Art-5_Pani
PROSTHETIC DENTISTRY www.stomaeduj.com
CONVENTIONAL VS SIMPLIFIED COMPLETE DENTURES
Review Articles
Eleftheria Pani1a* , Aspasia Sarafianou1b , Aspasia Chalazoniti1c , Ioli Ioanna Artopoulou1d , Gregory Polyzois1e
Department of Prosthodontics, School of Dentistry, National and Kapodistrian University of Athens, Athens, Greece
1
a
DDS, MSc; e-mail: elpani@dent.uoa.gr; ORCIDiD: https://orcid.org/0000-0003-1046-9470
b
DDS, MSc, Dr. Dent, Assistant Professor; e-mail: sarafia@otenet.gr; ORCIDiD: https://orcid.org/0000-0003-4826-2678
c
DDS, Postgraduate Student in Prosthodontics; e-mail: ahal@dhal.com; ORCIDiD: https://orcid.org/0000-0002-9833-1494
d
DDS,MSc, Dr.Dent; e-mail: iartopoulou@gmail.com; ORCIDiD: https://orcid.org/0000-0003-1711-3143
e
DDS, MScD, Dr. Dent, Professor, Head of Department; e-mail: grepolyz@dent.uoa.gr; ORCIDiD: https://orcid.org/0000-0003-0828-3423
ABSTRACT https://doi.org/10.25241/stomaeduj.2021.8(4).art.5
Background Complete dentures are fabricated with the conventional protocol which requires two impressions
-preliminary, final-, the recording of maxillomandibular relationships, two try-ins, and the delivery of the denture.
The final impression is challenging, demanding, and time-consuming. Therefore, simplified methods with the
omission of the final impression have been proposed.
Objective The aim of this systematic review is to compare the conventional with the simplified method according
to masticatory performance and ability, patient satisfaction, oral health related quality of life (OHRQoL), denture
quality, time, and cost.
Data sources An electronic search of the MEDLINE-PubMed, Scopus and Europe PMC databases was conducted
by two researchers.
Study selection Randomized clinical trials, cohort clinical studies and clinical studies of complete dentures
fabricated with the conventional or the simplified method were selected. Patients in need of a complete denture
(Participants/Population) were divided in two categories, those who were treated with the simplified technique
(Intervention) and those who were treated with the conventional technique (Comparison).
Data extraction Between these two categories various outcomes were examined: masticatory performance and
ability, patient satisfaction, OHRQoL, denture quality, time, and cost.
Data synthesis 19 articles fulfilled the inclusion criteria. Moreover, two systematic reviews and one meta-analysis
of the same topic were included. Cost and time differed significantly between the two methods favoring the
simplified protocol.
KEYWORDS
Conventional Complete Dentures; Simplified Complete Dentures; Patient Satisfaction; Clinical Outcomes; Oral
Health Related Quality of Life (OHRQoL)
1. INTRODUCTION They reconstruct all the missing hard and soft tissues.
Edentulism is the state of having lost all of the The standard protocol for fabricating a complete
natural teeth and increases following the ageing denture requires six clinical sessions followed by
of the population. According to the systematic five laboratory stages. The clinical sessions include
review and meta-analysis of Roberto et al. [1], the preliminary and final impression, maxillomandibular
prevalence of edentulism increases with age and in records, try-in of the dentures with the anterior teeth,
the elderly people this is influenced by demographic try-in with all the teeth, and finally delivery of the
and socioeconomic factors. All this indicate the complete denture. The preliminary impression is made
multifactorial etiology of edentulism [1]. with alginate on a stock tray or with compound on a
Implant therapy is well documented and can provide metal tray. The purpose of this impression is to create
a long term and efficient treatment for tooth loss. a cast which will be used to fabricate a custom tray.
However, it is not always possible to proceed with This custom tray combined with a variety of materials
implant rehabilitation for the edentulous patients due will reassure the most detailed impression. This clinical
to medication, risks, cost and time. Complete dentures session (final impression) is of the highest importance,
provide a solid rehabilitation for edentulism. as the stability of a complete denture relies on the
OPEN ACCESS This is an Open Access article under the CC BY-NC 4.0 license.
Peer-Reviewed Article
Citation: Pani E, Sarafianou A, Chalazoniti A, Artopoulou II, Polyzois G. Conventional vs simplified complete dentures: a systematic review.
Stoma Edu J. 2021;8(4):261-274
Received: November 29, 2021; Revised: December 11, 2021; Accepted: December 24, 2021; Published: December 27, 2021
*Corresponding author: Dr. Eleftheria Pani, DDS, MSc; Thivon 2, Goudi, Athens, 11527, Greece
Tel: +306932710055; Fax: +30210645992; e-mail: elpani@dent.uoa.gr
Copyright: © 2021 the Editorial Council for the Stomatology Edu Journal.
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supporting tissues. On the final casts, base plates simultaneously with the maxillomandibular records.
Review Articles are fabricated with occlusal rims to proceed with Previously, with the assistance of a preformed anterior
the maxillomandibular records, in order to transfer tooth arrangement guide (ANTAG) the position of
the final casts to the articulator. The try-in of the the maxillary anterior teeth is defined. The rest of the
complete dentures is also a two-stage approach: teeth will be placed in the laboratory by the technician
first only the anterior teeth are placed on the base who continues with the setting of the denture. In the
plates and tried-in and then all of them. After the following clinical session, the denture is delivered to
approval of both clinician and patient, the complete the patient. Interestingly, in this protocol the patient
dentures are processed and delivered to the patient never tries the dentures with all the teeth before the
[2]. This is the conventional technique, which is the delivery [5]. Ceruti et al. [6] used another version of
most widely taught technique for complete dentures a simplified protocol. This version consists of only
worldwide. There is insufficient evidence for the two clinical sessions and is defined as ‘simplified
necessity of the clinical step of the final impression. edentulous treatment (SET)’. The impression, the
Are two impressions -a preliminary and a final one- a maxillomandibular records, the selection of the teeth
prerequisite for the success of a complete denture? and the try-in of the anterior teeth are performed in
This question was the incentive for fabricating the first clinical session. After that, the technician
complete dentures with a simplified technique. completes the arrangement of the teeth and finalizes
There are protocols in the literature which suggest the denture. Therefore, in the next and last clinical
the fabrication of dentures with five, four, three or session the denture is delivered. This protocol is
even two clinical visits. It is worth mentioning that possible only by using a specific material fabricated
combining the two sessions of try-in into one converts for this purpose, the multilayer impression tray
the conventional technique into a five-step procedure. (MIT) [6,7]. As we can conclude from all the different
However, this is still considered conventional. It is, protocols, there are clinical steps which cannot be
therefore, important to clarify which steps are omitted omitted. So, the steps of at least one impression, the
in the simplified technique. As implied before, a maxillomandibular records, a try-in with all or some of
simplified protocol does not include a final impression. the teeth selected and the delivery cannot be omitted.
The five-session simplified protocol is described by Some of them may be combined in one session, but
Lira-Oetiker et al. [3]. The only difference between they definitely have to be performed. The clarification
the two protocols (conventional and simplified) used of these protocols and their stages are shown in Table
in this trial is the omittance of the final impression. 1. The stages of the conventional and the most used
Reviewing the literature, the most common simplified four-session simplified protocols are shown in Fig. 1.
protocol used is the four-session one, which includes a The simplified protocol aims to a shorter procedure
preliminary impression, maxillomandibular records, a of fabrication of the complete denture. Therefore, the
try-in, and the complete denture delivery. The majority use of a facebow and the remount of the denture in
of the researchers omit besides the final impression order to perform selected grinding before delivery,
also the second try-in session in the simplified are usually omitted.
protocol. That converts the simplified protocol into a In order to replace an established protocol with a
four-session one. The four-session simplified protocol new one, it is necessary to have adequate evidence
is thoroughly described by Duncan and Taylor [4]. In that the new protocol offers the same outcome as the
the first session the clinician makes an impression of previous one, if not better. The aim of this systematic
alginate using a stock tray, either metallic or plastic. review is to report on the current evidence and
This is the only impression required for the fabrication evaluate the differences between the simplified and
of the complete denture. The prerequisite for this the conventional method for fabrication of complete
simplified technique to be successful is, according dentures and do a narrative comparison in order to
to the writers, the knowledge of the oral anatomy. conclude if the simplified technique is equal to or
The cast produced from this impression is the final better than the conventional one. The outcomes to
cast on which the record bases with the occlusal be evaluated are masticatory performance and ability,
rims are fabricated. The next session is the recording patient satisfaction, oral health related quality of
of the maxillomandibular relationship. In the try-in life (OHRQoL), denture quality, time, cost, and cost
session the clinician and the patient evaluate the effectiveness. The null-hypothesis is that the simplified
aesthetics of the denture and test the phonetics by protocol results in superior outcomes compared to
the pronunciation of specific words and sounds. In the conventional protocol.
order to continue with the delivery of the denture,
both the patient and the clinician have to accept the 2. METHODOLOGY
denture at this session [4]. Owen and MacEntee [5] The present systematic review has been conducted
described a three-session simplified protocol defined according to the PRISMA instructions [8]. The protocol
as ‘abbreviated complete denture technique’ or of this systematic review was submitted to PROSPERO
‘minimum acceptable protocol (MAP) for complete (ID 160603). An electronic search of the MEDLINE-
dentures’. According to this, the anterior teeth are PubMed, Scopus and Europe PMC databases was
arranged by the clinician in the second session conducted by two independent researchers (PE and
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Review Articles
Table 1. Stages of conventional and simplified complete denture fabrication protocol.
Conventional protocol Simplified protocol
Table 1. Stages of conventional and simplified complete denture fabrication protocol.
Sessions 6 stages 5 stages 5 stages 4 stages 3 stages 2 stages
Preliminary X X X X X X
impression
Final impression X X
Maxillomandibular X X X X X X
records
Try-in X X X X
(anterior teeth)
Try-in X X X X
(anterior+posterior
teeth)
Delivery X X X X X X
Comments Most Not common Lira-Oetiker Most Owen & SET
common et al. [3] common MacEntee [5] Ceruti [6,7]
Figure 1. Flowchart of the conventional and the simplified protocol.
SA). The inclusion criteria were randomized clinical
trials, cohort clinical studies and clinical studies
Conventional Simplified
Simplified of complete dentures fabricated either with the
protocol protocol
protocol conventional or the simplified method. The PICO details
6-stage 4-stage can be seen in Table 2. The PICO question was formed
as such: ‘Does the simplified technique for fabrication
of complete dentures provide equal or even better
Preliminary Impression Preliminary Impression
outcomes to the treatment of the edentulous patients
than the conventional technique?’ All relevant studies
should have been published in English from January
Final Impression
1950 to January 2020. The keywords used in the
search included a combination of the following terms:
Maxillomandibular
Simplified OR conventional (technique OR method OR
Maxillomandibular
records records fabrication OR construction) AND complete dentures
AND patient satisfaction AND/OR cost AND/OR time
AND/OR masticatory ability AND/OR ability to speak
Try-in (anterior teeth) AND/OR success of the complete dentures AND/
OR performance ability. The results of the electronic
search were screened based on the relevance of the
Try-in Try-in
titles to our topic. Any disagreement between the two
(anterior+posterior (anterior+posterior reviewers was solved in consensus by discussion or by
teeth) teeth) a third reviewer (CA). Articles that appeared multiple
times during the search were considered only once.
Following that, the abstracts of the articles chosen
Delivery Delivery were read to identify if they met the inclusion criteria.
The full-text articles were then obtained and reviewed
if this determination could not be made only with
Figure 1. Flowchart of the conventional and the simplified protocol. the abstracts.
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Articles written in other languages than English and research has led to newer evidence on the topic since
Review Articles studies referring to implants, overdentures, immediate then. Our systematic review aims to overcome this
dentures and/or fixed partial dentures were excluded. limitation and include all the available information.
Furthermore, studies that did not compare the two We included these papers in the discussion section of
aforementioned methods were excluded, even if they the present review in order to compare their results
could provide information about each technique with ours and identify any differences. The flowchart
separately. for the selected articles used in this systematic review
The main difference between the two protocols can be seen in Fig. 2. The characteristics of the studies
-conventional and simplified- is the session of included are listed in Table 3.
the final impression. If the clinician performs two In the same table the risk of bias of each study
impression sessions-one preliminary and one final- individually is presented. All the included randomized
then the protocol used is called conventional. When studies except for one, were at low risk of bias. For the
the clinician takes only one impression from which study of Krishna et al.. [22] there were some concerns
the final casts will be fabricated, then we have the about the risk of bias. This doubt was raised from the
simplified protocol. randomization process because of lack of information.
The outcomes evaluated were masticatory performance The study of Duncan et al. [10] was the only one
and ability, patient’s satisfaction, oral health related evaluated with a different risk of bias assessment
quality of life (OHRQoL), denture quality, time, cost, tool (ROBINS-I). The authors of the present review
and cost effectiveness. concluded that the algorithm overestimated the risk
As part of the data extraction process, two reviewers of bias and the overall assessment for this study is
(PE, SA) independently assessed the risk of bias in the ‘no information’ and its results should be presented
included studies individually. In the present study, with precaution.
the risk of bias for randomized clinical trials was Table 4 presents the impression techniques and the
assessed according to ROBINS 2 (RoB 2) [9]. The study different materials used for final impression in each
of Duncan et al. [10] was the only study included in study.
this systematic review which was not randomized. The study of Mengatto et al. [23] could not be
Therefore, a different tool for accessing the risk of bias enlisted in any category of the materials used for the
was used (ROBINS-I) [11]. The risk of bias across the final impression, because the materials used were
studies was evaluated by GRADE, which is a system for not clarified, but rather were mentioned under the
rating the quality of a body of evidence in a systematic general term ‘compound with an impression material’.
review [12]. Interestingly, in the test group of the study of the de
The different studies included in the present review Resende et al. [15] group, the baseplate in the clinical
examined different factors. Due to this reason, they session of the try-in was relined with zinc oxide and
were compared in subgroups. A statistical analysis of eugenol. However, the procedure was defined and
the results was not feasible. considered as simplified by the authors.
Table 2. PICO question. As observed in Table 3, the included studies examined
different variables. In an effort to assess the studies’
outcomes more comprehensively, the different studies
were categorized based on their examined outcomes
(Table 5). It is worth mentioning that five outcomes
were examined only by one different research each.
This probably occurs because the definition of each
outcome differs between the study groups. Therefore,
we included studies, that examined similar variables
3. RESULTS but named them differently, in the same category
The electronic search of databases produced 474 in order to draw more robust conclusions (Table 6).
titles of articles relevant to the topic. 403 articles were Komagamine et al. [21] focused on the masticatory
duplicated and therefore excluded. After reading the performance of the patients but the authors also
abstracts, 22 articles were rejected because they also added two extra variables, i.e. the occlusal contact area
referred to other prosthetic rehabilitations (apart from and the maximum occlusal force. According to Lepley
complete dentures) such as overdentures and fixed et al. [28], the greater the occlusal contact and the bite
partial dentures. A full text was obtained from the force, the better the masticatory performance. Horie
remaining 49 articles and only 19 of these fulfilled et al. [29] also exhibited that the occlusal contact and
the inclusion criteria. All of the included studies were the near occlusal contact areas related significantly
clinical trials, 18 of which were randomized clinical with the mixing ability. However, the study involved
trials (RCT). The electronic search resulted also in the dentate patients.
identification of two systematic reviews and one meta- It is evident that the majority of the studies focused
analysis on the comparison between the conventional mainly on aspects of patient quality of life (patient
versus the simplified technique for complete denture satisfaction and OHRQoL).
fabrication. Their limitation was that none of these The quality of evidence in this systematic review was
papers examined all the outcomes, but rather they high for each outcome, mainly due to the low risk of
focused on some of them. Furthermore, additional bias of all but two studies and the homogeneity in
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their respective design. The fact that all studies did a stability and comfort of the complete denture. Hyde
Review Articles
power analysis to determine the study sample size and et al. [16] emphasized the impact of the impression
used a level of significance at 5% affected positively material. His team fabricated two sets of complete
the quality of evidence. dentures for each patient, one obtained after an
alginate impression and the other obtained from a
3.1. Masticatory performance silicone impression. He concluded that the patients
Alves et al. [2] tried to associate the masticatory
preferred the dentures fabricated from a silicone
ability based on the method used (simplified versus
impression. All the other studies proved the two
conventional) and on some sociodemographic
methods to be equal (Komagamine et al. [21], Kawai
characteristics. No difference on masticatory ability
was found between the two techniques. When et al. [18,20], Krishna et al. [22], Lira-Oetiker et al. [3],
evaluating the sociodemographic variables, only Mengatto et al. [23], Nunez et al. [25], Regis et al. [26]).
gender was found to have a statistically significant The only difference was that the satisfaction increased
difference with women presenting lower masticatory in both groups respectively following the time and
performance than men. the use of the complete dentures (Nunez et al. [25],
Cuhna et al. [14] differentiated the masticatory Regis et al. [26]). Kawai et al. [18] on the other hand
ability from the masticatory performance. Although concluded that there is increase of satisfaction in 3
masticatory performance was measured according months compared to the baseline, but they found a
to different number of chewing cycles (20 and 40) significant decrease in 6 months. This phenomenon
the researchers could not find a difference between was noticed in both categories making them not to
the two groups. However, there was an improvement
differentiate. It is remarkable that after 10 years Kawai
when the patients with complete dentures chewed
et al. [20] still found no difference between the control
40 rather than 20 times and this suggests that these
and test group except for esthetics. Patients with
patients can achieve a good masticatory performance
if they have patience and persistence. Subjectively, simplified dentures were significantly more satisfied
patients with complete dentures fabricated with with the maxillary denture’s esthetics after 10 years.
the simplified technique are presumed to have no Komagamine et al. [21] and Krishna et al. [22] failed
difficulties in mastication in contrary to the control to prove the improvement over time because of the
group. This was the only difference between the short-term follow up.
groups which did not affect the overall insignificant
score. 3.3. Oral Health Related Quality of Life (OHRQoL)
Interestingly, Komagamine et al. [21] included as their The OHRQoL test is performed by a series of
study outcomes the occlusal contact area and the questionnaires. The basic questions are universal
maximum occlusal force apart from the masticatory (OHIP-Edent) but every country has added questions
performance. Dentures fabricated by the conventional relevant to their population and their lifestyle in
method had a statistically higher occlusal contact area
order to get more specific answers. OHRQoL showed
than the simplified dentures, but this did not relate
no difference between the two examined methods
with a better mixing of the food. This was attributed
among all the studies.
to the fact that all the measurements were performed
only 1 month after delivery and this interval may have
been too short and that the final impression may 3.4. Quality of complete dentures
provide more stable acrylic resin bases and occlusion The complete dentures included in each trial were
rims during the following sessions. fabricated by the same technicians, therefore it was
Similar to de Villa Camargos et al. [13], Mengatto highly improbable to find a difference among the
et al. [23] found no difference in the masticatory complete dentures. Impeccable proof for this was
performance depending on the protocol used. In provided by the study group of Kawai et al. [18]. They
other words, there is evidence in all these studies that let prosthodontists, blinded the trial, to objectively
the method used to fabricate a complete denture does examine the quality of the dentures and the results
not affect the masticatory performance and ability were similar for conventional and simplified dentures.
and both techniques are held as equal.
3.2. Patient satisfaction
3.5. Time
Five clinical trials focused on the time spent for the
Many studies focused on the patient satisfaction
and the influence that the fabrication method has treatment plan. Kawai et al. [19] used a more general
on it. Only two of them found a significant difference term and measured the time spent for the treatment
between the two methods. Jo et al. [17] documented plan. On the other hand, Ceruti et al. [6] measured
that the conventional method was preferred among the time needed for each step, such as clinical time,
the patients because the final impression ensured number of clinical sessions but also the laboratory
more detailed borders and therefore increased time and the laboratory returns.
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The research group of de Resende et al. [15] separated treatment from the time a patient exits their house
Review Article time in two major categories: the time needed from until their return. Although the interpretation of cost
the consultation until the delivery of the dentures differs between the studies, all three came to the same
and the time needed for adjustments. If the number conclusion, that conventional method costs more
of visits for adjustments was outnumbered for one than the simplified method.
method, then this could be a critical clinical issue. Such
a differentiation in time was also made by Duncan et 3.7. Cost effectiveness
al. [10]. The researchers calculated the visits needed It is rational to think that studies which examined cost
toisfabricate
the resultthe
of the divisiondenture
complete of the cost
andbyseparately
the satisfaction.
and The
timeauthors
would haveconcluded that
also evaluated cost effectiveness.
the visits needed for adjustments. The results in both However, the only study group that referred to cost
cost effectiveness
outcomes is higher significant
were statistically for the conventional
favoring group.
the effectiveness was Miyayasu et al. [24]. According to
simplified protocol. Krishna et al. [22] limited their them cost effectiveness is a combination of cost and
evaluation to the number of visits. Generally, it was patient satisfaction where time is also considered
3.8. Need for reline
agreed in all studies that the simplified method was under the term of cost. Cost and patient satisfaction
faster in clinical time and clinical sessions than the have to be quantified, as cost effectiveness is the result
conventional
The study by method.
Duncan et al. [10] was the only one referring of thetodivision
the needofofthe costThis
reline. by the satisfaction. The
authors concluded that cost effectiveness is higher
need
3.6. Costand more specifically the time when this occurs,for reflects not only the group.
the conventional quality of
The cost of denture fabrication was evaluated in
the clinical
three denture trials.
but also
All ofthe effectiveness
them agreed that andtheprecision
cost 3.8. of Need
the impression
for reline technique.
of a conventional method was significantly higher The study by Duncan et al. [10] was the only one
Although
than the costtheof thought is veryone.
the simplified good in this
Kawai et al.case,
[19] wereferring
cannot draw
to theanyneedconclusion
of reline. This need and more
attributed the difference in cost to the final impression specifically the time when this occurs, reflects not only
because
step thethe
and to evaluation
remounthappened three months
of the denture beforeafter
the thethe
delivery.
quality of the denture but also the effectiveness
delivery. Miyayasu et al. [24] and Vecchia et al. [27] and precision of the impression technique. Although
considered also under the term of cost the time spent the thought is very good in this case, we cannot draw
from the professionals. Vecchia et al. [27] evaluated any conclusion because the evaluation happened
Figure
also 2. Flowchart
the time illustrating
that a patient studytoselection
needs spend for process.
their three months after the delivery.
Electronic database search: EXCLUDE
5500
Irrelevant titles: 5026
Relevant titles: 474
Duplicate titles: 403
Records after removal of
duplicates: 71
Abstract reading: 22
Records after reading the
abstracts: 49
Full-text articles: 5
Full-text articles: 44
Articles included according Systematic reviews: 3 Articles relevant to the
to inclusion criteria: 19 topic, cannot be included
according to the inclusion
criteria: 22
Figure 2. Flowchart illustrating study selection process.
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Table 3. Summary of the study characteristics included in the systematic review.
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S: simplified method, C: conventional method, SET: simplified edentulous treatment, pt: patients, CD: complete denture,
PROMs: patient-reported outcome measurements, OHRQoL: Oral Health Related Quality of Life
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Table 4. Impression technique and materials.
Table 5. Summary of the studies and the outcomes they studied.
Table 5. Summary of the studies and the outcomes they studied.
Outcomes Studies
Masticatory performance/ability Alves et al. [2], de Villa Camargos et al. [13], Cuhna et al.
[14], Komagamine et al. [21], Mengatto et al. [23]
Patient satisfaction Ceruti et al. [6], de Villa Camargos et al. [13], de Resende
et al. [15], Jo et al. [17], Kawai et al [18], Kawai et al [20],
Krishna et al. [22], Lira-Oetiker et al. [3], Nunez et al. [25],
Regis et al. [26]
OHRQoL de Villa Camargos et al. [13], de Resende et al. [15],
Hyde et al. [16], Jo et al. [17], Kawai et al. [20], Nunez et
al. [25], Regis et al. [26]
Denture Quality Ceruti et al. [6], de Resende et al. [15], Kawai et al. [18],
Regis e al. [26]
Time Ceruti et al. [6], de Resende et al. [15], Duncan et al. [10],
Krishna et al. [22], Kawai et al. [19]
Cost Kawai et al. [19], Miyayasu et al. [24], Vecchia et al. [27]
Comfort/stability/esthetics/ability to speak/ease to Hyde et al. [16], Kawai et al. [18], Kawai et al. [20], Lira-
clean/ability to chew specific foods Oetiker et al. [3], Mengatto et al. [23]
Complete dentures’ functional activity de Villa Camargos et al. [13]
Clinical outcomes de Resende et al. [15]
Occlusal contact area/maximum occlusal force Komagamine et al. [21]
Cost effectiveness Miyayasu et al. [24]
Need for reline Duncan et al. [10]
Impressions Hyde et al. [16], Krishna et al. [22]
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Table 6. Summary of the studies and the outcomes they studied revisited.
269
Need for reline Duncan et al. [10]
Impressions Hyde et al. [16], Krishna et al. [22]
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Table 6. Summary of the studies and the outcomes they studied revisited.
Review Article Table 6. Summary of the studies and the outcomes they studied revisited.
Outcomes Studies
Masticatory performance/ability, Occlusal contact Alves et al. [2], de Villa Camargos et al. [13], Cuhna et al.
area/maximum occlusal force [14], Komagamine et al. [21], Mengatto et al. [23]
Patient satisfaction, Comfort/stability/esthetics/ability to Ceruti et al. [6], de Villa Camargos et al. [13], de Resende
speak/ease to clean/ability to chew specific foods et al. [15], Hyde et al. [16], Jo et al. [17], Kawai et al. [18],
Kawai et al. [20], Krishna et al. [22], Lira-Oetiker et al. [3],
Mengatto et al. [23], Nunez et al. [25], Regis et al. [26]
OHRQoL de Villa Camargos et al. [13], de Resende et al. [15],
Hyde et al. [16], Jo et al. [17], Kawai et al. [20], Nunez et
al. [25], Regis et al. [26]
Denture Quality, Complete dentures’ functional activity, Ceruti et al. [6], de Resende et al. [15], Kawai et al. [18],
Clinical outcomes Regis et al. [26], de Villa Camargos et al. [13]
Time Ceruti et al. [6], Duncan et al. [10], de Resende et al. [15],
Kawai et al. [19], Krishna et al. [22]
Cost Kawai et al. [19], Miyayasu et al. [24], Vecchia et al. [27]
Cost-effectiveness Miyayasu et al. [24]
Need of reline Duncan et al. [10]
Impressions Hyde et al. [16], Krishna et al. [22]
4. DISCUSSION ridge height and patient satisfaction which comes
in agreement with our result. The included studies
4.1. Masticatory performance did not evaluate patient satisfaction based only on
The primary goal when fabricating a denture is to
the denture fabrication technique, but also assessed
evaluate the patients’ masticatory performance.
The comparison of the two methods could not omit all other factors that may influence it, such as the
the evaluation of the masticatory performance. This remaining ridge height. No differences in patient
evaluation is objective and subjective. Interestingly satisfaction were found between all the included
the results of the objective and subjective test do not groups.
always coincide. In other words, there is a difference
between the masticatory performance and the 4.4. Oral Health Related Quality of Life (OHRQoL)
assessment of their chewing ability [30]. The level of
Following patient satisfaction, the oral health related
bone resorption did not influence the masticatory
ability of the patients according to Marcello-Machado quality of life (OHRQoL) was examined. OHRQoL was
et al. [31]. This is in agreement with the results of the measured using different versions of the Oral Health
study of Alves et al. [2] and our results. Impact Profile (OHIP). OHIP-Edent is a shortened
4.2. Classification systems of complete edentulism version of OHIP and focused on the edentulous
The majority of the studies included used the patients. Moreover, OHIP-Edent can detect the
classification system for complete edentulism of the differences in the quality of life of the patients after
American College of Prosthodontics (ACP) [32]. They
recieving a new rehabilitation. De Souza et al. [36]
focused on the ridge resorption as the main factor
of a compromised case. However, this classification proved the validity of the Brazilian version of the OHIP-
system categorizes the edentulous patients based on Edent as well as the validity of the Geriatric Oral Health
the complexity of the case which depends not only Assessment (GOHAI). They compared the answers of
by the residual ridge. Only a minority belonged to these two OHRQoL inventories with the answers of a
the most favorable class (class I). This indicates that denture satisfaction questionnaire and they found a
the results are not biased as they would have been strong correlation [36]. Likewise, Sato et al. [37] found
if only patients with the most ideal oral condition
that the Japanese version of OHIP-Edent (OHIP-Edent
were included [32]. Lira-Oetiker et al. [3] used the
classification system of Cawood and Howell [33] and J) demonstrated good reliability and validity [37].
included patients of class II, III and IV. We could imply It is important to mention the study of Stober et al.
that the results may be optimized [33]. [38]. They correlated OHRQoL measured with OHIP-
Edent with the patient satisfaction measured with
4.3. Patient satisfaction questionnaires. Although they emphasized that
Huumonen et al. [34] indirectly associated the ridge patient satisfaction cannot per se predict the OHRQoL,
resorption with the patient satisfaction. In their study
they found a significant association between the two
patients with severe ridge resorption complained
about the stability of the mandibular denture and factors [38], strengthening the conclusion that the
that caused reduced satisfaction. Instead, Pan et al. method used did not affect either the OHRQOL or the
[35] did not find a significant association between patient satisfaction.
270 Stoma Edu J. 2021;8(4): 261-274 pISSN 2360-2406; eISSN 2502-0285
Conventional vs Simplified Complete Dentures
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4.5. Cost and time and Souza [44] provided the answer with their study
Review Article
The simplified and the conventional technique differed where the only difference between the two groups
significantly in two outcomes, named cost and time. was the use of the facebow. According to them the
The simplified technique did have a significant lower complete dentures fabricated without the use of
cost than the conventional technique. The cost of the facebow were better than the dentures of the
the conventional is higher as the clinicians use extra control group, proving that a complete denture can
materials. The session of the final impression includes also be fabricated with simple methods avoiding the
an acrylic resin custom tray, a compound for border use of a facebow. The differences found between the
molding and a wash material. The use of these three two groups were also attributed to the fact that the
additional materials inevitably increases the cost [39]. mandibular cast of the control group was articulated
The time needed for the conventional technique was with centric, lateral and protrusive records. This is very
longer, since the protocol included an extra clinical demanding especially in edentulous patients where
session. The time increases more if we take into the records are made with record bases and occlusal
consideration the difficulty of the final impression. rims which are impossible to be stable during the
Moreover, a randomized clinical trial of Kimoto et al. procedure [44].
[40] revealed a difference in time needed based on
the experience. Although Kimoto et al. [40] did not 4.9. Remount
mention the years of experience of each clinician, the A valid evaluation about the importance of the
time difference in the stage of the final impression remount could occur if that was the only difference
was statistically significant [40]. In the studies between the control and the test group. Such a study
included in the present review, the practitioners was performed by Shigli et al. [45] and they found
varied from undergraduate students to experienced the statistically significant superiority of the remount
prosthodontists. No study compared students and process. The patients of the test group needed less
prosthodontists directly. That means that the time post-insertion visits, experienced less pain and
difference was valid in all studies regardless of the discomfort during mastication and presented less
clinician and therefore the simplified method is quicker. sore spots. In the present review such a difference
was not noticed. However, we have to see this result
4.6. Cost effectiveness with precaution as the influence of the remount could
Cost effectiveness analysis is an economic analysis be lost among the influence of other factors.
which aims to give an answer between alternative
treatments. Its calculation is mathematical [41]. The 4.10. Systematic reviews and meta-analysis
simplified technique differs from the conventional Paulino et al. [46] concluded that the simplified
only in terms of cost and time. This could lead to the technique does not compromise patient satisfaction
assumption that the simplified technique is more and masticatory ability with the complete dentures,
cost effective. However, the analysis revealed the nor does it affect the quality of the denture. Ye et al.
superiority of the conventional method. Only one [47] found differences between the two techniques
study examined this factor and therefore we cannot only in cost and time. The most recent-in the searching
draw a conclusion. period of the present review- publication comparing
the two methods is a meta-analysis of Al- Ansari et al.
4.7. Post-insertion visits and need for reline [48]. They included 11 studies and drew conclusions
Duncan et al. [10] concluded that the simplified about patient satisfaction, quality of life, cost, and
technique required less visits for the necessary time. For the first two outcomes the researchers
adjustments and there was no difference in the need found no statistically significant difference between
for reline. During the first three months patients still try conventional and simplified technique contrary to
to adjust to the new rehabilitation so it is impossible the other two. The results of our systematic review
to testify the need for reline. Less post-insertion visits are more comprehensive and they are in agreement
for the simplified technique may be explained by the with the results of the aforementioned studies. Cost
fact that the final impression with border molding and time are the only outcomes with a difference
leads often to overextended dentures. in favor of the simplified dentures. Apart from that,
conventional and simplified method of fabrication of
4.8. Facebow complete dentures have equal outcomes.
In a lot of studies in the intervention group face bow
record was also omitted besides the final impression. 4.11. Limitations
Farias-Neto et al. [42] and Prakash et al. [43] concluded There is also a lot of heterogeneity among the studies
in their systematic review accordingly that the use of because of the different materials used, the different
a face bow does not result in a better outcome for the factors examined with a variety of tests, the differences
complete dentures. This comes in agreement with between the groups, the level of experience of the
our results, but it logically raises the question if the clinician and the short follow up.
results are valid as there is no included study which CAD/CAM complete dentures are out of the scopus
examines the use or not of only the facebow. Kumar of the present review.
Stoma Edu J. 2021;8(4): 261-274 pISSN 2360-2406; eISSN 2502-0285 271
Pani E, et al.
www.stomaeduj.com
5. CONCLUSION anatomy. Moreover, there is the need to establish a
Review Article
standarised simpliefied protocol in order to consider
The conclusions of the present systematic review are it as an alternative.
the following:
1. Our systematic review is in agreement with the CONFLICTS OF INTEREST
The authors declare no conflict of interest.
literature of the topic.
2. The null-hypothesis was confirmed in terms of cost AKNOWLEDGEMENTS
and time but rejected in all the other factors. Special thanks to Dr. Pinelopi Pani, Clinical Associate Professor in
3. Cost and time differed significantly between the two Henry M. Goldman School of Dental Medicine, Boston University,
Boston, MA 02118, USA, for editing and reviewing this systematic
methods favoring the simplified protocol. review.
4. Masticatory performance and ability, patient
satisfaction, Oral Health Related Quality of Life AUTHOR CONTRIBUTIONS
(OHRQoL) and denture quality are not affected by GP, EP: conceptualization. EP: methodology, software. EP, AS, GP:
validation. EP, AS, GP: formal analysis. EP, IA: investigation. EP, AS,
the method of fabrication. AC: resources. EP, AC, IA: data curation. EP: writing-original draft
5. The impression of the edentulous jaw is not a simple preparation. EP, AS, GP: writing-review and editing. GP: visualization.
task and requires profound knowledge of the oral AS: supervision. GP: project administration.
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Stoma Edu J. 2021;8(4): 261-274 pISSN 2360-2406; eISSN 2502-0285 273
Pani E, et al.
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Review Article
Eleftheria PANI
DDS, MSc
Department of Prosthodontics
School of Dentistry
National and Kapodistrian University of Athens
CV Athens, Greece
Eleftheria Pani graduated from the Dental School of the National and Kapodistrian, University of Athens, Athens, Greece in 2014.
She was accepted in the postgraduate program of Prosthodontics in the National and Kapodistrian University of Athens, Athens,
Greece from which she graduated in 2021 after presenting her master thesis.
Questions
1. What is the difference between conventional and simplified complete dentures?
q a. Ommitance of the final impression;
q b. Ommitance of the final impression and the try-in;
q c. The use of different materials;
q d. Ommitance of laboratory stages.
2. What is mainly used as impression material for the simplified complete dentures?
q a. Alginate;
q b. Silicone;
q c. Polyether;
q d. Compound.
3. Simplified complete dentures differ significantly from the conventional in:
q a. Cost;
q b. Cost and time;
q c. Cost, time, patient satisfaction;
q d. Cost, time, patient satisfaction, OHRQoL.
4. The majority of the studies examined:
q a. Cost and time;
q b. Patient satisfaction;
q c. Patient satisfaction and OHRQoL;
q d. Cost, time, patient satisfaction and OHRQoL.
274 Stoma Edu J. 2021;8(4): 261-274 pISSN 2360-2406; eISSN 2502-0285