satisfaction. This can be achieved by eliminating oral pain, excision of oral tumor, maintaining good oral hygiene, replacing missing teeth, restoring both soft and hard tissue defects and to ensure adequate chewing function, phonetics, as well as aesthetics ie. to retain the patient into state of health
The WHO’s defined health as “a complete state of physical, mental, and social well-being and not just the absence of disease” (171) So for everyone to be healthy, besides being physically and mentally well they should have adequate social interaction.
In 1995 the WHO considered the Quality of life (QOL) as a valid parameter in patient assessment in nearly every area of physical and mental health care, including oral health. (171)Cohen and Jago (172) first encouraged the development of socio-dental indicators, to measure the Oral Health Related Quality of Life (OHRQoL). Researchers such as Slade and Spencer (173) , Broder et al. (174) and McGrath and Bedi (175) developed many methods to measure the oral health quality of life. Gift and Atchison (176) studied the relation between the common clinical variables like diagnosis, clinical examination’s data, and self-reported health experience.(176) United States Department of Health and Human services DHHS (177) considered that the subjective evaluation of OHRQoL could reflect the comfort of the patients when eating, sleeping and engaging their self- esteem, social interaction;and their satisfaction with their oral health. Locker et al. (178) used a different technique by comparing the quality of life in patients with two different oral conditions. Atchison et al. (179) evaluated the oral health quality of life using a different method including both subjective and objective clinical evaluations indeces. (179)
Subjective questionnaires were commonly used to evaluate both patient satisfaction and quality of life. (180) Some of these questionnaires evaluated different dimensions using broad non-specific questions that affect the quality of life, and some focused on particular questions concerning specific parameters that usually affect oral health. (181) The main problem of non- specific broad questions was the high number of false-positive patients responses. To avoid this, these questionnaires should always contain more specific items. (180) Overall satisfaction, comfort, appearance, mastication, and speech were considered as the most common parameters used to assess quality of life and oral health in previous studies. (180-181)
Awad et al. (182-183) considered that the most common questions used in the quality of life measurements are related to general satisfaction, as well as to more specific items like chewing, speech, comfort and esthetics as quality of life parameters. Similarily, Strassburger et al. (184-185) stated that most questions in the Oral Health Impact Profile that measure the patient satisfaction related to “chewing function” (86%), esthetics (77%), speech (68%), and general satisfaction (67%). However, Yi (186) used questionnaires classified into pain-related, service-related, and complication-related factors to estimate the overall satisfaction level of dental implant patients.
Teeth loss is usually associated with age. Despite the recent advances in preventive dentistry, it is likely that large numbers of older adults will continue to lose their natural teeth. (187) Tooth loss is usually associated with periodontal disease and dental caries. (188) However, other causes may be present including trauma, tumor and orthodontic treatment. Studies showed that periodontal disease is more prevalent amongst older people, while caries is associated with the younger age groups. (188) Tooth loss have esthetic, functional, psychological and social impacts. The decrease in functions such as speech and mastication are observed especially in the elderly. (189-190) Similarly, nutritional choices can be affected by tooth loss, and as the masticatory efficiency of the patients decreases, it can affect both their oral and systemic health, reducing their self-esteem, and affect their psychological status. (191-192) Moreover, it can affect their health and quality of life. (193)
Gerritsen et al. (194) reviewed the literature analyzing the effect of missing teeth on oral health-related quality of life.They provided strong evidence that tooth loss was associated with impairment of oral health -related quality of life and it was related to the location and distribution of tooth loss.
Brotoluzzi et al.(195) concluded that the chewing disability produces a significant negative impact on oral health-related QoL and both, poor QoL and chewing disability are related to the decrease in the number of natural teeth.
Different treatment modalities are available for replacing missing teeth including;removable dentures, fixed dentures, and dental implants. Each modality has its advantages, disadvantages, and indications.
Jenei et al. (196) assessed the oral health quality of life in patients requiring prosthetic rehabilitation and determined the rate of improvement after1 month and 6–12 after therapy. They found that the restoration of oral health was associated with an improvement in patients’ OHRQoL independent to the type of prosthesis used.
The choice between the several treatment options for replacing missing teeth is influenced by clinical factors,dentist and patient factors. Previously, conventional dentures have been the first treatment option when considering rehabilitation of completely edentulous patients. (197) Complete dentures usually improve the patient appearance,speech, improve their occlusion support and food mastication. Additionally, these dentures should be comfortable to the patients and increase the patients’ satisfaction and improve the patients’ quality of life. (198-200) Previous studies showed that the majority of completely edentulous patients are satisfied with their complete dentures. However, some patients remained dissatisfied after denture insertion despite the perfection encountered during all the clinical steps of denture construction, and so the authors considered that denture satisfaction was related to patients’satisfaction with quality of life in general. (198, 200)
Shah et al (201) conducted a study and found that all the patients were satisfied with their maxillary denture. A higher rate of dissatisfaction was associated with the mandibular denture (36%) compared to the maxillary denture (10%).
Many factors can affect patient satisfaction with complete dentures. (202)These factors include the general health, age, gender, personality traits, experiences with previous dentures and patient expectation regarding the new treatment. Some researchers found that psychological factors may play a major role in patients who experience difficulty in adapting to new dentures. Furthermore, the majority of studies associated patient’s expectation to patients’ satisfaction with the new treatment. (203)
Zou and Zhan (197) evaluated the degree of patients’ expectations and their level of satisfaction, before and after using complete dentures. They investigated phonetics, chewing, comfort and aesthetics in forty totally edentulous patients.They found that the patient’s expectations about their complete dentures (how much they would improve their phonation, chewing, comfort and aesthetic) at the beginning of the treatment were usually higher than their satisfaction after denture wearing.
Nowadays, implant treatment is considered the gold standard treatment for replacing missing teeth. Many implant systems have been developed and spread in the dental marketing.
Heydecke et al. (204) compared satisfaction of edentulous patients who were treated either with complete denture or implant overdentures. They found that complete dentures failed to meet patients’ pretreatment expectations of satisfaction; on the other hand, implant overdentures, largely met patients’ expectations.
Grey et al. (205) made an interview study to discover patients’ motivations and expectations of dental implants. The participants expected implants to restore and retain their oral- related quality of life to ‘normal.’ However, each definition of normality differed; some were focused on appearance, while others were more concerned with their function. Several patients believed that dental implants are just like their natural teeth.
Many studies evaluated patients’ satisfaction of dental implant supported prosthesis, either fixed or removable, and compared it to conventional removable and fixed prosthesis. (201, 203-207)
In a prospective randomized controlled trial,Raghoebar et al. (206) compared the outcome of conventionally made dentures and implant-supported dentures at 1, 5 and ten years. Unsurprisingly they reported that the implant-supported dentures at all time periods produced fewer complaints than the conventional dentures.
According to a study conducted by Pjetursson et al. (208), who evaluated patients’ satisfaction following implant therapy after 10 years, more than 90% of the patients were completely satisfied with implant therapy.
Gurgel et al. (209) conducted an observational study to assess the degree of patient satisfaction toward implant-supported prostheses. They considered chewing, esthetics, speaking, comfort and overall satisfaction in 147 patients treated with implants and prostheses. They discovered that more than 91% in of patients were satisfied despite their gender, age, the number of implants or type of prosthesis.
Kumar et al. (210) assessed the difference in the quality of life (QoL) in patients following prosthetic rehabilitation using two or four Implant-supported overdentures after segmental mandibulectomy defect reconstruction with fibula free flap. The outcomes of treatment in 52 patients were evaluated after six months and one year following the rehabilitation. They found that implant-supported removable overdentures improved QoL outcomes in all the patients with no significant difference in patients with two and patients with four-implant supported removable prostheses.
All of these studies considered the use of conventional implant systems. However, there is a gap of knowledge regarding the treatment outcome, patient satisfaction and quality of life with basal implant supported prostheses.

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