Journal of Dental Research

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Masticatory Function with Implant-supported Overdentures

F.M.C. van Kampen, A. van der Bilt, M.S. Cune, F.A. Fontijn-Tekamp and F. Bosman
J DENT RES 2004 83: 708
DOI: 10.1177/154405910408300910

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 RESEARCH REPORTS
Clinical

F.M.C. van Kampen1,2, A. van der Bilt1*,

M.S. Cune1, F.A. Fontijn-Tekamp1, Masticatory Function
and F. Bosman1
with Implant-supported
1 Department of Head and Neck, Oral-Maxillofacial

Surgery, Prosthodontics and Special Dental Care,

University Medical Center Utrecht, Str. 4.115, PO Box
Overdentures
85.060, 3508 AB Utrecht, The Netherlands; and 2Central
Military Hospital, Utrecht, The Netherlands;
*corresponding author, [Link]@[Link]

J Dent Res 83(9):708-711, 2004

ABSTRACT INTRODUCTION
The type of attachment that is used in implant-
supported mandibular overdentures may influence
the retention and stability of the prosthesis and,
C omplete-denture wearers frequently report problems with oral function,
typically caused by retention and stability problems of the mandibular
prosthesis. Masticatory function of these subjects is quite poor in
thus, masticatory function. In this within-subject comparison with that of healthy dentate subjects (Slagter et al., 1993;
cross-over clinical trial, we examined the Fontijn-Tekamp et al., 2000). Complete-denture wearers need up to 7
hypothesis that greater retention and stability of times more chewing strokes than subjects with a complete natural
the overdenture improve the masticatory function. dentition to reduce the food to half of the original particle size. Oral
Eighteen edentulous subjects received 2 oral function significantly improves after mandibular implant overdenture
implants, a new overdenture, and, successively, 3 treatment. Most studies on implant treatment and oral function showed a
different suprastructure modalities: magnet, ball, significant improvement of the objective masticatory performance in the
and bar-clip. Masticatory performance, mandible (Haraldson et al., 1988; Geertman et al., 1994, 1999; Pera et al.,
masticatory efficiency, and swallowing threshold 1998; Fontijn-Tekamp et al., 2000; Bakke et al., 2002). Subjects with
were measured. The masticatory function mandibular implant-supported overdentures need 1.5 to 3.6 times fewer
significantly improved after implant treatment chewing strokes than complete-denture wearers to obtain an equivalent
with each of the 3 attachments. We observed small reduction in food particle size (Geertman et al., 1994). However, in
differences in masticatory function among the 3 another study, no significant advantage in masticatory performance was
attachment types: slightly better masticatory found for implant-supported overdentures compared with conventional
performance with ball and bar-clip than with dentures (Garrett et al., 1998).
magnet attachments. The number of chewing The degree of mandibular overdenture support, 2 vs. 4 implants
cycles until swallowing hardly decreased after (Geertman et al., 1994), or fixed vs. removable prostheses (Feine et al.,
implant treatment. We conclude that significantly 1994; Tang et al., 1999) did not influence the masticatory performance.
better masticatory performance, combined with a Nevertheless, the attachment type in implant-supported mandibular
slightly smaller number of chewing cycles after overdentures may influence the retention and the stability, and thus the
implant treatment, results in smaller food particles oral function, of the prosthesis. This aspect has never been studied within
being swallowed. the same subjects. Therefore, we designed a within-subject cross-over
clinical trial to study the effects of 3 mandibular implant overdenture
KEY WORDS: masticatory performance, suprastructure modalities using magnet, bar-clip, and ball attachments. We
swallowing threshold, oral implant, mandibular demonstrated that maximum bite force nearly doubles after implant
overdenture, attachment. treatment with these 3 suprastructure modalities, while no significant
differences in maximum bite force occur among the 3 attachment types
(van Kampen et al., 2002). How this affects masticatory function remains
unclear.
The aim of the present study was to test the hypothesis that mandibular
conventional denture treatment, implant-supported overdenture treatment,
and attachment type affects masticatory performance and efficiency as well
as swallowing threshold. Therefore, we measured these variables in 18
subjects before and after treatment with 2 oral implants in the mandible
using the 3 suprastructure modalities. These suprastructures were worn
successively in a randomized order by all subjects, so we could make a
Received June 24, 2003; Last revision June 24, 2004; within-subject comparison of the masticatory function obtained with the 3
Accepted June 28, 2004 attachment types.

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J Dent Res 83(9) 2004 Masticatory Function with Overdentures 709

MATERIALS & METHODS and the size after 15 and 30 chewing strokes (van der Bilt et al.,
1987).
Subjects We examined the swallowing threshold by having the subjects
Eighteen edentulous subjects from the Royal Dutch Army and Air chew on a piece of breakfast cake. The subjects chewed the
Force participated in this randomized cross-over clinical trial. They breakfast cake (4 g; size 20 x 20 x 20 mm) normally and swallowed
were referred to the Center for Special Dental Care at the Central it. The examiner counted the number of chewing strokes needed
Military Hospital in Utrecht because of persistent complaints with until swallowing occurred. This measurement was performed twice,
their conventional mandibular dentures. The group consisted of and the number of chewing strokes was averaged for each subject.
one female and 17 male subjects with a mean age of 51.6 yrs Procedure
(range, 33 to 56 yrs), all fit for military service. This cohort of
We measured the masticatory performance and the swallowing
subjects is a convenience sample. They had been edentulous in the
threshold at 5 moments during the 14-month treatment period. The
mandible for an average of 18 yrs and had worn, on average, 3
first measurement was performed with the old denture, just prior to
mandibular dentures. Their bone height in the inter-foraminal
the first-stage surgery. The second measurement was performed
region of the mandible exceeded 15 mm. The Ethics Committee of
just prior to the second-stage surgery, after the newly made denture
the University Medical Center approved the protocol. Written
without attachments had been used for 3 mos. We performed the
informed consent was obtained from each subject after a full
next 3 measurements at the end of each three-month period during
explanation of the clinical trial.
which the various attachment types were incorporated into the
Surgical and Prosthetic Procedures dentures.
The subjects received 2 oral implants (Frialit-2, Friadent, Statistical Analysis
Friedrichsfeld, Germany; diameter, 3.8 mm; length, 13 or 15 mm).
We applied repeated-measures analysis of variance (ANOVA) to
The implants were placed in the region of the 2 former cuspids,
test the null hypothesis that there would be no statistical difference
according to a standardized two-stage surgical protocol. New
between the results obtained at the 5 occasions. Subsequently, post
conventional dentures in the maxilla and mandible were made
hoc tests (least significant difference multiple-comparison test) were
following first-stage surgery. The dentures were made in centric
used for pairwise comparisons of results. Pearson correlations were
occlusion with balanced articulation and anatomically shaped acrylic
calculated between the change in masticatory performance due to the
teeth (Bonartic, Ivoclar, Schaan, Liechtenstein). In each quadrant, 1
treatment and the masticatory performance with the old denture.
bicuspid and 2 molars were used. Subjects started to wear their new
dentures without attachment 2 mos after first-stage surgery, for a
three-month period. After second-stage surgery, 5 mos after RESULTS
implantation, the mandibular dentures were successively fitted with
Masticatory Performance
magnets (Dyna Magnet ES, Dyna Dental Engineering, Bergen op
Zoom, the Netherlands), bar-clips (IMZ, Friadent Friedrichsfeld, Values of the average median particle sizes after 15 and 30
Germany), or ball (Frialit-2, Friadent Friedrichsfeld, Germany) chewing cycles (masticatory performance) are listed for the 5
attachments. The sequence in which the 3 attachments were applied measuring moments (Table). Repeated-measures ANOVA
was randomized (van Kampen et al., 2002). All 6 possible sequences showed a significant effect (p < 0.001) of the 5 situations—old
were used, so that possible cross-over effects could be studied. In and new dentures, and dentures attached with a magnet, bar-
that way, 6 groups of three subjects were formed, each group having clip, or ball attachment—on median particle size after 15 and
a different sequence of successive attachments. Each attachment 30 chewing cycles. Post hoc analysis showed that the median
type was used during a three-month period. particle size obtained with the unsupported new denture was
significantly larger than that for the old denture (p < 0.05). The
Masticatory Function and Swallowing Threshold masticatory performance significantly improved with the
We measured the masticatory function of all subjects by asking implant-supported new denture in comparison with that of the
them to chew on cubes of a dental impression material. This old and new dentures without implant support (p < 0.001). The
material (Optosil plus, Bayer AG, Leverkusen, Germany) was masticatory performance obtained with the magnet attachment
specially prepared to make it more brittle, so that it
could be fragmented by all participants (Fontijn- Table. Masticatory Function of 18 Subjects Wearing Unsupported and Implant-
Tekamp et al., 2004). The subjects chewed on supported Dentures
portions of 17 cubes with an edge size of 5.6 mm
(approximately 3 cm 3 ) for 15 and 30 chewing Performance Efficiency Swallowing
strokes. We determined the degree of fragmentation Attachment Denture X50(15) (mm)a X50(30) (mm)b N1/2c Nswallowd
of the chewed food portions by sieving the food
through a stack of 8 sieves, with square apertures None old 4.5 ± 0.8e 3.3 ± 0.7 47.0 ± 23.9 35.5 ± 13.7
between 5.6 and 0.5 mm and a bottom plate. The None new 4.9 ± 0.9 3.5 ± 0.8 50.9 ± 23.9 32.3 ± 13.9
degree of fragmentation of the food (chewing Magnet new 3.9 ± 0.9 2.7 ± 0.8 32.7 ± 22.2 28.8 ± 9.7
performance) is given by the median particle size, Bar-clip new 3.7 ± 0.5 2.4 ± 0.4 24.6 ± 6.0 29.1 ± 14.9
X 50, which is the aperture of a theoretical sieve Ball new 3.6 ± 0.6 2.4 ± 0.5 25.5 ± 12.9 31.6 ± 10.8
through which 50% of the weight of the comminuted
a Median particle size after 15 chewing cycles.
food could pass (van der Bilt et al., 1993). The b Median particle size after 30 chewing cycles.
number of chewing strokes needed to halve the c Number of chewing cycles needed to halve the initial size of the artificial test food.
initial median particle size (chewing efficiency), d Number of chewing cycles needed to prepare the breakfast cake for swallowing.
e Values are means ± standard deviation.
denoted as N1/2, was calculated from the initial size
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International and American Associations for Dental Research

710 van Kampen et al. J Dent Res 83(9) 2004

the supported new denture (p < 0.10 for all 3 attachments).

DISCUSSION
Masticatory Function
Masticatory performance deteriorated significantly when the
old dentures were replaced by new dentures without
attachments. Eleven out of 18 subjects had larger median
particle sizes, thus poorer masticatory performance, after the
old dentures were replaced with unsupported new dentures
(triangles in Fig.). The reduction in masticatory performance
did not lead to a significant increase in the number of chewing
cycles needed to halve the initial size, although some increase
was observed (Table). In a previous study, we observed a
reduction of about 20% in the maximum bite force after
Figure. Changes in the median particle size for the unsupported
(triangles) and supported new dentures (bar-clip attachment; circles) as denture treatment (van Kampen et al., 2002). This bite force
compared with the old denture are plotted as a function of the median reduction may be caused by mucosal soreness above the
particle size (X50) obtained with the old denture for 18 subjects. The submerged implants and adjustment of the subjects to new
results were obtained after 15 chewing cycles. Linear regression is dentures. Significant correlations between maximum bite force
indicated by the dashed lines. The changes in median particle size due
to implant treatment and the median particle size before treatment were
and masticatory performance were reported (Fontijn-Tekamp et
significantly correlated for the bar-clip and ball attachments (both p- al., 2000). Thus, the reduced maximum bite force may partly
values < 0.001) and for the magnet attachment (p < 0.05). explain the reduced masticatory performance. Deterioration of
masticatory performance after denture treatment has been
commonly observed (Lundquist et al., 1986; Garrett et al.,
1996).
was less effective than that with the bar-clip and ball After the new overdenture was attached to the oral implants,
attachments (p < 0.05), whereas no differences were observed we observed a significant improvement in masticatory function.
between performances with the bar-clip and ball attachment. All subjects chewed the food better, and thus achieved smaller
The individual changes in the median particle size after 15 median particle sizes after 15 as well as 30 chewing cycles. This
chewing cycles for the unsupported and supported new denture is reflected in negative values for the change in median particle
as compared with the old denture are shown as a function of the size for the supported new denture (circles in Fig.). We
median particle size obtained with the old denture (Fig.). The observed a significant negative correlation between the change
majority of the subjects had larger median particle sizes, thus in median particle size due to implant treatment and the median
poorer masticatory performance, with the unsupported new particle size obtained with the old denture. This means that the
denture than with the old denture, whereas all subjects had improvement in masticatory performance that can be expected
smaller median particle sizes when the new denture was depends on the masticatory performance before treatment.
supported by the bar-clip attachment. Similar results were Subjects with a relatively large median particle size before
obtained for the magnet and ball attachments but are not shown treatment (bad chewers) benefited more from the implant
so that congestion of data points can be avoided. A significant treatment than did subjects with a smaller median particle size
correlation between the change in median particle size and the (good chewers). The negative correlation could be attributed to
median particle size, as obtained with the old denture, was a so-called 'regression to the mean', where relatively large
observed when the new denture was supported by the bar-clip values obtained in the first measurement have a larger chance to
and ball attachment (r = -0.8; p < 0.001) and by the magnet be smaller in the second measurement, and vice versa. However,
attachment (r = -0.5; p < 0.05) for the measurements after 15 in a study on 81 healthy dentate subjects, where we measured
and 30 chewing cycles. the median particle size on 2 occasions with a three-month time
Masticatory Efficiency interval, there appeared to be no significant correlation between
Values of the average number of chewing cycles needed to the change in median particle size and the median particle size
halve the initial size (masticatory efficiency) are listed for the 5 at the first measurement (r = -0.19; p = 0.08, unpublished
measuring moments (Table), which did not significantly observation). In a study on the effect on oral function of
change from old to new dentures. However, a significant optimizing a denture, the subjects with the poorest pre-treatment
decrease occurred after implant treatment: from 50 to 25 for the values also benefited the most (Lundquist et al., 1986).
bar-clip and ball attachments (p < 0.001) and to 33 for the The improvement in masticatory efficiency obtained with
magnet attachment (p < 0.005). the magnet attachment was smaller than with the bar-clip and
ball attachments. The number of chewing cycles needed to
Swallowing Threshold halve the initial size was 33 with the magnet vs. 25 with the
The numbers of chewing strokes that subjects needed before bar-clip and ball attachments. We observed a similar trend in
they swallowed a piece of breakfast cake were tracked (Table). maximum bite force (van Kampen et al., 2002). The maximum
Repeated-measures ANOVA showed a significant effect (p < bite force obtained with the magnet attachment was
0.05) for the 5 situations on the swallowing threshold. Post hoc significantly smaller than the force obtained with the ball
analysis showed that the number of chewing cycles until attachment. This lower force may be caused by the much
swallowing with the old denture was slightly larger than with smaller retention force of the denture with the magnet
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J Dent Res 83(9) 2004 Masticatory Function with Overdentures 711

attachment (van Kampen et al., 2003). The lower retention of improvements of poorly fitting dentures and new dentures on
the mandible and the smaller resistance against horizontal masticatory performance. J Prosthet Dent 75:269-275.
movement (although the latter was not actually measured), in Garrett NR, Kapur KK, Hamada MO, Roumanas ED, Freymiller E,
combination with the conventional maxillary denture, may lead Han T, et al. (1998). A randomized clinical trial comparing the
to less denture stability during chewing and thus to a reduced efficacy of mandibular implant-supported overdentures and
masticatory performance. Indeed, subjects who received conventional dentures in diabetic patients. Part II. Comparisons of
mandibular overdentures with magnet attachments preferred a masticatory performance. J Prosthet Dent 79:632-640.
more retentive solution because of the denture instability they Geertman ME, Slagter AP, van Waas MAJ, Kalk W (1994).
experienced (Naert et al., 1999). Comminution of food with mandibular implant-retained
overdentures. J Dent Res 73:1858-1864.
Swallowing Threshold Geertman ME, Slagter AP, van 't Hof MA, van Waas MAJ, Kalk W
The effect of implant treatment on the swallowing threshold (1999). Masticatory performance and chewing experience with
was limited. The number of chewing cycles needed to prepare implant-retained mandibular overdentures. J Oral Rehabil 26:7-13.
the food for swallowing with the implant-supported Hamada MO, Garrett NR, Roumanas ED, Kapur KK, Freymiller E,
overdenture was only slightly smaller than with the old denture Han T, et al. (2001). A randomized clinical trial comparing the
(p < 0.10). Since the masticatory performance increased efficacy of mandibular implant-supported overdentures and
significantly (p < 0.001), and the number of chewing cycles conventional dentures in diabetic patients. Part IV: Comparison of
until swallowing hardly changed, we may conclude that, after dietary intake. J Prosthet Dent 85:53-60.
implant treatment, the food is better-chewed before it is Haraldson T, Jemt T, Stålblad P, Lekholm U (1988). Oral function in
swallowed. This may have a positive effect on the digestion of subjects with overdentures supported by osseointegrated implants.
the food. Indeed, improvement of the nutritional state of Scand J Dent Res 96:235-242.
edentulous people was observed after mandibular overdenture Lundquist LW, Carlsson GE, Hedegård B (1986). Changes in bite force
treatment (Morais et al., 2003). However, successful prosthetic and chewing efficiency after denture treatment in edentulous patients
treatment does not necessarily result in a satisfactory diet with denture adaptation difficulties. J Oral Rehabil 13:21-29.
(Hamada et al., 2001; Allen and McMillan, 2002; Shinkai et Morais JA, Heydecke G, Pawliuk J, Lund JP, Feine JS (2003). The
al., 2002), so dietary advice will be needed if subjects are to effects of mandibular two-implant overdentures on nutrition in
take advantage of the improved masticatory performance. elderly edentulous individuals. J Dent Res 82:53-58.
We conclude that mandibular implant overdenture Naert I, Gizani M, Vuylsteke M, van Steenberghe D (1999). A 5-year
treatment, opposing conventional maxillary dentures, results in prospective randomized clinical trial on the influence of splinted and
significantly better masticatory function. Only small unsplinted oral implants retaining a mandibular overdenture:
differences in masticatory function were observed among the prosthetic aspects and patient satisfaction. J Oral Rehabil 26:195-202.
magnet, bar-clip, and ball attachments. The improved Pera P, Bassi F, Schierano G, Appendino P, Preti G (1998). Implant
masticatory function after implant treatment resulted in food anchored complete mandibular denture: evaluation of masticatory
that was better-chewed when it was swallowed. efficiency, oral function and degree of satisfaction. J Oral Rehabil
25:462-467.
ACKNOWLEDGMENTS Shinkai RSA, Hatch JP, Rugh JD, Sakai S, Mobley CC, Saunders MJ
(2002). Dietary intake in edentulous subjects with good and poor
This work was supported by the University Medical Center
quality complete dentures. J Prosthet Dent 87:490-498.
Utrecht, the Military Hospital Utrecht, and the Netherlands
Slagter AP, Bosman F, van der Bilt A (1993). Comminution of two
Institute for Dental Sciences.
artificial test foods by dentate and edentulous subjects. J Oral
Rehabil 20:159-176.
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