86 Chapter 5 using solitary attachments. The greater leverage caused by biting off hard foods anteriorly, such as apples or carrots, may cause the solitary attachments to dislodge more easily compared to bar attachments, which could explain these results. Nonetheless, the improvement in both subjective and objective parameters suggests an independence over the number of implants used to retain an IOD in the maxilla. Improved PROMs Four studies reporting on 2/3-IODs also reported PROMs and showed high satisfaction scores throughout the entire study period8-11. The questionnaires differed to the present study’s, hindering proper comparison. A study reporting on 4-IODs retained with bars or solitary attachments used the same questionnaires as in the present study32. Scores on OHIP-NL49 and DCQ were favourable and similar to the present study. A similar result was reported by a study researching mandibular 1- and 2-IOD with ball-attachments33. After 1, 3 and 5 years the participants’ mean satisfaction improved significantly for both groups, but did not differ between groups. These results suggest that improvement of patient satisfaction may be independent of the number of implants or the type of retention used to retain an IOD. Strengths and limitations Though more invasive compared to the present therapy, reconstructive surgery prior to implant placement is a safe and reliable treatment and therefore most patients are willing to be treated this way. Therefore, an alternative approach such as described in the present study is not offered to the patient very often, which limited the group size even after three years of inclusion, which may have affected the power of the present study’s results. Also, the follow-up of this case series is short, limiting the results on complications that may increase in the long term. Nevertheless, in our opinion the present study gives a complete overview of the risks and benefits of 2-IOD treatment in patients unwilling to be treated with reconstructive maxillary surgery prior to maxillary IOD treatment. Future research Four implants should still be considered the gold standard for maxillary overdenture therapy. However, to be able to offer customised care for any patient, future research should continue to focus on alternative therapies such as presented in the present study. Conclusion Within the limitations of this study, it can be concluded that patients with extreme resorption of the maxilla that are unwilling to be treated with reconstructive surgery, benefit from 2-implant maxillary overdentures retained by solitary attachments in terms of improved masticatory functioning and denture satisfaction, but with a relatively high risk of implant loss.
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