Journal of Oral Rehabilitation 2006 33; 416–422

Evaluation of transitional implant stabilized overdentures:

a case series report
C . O H K U B O * , M . K O B A Y A S H I †, Y . S U Z U K I ‡, J . S A T O §, T . H O S O I ¶ &
K . S . K U R T Z * * *Department of Removable Prosthodontics, Tsurumi University School of Dental Medicine, Yokohama, Japan,
†
Department of Removable Prosthodontics, Tsurumi University School of Dental Medicine, Yokohama, Japan, ‡Department of Removable
Prosthodontics, Tsurumi University School of Dental Medicine, Yokohama, Japan, §Division of Maxillo-facial Oral Implant, Tsurumi University
School of Dental Medicine, Yokohama, Japan, ¶Department of Removable Prosthodontics, Tsurumi University School of Dental Medicine,
Yokohama, Japan and **International Program in Prosthodontics, New York University College of Dentistry, New York , NY, USA

SUMMARY Transitional implants (TI) can immedi-
ately improve the stability and retention of existing
unstable mandibular complete dentures. This study
evaluated the improvement of mandibular com-
plete denture stability and retention with the use of
TI. Three TIs were placed in the intraforaminal
region of the edentulous mandible of seven patients
(three men, four women; mean age 69Æ7 years). The
patients’ existing mandibular complete dentures
were immediately modified to TI-stabilized over-
dentures. Their masticatory movements (mandibu-
lar movements during mastication) were measured
using a commercially available tracking device
(BioPACK, Bioresearch, Japan), both before TI
placement and about 1 month after delivery of the
TI-stabilized overdentures. The mean time of each
chewing phase (opening, closing, and occluding)
and coefficients of variation were calculated. The
patients also completed a questionnaire about the
foods they could chew and indicated on a 100 mm
Visual Analog Scale (VAS) their personal levels of
comfort, ease of chewing, speech, and stability. For
masticatory movements, there were no significant
differences (P > 0Æ05) between the TI-stabilized
overdentures and existing complete dentures. How-
ever, the number of foods that could be chewed
increased, and the stability and comfort were repor-
ted as improved with the TI-stabilized overden-
tures. Using TIs, the stability and comfort of the
existing mandibular complete dentures studied in
this report could be immediately improved.
KEYWORDS: transitional implant, overdenture, com-
plete denture, masticatory movements, denture
stability
Accepted for publication 10 September 2005

the mandibular complete denture may not be receptive

Introduction
Treatment with osseointegrated dental implant-
retained overdenture prostheses is a well-accepted and
highly predictable treatment modality for edentulous
patients (1–5). If a sufficient number of implants are
placed, improved efficiency of implant-retained and
supported overdentures can be obtained (6–8). How-
ever, this protocol requires certain healing periods
based on the implant surface and implant type (9).
Some edentulous patients whose chief complaints are
related to discomfort, instability and lack of retention of
to an extended treatment time (10). Some patients
request immediate treatment to solve their problems.
Transitional implants (TIs) were developed to support
provisional fixed restorations during osseointegration of
definitive implants and are usually placed simulta-
neously at the time of definitive implant placement
(11–15). They are generally removed prior to place-
ment of the final implant prosthesis (13, 15). The
primary treatment goal of TIs is to serve as fixed
abutments for provisional prostheses during osseointe-
gration of the definitive implants. Other uses of TIs

ª 2006 Blackwell Publishing Ltd doi: 10.1111/j.1365-2842.2005.01580.x

 EVALUATION OF TI-STABILIZED OVERDENTURES 417

Table 1. Characteristics of seven patients participating in this tures (CD) that were <5 years old. The primary
study complaints among the patients were related to the
instability and lack of retention of the mandibular
Patient Age (years) Gender Maxirary arch
dentures. The approval of the Ethical Committee for
M. S 56 Man CD Human Clinical Research at the Tsurumi University
A. K 72 Woman CD School of Dental Medicine (no. 026) was procured, and
T. A 60 Woman CD
a signed informed consent form was obtained from all
A. Y 74 Man CD
S. I 76 Woman PD patients before the initiation of treatment.
T. K 76 Woman CD
I. K 74 Woman CD
Modification to TI-stabilized overdentures

include stabilization of existing dentures, protection of
osseous graft sites, and as vertical stops for tissue
supported prostheses during the healing period (15). In
the TI system used in this investigation, three imme-
diate provisional implants (IPIs)* were placed for each
patient, and IPI copings were fit on the existing denture
bases (16).
Some studies have shown that the prognosis is good for
immediate loading with definitive implants (17–21).
However, TI-stabilized overdentures (TIOD) should be
used in cases in which immediate loading cannot be app-
lied and a healing period is needed. Such cases include
the placement of fewer than four definitive implants, and
cases involving poor bone quality, history of radiation
therapy in the orofacial region and bone grafting.
The purpose of this investigation was to compare the
converted TI-stabilized overdentures with existing con-
ventional mandibular complete dentures (22, 23).
TI-retained overdentures were fabricated by converting
the existing mandibular complete dentures of seven
mandibular edentulous patients. To observe the
stability of the TI-stabilized overdentures (24–28),
masticatory movements (mandibular movements
during chewing) were measured before and after TI
placement, and the patients were questioned about the
function of each denture.
Materials and methods
Seven healthy patients (three men, four women; mean
age 69Æ7 years) participated voluntarily in this study
(Table 1). The criteria of patient selection included the
absence of any systematic contraindications to implant
surgery, and the presence of sufficient bone (>14 mm
length) between the mental foramina. The existing
prostheses were acrylic resin mandibular complete den-
*Nobel Biocare, Goteborg, Sweden.
Two to 3 weeks before IPI* placement, masticatory
movements were measured using the existing mandib-
ular CD, and questionnaires about comfort and chew-
ing were completed to evaluate the existing CD without
TI (24–27).
Using surgical guides, three IPIs were placed in the
interforaminal region following the manufacturer’s
recommendations (Fig. 1a). Two or four definitive
implants were to be placed in the future (16). The
parallelism of the IPIs was confirmed, and if necessary,
the IPI heads (abutment portion of the IPI) were
adjusted using the system’s bending tool to establish
parallelism (15, 16). The intaglio surface of the existing
complete denture was relieved and free of contact with
the IPI heads. Sufficient denture base resin was removed
to accommodate the IPI copings (Fig. 1b). After the IPI
copings were fitted on the IPI heads, the clearance
between the copings and the seating of the denture base
of the CD was verified† (Fig. 1c; 16). Polymethylmeth-
acrylate acrylic resin‡ was placed in the hollowed
surface of the CD. The CD was then seated over the
IPIs in the proper original position using occlusal
force until the resin completely polymerized. After the
excess acrylic resin was trimmed and polished, the TIOD
was delivered to the patient (Fig. 1d). Three to 4 weeks
after the TIOD was delivered and the denture adjust-
ments were finalized, the masticatory movements were
measured, and the questionnaires were again completed
by the patients to evaluate the TIOD.
Measurement of masticatory movements
Masticatory movements were measured with a com-
mercially available tracking device§ (28). A small
†
Fit-checker, GC, Tokyo, Japan.
‡
Uni-fast II, GC, Tokyo, Japan.
§
BioPACK, Bioresearch, Japan.

ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 416–422

418 C . O H K U B O et al.
magnet (13 · 6 · 4 mm) was attached to the lower
surface of the anterior tooth region of both CDs and
TIODs at the midlines. The test food used was one
piece of fresh gummy candy¶ (approximately 4 gm). All
chewing was performed on the side preferred by each
patient and proceeded at the patient’s own pace until
swallowing (24–27). This process was repeated three
times per denture. The data were calculated utilizing
the BioPACK system.
The middle of the chewing cycle, i.e.10 strokes from
the initial 10–19 strokes in the chewing cycle, was
selected to compare masticatory movements. Each
individual activity was identified, and the mean time
and standard deviation of each phase (namely, the
opening phase, closing phase and occluding phase)
were measured. A coefficient of variation (CV; %) for
each individual activity and each phase was then
calculated from the standard deviation divided by the
mean time (24–27). This measurement was repeated
three times before and after IPI placement.
All data obtained were analyzed with the SPSS
statistical package**. Wilcoxen signed rank tests were
used to compare the CD and TIOD at a significance level
of a ¼ 0Æ1.
Questionnaire about comfort
After measurements of the masticatory movements, all
patients completed a questionnaire about the foods
¶
Meiji, Japan.
**Version 10Æ0, SPSS Inc., Chicago, IL, USA.
ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 416–422
Fig. 1. (a) Using a surgical guide,
three immediate provisional implants
(IPI) were placed following manu-
facturer recommendations in the
interforaminal region. (b) IPI coping
(c) IPI copings are placed on the IPI
heads (d) IPI copings were embedded
in the intaglio surface of the existing
complete denture so that the copings
were fitted on the IPI heads with
polymethylmethacrylate resin.
they could chew when the existing CD and the TIOD
were worn. This questionnaire classified 19 foods
(including traditional Japanese foods) that were ranked
from one to five according to the hardness of the food.
These foods ranged from tender (soft) foods (i.e. Tofu
and rice gruel; no. 1) to tough (hard) foods (i.e. pickled
radish, peanuts, and hard rice crackers; no. 5). After
chewing these foods while wearing each prosthesis, the
patients indicated one of three categories: (i) could
chew, (ii) could not chew and (iii) never eaten.
In addition, questionnaires based on the 100 mm
Visual Analog Scale (VAS) method (29, 30) were filled
out by the subjects to assess their personal opinion
based on eight factors: comfort, fitness, stability, ease of
removal, speech, sucking, swallowing and chewing
(Fig. 2).
Results
The mean time with SD and CV (%) for each individual
activity and their phases are shown in Fig. 3a,b. There
Comfort
In general, are you comfort with your lower prosthesis?
Not at all Totally
comfortable X comfortable
65 mm
Fig. 2. Example of a visual analog scale translated into English.
The distance from the end of the horizontal line on the left to the
mark with an ‘X’ made by the subject was measured in
millimetres.
 EVALUATION OF TI-STABILIZED OVERDENTURES 419

(a) them after TIOD modification. Three patients could

1200 chew moderately hard foods (rank 3: boiled fish paste,
Conventional complete denture
sliced ham and raw squid) while wearing the CDs, and
1000 IPI-stabilized overdenture
all the patients could chew them while wearing the
800 TIODs. All of the patients could chew tender foods in
ranks 1–2 using both denture prostheses.
mS

600 The results of the VAS scores based on the eight

criteria are shown in Fig. 4. There were few changes in
400 the score for the TIOD for the ease of removal of the
denture (z ¼ )0Æ507, P ¼ 0Æ612) but the scores of the
200
other seven criteria were significantly higher (fitness:
0
z ¼ )2Æ197, P ¼ 0Æ028; stability: z ¼ )2Æ366, P ¼ 0Æ018;
Opening Closing Occluding Cycle sucking: z ¼ )2Æ201, P ¼ 0Æ028; swallowing:
z ¼ )2Æ366, P ¼ 0Æ018; chewing: z ¼ )2Æ028,
(b)
100 P ¼ 0Æ043; speech: z ¼ )2Æ197, P ¼ 0Æ028; comfort:
Conventional complete denture
90 z ¼ )2Æ366, P ¼ 0Æ018). The greatest increase in the
IPI-stabilized overdenture
80 criteria evaluated in this test was the denture stability of
70
the TIOD.
60

Discussion
(%)

50

40
30
20
10
0 occur (1–5). Many patients experience difficulties
Opening Closing Occluding Cycle
Fig. 3. (a) Mean time of each individual activity and each of three
phases. (b) Coefficient of variation of 10 activities and their phase.
There are no significant differences between the two dentures for
the mean time and coefficient of variation.
were no significant differences in the mean time
between the TIOD and the existing CD (opening:
z ¼ 0Æ00, P ¼ 1Æ0; closing: z ¼ )1Æ859, P ¼ 0Æ063;
occluding: z ¼ )1Æ521, P ¼ 0Æ128; cycle: z ¼ )1Æ183,
P ¼ 0Æ237). The CV for the TIOD was smaller than for
the conventional CD, except for the closing phase.
However, there was no significant difference in these
activities (CV: z ¼ )1Æ014, P ¼ 0Æ310; closing:
z ¼ )1Æ183, P ¼ 0Æ237; occluding: z ¼ )1Æ014,
P ¼ 0Æ310; cycle: z ¼ )0Æ507, P ¼ 0Æ612) and their
phases (P > 0Æ10) between the existing CDs and modi-
fied TIODs.
Table 2 shows the changes in the foods that the
patients could chew using the CD and TIOD. Although
four of the seven patients could not chew the toughest
foods in rank 5 (pickled radish and hard rice cracker)
with conventional CDs, five of the seven could chew
Using a classic two-stage surgical protocol, mandibular
overdentures retained by four implants generally
require a 3-month healing period, depending on the
implant surface, stability etc. for osseointegration to
during the healing phase, such as ill-fitting and unsta-
ble prostheses, and inadequate chewing ability during
this period (9). Accepted implant overdenture modal-
ities now include immediate loading methods (9). The
TIOD may also immediately improve patient satisfac-
tion with their modified prostheses during the healing
period.
However, the manufacturer (Nobel Biocare) suggests
that IPIs cannot be used for a long period of time
because fracture might occur if they serve as fixed
provisional restorations for >1 year. Therefore, IPIs
should be removed before the final prosthesis suppor-
ted by definitive implants is delivered. Regarding
removal of IPIs, Babbush et al. (15) reported that only
one out of 53 IPIs (12 patients) appeared to have
osseointegrated; the others (52 IPIs) could be removed
by reverse torque. In our cases, the IPIs that remained
stable were easily removed without complication.
Furthermore, they did not cause any harm to the bone
as no ostemyelitis, pain, or radiolucency were observed.
Regarding masticatory movements, there is no signi-
ficant difference between the conventional CD and the
TIOD. The CV of the opening and occluding phases, and

ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 416–422

420 C . O H K U B O et al.

Table 2. Foods that patients could chew

Before After

Rank Test foods Could chew Could not chew Never eaten Could chew Could not chew Never eaten

5 Pickled radish 2 5 5 1 1
Peanuts 3 4 5 1 1
Hard rice cracker 2 5 4 2 1
Rice cake 4 2 1 6 1
4 Beef steak 5 2 6 1
French bread 2 5 4 2 1
Dried squid 1 5 1 3 1 3
Carameled rice cake Pickle 3 1 3 5 1 1
Octopus 3 2 2 4 3
3 Steamed seasoned rice 5 2 7
Boiled fish paste 5 2 7
Ham 5 2 7
Sliced raw cuttlefish 3 4 6 1
2 Sliced raw tuna 7 7
Eel split and broiled 7 7
Cooked fish 7 7
Rice 7 7
1 Rice gruel 6 1 7
Bean curd 7 7

Conventional complete denture number of foods, it is simple compared with other

IPI-stabilized overdenture masticatory performance tests but there is high corre-
100
lation between these tests (31). The foods that patients
80
reported being able to chew increased with the TIODs,
60 specifically the moderately hard foods and the toughest
(%)

foods.
40
In this study, all patients used mandibular acrylic
20 resin CDs with instability and poor retention, which
were the primary source of patient complaints. There-
0
fore, patient satisfaction improved with TI-retention, as
g

rt
ch
g

in
g
s

fo
in

indicated by the VAS. Only the ease of denture removal

ee
es

in

w
y

om
ck
al
lit
tn

Sp
w

he
ov

Su

lo
bi
Fi

C
C
al
a

em

had a similar VAS score between the ‘before’ and ‘after’

St

Sw
fr
eo

assessments. The retention system of the TIOD in this

as
Ee

study uses contact or friction between the IPI head and

Fig. 4. Results of Visual Analog Scale (VAS) scores based on the
eight criteria before and after transitional implant (TI) placement.
The lines connect columns that are significantly different
(P < 0Æ05).
chewing cycle for the TIODs tended to be smaller than
for the conventional CDs. These phenomena may
indicate that the TIOD improves the stability and
chewing of the existing CD.
The questionnaire about the ease of difficulty of
chewing certain foods was modified in our Department.
As this test does not require any extra devices or a large
IPI coping. Therefore, the use of an O-ring fit on the IPI
head is recommended (16).
Summary
To evaluate the efficiency of the TI, the performance of
the TIODs and conventional CDs for seven patients was
compared. Masticatory movements were measured for
both dentures, the patients were questioned about the
foods that could be chewed, and eight prosthetic criteria
were evaluated. Within the limits of this study, the
following results were obtained:

ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 416–422

 EVALUATION OF TI-STABILIZED OVERDENTURES
1 The mean time and CV of masticatory movements
were not significantly (P < 0Æ1) affected by TI retention.
2 The number of foods that the patients could chew
increased when the TIOD was worn.
3 Except for the ease of removal of the denture, the
patients preferred the TIOD for seven criteria, namely,
comfort, fitness, stability, speech, sucking, swallowing
and chewing.
Until a denture is assisted by definitive implants
during the healing period, the use of a TIOD could
avoid some patient discomfort.
Acknowledgment
This research was partially supported by Research Grant
No. 05-04 from Tsurumi University Dental Association.
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Correspondence: Chikahiro Ohkubo, Department of Removable Pros-
thodontics, Tsurumi University School of Dental Medicine, 2-1-3
Tsurumi Tsurumi-ku, Yokohama 230-8501, Japan.
E-mail: okubo-c@tsurumi-u.ac.jp