Oral health‐related quality of life of patients rehabilitated with fixed and removable implant‐supported dental prostheses

Abstract Dental implants have become a mainstream treatment approach in daily practice, and because of their high survival rates over time, they have become the preferred treatment option for prosthetic rehabilitation in many situations. Despite the relatively high predictability of implant therapy and high costs to patients, patient perceptions of success and patient‐reported outcome measures have become increasingly significant in implant dentistry. Increasing numbers of publications deal with oral health‐related quality of life and/or patient‐reported outcome measures. The aim of this paper was to provide an overview of the available evidence on oral health‐related quality of life of fully and partially dentate patients rehabilitated with fixed and removable implant‐supported dental prostheses. A comprehensive electronic search was performed on publications in English up to 2021. A selection of standardized questionnaires and scales used for the evaluation of oral health‐related quality of life were analyzed and explained. The analysis encompassed three aspects: a functional evaluation of oral health‐related quality of life, an esthetic assessment of oral health‐related quality of life, and a cost‐related evaluation of oral health‐related quality of life for rehabilitation with dental implants. The data demonstrated that the preoperative expectations of patients markedly affected the outcomes perceived by the patients. As expected, reconstructions supported by implants substantially improved the stability of conventional dentures and allowed improved function and patient satisfaction. However, from a patient's perspective, oral health‐related quality of life was not significantly greater for dental implants compared with conventional tooth‐supported prostheses. The connection of the implants to the prostheses with locators or balls indicated high oral health‐related quality of life. The data also suggest that patient expectation is not a good predictor of treatment outcome. In terms of esthetic outcomes, the data clearly indicate that patients’ perceptions and clinicians' assessments differed, with those of clinicians yielding higher standards. There were no significant differences found between the esthetic oral health‐related quality of life ratings for soft tissue‐level implants compared with those for bone‐level implants. Comparison of all‐ceramic and metal‐ceramic restorations showed no significant differences in patients’ perceptions in terms of esthetic outcomes. Depending on the choice of outcome measure and financial marginal value, supporting a conventional removable partial denture with implants is cost‐effective when the patient is willing to invest more to achieve a higher oral health‐related quality of life. In conclusion, the oral health‐related quality of life of patients rehabilitated with implant‐supported dental prostheses did not show overall superiority over conventional prosthetics. Clinicians' and patients' evaluations, especially of esthetic outcomes, are, in the majority of cases, incongruent. Nevertheless, patient‐reported outcomes are important in the evaluation of function, esthetics, and the cost‐effectiveness of treatment with implant‐supported dental prostheses, and should be taken into consideration in daily practice.

(which is closely linked to clinically defined health status) to social function, and to more global constructs such as "opportunity." These dimensions have been linked to conceptual models, in which the effects of impairment on disability or reduced opportunity are mediated by intervening with personal and environmental factors. 16 This makes it difficult to summarize oral health-related quality of life in a single term. In fact, there is still a lack of consensus on the plethora of terms used in the literature for oral health-related quality of life. 17 Moreover, the instruments used to analyze oral health-related quality of life remain unstandardized and rather heterogenic in nature. Nevertheless, there are many standardized questionnaires and scales employed to assess the impact of dental interventions upon oral health-related quality of life, and a selection of these questionnaires are listed and explained in Table 1.

| Visual analog scale
The visual analog scale is defined as the distance on a horizontal line between two anchoring points representing the minimum and the maximum perception. The anchoring points are usually 10 cm apart, and the scale on the line is in millimeters or other units. In order to quantify a parameter on a visual analog scale, the evaluator will present a mark on the line. Thus, the distance from the mark to the anchoring point may be calculated. 18,19 The scale is often used as answer modality in standardized questionnaires (Table 1).

| Likert scale
The Likert scale is named after its inventor. 20 Likert was a psychologist and he used the scale as a technique for evaluation of people's attitudes. The scale contains five points on a horizontal line with a maximal distance between each. Each point is tagged with a descriptor. The patient is summoned to highlight the most accurate description according to their opinion. Today, the scale is widely used in research and it has undergone many adaptations. 18,20 The scale is employed as a component of several standardized questionnaires (Table 1).

| Standardized questionnaires
In the last 3 decades, a variety of standardized questionnaires have been proposed and propagated. The questionnaires usually comprise different areas.
Prior to the conference on oral health-related quality of life in North Carolina, 16 there was no consensus regarding how to evaluate oral health-related quality of life. At that conference, efforts were made to standardize health questionnaires. The questionnaires were analyzed in terms of reliability, validity, and precision. Following the conference, further questionnaires were introduced. 21 A detailed table of the questionnaires, with descriptions of the dimensions evaluated, as well as the number of questions and answering modalities, is listed in Table 1. One questionnaire in particular is emphasized because it is frequently used in the publications cited in this review: the oral health impact profile. 22 The oral health impact profile assesses the dimensions of function, pain, physical disability, social disability, and handicap. The patient is asked to answer 49 standardized questions with answering modalities in five categories.
A shorter version applying 14 standardized questions has also been validated and propagated. 22 The methods for the judgment of the esthetics by clinicians are depicted in Table 2.

| RE SULTS
The evaluation of oral health-related quality of life of patients rehabilitated with dental implants can be summarized in three domains: the aspect of function, esthetics, and cost-effectiveness.
Furthermore, the functional aspect was subdivided into fully edentulous, partially edentulous patients, and the topic of implantsupported vs tooth-supported fixed dental prostheses. An overview of the results is summarized in Table 3.

| Functionalevaluationoforalhealthrelated quality of life of patients rehabilitated with dental implants
The functional aspect of oral health-related quality of life is not only important in the field of dentistry. Oral health-related quality of life also affects the overall well-being of the individual. In other words, oral health-related quality of life correlates to general health-related quality of life. 41 In terms of rehabilitation with dental implants and the different surgical protocols, it appears that immediate loading protocols achieved the highest patient satisfaction. 42

| Fully edentulous patients
The majority of studies dealing with implant placement and oral health-related quality of life has been performed in edentulous patients. Edentulism may be associated with functional impairment, which includes chewing ability, bite force, swallowing mechanism, differences in salivary flow, phonetics, and oral sensory function in general. Moreover, cleansability, as well as social behavior, are included. Ill-fitting and unstable prostheses are a particular source of distress and reduced self-esteem. Therefore, implant placement in edentulous patients severely impacts on their functional well-being. 42 Fonteyne et al 43  Social dental scale Cushing et al (1986) 24 Chewing, talking, smiling, laughing, pain appearances 14 Yes/no GOHAI Atchison and Dolan (1990) 25 Chewing, eating, social contacts, appearance, pain, worry, self-consciousness 12 Six categories; "always-never" DIP Strauss and Hunt (1993) 26 Appearance, eating, speech, confidence, happiness, social life, relationships 25 Three categories; good effect, bad effect, no effect OHIP Slade and Spencer (1994) 22 Function, pain, physical disability, social disability, handicap 49 Five categories; "very often-never" Short forms: OHIP-14 = short form with 14 items OHIP-Edent = short form for edentulous patients SOHSI Locker and Miller (1994) 27 Chewing, speaking, symptoms, eating, communication, social relations 42 Various depending on question format DIDL Leao and Sheiham (1996) 28 Comfort, appearance, pain, daily activities, eating 36 Various depending on question format OIDP Adulyanon and Sheiham (1997) 29 Performance in eating, speaking, oral hygiene, sleeping, appearance emotion 9 Various depending on question format OH-QoL measure Kressin (1997) 30 Daily activities, social activities, conversation 3 Six categories; "all of time" to "none of the time" bother me at all", 4 = "bothers me very much") Part 2/frequency: 0 = "never", 1 = "once/twice", 2 = "sometimes", 3

SOOQ
Patients' satisfaction improved even in the group of patients who preferred implant-stabilized prostheses but instead were treated with conventional prostheses. But the extent of patients' satisfaction was higher with patients who received their desired treatment. Therefore patient expectations did not indicate them to be a good predictor of treatment outcome Assessing the impact of conventional and implant-supported prostheses on social and sexual activities in edentulous adults Subjective assessment: OHIP-questionnaire and Social Impact Questionnaire Eating, speaking, kissing, and yawning were significantly improved in the group receiving implant-supported prostheses Nevertheless there were only weak correlations found between the two sexual activity items (uneasiness when kissing and during sexual relations) and the OHIP scores Comparing OH-QoL outcome measures of implant-retained maxillary overdentures and conventional dentures Subjective assessment: OHIP-questionnaire and visual analog scale Patient satisfaction significantly increased for implantsupported dentures compared with old dentures in all seven OHIP subgroups, as well as for cleaning ability, general satisfaction, ability to speak, comfort, esthetics, and stability To investigate evolution of masticatory function, OH-QoL, and prosthetic occurrences of implant-retained mandibular overdenture wearers according to mandibular bone atrophy over 3 y of usage Prevalence of peri-implantitis was 30%. Prevalence of peri-implant mucositis was 24% Statistical analysis failed to reveal any significance between patients with peri-implantitis or periimplant mucositis. Plaque index and gingival index were statistically significantly correlated with total OHIP-14 score How do reconstructions affect patientreported outcomes of conventional dentures vs implant-supported overdentures QoL, OH-QoL, patient satisfaction (with a range of parameters) The overall rating for OH-QoL of patients receiving implant-supported overdentures was not significantly better than for conventional dentures

OH-QoL of life correlations in a national geriatric sample
Subjective assessment: OIDP -questionnaire Patients with > 8 occluding pairs of teeth were 2.66 times, and those with up to 2 anterior occluding pairs, were 3.00 times less likely to report oral impacts Edentate participants with inadequate denture adaptation and subjects with inadequate denture retention were more likely to report oral impacts than the remaining edentate patients In each case OH-QoL is significantly related to the number of occluding pairs of natural teeth among the dentate and denture quality among the edentate

Objective/primary outcome Assessment tool/ procedure Results
Long-term performance of 3 prostheses: implant-supported fixed denture, FPD, and removable partial denture in terms of survival and OH-QoL From baseline to 1st y of observation a significant increase of patients' OH-QoL in terms of functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, and social disability but not handicap was found From baseline to 2nd and 3rd y all variables also significantly indicated an increase of OH-QoL There were no significant differences between gender

Impact of tooth loss on OH-QoL
Subjective assessment: OHIP-49, OHIP-14, GOHAI, OIDP, ad hoc satisfaction questionnaires The results indicated that not only number of tooth loss, but location and distribution of missing teeth, affect the reduction of OH-QoL. Furthermore, the extent and severity of impairment seems to be contextdependent (eg, cultural background) OH-QoL of patients rehabilitated with dental implants The 3-y survival rate for implants was 100% and for abutments was 97% Significantly more marginal bone loss was found for gold-alloy abutments compared with zirconia abutments The most frequent technical complication was loss of retention, which was only found in metal-ceramic crowns All-ceramic restorations showed more frequently biologic complications than metal-ceramic crowns. Marginal adaptations of all-ceramic crowns were significantly less optimal than metalceramic crowns. Significant better color match for all-ceramic compared with metal-ceramic restorations was reported from professionals. No significant discrepancies in patients' satisfaction for esthetic outcome was found for patients rehabilitated with allceramic vs metal-ceramic restorations The question arises as to whether bone atrophy has an impact on the oral health-related quality of life of patients treated with implantretained overdentures, foremost in the mandibular region. A 3-year prospective study compared patients treated with implant-retained mandibular overdentures with and without atrophic mandibles and, interestingly, did not reveal any statistical significant differences. 56 More recent studies support the finding that retention and therefore better stability of prostheses appears to be an important factor for patients' oral health-related quality of life. 57 Twenty-one patients were examined preoperatively and following

TA B L E 3 (Continued)
the connection to an implant bar. The design of the conventional denture before surgery was with palatal coverage. The implantsupported overdenture after treatment was designed without palatal coverage. All seven domains improved oral health-related quality of life for implant-supported overdentures compared to conventional dentures. 58 By contrast, a recent prospective study failed to show significant differences between the aforementioned treatment modalities. 59 Nevertheless, implant retention of overdentures does appear to be an important driver of patient satisfaction. The connections between implants and the denture are diverse. The different attachment modalities (ie, magnetic, locator, or ball attachments) were assessed in recent studies. 60 However, no difference in terms of oral health-related quality of life was discerned between bar attachment and magnetic attachment. 63 With rehabilitations using implants, there is always a risk of periimplant diseases. An interesting cross-sectional study, including In conclusion, there is increasing evidence that the use of dental implants to support either fixed or removable dental prostheses in fully edentulous patients significantly improves overall patient satisfaction when focusing on functional ability, especially in the lower jaw. 65

| Partially edentulous patients
Replacing missing single teeth with dental implants has become a routine procedure for the rehabilitation of partially edentulous patients, although the lack of a periodontal ligament may have an impact on chewing sensation. The number of missing teeth is reflected in the oral health-related quality of life 66,67 assessment, demonstrating that tooth loss per se affects patients psychologically. Recently, it was reported that tooth loss had a negative impact on eating in public and forming close interhuman relationships. 68 Kurosaki et al 69 compared the long-term performance of three different prosthetic reconstruction types-implant-supported fixed denture, fixed partial denture, and removable partial denture-in terms of prosthetic survival and oral health-related quality of life.
Concerning survival, the 6-year cumulative survival rates of the implant-supported fixed dentures, fixed dentures, and removable partial dentures were 94.7%, 77.4%, and 33.3%, respectively. The oral health-related quality of life scores for the implant-supported fixed denture group immediately after treatment and 6 years after treatment were significantly higher than those observed before treatment. However, there was no improvement in the oral healthrelated quality of life scores in the fixed partial denture or removable partial denture groups compared with before treatment. 69

F I G U R E 4 Clinical view at 3 months following nonsurgical periodontal therapy (ie, step 2 of periodontal therapy)
F I G U R E 5 Periodontal chart after nonsurgical periodontal therapy (ie, step 2 of periodontal therapy, after 3 months) According to a questionnaire-based survey, only 15.3% of patients receiving single implants considered masticatory function as their major concern. A total of 8.6% were most worried about food impaction and another 4.5% about pronunciation, occlusion, and swallowing. 70 Functional limitations, along with psychological discomfort, significantly decreased in patients who had received implant-supported single crowns or fixed partial dentures over a period of 3 years following implant installment. 71 A systematic review with a meta-analysis, including different questionnaires such as oral health impact profile-49, oral health impact profile-14, geriatric oral health assessment index, oral impacts on daily performances, and ad hoc satisfaction, indicated that not only the number of teeth lost, but also the location and distribution of missing teeth, affect the reduction in oral health-related quality of life. Furthermore, the extent and severity of impairment appears to be context-dependent (eg, cultural background). 72 An evaluation of implants and their contralateral teeth clinically, alongside patient satisfaction by oral health impact profile-14, confirmed that patients with implants were highly satisfied with their oral health-related quality of life. The majority (72.8%) felt that they were never limited in function. Moreover, they indicated satisfaction with their dietary consumption (69.5%). Nearly half of the patients (48.9%) had encountered phonetic problems pretherapy and had become more self-confident through implant treatment. 73 Comparing the oral health-related quality of life pre-and postimplant placement revealed that, prior to surgery, patients reported F I G U R E 6 Cone beam computed tomography planning for implant placement in the area of 46

F I G U R E 7 Intraoperative situation depicting implant placement
functional problems, specifically eating (78%), but also speaking and smiling, which when considered together were a cause of general embarrassment (53%). 74 After implant placement, the oral healthrelated quality of life changed in many aspects. Besides those functions directly related to tooth replacement, such as eating, speaking, or oral sensory function, oral health-related quality of life increased in general terms. Going out or meeting others, communication, smiling, and showing teeth without discomfort became natural and enjoyable. Interestingly, patients reported that becoming upset, in general, as well as job-related activities, significantly improved after implant placement. 74 3.1.3 | Implant-supported vs tooth-supported fixed dental prostheses A recent review suggested that in partially dentate patients there was insufficient evidence that implant-supported fixed dental prostheses yielded better oral health-related quality of life scores than tooth-supported fixed dental prostheses. 75 In partially dentate patients, the consensus of oral health-related quality of life studies is that treatment with implant-supported fixed dental prostheses improved oral health-related quality of life. However, all of these studies need to be interpreted with caution. First, it is clear that all these patients had an edentulous gap or a provisional prosthesis before treatment. It is well known that fabrication of new definitive prostheses positively influences oral health-related quality of life. 76 Thus, it remains plausible that the prosthetic replacement rather than the implants per se were responsible for the improved oral healthrelated quality of life. Second, patients restored with implants usually have higher levels of education and income, which may affect their satisfaction scores. 77 To date there is limited evidence for partially dentate patients that implant-supported fixed dental prostheses are superior in terms of patient perception than conventional fixed dental prostheses. Have you had trouble pronouncing any words because of problems with your teeth, mouth, or dentures?
x Functional limitation 0.51 2 Have you felt that your sense of taste has worsened because of problems with your teeth, mouth, or dentures?
x Functional limitation 0.49 3 Have you had painful aching in your mouth?
x Physical pain 0.34 4 Have you found it uncomfortable to eat any foods because of problems with your teeth, mouth, or dentures?
x Physical pain 0. 66 5 Have you been self-conscious because of your teeth, mouth, or dentures?
x Psychological discomfort 0.45 6 Have you felt tense because of problems with your teeth, mouth, or dentures?
x Psychological discomfort 0.55 7 Has your diet been unsatisfactory because of problems with your teeth, mouth, or dentures?
x Physical disability 0.52 8 Have you had to interrupt meals because of problems with your teeth, mouth, or dentures?
x Physical disability 0.48 9 Have you found it difficult to relax because of problems with your teeth, mouth, or dentures?
x Psychological disability 0. 60 10 Have you been a bit embarrassed because of problems with your teeth, mouth, or dentures?
x Psychological disability 0. 40 11 Have you been a bit irritable with other people because of problems with your teeth, mouth, or dentures?
x Social disability 0.62 12 Have you had difficulty doing your usual jobs because of problems with your teeth, mouth, or dentures?
x Social disability 0.38 13 Have you felt that life in general was less satisfying because of problems with your teeth, mouth, or dentures?
x Handicap 0.59 14 Have you been totally unable to function because of problems with your teeth, mouth, or dentures?  81 Both systems were successfully used in subsequent reports on esthetic outcomes in implant dentistry (Table 2). It has to be kept in mind, however, that both systems require the ability to compare the implant reconstruction with a contralateral or control tooth. Nevertheless, the index systems helped clinicians to objectively assess the esthetic aspects of newly placed and reconstructed implants. However, esthetic assessment by means of the index system described is significantly affected by the paradigms of the respective specialties. 82 In a validation study, prosthodontists were the most critical evaluators and yielded the lowest mean rank scores regardless of the index, while dental assistants and periodontists had significantly better ratings than other specialties. 82 Hence, it has to be realized that esthetic scores are dependent on the professional experience of the examiners, irrespective of the esthetic index system utilized. 82 In that respect, a recent review 83 applied objective and subjective criteria for clinicians and patients to evaluate esthetic outcomes. In that review, the oral health impact profile and oral health-related quality of life questionnaires were used for esthetic evaluation ( Table 2). These standardized and validated questionnaires allowed comparisons. A comparison of the objective and subjective assessments yielded a discrepancy between subjective patient-related criteria and objective prosthodontist-related evaluations.
An important aspect to be mentioned is that professionals were more critical than patients when subjective patient-evaluation was used. 83 In one study, five prosthodontists were asked to evaluate the esthetic outcome of single implant-supported crowns based on intraoral and extraoral photographs. 83  Have you had trouble pronouncing any words because of problems with your teeth, mouth, or dentures?
x Functional limitation 0.51 2 Have you felt that your sense of taste has worsened because of problems with your teeth, mouth, or dentures?
x Functional limitation 0.49 3 Have you had painful aching in your mouth?
x Physical pain 0.34 4 Have you found it uncomfortable to eat any foods because of problems with your teeth, mouth, or dentures?
x Physical pain 0. 66 5 Have you been self-conscious because of your teeth, mouth, or dentures?
x Psychological discomfort 0.45 6 Have you felt tense because of problems with your teeth, mouth, or dentures?
x Psychological discomfort 0.55 7 Has your diet been unsatisfactory because of problems with your teeth, mouth, or dentures?
x Physical disability 0.52 8 Have you had to interrupt meals because of problems with your teeth, mouth, or dentures?
x Physical disability 0.48 9 Have you found it difficult to relax because of problems with your teeth, mouth, or dentures?
x Psychological disability 0. 60 10 Have you been a bit embarrassed because of problems with your teeth, mouth, or dentures?
x Psychological disability 0. 40 11 Have you been a bit irritable with other people because of problems with your teeth, mouth, or dentures?
x Social disability 0.62 12 Have you had difficulty doing your usual jobs because of problems with your teeth, mouth, or dentures?
x Social disability 0.38 13 Have you felt that life in general was less satisfying because of problems with your teeth, mouth, or dentures?
x Handicap 0.59 14 Have you been totally unable to function because of problems with your teeth, mouth, or dentures?
x Handicap 0.41 All-ceramic and metal-ceramic restorations were compared in a prospective study. A total of 59 patients with tooth agenesis were treated and followed up for 3 years. Finally, a total of 98 implantsupported single unit crowns were evaluated. Materials used for crowns were either all-ceramic or metal-ceramic. Zirconia, titanium, and gold alloys were used for abutments, which retained these crowns.
Patient-reported and professionally reported esthetic outcomes were assessed with the oral health impact profile-49 questionnaire and the Copenhagen index score, respectively. 86 The professionals reported significantly superior color match of all-ceramic over metal-ceramic crowns. Patient reports for esthetic outcomes did not show a significant discrepancy between restoration materials after 3 years. 87 It is important to understand that esthetic outcomes should be evaluated separately for partially and fully edentulous patients.
It is clear that patients in need of a single unit crown in the frontal region of the maxilla may have higher expectations than fully edentulous patients in need of implant-supported overdentures.
Obviously, patient priorities will be driven by individual differences in their perceived need. In addition, the patient is confronted with proportionally higher costs for a single crown compared with those for an implant-supported overdenture. It is, therefore, important to understand patient satisfaction scores in conjunction with costeffectiveness, which is analyzed in the following section.

| Cost-relatedevaluationbypatients rehabilitated with dental implants
Introducing oral implants as a treatment for partially edentulous patients to improve their quality of oral health was usually accompanied by an increased cost compared with traditional removable prosthetic treatment. 93 bone-level implants supporting either three nonsplinted crowns, three splinted crowns, or a three-unit implant-supported bridge over two implants. Comparing the three-unit implant-supported bridge with one implant less with either the nonsplinted or splinted crowns yielded a reduction in initial costs of 16%. Furthermore, this reduction increased over the duration of the study because the complications were substantially higher in the nonsplinted crowns group. 100 Despite the increasing levels of evidence in this field of dental research, adjunctive costs-related analyses should be encouraged, focusing particularly on the costs related to biologic and technical complications.

| SUMMARYANDCON CLUS IONS
Oral health-related quality of life has become an important parameter for the assessment of treatment outcomes following implant therapy. However, there is no consensus on the definitions and standardization of this evaluation tool. The discrepancies in the terms, questionnaires, and scales presented in recent decades render a comparison of data challenging. Consequently, further studies with standardized questionnaires are necessary in the future.
Nevertheless, the current evidence on function, esthetics, and costeffectiveness indicates that: 1. There is evidence that implant-supported reconstructions have substantially improved the retention and stability of conventional dentures and, hence, enable better chewing and speaking ability of the patient.
2. The connection of implants to prostheses with either locators or balls indicated high oral health-related quality of life.
3. Patient expectation is not a good predictor of treatment outcome.
4. There is no convincing evidence that oral health-related quality of life is improved by implant therapy compared with conventional bridge work. 5. In general, there is poor agreement between patients' perceptions and clinicians' objective assessments of esthetic outcomes.
6. There are no significant differences found between the esthetic oral health-related quality of life ratings for soft tissue-level implants compared to those for bone-level implants.
7. Comparison of all-ceramic and metal-ceramic restorations showed no significant differences in patients' perceptions in terms of esthetic outcomes.
8. Depending on the choice of outcome measure and financial marginal value, supporting a conventional removable partial denture with implants is cost-effective when the patient is willing to pay more for achieving a higher level of oral health-related quality of life.

| Clinicalcase1
The After prosthetic restoration, the patient was asked to compete the oral health impact profile-14 questionnaire (Table 4).
According to Slade & Spencer, 22 the responses are coded 0 = never, 1 = hardly ever, 2 = occasionally, 3 = fairly often, and 4 = very often. The coded responses can be subdivided into seven dimensions (functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability, and handicap). Within each dimension, coded responses were multiplied with specific weights. The result of the response was 0, showing the highest possible score for quality of life according to this questionnaire and this treatment modality.

| Clinicalcase2
The followed by transmucosal healing. The patient did not receive any provisional prosthesis during the healing period of 3 months. After 3 months, the implant was loaded with a full zirconia screw-retained crown. After prosthetic restoration, the patient was asked to complete the oral health impact profile-14 questionnaire (Table 5).
According to Slade & Spencer, 22 the result of the response was 0, showing the highest possible score for quality of life according to this questionnaire and this treatment modality (Table 5).

ACK N OWLED G M ENT
Open Access Funding provided by Universitat Bern.