UNIVERSIDADE ESTADUAL DE CAMPINAS FACULDADE DE ODONTOLOGIA DE PIRACICABA
CAMILLA FRAGA DO AMARAL
FUNÇÃO MASTIGATÓRIA E ANÁLISE PSICOMÉTRICA DE IDOSOS
REABILITADOS COM OVERDENTURES RETIDAS POR IMPLANTE CENTRAL
MANDIBULAR ÚNICO
MASTICATORY FUNCTION AND PSICOMETRIC ANALYSIS OF ELDERS
REHABILITATED BY SINGLE IMPLANT MANDIBULAR OVERDENTURES
PIRACICABA 2018
CAMILLA FRAGA DO AMARAL
FUNÇÃO MASTIGATÓRIA E ANÁLISE PSICOMÉTRICA DE IDOSOS
REABILITADOS COM OVERDENTURES RETIDAS POR IMPLANTE CENTRAL
MANDIBULAR ÚNICO
MASTICATORY FUNCTION AND PSICOMETRIC ANALYSIS OF ELDERS
REHABILITATED BY SINGLE IMPLANT MANDIBULAR OVERDENTURES
Tese apresentada à Faculdade de Odontologia de Piracicaba da Universidade Estadual de Campinas como parte dos requisitos exigidos para obtenção do título de Doutora em Clínica Odontológica, na Área de Prótese Dental.
Thesis presented to the Piracicaba Dental School of the University of Campinas in partial fulfillment of the requirements for the degree of Doctor, in the area of Dental Prostheses.
Orientadora: Profª. Drª. Renata Cunha Matheus Rodrigues Garcia
ESTE EXEMPLAR CORRESPONDE À VERSÃO FINAL DA TESE DEFENDIDA PELA ALUNA CAMILLA FRAGA DO AMARAL, E ORIENTADA PELA PROF.a DR.a RENATA CUNHA MATHEUS RODRIGUES GARCIA
PIRACICABA 2018
DEDICATÓRIA
Aos meus pais, Rosangela Fraga do Amaral e Geraldo Antônio do Amaral por me apoiarem a alcançar todos os objetivos que coloquei em minha vida até agora. Obrigada por abdicarem seus sonhos e objetivos de vida para que eu, e minhas irmãs pudéssemos passar por um caminho sem muitas pedras, ou que estas fossem um pouco menores do que as que enfrentaram. Para sempre meus modelos de honestidade e renúncia para com o próximo.
Às minhas irmãs, Roberta Amaral West e Giselle Fraga do Amaral, pela oportunidade de viver a vida ao lado de pessoas tão semelhantes a mim, e que por isso me fizeram entender e aprender quem eu realmente sou.
À minha família, que mesmo distante, sempre me apoiaram e torceram por meu sucesso.
Ao meu namorado, Rodrigo Hernandez de Luzia Gurdos, que desde o começo me incentivou a seguir o caminho mais tortuoso e longínquo, pelo simples fato de que o que realmente devemos fazer de nossas vidas, é aproveitar o passeio. Obrigada por cada comemoração das pequenas vitórias e por toda paciência e motivação para com as derrotas.
AGRADECIMENTO ESPECIAL
À Profª. Drª. Renata Cunha Matheus Rodrigues Garcia, que por todo trabalho duro e dedicação, me motiva cada dia mais e mais para que eu me torne um bom profissional, com ética e respeito por todos ao redor. Obrigada pelo modelo e exemplo que vem sendo desde minha graduação, por todo aprendizado, pela orientação e por sempre me impulsionar a ir além. O meu mais singelo, obrigada.
AGRADECIMENTOS
À Universidade Estadual de Campinas, na pessoa do Magnífico Reitor Prof. Dr. Marcelo Knobel.
À Faculdade de Odontologia de Piracicaba da Universidade Estadual de Campinas, na pessoa de seu Diretor, Prof. Dr. Guilherme Elias Pessanha Henriques, e de seu Diretor Associado, Prof. Dr. Francisco Haiter Neto.
À Coordenadora dos Cursos de Pós-Graduação da Faculdade de Odontologia de Piracicaba da Universidade Estadual de Campinas, Profª. Drª. Karina Gonzales Silvério Ruiz.
Ao Coordenador do Programa de Pós-Graduação em Clínica Odontológica da Faculdade de Odontologia de Piracicaba, Prof. Dr. Valentim Adelino Ricardo Barão.
Aos voluntários da pesquisa, que sempre estiveram dispostos a ajudar e foram fundamentais para a realização deste trabalho.
Aos professores da área de Prótese Parcial Removível da Faculdade de Odontologia de Piracicaba, Drª. Altair A. Del Bel Cury, Drª. Celia Rizatti Barbosa e Dr. Wander José da Silva pelo apoio e ensinamentos, os quais contribuíram para meu amadurecimento profissional.
Aos professores Dr. Márcio de Moraes e Dra. Luciana Asprino, docentes da Área de Cirurgia Buco-Maxilo-Facial, do Departamento do Diagnóstico Oral da Faculdade de Odontologia de Piracicaba, pelo ínfimo suporte, e constante aprendizado desde o início do projeto, quando tudo não passava de ideias. Tenho certeza que esta parceria se dará para muitos outros projetos futuros.
Ao Prof. Dr. Francisco Haiter Neto, que, muito solícito, nos forneceu suporte técnico para documentação e planejamento dos casos clínicos, por meio de exames de imagens dos voluntários.
Ao Prof. Dr. Valentim Adelino Ricardo Barão, da área de Prótese Total da Faculdade de Odontologia de Piracicaba, que por suas aulas na pós-graduação, me ajudou imensamente a desenvolver habilidades necessárias à pesquisa.
À todos os docentes da Faculdade de Odontologia de Piracicaba, que de alguma forma contribuíram para meu aprendizado e crescimento profissional.
Às alunas do programa de Pós-Graduação em Clínica Odontológica, área de Prótese Dental, Mayara Abreu Pinheiro e Ingrid Andrade Meira, pessoas fundamentais para a continuidade de nosso projeto e assistência de nossos queridos voluntários.
Aos alunos do Programa de Pós-Graduação na área de Cirurgia Buco-Maxilo-Facial Gustavo Almeida Souza e Carolina Santos Ventura de Souza pela assistência direta no projeto, com a realização das cirurgias para instalação do implante e reabertura do mesmo, além do companheirismo e trocas de conhecimento.
Aos meus amigos para toda hora e lugar, Mariana Barbosa Câmara de Souza, Jairo Matozinho Cordeiro e Olívia Maria Costa de Figueredo. Uma família que a gente escolhe por afinidades, complementos e pura vontade de estar junto. Agradeço imensamente todo apoio, aprendizado e paciência por entre minha formação profissional e pessoal.
Às amigas Heloisa Navarro Pantaroto, Halina Massignan Berejuk e Louise Morais Dornelas Bezerra agradeço o apoio, paciência, amizade, disponibilidade em ajudar, boas risadas e momentos de superação.
Aos queridos amigos, colegas e companheiros de laboratório, Giancarlo de la Torre Canales, Bruna Gabriela Araújo Ximenes, Rafael Soares Gomes, Talita Malini Carletti, Edmara Tatiely Pedroso Bergamo, Victor Ricardo Manuel Muñoz Lora, Raissa Micaella Marcello Machado, Aline Araújo Sampaio, Cindy Góes Dodo, Dimorvan Bordin, Gabrielle Alencar Ferreira Silva, Kelly Machado de Andrade, Marco Aurélio Carvalho, Paula Furlan Bavia, Priscilla Cardoso Lazari, Samilly Evangelista Souza, Thaís Emídio, Bruna Fernandes Moreira Alfenas, Vinicius Rodrigues dos Santos e Yeidy Natalia Alvarez Pinzon pelo convívio, experiências e desenvolvimento profissional científico.
Às admiradas professoras Drª Camila Heitor Campos e Drª Giselle Rodrigues Ribeiro, da Universidade Federal Fluminense, e Drª Thaís Marques Simek Veja Gonçalves, da Universidade Federal de Santa Catarina, que desde o começo me ajudaram tanto com ensinamentos direcionados à pesquisa e à direção que iria tomar na pós-graduação, quanto também para meu amadurecimento pessoal. Foi maravilhoso tê-las como guias durante este processo. Obrigada pelo imenso suporte.
Aos funcionários da Faculdade de Odontologia de Piracicaba, em especial à Srª. Gislaine Regina Alves Piton, técnica do laboratório de Prótese Parcial Removível da Faculdade de Odontologia de Piracicaba, por toda sua ajuda durante a pesquisa, dedicação ao realizar suas funções, pelo carinho, cuidado e amizade.
À Srª. Eliete Aparecida Ferreira Marim, secretária do Departamento de Prótese e Periodontia da Faculdade de Odontologia de Piracicaba, pela disponibilidade, presteza em ajudar e companheirismo para conosco sempre.
À CAPES, Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, pela concessão da bolsa de estudos.
À FAPESP, Fundação de Amparo à Pesquisa do Estado de São Paulo, pelo Auxílio à Pesquisa concedido (processo números 2015/21704-1).
RESUMO
Overdentures retidas por implante central mandibular único (SIO) podem se apresentar como uma solução para a ausência de retenção e estabilidade de próteses totais (PT) convencionais, sendo mais acessíveis e simplificadas que a reabilitação padrão ouro, a overdenture retida por dois implantes mandibulares. Assim, o capítulo 1, comparou aspectos psicométricos clínicos e eficiência mastigatória de idosos edêntulos reabilitados com PT e posteriormente, transformadas SIO. O capítulo 2, analisou os efeitos da SIO na percepção oral, função mastigatória, padrão dos movimentos mastigatórios e ingestão nutricional do mesmo grupo de idosos. E por fim, o capítulo 3, propos uma técnica para confecção de estrutura metálica individualizada em região anterior da SIO, com o intuito de diminuir a incidência de fraturas da mesma. Desta forma, para o estudo clínico pareado foram selecionados 12 idosos (idade média = 68,66 ± 5,22 anos) com rebordos residuais Classes III e IV de acordo com a American College of Prosthodontics, e portadores de PT insatisfatórias, segundo critérios de Rise. Receberam novas PT com uma infraestrutura metálica em região anterior das próteses inferiores para evitar fraturas quando transformadas em SIO. Após 2 meses de uso da PT, as seguintes variáveis foram analisadas: performance, eficiência e habilidade mastigatória, padrão dos movimentos mandibulares, diário de dieta, função sensorial oral e satisfação dos voluntários frente ao tratamento reabilitador. Em segunda etapa, os voluntários receberam único implante cilindrico em região central mandibular com planejamento tomográfico cirúrgico e da estrutura metálica prévio. Após o período de osseointegração, foram instalados attachments do tipo perfil baixo e as PT inferiores foram transformadas em SIO. Após proservação e dois meses de uso, as variáveis foram novamente mensuradas. O teste t de Student e Wilcoxon foram utilizados para a análise estatística de acordo com a normalidade dos dados à um nível de significância de 5%. Participantes relataram maior satisfação com a retenção da SIO. No entanto, a satisfação com o aspecto
estético diminuiu quando PT foram convertidas em SIO (P <0,05). A habilidade mastigatória não apresentou diferença entre PT e SIO; no entanto, a transição para a SIO aumentou a eficiência mastigatória (P <0,0001). Já como resultados do capítulo 2, os dados do teste de capacidade de estereognose oral não apresentou diferença entre tipos de próteses (P <0,05). Entretanto, as velocidades de abertura e fechamento dos movimentos mastigatórios e a performance mastigatória melhoraram após a inserção da SIO (P <0,05). Ainda, a ingestão de sódio diminuiu após a terapia SIO (P <0,05). O atual estudo pode concluir diante dos achados clínicos que SIO mandibulares promovem maior satisfação de pacientes idosos frente à retenção, melhora na função mastigatória e aumento na velocidade de abertura e fechamento dos ciclos mastigatórios, além de redução de ingestão de sódio, podendo ser uma alternativa para indivíduos idosos desdentados com reduzida altura residual dos rebordos mandibulares. Ainda, a técnica de reforço da SIO pode ser considerada como um procedimento simplificado e eficiente, uma vez que constitui um instrumento de fortalecimento para a reabilitação. Palavras-chave: prótese total completa, idosos, função mastigatória, rabilitação sobre implante.
ABSTRACT
Single implant-retained mandibular overdentures (SIO) may present as a solution for the absence of retention and stability of conventional total dentures (CD), being more accessible and simplified than the gold standard rehabilitation, the overdenture retained by two mandibular implants. Thus, chapter 1, compared clinical psychometric aspects and masticatory efficiency of edentulous elderly rehabilitated with PT and later, transformed into SIO. Chapter 2 analyzed the effects of SIO on oral perception, masticatory function, pattern of masticatory movements and nutritional intake of the same group of elderly. Finally, chapter 3 proposed a technique for making an individualized framework in the anterior region of the mandibular prosthesis, in order to avoid incidence of fractures in SIO rehabilitation. Thus, for the paired clinical study, 12 elderly subjects (mean age = 68.66 ± 5.22 years) with Class III and IV residual borders were selected according to the American College of Prosthodontics and unsatisfactory PT patients, according to Rise criteria. They received new CD with a metallic framework in the anterior region of mandibular prostheses to avoid fractures when transformed into SIO. After 2 months of CD use, the following variables were analyzed: masticatory performance, efficiency, and ability, pattern of mandibular movements, nutritional intake, oral sensory function and volunteers' satisfaction with reha bilitation treatment. In the second stage, the volunteers received a single cylindrical implant in the mandibular central region according to previous tomographic planning of surgical and markers of the framework made. After the osseointegration period, low profile type attachments were installed and the lower CD were transformed into SIO. After proservation and two months of use, the variables were again measured. The Student t test and Wilcoxon were used for the statistical analysis according to the normality of data at a significance level of 5%. Participants reported greater satisfaction with the retention of SIO. However, aesthetic satisfaction decreased when CD were converted to SIO (P <0.05). The masticatory ability
showed no difference between CD and SIO; however, the transition to SIO increased masticatory efficiency (P <0.0001). As results of chapter 2, oral stereognosis ability did not present difference between types of prostheses (P <0.05). However, the velocities of opening and closing masticatory movements and masticatory performance improved after insertion of SIO (P <0.05). In addition, sodium intake decreased after SIO therapy (P <0.05). The present study may conclude from clinical findings that mandibular SIO promote greater satisfaction of the elderly in the face of retention, improvement in masticatory function and increase in the speed of opening and closing of the masticatory cycles, besides reduction of sodium intake, being an alternative for edentulous elderly individuals with reduced residual height of the mandibular ridges. Also, the technique of strengthening the SIO can be considered as a simplified and efficient procedure, since it saves chairside management time for the clinician and constitute a strengthen instrument for the rehabilitation.
Keywords: complete dentures, older people, masticatory function, implant rehabilitation.
SUMÁRIO
1. INTRODUÇÃO 15
2. ARTIGOS 20
2.1 Artigo 1: Psychometric analysis and masticatory efficiency of elderly people with single-implant overdentures 21
2.2 Artigo 2: Sensorial ability, mastication and nutrition of single-implant overdentures wearers 42
2.3 Artigo 3: Reinforcement of single implant-retained mandibular overdenture with a cobalt-chromium framework before implant surgery. 60
3. DISCUSSÃO 73
4. CONCLUSÃO 77
REFERÊNCIAS 78
ANEXOS 84
Anexo 1 - Certificado de aprovação do Comitê de Ética em Pesquisa da Faculdade de Odontologia de Piracicaba 84
Anexo 2 - Avaliação da condição das próteses totais e parciais removíveis segundo Rise 85
Anexo 3 - Placa de visualização dos formatos geométricos do material teste cenoura – Análise de estereognose oral. 88
Anexo 4 - Protocolo de aceite Artigo 1 – The International Journal of Oral & Maxilofacial Implants 88
Anexo 5 - Protocolo de aceite Artigo 2 – Brazilian Dental Journal 89
1. INTRODUÇÃO
A população mundial envelhece exponencialmente, e assim todos os países do mundo presenciam o alargamento do topo da pirâmide etária com a crescente proporção de idosos em sua população, ocasionando participação ativa dos idosos na sociedade e a consequente melhoria em sua qualidade de vida (World Population Ageing, 2015). Uma a cada oito pessoas no mundo apresenta mais de 60 anos, o que representa 901 milhões de idosos. O edentulismo afeta nossas populações mais vulneráveis, a idosa e a população economicamente desfavorecida. Na população geriátrica a proporção de indivíduos desdentados é de 2 para 1, e 90% das pessoas que sofrem de edentulismo usam próteses totais convencionais (Dye et al,. 2015).
A perda dentária é fator importante na nutrição do idoso, afetando diretamente a saúde geral (Bardbury et al., 2008). Sabe-se que a desnutrição crônica em idosos está relacionada com condições bucais inadequadas, gerando uma diminuição da ingestão de proteínas e assim, uma retroalimentação negativa no índice de massa muscular corpórea (Fried et al., 2004, Santilli et al., 2014). Tal déficit proteico, resulta em generalizado declínio dos sistemas fisiológicos, proporcionando o surgimento de doenças mais debilitantes ao idoso, inserindo-o antecipadamente no estágio de fragilidade (Fried et al. 2001). Portanto, uma boa e estável saúde bucal pode influenciar diretamente na saúde geral e no processo de envelhecimento (Fitzpatrick, 2006).
Estima-se que 3 milhões de idosos brasileiros sejam totalmente edêntulos (Brasil, 2011) e que, por mais que a expectativa de vida e o índice de edentulismo tenham evoluído, a qualidade das reabilitações orais e soluções inovadoras para tais pacientes necessitam ser encorajadas. Próteses totais (PTs) convencionais são regularmente mais utilizadas devido ao baixo custo e maior acessibilidade, entretanto, atender todas as expectativas dos pacientes edêntulos com tal procedimento é uma árdua tarefa (Muller, 2014). Um dos fatores de maior
insatisfação dos pacientes portadores de PTs convencionais está relacionado à falta de retenção e estabilidade das mesmas, que em última análise acarreta a má ingestão de alimentos e dificuldades fonéticas (Moriya et al., 2014). Por sua vez, a falta de retenção e estabilidade das PTs está relacionada à pouca quantidade e tamanho ósseo do rebordo residual remanescente para sua ancoragem (Laird e McLaughlin, 1989).
Simultaneamente à perda total dos elementos dentários, ocorre drástica perda de outras estruturas orofaciais como tecido periodontal e seus proprioceptores, osso alveolar e tecidos gengivais associados (Spitzl et al., 2012). Ligamentos temporomandibulares sofrem atrofia assim como toda musculatura adjacente, o que diminui a função mastigatória, compromete a estética devido à perda de tônus muscular e pode dar origem às desordens temporomandibulares (Atwood, 2001). As PTs tem a função de restabelecer algumas destas estruturas, entretanto, a adaptação à limitação de movimentos mastigatórios e propriocepções imposta por este tipo de reabilitação é sempre um desafio.
A manutenção das PTs em posição durante a função ocorre basicamente por meio de coesão, mecanismo de atração física entre a fibromucosa e base da prótese na presença de uma fina película de saliva (Turano, 2007). Com a subsequente reabsorção óssea fisiológica devido à idade avançada, exige-se maior desempenho da musculatura adjacente para manutenção da retenção e estabilidade das PTs convencionais (Atwood, 2001; Muller, 2014), e que na maioria das vezes não consegue suprir satisfatoriamente as necessidades de se manter em posição durante desempenho da função mastigatória ou fala.
Com o advento da implantodontia, reabilitações complexas de maxilares edêntulos sofreram uma impactante melhora, onde os problemas de retenção e estabilidade foram praticamente solucionados. Atualmente, a reabilitação da mandíbula edêntula por meio de PT convencional não representa mais a primeira opção de tratamento protético, sendo que as overdentures mandibulares retidas por dois implantes em região de caninos constituem-se,
atualmente, na escolha padrão ouro (Feine et al., 2002). A instalação de overdentures sobre dois implantes osseointegrados fornece prognóstico favorável e estudos mostram que o índice da qualidade de vida e função mastigatória dos pacientes reabilitados com este tipo de prótese progrediram consideravelmente (Klemetti, 2008; Carlsson et al., 2010; Boven et al., 2015). Entretanto, não há evidências científicas sobre o número de implantes necessários para que a overdenture apresente melhores propriedades biomecânicas associado à reduzido índice de complicações e reparos, além da satisfação do paciente frente à reabilitação (Klemetti, 2008; Roccuzzo et al., 2012).
Desta maneira, overdenture retida por um único implante instalado na região central mandibular (SIO) é um protocolo simplificado, proposto em meados dos anos noventa para tratamentos de pacientes geriátricos (Cordioli et al., 1997). Devido à senilidade, esses pacientes necessitavam de procedimentos pouco invasivos que obtivessem uma efetividade satisfatória em se tratando de estabilidade e retenção de suas próteses (Cordioli et al., 1997). Biomecanicamente, apresenta-se como uma estrutura menos complexa, sem a necessidade do devido paralelismo entre os implantes e maior facilidade na captura da fêmea do encaixe durante transição para overdenture (MacEntee et al., 2005; Passia et al., 2014; Cheng et al., 2012).
Outro fator que fortemente contribui para a indicação de SIO, é a necessidade de um tratamento reabilitador acessível para idosos com baixo poder aquisitivo (Wolfart et al., 2008; Srinivasan et al, 2014; Bryant et al., 2015), enveredando-se por entre possíveis políticas governamentais de países emergentes e subdesenvolvidos. Em contraste, sabe-se que SIO, apresenta um direcionamento das forças oclusais para a região implantar, acarretando estresse ao redor do implante e em última análise fratura da prótese (Gonda et al., 2010; Grover et al., 2013; Bryant et al., 2015). Contudo, a inclusão de uma infraestrutura na região anterior da PT inferior pode contribuir para a diminuição do índice de fratura da prótese (Gonda et al., 2007;
Harder et al., 2011; Passia et al., 2014; Grageda and Riek 2014). Assim, faz-se importante o desenvolvimento de um método para a inserção e confecção desta estrutura individualizada de reforço, com o intuito de dissipar forças oclusais na região anterior da SIO.
Estudos sobre a reabilitação trazem resultados promissores quanto aos aspectos subjetivos de qualidade de vida, satisfação e habilidade mastigatória (Harder et al., 2011; Bryant et al., 2015). Entretanto, revisões sistemáticas (Srinivasan et al., 2014; Passia et al., 2014) elucidam que um melhor direcionamento de sua indicação seria recomendado, direcionando a reabilitação à idosos fisicamente mais debilitados, como seria o caso de idosos com rebordos residuais de baixa altura. Ainda, estudos sobre variáveis mastigatórias objetivas além de análises subjetivas da percepção do paciente frente a reabilitação sobre implante central mandibular único são necessários para que possamos consolidar de fato a eficácia da reabilitação em estudo, expondo, assim, a importância do atual tema.
Tendo em vista as considerações acima, torna-se importante avaliar a mastigação de idosos que apresentam rebordos residuais com pouca altura óssea, reabilitados por meio de SIO. Desta forma, o atual trabalho teve como objetivo geral avaliar clinicamente função mastigatória e aspectos psicométricos associados à overdentures retidas por implante central mandinular único e propor uma técnica de inserção de infraestrutura para minimizar a incidência de fratura desta reabilitação. E como objetivos específicos, o presente estudo teve como: 1) Comparar aspectos psicométricos clínicos (satisfação e habilidade mastigatória) e eficiência mastigatória de idosos edêntulos reabilitados primeiramente com PTs convencionais e posteriormente, transformadas em SIO; 2) Avaliar os efeitos de SIO na percepção oral, função mastigatória, padrão dos movimentos mastigatórios e ingestão nutricional dos idosos; e 3) Propor uma técnica para confecção de estrutura metálica individualizada em região anterior da SIO, com o intuito de diminuir a incidência de fraturas da mesma.
2. ARTIGOS
Este trabalho foi realizado no formato alternativo, conforme a Informação CCPG/001/2015, da Comissão Central de Pós-Graduação (CCPG) da Universidade Estadual de Campinas.
O artigo 1, intitulado “Psychometric analysis and masticatory efficiency of elderly people with single-implant overdentures”, foi aceito para publicação no periódico The International Journal of Oral & Maxillofacial Implants (Anexo 4).
O artigo 2, intitulado “Oral sensorimotor, mastication and nutrition of elders with single-implant overdentures”, foi submetido à publicação no periódico Brazilian Dental Journal (Anexo 5).
O artigo 3, intitulado “Reinforcement of single-implant retained mandibular overdenture with a cobalto-chromium framework before implant surgery”, foi publicado no periódico Journal of Prosthodontics (Anexo 6).
2.1 ARTIGO 1
Psychometric analysis and masticatory efficiency of elderly people with single-implant overdentures
Short Title: Analysis of elderly people with single-implant overdentures
Camilla Fraga do Amaral, DDS.a Mayara Abreu Pinheiro, DDS, MS,a Márcio de Moraes, Ph.D.b
Renata Cunha Matheus Rodrigues Garcia, Ph.D.c
aGraduate Student, Department of Prosthodontics and Periodontology, Piracicaba Dental School, University of Campinas. Avenida Limeira, 901, Bairro Areião, Piracicaba, SP, Brazil.
bProfessor, Department of Oral and Maxillofacial Surgery, Piracicaba Dental School, University of Campinas. Avenida Limeira, 901, Bairro Areião, Piracicaba, SP, Brazil.
cProfessor, Department of Prosthodontics and Periodontology, Piracicaba Dental School, University of Campinas. Avenida Limeira, 901, Bairro Areião, Piracicaba, SP, Brazil.
Corresponding author:
Renata Cunha Matheus Rodrigues Garcia
Department of Prosthodontics and Periodontology, Piracicaba Dental School,
University of Campinas. Avenida Limeira, nº 901, Bairro Areião, Piracicaba, SP, Brazil, CEP: 13414-903. Phone: + 55 19 2106-5240, Fax: + 55 19 2106-5211
Abstract
Purpose: The aim of this paired clinical study was to evaluate psychometric parameters (patient satisfaction and masticatory ability) and masticatory efficiency in elderly people before and after oral rehabilitation by a single-implant overdenture. Materials and Methods: This study included elderly individuals with residual alveolar bone height classified as Class III or IV according to the American College of Prosthodontics, and who wore clinically unsatisfactory complete dentures. Subjects first received new maxillary and mandibular conventional complete dentures. After 2 months of patient adaptation to the new complete dentures, subjective and objective variables were measured. Satisfaction with the new complete dentures was verified by applying a visual analogue scale to rate patient satisfaction with stability, comfort, ability to chew, ability to speak, ease of cleaning, aesthetics and general satisfaction of their new complete dentures. Masticatory ability was assessed by asking participants to rate on a visual analogue scale their ability to chew foods with different roughness and consistencies. Masticatory efficiency was measured by the sieving method using a silicone-based artificial test food. After evaluations were completed, each participant received one implant, which was placed in the symphysis region. After 3 months of implant osseointegration, the conventional complete dentures were transitioned to mandibular single-implant overdentures through placement of a low-profile attachment on the intaglio surface of the prostheses. Subjects used the single-implant overdentures for 2 months, and then all variables were reevaluated. Parametric t-test and nonparametric Wilcoxon statistical tests were used to analyze data. Results: Participants reported increased satisfaction with stability of their mandibular single-implant overdentures compared to their new conventional complete dentures. However, satisfaction with the aesthetics decreased when the new complete denture was converted into the single-implant overdenture (P < .05). Masticatory ability with the rehabilitation was not different between the new conventional complete dentures and the
single-implant overdentures; however, transition to single-implant overdenture greatly increased masticatory efficiency (P < .0001). Conclusions: Single-implant overdentures changed the patient perceptions, improving their satisfaction with stability, although decreasing satisfaction with aesthetics. Despite of that, masticatory efficiency of elderly individuals with decreased residual bone height was greatly improved after single-implant overdenture uses.
Keywords: edentulous mandible, implant, overdenture, patient satisfaction, mastication
Introduction
In recent years, the development of simple, low-cost implant therapies for edentulous elderly patients has been a major goal of the dental research community.1-4 The two-implant overdenture has been the standard of care for edentulous elderly patients with resorbed residual ridges because of the poor stability and retention that the conventional complete dentures.5-8 To reduce cost and chairside management time, researchers have proposed the use of the mandibular single-implant overdenture opposing a conventional maxillary complete denture.9-14
Patient self-perceptions of different types of prostheses are widely considered when evaluating clinical outcomes, as such perceptions reflect the true advantages and effects of treatment on the patient’s life.5 Questionnaires using a visual analogue scale to detect differences between prosthetic treatments have been conducted to evaluate the patient’s ability to chew specific foods or to predict levels of satisfaction throughout the entire oral rehabilitation process.15,16 Several reports10,17,18 showed improvements in patient perceptions about single-implant overdentures treatment and its positive influence on their quality of life.
In this sense, it is known that after a long term assessment, the overall satisfaction of patients using overdentures attached to one or two implants is similar.17 In addition, the subjective chewing ability of hard food was improved after only 4 weeks of overdentures retained by a single-implant overdenture10. However, no consideration was given to the levels of loss of the denture-supporting structures, mainly in the posterior mandible region, which can influence denture retention and stability.
Aside from the negative psychosocial effects of edentulism, the masticatory function of edentulous individuals is impaired compared to that of the dentate population.19 Accordingly, it is important to evaluate psychometric variables alongside objective analyses, such as masticatory efficiency. Reports on clinical outcomes, such as bone loss and
masticatory function, have endorsed the use of the single-implant overdenture rehabilitation for elderly patients as a conservative and simplified implant-based oral rehabilitation.20-23 Some authors24,25 found masticatory improvements for single-implant overdenture rehabilitated elderly patients. However, those studies24,25 used natural foods to evaluate mastication, whereas no study to date has analysed masticatory efficiency with an artificial test material, such as Optocal. This artificial material does not undergo structural changes when exposed to the salivary environment26. In addition, the cited studies24,25 used a paired design to evaluate edentulous patients before and after single-implant overdenture installation, but they did not evaluate their findings with respect to the quality of the complete denture used by their subjects earlier to the implant treatment. This choice could lead to performance bias if the complete dentures prostheses were not constructed in a standardized manner.
Therefore, the purpose of the present study was to evaluate psychometric parameters in terms of patient satisfaction according to the prosthetic treatment received, as well as the subjective masticatory ability of edentulous elders with loss of residual bone height before and after oral rehabilitation by single-implant overdenture. In addition, masticatory efficiency was objectively verified by a sieving method using artificial test material.
Materials and Methods
Study Design and Patient Selection
This paired clinical trial was approved by the Ethics Committee of Piracicaba Dental School, University of Campinas (Piracicaba, Brazil) under protocol #087/2015. The study was registered in the Brazilian Registry of Clinical Trials (#RBR-3kgttj), a spin-off of the International Clinical Trials Registration Platform (ICTRP/World Health Organization).
Participants were recruited from a population of completely edentulous elderly
School, State University of Campinas, Brazil. Participants signed a consent form according to
the 1964 Helsinki Declaration.
A sample size calculation was done based on a previous study27 and a total of 12 elders were indicated to obtain statistical differences with 80% power and 5% error probability. In view of the expected loss rate of 25%, the final sample included 15 participants.
Selection criteria were as follows: patient age of 60 years or older; good general
health or adequately medication-controlled systemic disease, such as hypertension or diabetes;
completely edentulous, classified as Class III or IV according to the American College of
Prosthodontics;28 and current use of a clinically unsatisfactory complete dentures. Type IV
subjects must present enough bone in the mandibular midline region for an implant length of
11 mm. Subjects presenting signs and symptoms of temporomandibular disorders,
uncontrolled systemic diseases, or osteoporosis, smokers, and alcoholics were excluded. Determination of whether the patient’s current complete denture was clinically unsatisfactory was made according to the Rise Index.29 This prosthetic quality assessment method analyzes several denture characteristics, such as retention, stability, presence of defects, denture material, presence of soft tissue injury, and occlusion, to generate a score reflecting whether the prosthesis is clinically satisfactory. The complete denture is classified in four degrees (0, I, II, or III) according to its score (range: 0–13), with lower degree indicating better prosthetic quality. Two researchers, who had been previously calibrated for the assessment (Cohen’s Kappa inter- and intra-rater agreements of 1.00), evaluated characteristics of the maxillary and mandibular complete denture in use by subjects at the beginning of the study.
Recruited participants were submitted to anamnesis, including a medical history questionnaire and a clinical examination. Participants received new conventional maxillary and mandibular complete denture, which were constructed in accordance with standard techniques30 and adjusted to a bilaterally balanced occlusal scheme. A cobalt-chromium
framework was inserted in the acrylic denture base at the anterior region of the mandibular
denture, to dissipate forces and prevent early fracture of the prosthesis.31 Immediately after
the conventional complete denture installation, the subjects were given verbal and written
instructions on how to use and clean their new prostheses. During the next three weeks, and
according to individual needs, they were instructed to return to the clinic for denture
adjustments. After the subject was free of any complaint about their new conventional
denture, a period of two months of using the new prostheses was allowed, and variables
related to patient satisfaction, masticatory ability, and masticatory efficiency were assessed.
Patient Satisfaction
Patient satisfaction related to the prosthetic treatment were determined according to Awad & Feine32. Subjects were asked about their general satisfaction with the new conventional denture. They were also asked to rate their prosthesis stability, comfort, ability to chew, ability to speak, ease of cleaning, and aesthetic appearance of their maxillary and mandibular new complete denture.32 Participants rated each item on a 100-mm visual analogue scale, where the anchor words were “totally dissatisfied” for zero and “completely satisfied” for 100. Participants drew a vertical line at the point on the scale that best reflected their response, for which higher scores indicate greater satisfaction.
A questionnaire based on a visual analogue scale was also applied to rate the easy of chewing seven types of food with different roughness and consistencies,33 such as bread, hard cheese, sausage, lettuce, peanuts, raw apples and carrots15. Participants rated their ability to masticate these foods by placing a dot on a scale ranging from “very easy” to “very difficult”. Lower scores represented greater masticatory ability.
Masticatory Efficiency
Masticatory efficiency was evaluated quantitively by using Optocal, a standardized artificial chewable test material.34,35 Subjects were asked to chew portions of 17 cubes, with an edge size of 5.6 mm, for 40 chewing strokes in the manner of the completely edentulous population. Chewing strokes were counted by a trained researcher.27 By the fractional sieving method, the chewed material was separated through eight sieves with decreasing mesh aperture from 5.6 to 0.5-mm. Masticatory efficiency was calculated as the weight percentage of material that was passed through the 2.8-mm sieve, representing the initial particle size suitable for swallowing.36
Single Implant Overdenture Process
After 2 months of new conventional complete denture use and variables assessment, each participant received one osseointegrated implant. All surgeries were performed by two dental surgeons at the Piracicaba Dental School Surgery Center, using tomographic guides
and computed tomography images. Through a conventional two-stage technique37 under local
anesthesia, one implant measuring 11 mm length and 3.75 mm width (Titamax-ticortical,
Neodent, Brazil) was placed in the central symphysis region of the edentulous mandible. The
conventional mandibular denture was relined with resilient soft lining material (Dencril,
Periapical radiographs using a long-cone paralleling technique were taken to evaluate
the osseointegration process, and once osseointegration was complete, the new mandibular
conventional denture was converted into an overdenture over the implant. The hexagon
platform of the implant was exposed, and a low-profile abutment patrix (Locator, Neodent,
Brazil) was attached, using 32-N·cm of torque, according to the manufacturer’s instructions.
The central region of the mandibular denture base was relieved, and the matrix was intraorally
captured by using a self-curing acrylic resin (Vipi, Brazil). The acrylic base was polished, and
adjustments were made to maintain an occlusion that was bilaterally balanced with the single implant overdenture similarly to how it was with the conventional denture.
Participants received verbal and written instructions about implant cleaning and overdenture maintenance, such as its insertion and removal, as well as hygiene. Once adjusted and the subjects showing no complains about their overdentures, a period of two months was released for its use. Subsequently, all variables were reassessed.
Statistical Analysis
Data were evaluated by using SAS 9.3 (SAS Institute Inc., SAS Campus Drive, Cary, NC, USA). Exploratory statistical analysis by the Shapiro–Wilk test was used to verify the Gaussian distribution. Student’s t-tests were used to analyze normally distributed data, including questions 3, 4, 6, 10, and 11 from the patient satisfaction questionnaire, chewing ability, and masticatory efficiency. Remaining questions of the satisfaction survey were not normally distributed and were analyzed by the nonparametric Wilcoxon signed-rank test. All analyses were carried out at a significance level of 5%.
Fifty-seven patients were initially recruited for possible inclusion in this study. After anamnesis, clinical and radiographic exams, 19 subjects were excluded due to the presence of residual alveolar bone height classified as Class I or II, four subjects presented osteoporosis, three presented uncontrolled type 2 diabetes mellitus, two were partially dentate, two presented mandibular implants already installed, and finally one patient was less than 60 years old and therefore were also excluded. In addition, 11 patients refused to participate. Thus, 15 subjects were selected to participate, however three of them could not conclude the study due to personal problems. Consequently, the final sample was composed by 12 volunteers, which sociodemographic data are presented in Table 1. A typical panoramic radiograph of the subjects is presented in Figure 1.
Table 1. Sociodemographic data of subjects (n = 12).
Characteristic Value
Age, mean ± SD (years) 68.66 ± 5.22
Sex, frequency (%)
Male 25
Female 75
Monthly income, mean ± SD (BRL, minimum age) 2.42 ± 0.87
Educational level, mean ± SD (years) 3.33 ± 1.15
Fig 1. A panoramic radiograph with the pattern of residual alveolar ridge of completely edentulous subjects.
Psychometric analysis of patient satisfaction and masticatory ability with the new conventional complete denture and the single-implant overdenture are shown in Table 2. Comparisons of satisfaction scores between the new conventional denture and single-implant overdenture showed increased satisfaction with stability (P = .0057) but decreased satisfaction with the aesthetics of the mandibular overdenture (P = .0339) after single-implant overdenture installation. No significant difference in masticatory ability was observed before and after single-implant overdenture rehabilitation.
Table 2. Mean ± standard deviation of patient satisfaction and masticatory ability with new conventional complete denture or single implant-retained overdenture treatment (n = 12).
Satisfaction Complete denture Single implant
overdenture
P
General satisfaction 95.58 ± 5.21 96.83 ± 5.15 .7031*
Stability
* Wilcoxon or ϯ Student’s t-test, P < .05.
Masticatory efficiency demonstrated a marked increase (P < .0001) after installation of the single-implant overdenture (Fig 2).
Mandible 87.00 ± 12.53 98.75 ± 1.36 .0057ϯ Comfort Maxilla 98.83 ± 2.48 98.17 ± 1.75 .3752 ϯ Mandible 88.92 ± 18.32 95.58 ± 6.29 .333* Ability to chew Maxilla 97.58 ± 5.21 95.00 ± 5.62 .3191 ϯ Mandible 84.67 ± 20.72 95.92 ± 4.81 .7539* Ability to speak Maxilla 96.17 ± 8.96 98.83 ± 2.12 .675* Mandible 90.92 ± 13.09 99.00 ± 1.54 .7266* Ease of cleaning Maxilla 96.50 ± 5.74 97.67 ± 2.42 .5655 ϯ Mandible 93.08 ± 11.15 96.58 ± 4.17 .35 ϯ Aesthetics Maxilla 98.17 ± 3.43 98.83 ± 2.04 .9531* Mandible 99.58 ± 1.44 98.67 ± 1.44 .0339 ϯ Masticatory ability 51.65 ± 17.10 51.12 ± 13.44 .146 ϯ
Fig 2. Mean (standard deviation) of masticatory efficiency values for elderly individuals after installation of the new conventional complete denture or mandibular single implant overdenture. P < .0001.
Discussion
The purpose of this trial was to investigate patient satisfaction and masticatory function in elderly individuals following rehabilitation with a new conventional complete denture or single-implant overdenture. Elderly presenting complete edentulism Class III or IV were selected because their insufficient supporting structures, which shows the most debilitated edentulous condition28 with the least favorable status for complete denture
insertion.38 The single-implant overdenture therapy improved satisfaction with stability of the
mandibular prosthesis and improved masticatory efficiency. Despite the similar overall satisfaction and masticatory abilities with both types of prostheses, patients reported decreased satisfaction with the aesthetics of the single-implant overdenture.
As expected, most of the study participants were women. Studies have shown that women are more concerned and proactive with their health than men and tend to search for new treatments that could improve their quality of life.39 Despite their relatively low educational level, participants showed monthly earnings that were almost twice the average Brazilian income40 and were considered to belong to the middle class. This result was unexpected but should be considered as a random occurrence.
After single-implant overdenture therapy, patient satisfaction with mandibular stability improved, but satisfaction with aesthetics decreased compared to satisfaction with the new conventional complete denture. Findings on mandibular stability agree with previous studies,18,20,23,24,41 which reported overall increases in patient satisfaction with parameters such as oral comfort and function after single-implant overdenture use. The increased stability of the single-implant overdenture is explained by the presence of the implant in the anterior region of the mandible, thereby providing retention and stability to the lower prosthesis.17,18,22,41
On the other hand, the decreased satisfaction with aesthetics of the single-implant overdenture was totally unexpected result, and evidently this finding is in contrast with some studies.10,11,24,42. Compared to the conventional complete prosthesis, the overdenture has no alteration in its external region of the denture base. However, the intaglio surface of the overdenture can show some metallic components, such as the matrix. Thus, even the matrix does not appear when the overdenture is in its position in the mouth, the subjects can see this metallic component every time that they insert or remove their overdentures, and this is likely to negatively influence their aesthetics perception.
Nevertheless, the decrease in satisfaction with aesthetics did not seen to influence overall satisfaction with the new treatment, that remained high after overdentures insertion. Therefore, we believe that this finding has no clinical relevance and does not influence the
successful of the single-implant overdenture. In addition, the most complain about mandibular denture were the poor stability and this aspect was improved.
An interesting finding is that, in spite of the improved satisfaction with stability after using their overdentures, subjects revealed similar satisfaction with their masticatory ability after using both types of prostheses. Thus, the individual’s opinion about how difficult a food is to chew,15 did not change after overdenture using. This finding is in contrast with Harder et al10 who showed an improvement in masticatory ability after connection of the denture to the implant for hard foods. This opposing data may be explained by methodological differences between studies. While the latter author10 selected patients already using technically acceptable complete dentures, our subjects were using old and unsatisfactory prostheses (Rise Index degrees II and III),29 which were replaced by new maxillary and mandibular conventional dentures. In addition, the absence of differences in masticatory ability after conventional complete dentures and single implant overdentures using, could be because our subjects have experienced the greater masticatory ability when their old and unsatisfactory dentures were changed by the new conventional ones. Consequently, when the single-implant overdenture was used, our subjects continued to be satisfied with their mastication as much as they were with the conventional complete dentures use.
In spite of the absence of difference in the most of subjective masticatory parameters, masticatory efficiency values were at least seven times greater after single-implant overdenture installation than they were after conventional complete denture insertion. Although modest, Cheng et al24 also observed an improvement in masticatory efficiency. The higher masticatory efficiency improvement observed in the present study may be related to the differences in the test food material and sieve sizes that were used. Whereas Cheng et al24 used peanuts as a natural food, the present study used an artificial test food (Optocal) that does not undergo changes in its intrinsic properties due to contact with saliva.34 The distinct
properties of natural foods and Optocal may explain the difference in the magnitude of improvement between the studies.
Considering our data, it is possible to conclude that single-implant overdenture treatment can be considered as a choice for the elderly population with loss of residual alveolar bone height. This rehabilitation improved patients’ satisfaction with their mandibular prostheses stability and increased objectively their masticatory efficiency, even though showing a decreased on aesthetics satisfaction. However, it is important to mention that there are many other factors that can influence food choice, as socio-economics status, cultural beliefs and personal preference,43 and greater masticatory efficiency may not improve nutritional status.43 Thus, future studies on nutritional intake of elderly people using single implant overdentures are important, and additional longitudinal clinical trials are needed to confirm the long-term success of this type of oral rehabilitation in terms of elders perceptions and masticatory function as well.
Conclusion
After two months of conventional complete dentures and single-implant overdenture use, elderly people with decreased residual ridge bone height were more satisfied with the aesthetics of mandibular conventional dentures when compared to the overdentures. Additionally, a significantly increase on satisfaction with stability and objective masticatory efficiency was observed after single-implant overdenture use.
Acknowledgments
The authors report no conflicts of interest related to this study. This study was supported by grant number 2015/21704-1 from São Paulo Research Foundation (FAPESP).
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2.2 ARTIGO 2
Sensorial ability, mastication and nutrition of single-implant overdentures wearers Short title: One-implant overdenture and related aspects
Camilla Fraga do Amarala; Gustavo Almeida Souzab; Mayara Abreu Pinheiroa; Camila Heitor Camposc; Renata Cunha Matheus Rodrigues Garciaa.
a. Department of Prosthodontics and Periodontology Piracicaba Dental School, University of Campinas
Avenida Limeira, 901, 13414-903. Piracicaba, São Paulo, Brazil.
b. Department of Oral and Maxillofacial Surgery Piracicaba Dental School, University of Campinas
Avenida Limeira, 901, 13414-903. Piracicaba, São Paulo, Brazil.
c. Department of Specific Formation
Nova Friburgo Health Institute, Federal Fluminense University
Rua Dr. Silvio Henrique Braume, 22, 28625-650. Nova Friburgo, Rio de Janeiro, Brazil.
Corresponding author:
Renata Cunha Matheus Rodrigues Garcia
Avenida Limeira, nº 901, Bairro Areião, Piracicaba, SP, Brazil, CEP: 13414-903 Phone Number: + 55 19 2106-5240, Fax Number: + 55 19 2106-5211
Summary
The use of two-implant overdentures improves mastication of edentulous elderly patients. However, little is known about the effects of single-implant overdentures (SIO) on oral perception and masticatory function in such elders. This study compared the effects of conventional complete dentures (CD) and SIO on the oral sensorimotor ability (OSA), masticatory function, and nutritional intake of elderly people with residual alveolar mandibular height classified as Class III or IV according to the American College of Prosthodontics. Twelve elders first received new conventional CD, which were later converted to SIO. All variables were evaluated after use of each prosthesis for 2 months. To evaluate OSA, elders closed their eyes and orally identified test pieces prepared from raw carrots. A kinesiographic device was used to measure chewing movements during mastication of a test material (Optocal). Masticatory performance (MP) was determined with the sieving method, and a 3-day food diary verified nutrient intake based on a standard Brazilian Food Composition Table. Data were analyzed using the Wilcoxon signed rank test and Student’s paired t test (P < 0.05). OSA results did not differ according to prosthesis type. However, opening and closing velocities during chewing and MP increased after SIO insertion (P < 0.05). Although no difference was observed in the intake of most nutrients, sodium ingestion decreased after SIO insertion (P < 0.05). SIO use had no effect on OSA, but significantly improved mastication and reduced sodium intake of elders with decreased residual ridges height (Brazilian Registry of Clinical Trials #RBR-3kgttj).
Introduction
Complete denture (CD) wearers with severely loss of bone height may present chewing problems due to the lack of retention and stability of the mandibular dentures (1), which could negatively impact food selection and nutritional intake among elderly individuals, reflecting in their frailty process (2). The performance of masticatory processes, such as positioning of food between the teeth, breaking down it into smaller particles, and preparating bolus food for swallowing, is considered to be essential for proper oral function (3).
In the body, the somatosensory system is responsible for the oral tactile perception of stimuli, whether mechanical, chemical or physical. Sensory innervation involves receptors in periodontal ligament, oral mucosa, muscles of mastication, and the temporomandibular joints (4). Neurophysiological interactions at the cerebral cortex between sensory and motor units of the trigeminal nerve are necessary in order to chewing muscles prosecute function (5). In the absence of teeth, spatial control of jaw movements during mastication is impaired and masticatory forces are reduced in elders (3). Oral motor ability may also be impaired because of the absence of proprioception from the periodontal ligament and the denture’s coverage of some receptors (1).
To improve the masticatory function and food comminution of elders with loss of residual ridges height, overdentures with two mandibular implants have been used (6). The use of a mandibular single-implant overdenture (SIO) opposing a maxillary CD have also been proposed for such patients, due to advantages such as less-invasive implant surgery and reduced component costs (7). Although SIO use has been reported to improve patients’ masticatory efficiency, satisfaction, and quality of life (8,9), little is known about whether it can improve nutrient intake among elderly people.
Usually, CD wearers present lower intake of fruits, vegetables and fibers (10). Conversely, they consume more foods containing saturated fat in comparison with similar dentate individuals (11). In addition, elders may adjust their diet composition by refusing raw foods or cooking it for more time in order to make it easier to prosecute chewing function, which reduce their nutritional daily intake (10). However, according to some authors (12), two implant-supported mandibular overdentures insertion improves nutritional state of edentulous elderly people (12), because its better retention and stability (13). Thus,
considering that SIO also improves prosthesis stability (7), it can be supposed that they should also influence nutritional intake of elderly people.
Besides the prosthetic factor, masticatory performance (MP), can be associated with oral sensorimotor ability (OSA). Oral sensory receptors located at the oral mucous membrane perceive physical foods, initiate coordination of oral motor muscle functions to chew and prepare food bolus for swallowing (14). Thus, one could reasonably suppose that the age-related decline in oral sensory function (1) impairs mastication, ultimately contributing to poor nutrient intake, in edentulous elders. OSA is known to be similar in patients with two-implant overdentures and those with two-implant-supported fixed prostheses (15). However, no report has described OSA in edentulous elders who have undergone rehabilitation with SIO.
In addition, mastication is controlled by peripherical and central nervous feedback system, and the sensory awareness when chewing provides information about the relative position and movements of the mandible (15). Therefore, OSA could also influence masticatory movements of edentulous elderly patients using SIO.
Considering that an SIO can improve function by providing stability and retention to the mandibular prosthesis (8), the working hyphotesis is that SIO could also improve the sensory function and mastication of elderly people with loss of residual ridges. Thus, the aim of the present study was to determine whether the increased mandibular retention and stability provided by an SIO improves OSA, chewing movements, MP, and nutritional intake of edentulous elderly patients.
Materials and Methods
This unblinded observational clinical trial had a paired and controlled design. The Ethics Committee of Piracicaba Dental School, University of Campinas (Piracicaba, Brazil), approved the research protocol (#087/2015). Participants signed an informed consent document after being given a full explanation of the study.
Completely edentulous subjects first received new conventional CDs. Later, single implants were installed in the anterior region of the mandible by a single operator. Then, conventional CDs were converted to SIOs by a distinct researchers after a healing period. After 2 months use of each prosthetic treatment, OSA, mandibular movements, MP, and
