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Original Article
A multicentric study to evaluate the treatment
outcome and complications after oral rehabilitation
with implant-supported hybrid prostheses
Anup Gopi a,*, A. Edwin b
a
DO & Classified Specialist (Prosthodontics), Army Dental Center (R&R), New Delhi, India
b
DO & Graded Specialist (Prosthodontics), AFDC, New Delhi, India
article info abstract
Article history: Background: As a newer modality of rehabilitation of completely edentulous patients, there
Received 30 January 2021 is no conclusive evidence on which of the variants of hybrid prosthesis, namely acrylic
Accepted 15 June 2021 teeth on a metal substructure or porcelain fused to metal teeth over on a metal sub-
Available online xxx structure, is better in terms of treatment outcome, reduced mechanical complications, and
better patient compliance.
Keywords: Methods: Sixteen completely edentulous patients, both male and female, were selected
Hybrid prosthesis from the OPD of the study centers during the study period. Group A: Eight patients reha-
Fixed prosthesis bilitated by maxillary and mandibular hybrid prosthesis using a substructure of metal
Oral Health Impact Profile covered by acrylic teeth, which was screwed on the implants. Group B: Eight patients
Implant complications rehabilitated by maxillary and mandibular hybrid prosthesis using a substructure of metal
covered by porcelain fused to metal teeth, which was screwed on implants. The patients
were recalled at 3 months, 6 months, and 1 year following rehabilitation, and necessary
clinical and radiological observations were made to evaluate the overall health and com-
plications. Oral healtherelated quality of life was measured using the Oral Health Impact
Profile (OHIP)-EDENT questionnaire before treatment and after rehabilitation. The same
methodology, clinical procedures, and evaluation criteria were followed in all the study
centers. The data obtained were then compiled and analyzed.
Results: None of the patients in group A or B showed any signs of need to remake. There
was no statistically significant difference in proportions of cases showing signs of loos-
ening of components, soft tissue overgrowth, breakage of acrylic, chipping of porcelain,
and wear of teeth in both the groups. The amount of screw loosening, wear of prosthetic
superstructure, and bone loss around implants were less (even though not statistically
significant) in group A. Both the groups showed satisfactory esthetics. OHIP- EDENT eval-
uation gave completely satisfactory report after rehabilitation in both groups.
Conclusion: Both the types of complete rehabilitation, hybrid prosthesis of acrylic teeth on a
metal substructure and hybrid prosthesis of porcelain fused to metal teeth on a metal
substructure were successful and comparably reliable.
* Corresponding author.
E-mail address: [email protected] (A. Gopi).
https://doi.org/10.1016/j.mjafi.2021.06.016
0377-1237/© 2021 Director General, Armed Forces Medical Services. Published by Elsevier, a division of RELX India Pvt. Ltd. All rights
reserved.
Please cite this article as: Gopi A, Edwin A, A multicentric study to evaluate the treatment outcome and complications after oral
rehabilitation with implant-supported hybrid prostheses, Medical Journal Armed Forces India, https://doi.org/10.1016/
j.mjafi.2021.06.016
2 medical journal armed forces india xxx (xxxx) xxx
© 2021 Director General, Armed Forces Medical Services. Published by Elsevier, a division of
RELX India Pvt. Ltd. All rights reserved.
e. Adequate interocclusal space
Introduction
The prevalence of tooth loss has declined considerably over Exclusion criteria
the last decade; however, edentulism remains a major disease
worldwide, especially among older adults. The World Health a. Systemic disease that would interfere with dental implant
Organization in 2016 estimated the prevalence of edentulism placement
among 65e74-year-olds in India at 19%. It is, hence, impera- b. Inflammatory and autoimmune diseases of the oral cavity
tive that our dependents and veterans get the best and the c. Presence of psychiatric disorders
latest modality of rehabilitation. d. Patients who have undergone bone or ridge augmentation
Even in this era of dental implants, the most common e. Chronic smokers
modality of rehabilitation following complete edentulism is to f. Patient under radiation therapy, chemotherapy, immuno-
give the patient a conventional complete denture or an suppressive drugs, and corticosteroids
implant-supported overdenture. However, the patient's desire
to have “fixed teeth” still remains unachievable. A hybrid Each participant was informed of the study protocol, the
prosthesis is one which is composed by a substructure of procedure, and the time duration, and a written consent was
noble metal that it is covered by acrylic teeth or a metal sub- obtained.
structure covered by porcelain fused to metal teeth and that is Firstly, a thorough case history was recorded. The treat-
screwed on diverse implants. It is a fixed prosthesis for the ment plan, time duration, and the probable complications
patient, which can be removed by the professional. There is no were explained, and a signed consent was then obtained.
conclusive evidence on which of these variants of hybrid Following this, the patient was referred for blood in-
prosthesis, acrylic teeth on a metal substructure, or porcelain vestigations. The pretreatment quality of life was evaluated
fused to metal teeth over on a metal substructure is better in using the OHIP-EDENT questionnaire. Complete denture
terms of treatment outcome, reduced mechanical complica- prosthesis was fabricated and duplicated for all the patients
tions, and better patient compliance. and used for treatment planning as a radiographic guide
This study aims to evaluate the treatment outcome of re- and also as a surgical template (Fig. 1). The existing pros-
habilitations using these two types of hybrid prosthesis and to thesis of any patient, which was found adequate, was also
formulate a treatment protocol, which will ensure that hybrid used. The implant placement sites and implant size were
prosthesis is free of complications. decided according to the available bone and the design
parameter of the prosthesis. Implant placement was done
under local anesthesia, and five implants were placed in the
Material and methods mandible and five implants in the maxillary arch (Fig. 2).
The implants were left undisturbed without loading for 6
A total of 16 completely edentulous cases were selected from months to allow adequate osseointegration. The existing or
the OPD of the proposed study centers. Presurgical intraoral the newly fabricated complete denture prosthesis was
and clinical observations and radiograph were taken for all relieved over the region of the implants and used as an
cases. The same methodology, clinical procedures, and eval- interim prosthesis. After 6 months, the patient was recalled,
uation criteria were followed in the study centers. A pilot and the implants were evaluated both clinically by tran-
study was done by the principal worker and the coworkers simplant probing and radiographically, and the findings
together incorporating all the study parameters to ensure that were tabulated. Addition polymerizing polyvinyl siloxane
the techniques followed were the same. The data obtained impression material (Dentsply) was used to make the
were then compiled centrally and analyzed. impression using an open tray, and the master cast was
retrieved. The jig try-in was then done using plastic castable
Inclusion criteria sleeves and pattern resin (Fig. 3). Passivity of the entire
framework was ensured by splitting the framework and
a. Male and female who are less than 75 years of age rejoining the same using pattern resin (Coltene). The metal
b. Willingness to participate in the study framework was casted with multiple sprues, and try in was
c. Edentulous maxilla and mandible (more than 3 months done intra-orally. For the metal framework with porcelain
since tooth extraction or wearing conventional complete fused to metal teeth, a bisque trial (Dentsply) was done
dentures) before final insertion. The occlusion was checked and
d. More than 10 mm height of bone to receive implants adjusted (Fig. 3). All the patients were given a soft occlusal
Please cite this article as: Gopi A, Edwin A, A multicentric study to evaluate the treatment outcome and complications after oral
rehabilitation with implant-supported hybrid prostheses, Medical Journal Armed Forces India, https://doi.org/10.1016/
j.mjafi.2021.06.016
medical journal armed forces india xxx (xxxx) xxx 3
Fig. 1 e CBCT with radiographic stent and simulation of implant position.
night guard to be used for a month following the rehabili- loosening of any prosthetic components, breakage of acrylic,
tation. The patients were then recalled at 3 months, 6 chipping of porcelain, wear and tear of teeth, and soft tissue
months, and 1 year following rehabilitation for the neces- overgrowth under the framework.
sary clinical and radiological observations. OHIP-EDENT
questionnaire was once again given after rehabilitation.
Implant and prosthesis survival rate was calculated based Statistical analysis
on the clinical and radiological evaluation conducted at 03, 06
and 12 months after rehabilitation (Fig. 4). Implant survival Descriptive and analytical statistics were done. The data were
was determined by the absence of suppuration, infection, represented in number and percentages. Chi-square test was
symptoms of neurologic problems, signs of peri-implantitis, used to check differences in proportions. The level of signifi-
or radiolucent areas around the implants. The prosthetic su- cance was kept at p < 0.05. SPSS (Statistical Package for Social
perstructure was defined as surviving if there was no Sciences) Software Version 24.0 (IBM Corporation, Chicago,
requirement for remake of the definitive prosthesis. Me- USA) was used. Oral healtherelated quality of life (OHRQoL)
chanical complication evaluated included fracture or was measured using the Oral Health Impact Profile (OHIP)-
Fig. 2 e Postimplant placement.
Please cite this article as: Gopi A, Edwin A, A multicentric study to evaluate the treatment outcome and complications after oral
rehabilitation with implant-supported hybrid prostheses, Medical Journal Armed Forces India, https://doi.org/10.1016/
j.mjafi.2021.06.016
4 medical journal armed forces india xxx (xxxx) xxx
EDENT questionnaire before treatment and after complete patient (12.5%) in group A and zero patient (0.0%) in group B
rehabilitation. showed signs of soft tissue overgrowth. The difference be-
tween the two groups did NOT show any statistically signifi-
cant difference in proportions of cases showing signs of
Results fracture of components (p ¼ 0.302), loosening of components
(p ¼ 0.302), and soft tissue overgrowth (p ¼ 0.302). Both the
Implant survival at 3 months between the two groups was groups showed satisfactory esthetics.
compared (Table 1). None of the implants in group A or B Implant survival at 6 months between group A and B
showed any signs of suppuration, infection, or neurologic showed no signs of suppuration, infection, neurologic prob-
problems. Three implants (37.5%) in group A and two implants lems, and increased probing depth around implants (Table 2).
(25.0%) in group B showed signs of peri-implantitis. Three One implant (12.5%) in group A and two implants (25.0%) in
implants (37.5%) in group A and one implant (12.5%) in group B group B showed signs of peri-implantitis. The difference be-
showed signs of increased probing depth around implant. The tween the two groups did NOT show any statistically signifi-
difference between the two groups did NOT show any statis- cant difference in proportions of implants showing signs of
tically significant difference in proportions of implants peri-implantitis (p ¼ 0.522). Prosthesis survival at 6 months
showing signs of peri-implantitis (p ¼ 0.590) or increased between the two groups was compared. None of the patients
probing depth around implant (p ¼ 0.248). Prosthesis survival in group A or B showed any signs of need to remake, fracture
at 3 months between the two groups was compared. None of of components, breakage of acrylic, chipping of porcelain, and
the patients in group A or B showed any signs of need to wear and tear of teeth. Zero patient (0.0%) in group A and one
remake, breakage of acrylic, chipping of porcelain, and wear patient (12.5%) in group B showed signs of loosening of com-
and tear of teeth. Zero patient (0.0%) in group A and one pa- ponents. One patient (12.5%) in group A and zero patient (0.0%)
tient (12.5%) in group B showed signs of fracture of compo- in group B showed signs of soft tissue overgrowth. The dif-
nents. Four patients (50.0%) in group A and six patients (75.0%) ference between the two groups did NOT show any statisti-
in group B showed signs of loosening of components. One cally significant difference in proportions of cases showing
Fig. 3 e Master cast, jig trial, and try-in.
Please cite this article as: Gopi A, Edwin A, A multicentric study to evaluate the treatment outcome and complications after oral
rehabilitation with implant-supported hybrid prostheses, Medical Journal Armed Forces India, https://doi.org/10.1016/
j.mjafi.2021.06.016
medical journal armed forces india xxx (xxxx) xxx 5
Fig. 4 e Recall visit, OHIP-EDENT evaluation and tabulation of results.
signs of loosening of components (p ¼ 0.302) and soft tissue groups gave a completely satisfactory report after
overgrowth (p ¼ 0.302). Both the groups again showed satis- rehabilitation.
factory esthetics.
Implant survival at 12 months between the two groups was
compared (Table 3). Once again, none of the implants in group Discussion
A or B showed any signs of suppuration, infection, or neuro-
logic problems. Three implants (37.5%) in group A and two To obtain satisfactory functional and esthetic results, it is
implants (25.0%) in group B showed signs of peri-implantitis. important to place the implant in an ideal location to support
Three implants (37.5%) in group A and one implant (12.5%) the intended restoration. To achieve this, the existing denture
in group B showed signs of increased probing depth around was duplicated in clear acrylic, and the radio opaque material
implant. The difference between the two groups did NOT was then placed in the most preferred positions to fabricate a
show any statistically significant difference in proportions of radiographic stent. CBCT with the stent was analyzed to
implants showing signs of peri-implantitis (p ¼ 0.590) or evaluate the amount of bone at the specific regions of interest
increased probing depth around implant (p ¼ 0.248). (Fig. 1). Implant positions and size were simulated accord-
Prosthesis survival at 12 months between the two groups ingly. While Tarlow has highlighted the fabrication of an
when compared revealed that none of the patients in group A implant surgical stent for the edentulous mandible, Londono
or B showed any signs of need to remake, breakage of acrylic, et al, have described the use of digital technology and 3D
chipping of porcelain, and wear and tear of teeth. Zero patient printing for fabrication of stents.1e3 A hybrid prosthesis is a
(0.0%) in group A and one patient (12.5%) in group B showed fixed prosthesis for the patient, which can be removed by a
signs of fracture of components. Four patients (50.0%) in group professional. The primary factor that determines the resto-
A and six patients (75.0%) in group B showed signs of loos- ration type is the amount of intra-arch space, lip support, lip
ening of components. One patient (12.5%) in group A and zero line during smiling, speech, and the patient's overall func-
patient (0.0%) in group B showed signs of soft tissue over- tional and esthetic demands. The primary factor is adequate
growth. The difference between the two groups did not show restorative space for the various prosthetic designs.4,5 Hybrid
any statistically significant difference in proportions of cases prostheses are indicated for implant restoration in large
showing signs of fracture of components (p ¼ 0.302), loosening crown height spaces as a general rule.6,7 In a completely
of components (p ¼ 0.302), and soft tissue overgrowth edentulous patient, there is no conclusive evidence on the
(p ¼ 0.302). Both the groups again showed satisfactory es- number of implants required per arch, their preferred location
thetics. None of the patients in group A or B showed any need and also regarding the long-term outcome of using tilted im-
to remake the prosthesis and OHIP-EDENT evaluation in both plants in the posterior region or placement of implants after
Please cite this article as: Gopi A, Edwin A, A multicentric study to evaluate the treatment outcome and complications after oral
rehabilitation with implant-supported hybrid prostheses, Medical Journal Armed Forces India, https://doi.org/10.1016/
j.mjafi.2021.06.016
6 medical journal armed forces india xxx (xxxx) xxx
Table 1 e Comparison of implant and prosthesis survival at 3 months between the two groups.
3 months Group A Group B p-value
Yes No Yes No
n (%) n (%) n (%) n (%)
Implant survival
Suppuration 0 (0.0) 8 (100.0) 0 (0.0) 8 (100.0) e
Infection 0 (0.0) 8 (100.0) 0 (0.0) 8 (100.0) e
Neurologic problems 0 (0.0) 8 (100.0) 0 (0.0) 8 (100.0) e
Signs of peri-implantitis 3 (37.5) 5 (62.5) 2 (25.0) 6 (75.0) 0.590
Increased probing depth around implant 3 (37.5) 5 (62.5) 1 (12.5) 7 (87.5) 0.248
Prosthesis survival
Need to remake 0 (0.0) 8 (100.0) 0 (0.0) 8 (100.0) e
Fracture of components 0 (0.0) 8 (100.0) 1 (12.5) 7 (87.5) 0.302
Loosening of components 4 (50.0) 4 (50.0) 6 (75.0) 2 (25.0) 0.302
Breakage of acrylic 0 (0.0) 8 (100.0) 0 (0.0) 8 (100.0) e
Chipping of porcelain 0 (0.0) 8 (100.0) 0 (0.0) 8 (100.0) e
Wear and tear of teeth 0 (0.0) 8 (100.0) 0 (0.0) 8 (100.0) e
Soft tissue overgrowth 1 (12.5) 7 (87.5) 0 (0.0) 8 (100.0) 0.302
Satisfactory esthetics 8 (100.0) 0 (0.0) 8 (100.0) 0 (0.0) e
additional surgical procedures and grafting. Advantages of compared with conventional complete dentures as seen in
using lesser implants include reduced surgical procedures, no this study, since they offer functional, esthetic and psycho-
requirement of divergent implants, passive fit, and relative logical advantages. The overall acceptance of an implant-
simplicity of repair.8 Hybrid prostheses have a great number supported hybrid prosthesis was highly satisfactory.10 The
of advantages including reducing the impact force of dynamic OHIP questionnaire is one of the most technically sophisti-
occlusal loads and being highly esthetic restorations. They cated instruments for the assessment of OHRQoL.11 This can
may be successfully used by a combination of tilted and be conveniently used to detect the impact of oral health on the
axially placed implants in a resorbed maxillae or mandible.9 quality of life of patients with total prostheses, before and
Bilateral balanced occlusion and mutually protected occlu- after they have received them. It is specific to edentulous
sion is the most preferred type of occlusal schemes with patients and includes questions addressing masticatory ca-
special care to ensure minimum cuspal height, narrow pacity, pleasure in eating, and also the level of comfort and
occlusal table, freedom in centric occlusion, and smooth assuredness while wearing the prosthesis. It is the recom-
protrusive and lateral movements. This type of prosthesis is mended tool for determining the influence of implant-
supposed to enhance the quality of life of edentulous patients retained over dentures and hybrid prostheses on the well-
Please cite this article as: Gopi A, Edwin A, A multicentric study to evaluate the treatment outcome and complications after oral
rehabilitation with implant-supported hybrid prostheses, Medical Journal Armed Forces India, https://doi.org/10.1016/
j.mjafi.2021.06.016
medical journal armed forces india xxx (xxxx) xxx 7
Table 2 e Comparison of implant and prosthesis survival at 6 months between the two groups.
6 months Group A Group B p-value
Yes No Yes No
n (%) n (%) n (%) n (%)
Implant survival
Suppuration 0 (0.0) 8 (100.0) 0 (0.0) 8 (100.0) e
Infection 0 (0.0) 8 (100.0) 0 (0.0) 8 (100.0) e
Neurologic problems 0 (0.0) 8 (100.0) 0 (0.0) 8 (100.0) e
Signs of peri-implantitis 1 (12.5) 7 (87.5) 2 (25.0) 6 (75.0) 0.522
Increased probing depth around implant 0 (0.0) 8 (100.0) 0 (0.0) 8 (100.0) e
Prosthesis survival
Need to remake 0 (0.0) 8 (100.0) 0 (0.0) 8 (100.0) e
Fracture of components 0 (0.0) 8 (100.0) 0 (0.0) 8 (100.0) e
Loosening of components 0 (0.0) 8 (100.0) 1 (12.5) 7 (87.5) 0.302
Breakage of acrylic 0 (0.0) 8 (100.0) 0 (0.0) 8 (100.0) e
Chipping of porcelain 0 (0.0) 8 (100.0) 0 (0.0) 8 (100.0) e
Wear and tear of teeth 0 (0.0) 8 (100.0) 0 (0.0) 8 (100.0) e
Soft tissue overgrowth 1 (12.5) 7 (87.5) 0 (0.0) 8 (100.0) 0.302
Satisfactory esthetics 0 (0.0) 8 (100.0) 0 (0.0) 8 (100.0) e
being of patients. Hybrid prostheses have also been recom- for improved mastication must also be considered as a pri-
mended as the most predictable treatment option for mary reason for the treatment with implant hybrid prosthesis.
improving patient satisfaction in terms of oral pain and However, despite the favorable long-term outcomes achieved
chewing functionality compared with implant overdentures with these rehabilitations, complications such as surgical
and complete dentures.12 Implant-hybrid prostheses do not complications, implant loss, bone loss, peri-implant soft-tis-
require a flange or extension of the denture bases because the sue complications, mechanical complications, and esthetic/
support comes from the implants. Since the implants provide phonetic complications are frequent.13,14 These complications
greater stability when these prostheses are screwed or are affected by many factors including the operator's skill and
cemented, they perform like natural teeth. As established in judgment in treatment planning, prosthesis design, materials,
our study, these prostheses do not limit the movements of the local and systemic conditions, and habits such as bruxism,
tongue, thereby they do not interfere with the phonetics and smoking and maintenance. Also important is the length,
allow better perception of taste and temperature and there- height and width of the cantilever in minimizing the amount
fore better psychological comfort. Both groups in this study of deformation of the prosthesis. The length of the cantilever
reported an improved masticatory ability compared with should be minimized while maximizing the height and width
conventional complete dentures. Hence, the patient's desire of the cantilever. It should not exceed 20 mm in length while
Please cite this article as: Gopi A, Edwin A, A multicentric study to evaluate the treatment outcome and complications after oral
rehabilitation with implant-supported hybrid prostheses, Medical Journal Armed Forces India, https://doi.org/10.1016/
j.mjafi.2021.06.016
8 medical journal armed forces india xxx (xxxx) xxx
Table 3 e Comparison of implant and prosthesis survival at 12 months between the two groups.
12 months Group A Group B p-value
Yes No Yes No
n (%) n (%) n (%) n (%)
Implant survival
Suppuration 0 (0.0) 8 (100.0) 0 (0.0) 8 (100.0) e
Infection 0 (0.0) 8 (100.0) 0 (0.0) 8 (100.0) e
Neurologic problems 0 (0.0) 8 (100.0) 0 (0.0) 8 (100.0) e
Signs of peri-implantitis 3 (37.5) 5 (62.5) 2 (25.0) 6 (75.0) 0.590
Increased probing depth around implant 3 (37.5) 5 (62.5) 1 (12.5) 7 (87.5) 0.248
Prosthesis survival
Need to remake 0 (0.0) 8 (100.0) 0 (0.0) 8 (100.0) e
Fracture of components 0 (0.0) 8 (100.0) 1 (12.5) 7 (87.5) 0.302
Loosening of components 4 (50.0) 4 (50.0) 6 (75.0) 2 (25.0) 0.302
Breakage of acrylic 0 (0.0) 8 (100.0) 0 (0.0) 8 (100.0) e
Chipping of porcelain 0 (0.0) 8 (100.0) 0 (0.0) 8 (100.0) e
Wear and tear of teeth 0 (0.0) 8 (100.0) 1 (12.5) 7 (87.5) 0.302
Soft tissue overgrowth 1 (12.5) 7 (87.5) 0 (0.0) 8 (100.0) 0.302
Satisfactory esthetics 0 (0.0) 8 (100.0) 0 (0.0) 8 (100.0) e
using five or more abutments.15 There should be about based on the planned prosthetic design must be in place
1e2 mm of space between the inferior border of the cantilever before the surgical intervention. Screw loosening was the
and the alveolar ridge to allow for adequate oral hygiene. most common problem in both groups as seen in the initial 3
Acrylic resin teeth have been recommended to absorb the months of this study. Reasons for screw loosening may be
shock of occlusal forces.15 In their recent clinical studies, inadequate preload, improper occlusal scheme, variations in
Blaschkeet et al reported that dental implants made from fit and accuracy, or excessive occlusal forces. This was, how-
zirconia are a feasible alternative to titanium dental implants. ever, seen to reduce once the underlying problem was iden-
Apart from the excellent esthetics, zirconia implants provide a tified and corrected and with time as the patient got adapted
soft tissue response that is superior to that of titanium dental to the prosthesis. As seen in this study, the amount of screw
implants.15e18 There was no correlation between the level of loosening, wear and tear of prosthetic superstructure, and
marginal bone changes and the implant stability during the 1- bone loss around implants was less in the patients given a
year observation period of both groups in this study. Here, it metal framework with acrylic teeth probably since acrylic acts
must be repeated that a proper treatment plan that includes as an intermediary between the teeth and metal substructure,
the number, position, size, and distribution of the implants thereby reducing the impact force during dynamic occlusal
Please cite this article as: Gopi A, Edwin A, A multicentric study to evaluate the treatment outcome and complications after oral
rehabilitation with implant-supported hybrid prostheses, Medical Journal Armed Forces India, https://doi.org/10.1016/
j.mjafi.2021.06.016
medical journal armed forces india xxx (xxxx) xxx 9
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Disclosure of competing interest
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Please cite this article as: Gopi A, Edwin A, A multicentric study to evaluate the treatment outcome and complications after oral
rehabilitation with implant-supported hybrid prostheses, Medical Journal Armed Forces India, https://doi.org/10.1016/
j.mjafi.2021.06.016
