81 Maxillary implant overdentures: two implants in atrophic jaws slight oedema and redness (1), moderate inflammation with oedema, redness and glazing (2); and severe inflammation with marked redness, oedema and ulceration (3). • Bleeding on probing was assessed by using the Mombelli et al. index15, ranging from 0 to 3, corresponding with no bleeding (0); isolated bleeding (1); confluent bleeding along the mucosal margin (2); and heavy or profuse bleeding (3). Masticatory performance To objectively measure masticatory performance, the mixing ability test (MAT) was performed. For the MAT each participant was asked to chew 20 strokes on a prefabricated paraffine wax tablet with a red and blue layer. Chewing the tablet gradually decreases the spread of blue and red colour intensities, representing the masticatory performance. To prepare the chewed tablet for analysis, it was heated to 28°C and compressed to a thickness of 2.0 mm using a hydraulic hand press at 50 bar. Both sides of each tablet were then optically scanned using a high quality scanner (Epson V750, Long Beach, California), resulting in an image with a spread of blue and red colours16. Using computer software (Adobe Photoshop CS3; Adobe, San Jose, California) the mixing ability index (MAI) was obtained by measuring the intensity distributions of the red and blue colours of the combined images17. The MAI ranges from 30 (badly mixed) to 5 (a theoretically perfect mix). Patient related outcome measures The PROMs were assessed using validated questionnaires, i.e. the chewing ability questionnaire (CAQ)18. the denture complaints questionnaire (DCQ)19 and the Dutch version of the Oral Health Impact Profile 49 questionnaire (OHIP-49NL)20. The CAQ was used to test masticatory ability. The participants were asked to rate their ability to chew nine different foods on a three-point scale, e.g., good, moderately, or bad. The foods were divided in three categories, e.g., soft foods (boiled vegetables, crustless bread, minced meat), tough foods (crusty bread, steak, Gouda cheese), and hard foods (apple, carrot, peanuts). The DCQ consists of 54 questions, divided in six categories, addressing functional problems of the lower denture, the upper denture, general functional complaints, denture aesthetics, facial aesthetics, and accidental lip, cheek, and tongue biting (‘neutral space’). Questions could be answered on a four-point scale, ranging from 0 (no complaints) to 3 (severe complaints). At the end of the questionnaire, the participant is asked to rate the overall denture satisfaction on a 10-point scale, ranging from 1 (very bad) to 10 (excellent). The OHIP-49NL questionnaire consists of 49 questions, divided in seven categories, i.e. functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability and handicap. Questions could be answered on a fivepoint scale, ranging from 0 (never) to 4 (very often). Complications Complications, such as loosening or fracture of denture teeth, replacement of nylon caps, and pressure ulcers, were scored throughout the entire follow-up period. 5
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