The multi-modal prosthetic treatment of mentally handicapped patients--necessity and challenge

The dental treatment of 573 mentally handicapped patients, over a period of twelve years from 1984 to 1996, is reported. The patients suffered from different varieties of mental retardation and/or schizophrenia, classified according to the International Statistical Classification of Disease N'. 10 of the World Health Organization. 189 patients were equipped with different types of removable prostheses which were followed to determine the survival time and the predictability of the prosthetic treatments. The findings showed greater risk factors related to long term hospitalised Schizophrenic patients and those with edentulous atrophic mandibles. 90% of the full-arch overdentures in the maxilla were in situ after 5 years in comparison with only 30% in the mandible. 81% of overdentures, retained telescopically by 3 teeth survived, while only 30% of overdentures anchored over a single tooth were still in place. These findings showed acceptable success rates of comprehensive restoration procedures for handicapped patients.     

Complications of orthodontic-orthognathic surgery treatment in mentally handicapped patients.

AIM: The aim of this study was to analyse possible intra- and postoperative complications and long-term results in combined orthodontic-orthognathic treatment of mentally handicapped patients compared with a control group of patients without handicap. PATIENTS AND METHODS: A group of 20 mentally handicapped patients (male = 7, female = 13) and of 102 non-handicapped patients (male = 36, female = 66) were evaluated retrospectively. The results of the two point-discrimination sensory test and the cephalometric findings of both groups were assessed. Complications during and after the operation, the results of nerve function tests and relapse rates were reported. The statistical analysis was carried out using binary logistical regression analysis with adjustment according to the diagnosis and the type of operation (p < 0.05) RESULTS: No significant differences could be found between the mentally handicapped and the non-handicapped patients. Only the nerve function test immediately postoperatively revealed differences between the two patient groups. The relapse rate in mentally handicapped patients was similar to non-handicapped patients. Forty-seven months after the operation, relapse (change in the ANB angle of more than 0.5 degrees ) was observed in four patients only (handicapped patients). CONCLUSION: Orthognathic surgical procedures in mentally handicapped patients can be carried out with a similarly high success rate as in mentally healthy patients.     

Long-term experience with telescopically retained overdentures (double crown technique)

To evaluate the long term results of telescopically retained overdentures, 92 patients with a total of 106 overdentures on 236 teeth were examined after two to eleven years. Thirty-three teeth were lost during the follow-up period. A higher tooth survival rate of the double-crowned teeth was found under mandibular overdentures (92%) than under maxillary overdentures (86%) after five years. The palladium-silver-alloy used seemed to be more suitable for telescopic crowns than the use of precious gold-copper-alloys because of tarnishing the latter alloys.     

Differences in dental health observed within a group of non-institutionalised mentally handicapped adults attending day centres.

A group of 350 mentally handicapped adults living in the community and attending three social services day centres were dentally examined in 1989. Although all those examined were collectively classified as a group of people with a mental handicap and therefore "a population group with special needs", great differences were observed in the dental health of the sub-groups attending each of the centres; it was evident that they did not constitute a uniform group of people. Those who were less mentally handicapped had better oral hygiene, less gingival inflammation, more fillings and fewer teeth extracted because of caries. Overall DMFT was similar at all centres but a greater proportion of the less handicapped group had active, untreated caries. Seventy-four per cent of the less mentally handicapped people attended the general dental services, and up to seventy per cent of those with a greater handicap were reported as attending the community dental service. Dental care for non-institutionalised mentally handicapped adults living in the community cannot be planned with the assumption that they are a homogeneous group of people.     

Survival and retreatment need of abutment teeth in patients with overdentures: a retrospective study

Abstract The retreatment need was assessed in 148 patients wearing 125 overdentures in the mandible and 56 in the maxilla. The total number of abutment teeth was 512. During the evaluation period 44 abutments were extracted. The endpoints of the survival analysis after ft yr were 89%. taking the loss of all abutments as the failure criterion for overdentures. During the clinical examination it was found that 31% of the abutments needed retreatment while the retrospective part showed a mean yearly restoration need of 17.5%. Caries was the most important reason for re-treatment. These data demonstrated that patients with overdentures should be regarded as high risk patients for retreatment of abutments. Therefore a stringent maintenance program, including regular recall appointments and the application of a preventive regimen, is desirable.     

Maxillary implant‐supported overdentures opposed by (partial) natural dentitions: a 5‐year prospective case series study

The aim of this study was to assess the 5‐year treatment outcome of maxillary implant‐retained overdentures opposed by natural antagonistic teeth. Fifty consecutive patients received maxillary overdentures supported by six dental implants. Implants were placed in the anterior region, if enough bone was present (n = 25 patients) Implant were placed in the posterior region if implant placement in the anterior region was not possible (n = 25 patients). Variables assessed included survival of implants, condition of hard and soft peri‐implant tissues and patients' satisfaction. The five‐year implant survival rate was 97·0% and 99·3%, and mean radiographic bone loss was 0·23 and 0·69 mm in the anterior and posterior group, respectively. Median scores for plaque, calculus, gingiva, bleeding and mean scores for pocket probing depth were low and stayed low. Patients' satisfaction after treatment was high in both groups. Within the limits of this 5‐year study, it is concluded that six dental implants (placed in the anterior or posterior region) connected with a bar and opposed to natural antagonistic teeth result in acceptable results for clinical parameters and good outcomes for marginal bone level changes and patient satisfaction.     

Dental care for the handicapped adolescent

A total of 932 physically, mentally and multiple handicapped children, including many adolescents, were examined at their special schools in a mobile dental unit, during a 4-year pilot period, and 744 were treated. Their dental needs were compared with those of 450 children at normal schools. Although a greater proportion of handicapped children were caries-free, more required extractions and periodontal treatment. In the group aged 12-16 years there were more decayed teeth, more missing teeth and fewer fillings than in the controls of the same age. Over 90 per cent of the 744 children were treated satisfactorily in the mobile clinic, cooperation being acceptable in 79 per cent. Only 2 per cent were totally uncooperative and required a general anaesthetic, even for an examination. In total, 8.5 per cent of the children received some treatment under general anaesthesia. Treatment should aim to create understanding by adolescent or parent of good dental health, to obtain oral health, to create the most pleasing appearance possible, to encourage acceptance of further treatment and, where possible, to involve adolescent patients by providing treatment along normal lines.     

Caries control in overdenture patients: 18-month evaluation on fluoride and chlorhexidine therapies

The aim of this study was to test the clinical effects of preventive regimens using fluoride and chlorhexidine on caries development in abutment teeth in patients with overdentures. 30 patients with immediate overdentures were distributed at random among three experimental groups. In these groups three different gels (placebo, fluoride, and chlorhexidine-fluoride) were tested by daily application. The patients were recalled at 6-month intervals for a period of 18 months. The life table survival ratios at patient level showed that in the chlorhexidine group caries development in the abutments was significantly reduced. In this group no caries developed. On comparison with the control group (placebo), no preventive effects of the gel were noticed for those in the fluoride group.     

Caries, oral hygiene and periodontal disease in handicapped adults

Caries, periodontal disease, oral hygiene and treatment needs were assessed in a group of handicapped adults. The study group comprised 199 individuals aged 17-64 yr, most of whom were mentally subnormal. The mean DMFT values ranged from 17.4 in the 17-24-yr-old age group to 26.9 in the 55-64-yr-old age group. Tooth loss increased rapidly with advancing age. In all age groups the F component was less than 20% and high numbers of untreated carious lesions were found. Of the group studied, 90% needed some conservative treatment. Oral hygiene was poor and a high prevalence of periodontal disease was found. Of the dentulous persons, 49% needed scaling and 34% complex periodontal treatment. The percentage of study group patients requiring dental treatment was very high, so that it can be concluded that dental care for the handicapped is insufficient. This situation must be improved and a suitable system for the delivery of preventive measures must be devised for this group of the population.     

Effectiveness of maxillary overdentures supported by implants: maintenance and prosthetic complications

PURPOSE: The aim of this study was to evaluate the prosthetic complications with implant-supported overdentures in the maxilla. MATERIALS AND METHODS: Forty-one patients (mean age 61 years) were consecutively admitted for treatment from 1991 to 1998. A total of 173 ITI implants were placed. Four to six implants either connected with a bar (34 overdentures) or with single anchors (seven overdentures) supported the denture, and only a few parties had fewer than four implants. The overdentures had a horseshoe design and were reinforced by a cast-metal framework. The mean observation time was 3.2 years. Oral hygiene and periimplant parameters were regularly assessed, and records were kept of prosthetic maintenance service. All prosthetic complications encountered were classified related to (1) implant components and anchorage devices, (2) mechanical and structural failures of dentures, or (3) denture-related adjustments. RESULTS: Three implants did not osseointegrate, and five implants were lost after loading. Thus, the overall survival rate of the implants was 95.5%. Altogether, 85 prosthetic complications were encountered. The most frequent finding was retightening of the bar screw and adjustments of the bar retainers. Repair of dentures was not frequent and was mostly related to broken teeth. No fracture of dentures was observed. Renewal of dentures occurred twice, once after loss of all implants in one patient. Thirty-nine overdentures had been continuously worn; thus, the overall denture stability was 95%. Mucosal irritation and need for occlusal adjustment were the most frequent findings in the first year. Over time, a decrease of complications was observed. CONCLUSION: Planned maxillary overdentures supported by implants are a successful treatment modality on a short-term basis.     

Maxillary Overdentures Supported by Anteriorly or Posteriorly Placed Implants Opposed by a Natural Dentition in the Mandible: A 1‐Year Prospective Case Series Study

Background: For maxillary overdenture therapy, treatment guidelines are missing. There is a need for longitudinal studies. Purpose: The purpose of this 1‐year prospective case series study was to assess the treatment outcome of maxillary overdentures supported by six dental implants opposed by natural antagonistic teeth in the mandible. Materials and Methods: Fifty patients were treated with a maxillary overdenture supported by six dental implants, either placed in the anterior region (n = 25 patients) or in the posterior region (n = 25 patients). Items of evaluation were the following: survival of implants, condition of hard and soft peri‐implant tissues, and patients' satisfaction. Results: One‐year implant survival rate was 98% in the anterior group and 99.3% in the posterior group. Mean radiographic bone loss in the anterior and posterior groups after 1 year of loading was 0.22 and 0.50 mm, respectively. Mean scores for plaque, calculus, gingiva, bleeding, and pocket probing depth were low, and patients' satisfaction was high, with no differences between the groups. Conclusion: Six dental implants placed in either the anterior region or the posterior region of the edentulous maxilla, connected with a bar, and opposed by antagonistic teeth in the mandible supply a proper base for the support of an overdenture.     

Implant-supported maxillary overdentures retained with milled bars: maxillary anterior versus maxillary posterior concept--a retrospective study

PURPOSE: The aim of the present retrospective investigation was to evaluate implant-supported maxillary overdentures using either anterior (group 1) or posterior (group 2) maxillary implant placement. MATERIAL AND METHODS: Maxillary overdentures were planned with support by either 4 implants placed in the maxillary anterior region (group 1) or 6 to 8 implants placed in augmented maxillary posterior regions (group 2, bilateral sinus augmentation) and anchored either on an anterior or on 2 bilaterally placed milled bars. Cumulative implant survival rate, peri-implant conditions (marginal bone loss, pocket depth, Plaque Index, Gingival Index, Bleeding Index, and Calculus Index) and the incidence and type of prosthodontic maintenance were assessed and compared for the 2 groups. In addition, the cumulative survival rate for implants placed in grafted regions was compared with that of implants placed in nongrafted regions. RESULTS: Thirty-four patients (16 for group 1 and 18 for group 2) with 179 implants were available for follow-up examination after a mean period of 42.1 +/- 20.1 months. Four initially placed implants failed to osseointegrate and were replaced, but no further losses were seen during the loading period, for a 5-year cumulative implant survival rate of 978%. No differences in implant survival rates were seen between either the group-1 (98.4%) and group-2 (97.4%) concepts or nongrafted (98.0%) and grafted (97.5%) implants. The peri-implant parameters showed a healthy soft tissue, good oral hygiene, and an acceptable degree of peri-implant marginal bone loss. The rigid fixation of all overdentures was associated with a low incidence of prosthodontic maintenance, without any significant differences between the 2 groups. CONCLUSIONS: In well-planned overdenture treatment programs, a high survival rate and excellent peri-implant conditions can be achieved for implants placed in the anterior or posterior maxilla. Rigid anchorage of maxillary overdentures either on an extended anterior milled bar or on 2 bilateral posterior milled bars provides for a low incidence of prosthodontic maintenance.     

Hibitane in oral disease in handicapped patients

Abstract All the problems connected with conservative dental treatment for handicapped patients and the hazards to dental health which many handicaps represent, indicate that preventive measures are of special importance for these patients. Conventional toothcleaning techniques may be difficult or impossible to carry out for a large number of handicapped persons. In these cases chemical plaque control may be the only alternative. Chlorhexidine gluconate has so far proved to be the chemical agent best suited for removal of dental plaque. Different modes of chlorhexidine application have been tried. Mouthrinse with a 0.1 % or 0.2 % aqueous solution of Chlorhexidine twice a day has proved to give a good plaque-inhibiting effect. Such mouthrinses are often the treatment of choice for short-term plaque control for a wide variety of patient groups. Chlorhexidine-containing toothpastes have been used in controlled clinical trials on handicapped children. This method of application may be indicated for long-term use. Chlorhexidine gel in individually made applicators may be the only possible toothcleaning method in seriously handicapped, uncooperative adult patients. Side effects of Chlorhexidine application such as discolouration of teeth and fillings and temporary disturbance of taste has so far limited the use of Chlorhexidine in preventive dentistry. These side effects are, however, often overshadowed by the fact that the use of Chlorhexidine may be the only possible solution to the handicapped patient's oral health problems.     

A new coping for overdentures. Part 2: Preliminary results of a clinical study

The aim of this study was to evaluate a new type of coping used for overdentures. Twenty-nine patients received 60 new chairside copings prepared by 3 operators. The copings, used to anchor removable prostheses, were followed up for between 6 months and 4 years with inspection, probing, and radiographic evaluation. Five teeth (8.3%) were extracted. A few clinical problems occurred, including decementation, periodontal pathology (loss of support and bleeding on probing), subgingival decay, and root fracture. No differences were noted in the incidence of complications among the 3 operators. The study demonstrated the clinical predictability of the new copings.     

Telescopic crowns as attachments for implant supported restorations: a case series

The use of dental implants to support mandibular or maxillary overdentures is a widely used treatment modality. Advantages are an increase in retention, an increase in chewing ability, and easy access for oral hygiene procedures. While telescopic and conical crowns have been used for decades to connect natural teeth to overdentures, not many cases have been reported in the literature of telescopic crowns placed on implants to support overdentures. This article describes 7 patients with overdentures supported by telescopic crowns who received 65 implants (ITI Straumann). The cases presented in this report have been in function for up to 4.5 years. During that time no adverse events were reported. The use of telescopic crowns as attachments for implant-supported overdentures may be a viable treatment option.     

A 5‐year prospective clinical study of Astra Tech dental implants supporting fixed bridges or overdentures in the edentulous mandible

In a 5‐year prospective clinical study, 1.55 endosseous implants were installed in the mandible anterior to the mental foramina in 33 edentulous patients (13 males and 20 females). Usually 6 implants were installed for fixed prostheses (FP). 13 patients with 77 implants, and 4 implants for overdentures (OD) with a Dolder bar, 20 patients with 78 implants. At the time of abutment connection 1 implant in 2 patients was found to be loose and removed. However, in both these patients overdentures were successfully placed on the remaining 3 implants. Narrow‐beam radiography was used for radiological evaluation. The mean (SD) total marginal bone loss in 5 years was 0.48 (0.38) mm (0.36 (0.22) mm in the FP group and 0.56 (0.45) mm in the OD group). Very few complications were reported during the 5 years, most of them being related to the superstructures. The overall cumulative implant survival rate was 98.7%(100% in the FP group and 97.4% in the OD group). The survival rate of the superstructures was 100%. The present study has demonstrated that Astra Tech implants offer reliable and predictable medium‐term support for fixed prostheses and overdentures in the edentulous mandible.     

A two-year longitudinal study of the periodontal health status of overdenture patients

Eleven patients who were treated with maxillary or mandibular overdentures or both were recalled at 6-month intervals and studied for a period of 2 years A periodontist evaluated the periodontal health status of the abutment teeth at initial placement of the overdenture and at all subsequent recalls using standardized periodontal indices. Statistical comparisons of the data from initial examination to the 2-year recall were made to assess the periodontal health status of roots supporting overdentures.Periodic, regular recall of patients treated with overdentures is one of the most important factors in the maintenance of the integrity of the root stumps and attachment apparatus, particularly since the roots supporting mandibular overdentures are at greater risk periodontally than those supporting maxillary overdentures. Measurements of pocket depth and width of attached gingivae seem to be the most definitive criteria to determine the status of the attachment apparatus in overdenture patients. With frequent recall, overdentures appear to be a successful method of treatment.     

Intravenous sedation with propofol in dental treatment. Experience in mentally handicapped patients

Simple dental procedures in mentally handicapped patients can be facilitated by the use of intravenous sedation. This article describes our experiences with eleven such patients undergoing a total of eighteen procedures in 1994-1995. Sedation was administered by a consultant anesthetist using propofol in 'Sterrenberg'--a home for the mentally handicapped in the Netherlands. The article describes the organization of the patients selection and pre- per- and post-sedation care using a management protocol. It is concluded that the technique is effective and safe for simple dental procedures such as examination, removal of tartar, radiography and the treatment of cavities, provided that patients selection and care are meticulous.     

A long-term study of implants supporting overdentures as a model for implant success

BACKGROUND: Implant-supported overdentures have been a common treatment for edentulous patients for the past 20 years, achieving good clinical results. The purpose of this study was to examine survival and success rates of implants supporting overdentures in the maxilla and mandible and to examine the influence of factors related to patients, implant procedure, implant data, and follow-up period on implant success. METHODS: During a 10-year period (1990 to 2000), 285 implants were placed in 62 patients to support 69 overdentures (seven patients had overdentures in both jaws). Patients ranged in age from 45 to 85 years (mean 64.5 years). The files of 61 patients, including 277 implants supporting 68 overdentures (14 maxillary and 54 mandibular), had measurable radiographic post-exposure follow-up (range 6.63 to 110.93 months, mean 37.93 months) for cervical bone loss (CBL) measurements. Bone loss was measured by radiographic examination in which the mean number of exposed threads in mesial and distal sides of the implant was considered. Implants were rehabilitated by overdentures with bar (N = 52) or ball (N = 16) attachments. RESULTS: Implant survival rate was 96.1% (11/285 did not survive) and total 10-year cumulative survival rate was 95.4% (maxilla, 83.5%, mandible, 99.5%). The success rate was 70.4% (maxilla, 41.9%; mandible, 80.8%) when using Albrektsson et al. success criteria. A logistic regression analysis showed that the maxilla (P <0.0001) and a short follow-up period (up to 5 years) (P = 0.017) were the most influencing factors enhancing CBL. CONCLUSIONS: 1) Survival of implants supporting overdentures was very high; 2) implants supporting overdentures in the maxilla had greater CBL than in the mandible; and 3) new criteria of implant success should be considered.