- Email: [email protected]
Fracture incidence in mandibular overdentures retained by one or two implants
Fracture incidence in mandibular overdentures retained by one or two implants Tomoya Gonda, DDS, PhD,a Yoshinobu Maeda, DDS, PhD,b Joanne N. Walton, DDS,c and Michael I. MacEntee, LDS, PhDd Osaka University Graduate School of Dentistry, Osaka, Japan; Faculty of Dentistry, University of British Columbia, Vancouver, Canada Statement of problem. While 2 to 4 implants are preferred to retain and stabilize an implant overdenture, some reports suggest a single implant is adequate to retain an overdenture. Denture fracture is one of the common complications with overdentures; however, there is no information on the incidence of fractures when dentures are retained by 1 implant. Purpose. The purpose of this study was to compare the fracture incidence of mandibular overdentures retained by 1 and 2 implants. Material and methods. The records of 85 subjects enrolled in the Vancouver Implant Prosthesis (VIP) clinical trial between 2003 and 2008 and followed up for at least 17 months were reviewed retrospectively. From the clinical records, subjects who had experienced a fractured overdenture were identified. A fracture was considered as either a visible crack in the acrylic resin or complete separation of the denture parts. The same clinical records listed 3 denture fracture sites: over the implant, elsewhere, or unknown. A chi-square test was used to compare the incidence of fracture (_=.05). Kaplan-Meier and log rank tests were used to compare the survival rate of overdenture or “time to fracture” (_=.05). Results. Forty-two subjects received a single implant, and 43 received 2 implants. In total, there were 17 fractures recorded for 13 subjects. Nine single-implant subjects experienced 11 denture fractures, while 4 double-implant subjects experienced 6 fractures. There was no significant difference in the incidence of denture fractures in prostheses retained by 1 or 2 implants. When denture fractures did occur, they were found most frequently in areas adjacent to the implant(s). Conclusions. The incidence of denture base fractures was not significantly different between overdentures retained by 1 implant and those retained by 2 implants. When fractures did occur, they tended to be in areas adjacent to implants. (J Prosthet Dent 2010;103:178-181)
Clinical Implications This study suggests that an overdenture retained by either 1 implant or 2 implants is a treatment option for patients with an edentulous mandible, when considering denture fracture incidence.
The clinical trial from which the data for this study were generated was supported by the Canadian Institutes of Health Research (grant no. 58954), the ITI Foundation (grant no. 222), and Straumann Canada Ltd. a
Assistant Professor, Department of Prosthodontics and Oral Rehabilitation, Osaka University Graduate School of Dentistry. Professor, Department of Prosthodontics and Oral Rehabilitation, Osaka University Graduate School of Dentistry. c Professor, Department of Oral Health Sciences, Faculty of Dentistry, University of British Columbia. d Professor, Department of Oral Health Sciences, Faculty of Dentistry, University of British Columbia. b
The Journal of Prosthetic Dentistry
Gonda et al
179
March 2010 Implant-retained overdentures are standard treatment options for rehabilitating edentulous jaws.1,2 While 2 to 4 implants have been preferred to retain and stabilize an implantretained overdenture, some reports suggest a single implant is adequate for overdenture retention.3-6 Cordioli et al3 and Krennmair et al4 evaluated treatment with mandibular overdentures retained by single implants in a geriatric patient population. The authors concluded that oral rehabilitation using mandibular complete dentures retained by a single implant is an economical therapeutic alternative to conventional mandibular complete dentures, especially for older patients. Fracture of the acrylic resin denture base, whether for a conventional or implant prosthesis, can be an inconvenient complication, as the patient is generally unable to wear the denture until it is repaired. Information on denture fractures has been reported7-12; however, there is no information on the incidence of fractures when dentures are retained by a single implant. The objective of this study was to compare the fracture incidence of acrylic resin mandibular overdentures retained by 1 or 2 implants. The null hypothesis was that there would be no difference in fracture incidence for overdentures retained by 1 or 2 implants.
MATERIAL AND METHODS The present study included data from the Vancouver Implant Prosthesis (VIP) clinical trial, which ran from 2003 to 2008.6 The goal of the trial was to compare patient satisfaction,
component costs, and treatment and maintenance time associated with mandibular overdentures retained by 1 or 2 implants. This research was approved by the University of British Columbia’s Clinical Research Ethics Board. The clinical records of 85 patients (43 men and 42 women; mean age: 67 years) wearing a mandibular implant-retained overdenture for at least 1 year were examined. The dentures of all subjects had been made by dental students at the undergraduate clinic of the Faculty of Dentistry or by local clinicians. Dentures were accepted if judged technically satisfactory by a faculty-based prosthodontist. Implants (Solid screw, SLA surface; Straumann Canada Ltd, Burlington, Canada) were placed in either the mandibular midline for the singleimplant option, or bilaterally in the mandibular canine area for 2-implant situations. During a 6-week healing period, a healing abutment (Healing Cap; Straumann Canada Ltd) protected each implant, and a provisional reline material (COE-SOF T; GC America, Alsip, Ill) was placed in the mandibular denture. After a 3-month healing period, a ball abutment (Retentive Anchor; Straumann Canada Ltd) was placed on each implant, followed by a localized relining of the denture to attach the gold matrices (Gold Matrix; Straumann Canada Ltd). No reinforcement was added to the overdenture base. The follow-up period after denture relining varied from 481 to 1762 days, with a mean follow up of 3.23 years. Subjects who had experienced a fractured overdenture were identi-
fied from the clinical records. A fracture was considered as either a visible crack in the acrylic resin or a total separation of the denture parts. The same clinical records listed 3 denture fracture sites: over the implant, elsewhere (not over the implant), or unknown. A chi-square test with Yates’ continuous correction was used to compare the incidence of fracture (_=.05). Kaplan-Meier method and log-rank test were used to calculate and compare the survival rate until fracture or “time to fracture” of overdentures retained by 1 or 2 implants. In this study, a fractured denture was classified as not surviving.
RESULTS Forty-two subjects received a single implant, and 43 received 2 implants. In total, there were 17 fractures recorded for 13 subjects. Nine single-implant subjects experienced 11 denture fractures, while 4 double-implant subjects experienced 6 fractures. Comparing these results using a chi-square test with Yates’ continuity correction, this difference was not significant (P=.211) (Table I). The survival rate until fracture of overdentures retained by 1 implant was 81.0%, and of overdentures retained by 2 implants, 93.2%, using the Kaplan-Meier method (Fig. 1). There was no significant difference in survival rate between the 1 and 2-implant situations, according to the log rank test (P=.07). Twelve (70%) of the fractures occurred over the implant, 2 (12%) occurred elsewhere, and the locations of 3 (18%) fractures were not recorded. Over-the-implant fractures
Table I. Comparison of subjects with 1 and 2 implants who experienced overdenture fracture, using chi-square test with Yates’ continuity correction
Gonda et al
No Fracture
Fracture
Total
One implant
33 (78.6%)
9 (21.4%)
42
Two implants
39 (90.7%)
4 (9.3%)
43
Total
72 (84.7%)
13 (15.3%)
85
P
.211
180
Volume 103 Issue 3
Cumulative Survival Rate
1.00
0.75
0.50
0.25 One implant
0
0
500
1000
Two implants
1500
2000
Days after Reline 1 Survival curves to illustrate differences between time to fracture of overdentures retained by 1 or 2 implants, with Kaplan-Meier method.
Table II. Time (days) to fracture of denture after reline Subject
Days after Reline
A
139; 774
B
1392
C
14; 54
D
362
E
302
F
14
G
230
H
219
I
388
J
937
K
41
L
776
M
299; 340; 375
were distributed differently between the 2 groups, accounting for 64% of the single-implant denture fractures, versus 83% of the 2-implant denture fractures. Ten subjects experienced a fracture once, 2 experienced fractures twice, and 1 subject experienced fractures 3 times. The length of time from denture reline with implant retention to denture fracture varied from 14 to 1392 days, with a mean of just over 1 year (392 days) (Table II).
DISCUSSION In comparing subjects with dentures retained by 1 or 2 implants, the null hypothesis for incidence of denture fracture was not rejected, as the incidence of denture base fractures was not significantly different between the 1- and 2-implant situations. Like fractures of overdentures supported by natural teeth, fractures of overdentures retained by implants
The Journal of Prosthetic Dentistry
tend to occur where there is a concentration of stress, usually over the implant. Walton et al10 reported that 5.8% of removable implant-supported prosthesis repairs (n=137) involved fractures in the acrylic resin. However, this investigation could not be compared to the present study, as data from the study by Walton et al did not indicate the total number of fractures for all study subjects. Chaffee et al11 reported that 4 of 58 patients (6.9%) required 12 mandibular denture repairs due to fracture, primarily in the midline. This distribution of fractures is less than the findings (15.3%) of the present study, but the reasons for this difference are unclear. For example, the influence of denture base reinforcement is unknown, since it was not stated whether denture base reinforcement was used by Chaffee and colleagues. Reinforcement of the denture base over the implants may increase resistance to this concentration of stress, and this approach has been suggested to prevent fractures over both natural teeth8 and implants.7,9 An in vitro study12 using strain gauges suggested that acrylic resin reinforced with a cast chrome-cobalt framework strengthens the resistance to fracture of a denture base. However, a clinical trial comparing ball and bar attachments with mandibular overdentures retained by 2 implants did not demonstrate any difference in denture repairs, whether or not the denture base was reinforced with a cast framework embedded in the acrylic resin across the midline from premolar to premolar.2 Apparently, the number and variety of forces on a denture base in clinical function are more complex than those rendered in an in vitro study, which indicates that further research is necessary, preferably with a prospective design, to address the problem of fractures in overdentures. The small sample size was a limitation of this study, which may account for the lack of significance between the fractures of overdentures with single and double implants. Estimated
Gonda et al
181
March 2010 power of the chi-square test was 0.29, and that of the log-rank test was 0.28.
CONCLUSIONS The incidence of denture base fractures was not significantly different between overdentures retained by 1 or 2 implants; however, when fractures did occur, they tended to do so in areas adjacent to implants.
REFERENCES 1. Feine JS, Carlsson GE, Awad MA, Chehade A, Duncan WJ, Gizani S, et al. The McGill consensus statement on overdentures. Mandibular two-implant-overdentures as first choice standard of care for edentulous patients. Montreal, Quebec, May 2425, 2002. Int J Oral Maxillofac Implants 2002;17:601-2. 2. MacEntee MI, Walton JN, Glick N. A clinical trial of patient satisfaction and prosthodontic needs with ball and bar attachments for implant-retained complete overdentures: three-year results. J Prosthet Dent 2005;93:28-37.
3. Cordioli G, Majzoub Z, Castagna S. Mandibular overdentures anchored to single implants: a five-year prospective study. J Prosthet Dent 1997;78:159-65. 4. Krennmair G, Ulm C. The symphyseal single-tooth implant for anchorage of a mandibular complete denture in geriatric patients: a clinical report. Int J Oral Maxillofac Implants 2001;16:98-104. 5. Maeda Y, Horisaka M, Yagi K. Biomechanical rationale for a single implant-retained mandibular overdenture: an in vitro study. Clin Oral Implants Res 2008;19:271-5. 6. Walton JN, Glick N, MacEntee MI. A randomized clinical trial comparing patient satisfaction and prosthetic outcomes with mandibular implant overdentures retained by one or two implants. Int J Prosthodont 2009;22:331-9. 7. Naert I, De Clercq M, Theuniers G, Schepers E. Overdentures supported by osseointegrated fixtures for the edentulous mandible: a 2.5-year report. Int J Oral Maxillofac Implants 1988;3:191-6. 8. Langer Y, Langer A. Root-retained overdentures: Part I--Biomechanical and clinical aspects. J Prosthet Dent 1991;66:784-9. 9. Carlson B, Carlsson GE. Prosthodontic complications in osseointegrated dental implant treatment. Int J Oral Maxillofac Implants 1994;9:90-4.
10.Walton JN, MacEntee MI. Problems with prostheses on implants: a retrospective study. J Prosthet Dent 1994;71:283-8. 11.Chaffee NR, Felton DA, Cooper LF, Palmqvist U, Smith R. Prosthetic complications in an implant-retained mandibular overdenture population: initial analysis of a prospective study. J Prosthet Dent 2002;87:40-4. 12.Gonda T, Ikebe K, Dong J, Nokubi T. Effect of reinforcement on overdenture strain. J Dent Res 2007;86:667-71. Corresponding author: Dr Tomoya Gonda Department of Prosthodontics and Oral Rehabilitation Osaka University School of Dentistry 1-8 Yamadaoka Suita Osaka 565-0871 JAPAN Fax: +81-6-6879-2957 E-mail: [email protected] Acknowledgements The authors thank Dr Ross Bryant for his clinical management of the subjects in the trial, and Philip Feeley for assistance with data. Copyright © 2010 by the Editorial Council for The Journal of Prosthetic Dentistry.
Access to The Journal of Prosthetic Dentistry Online is reserved for print subscribers! Full-text access to The Journal of Prosthetic Dentistry Online is available for all print subscribers. To activate your individual online subscription, please visit The Journal of Prosthetic Dentistry Online. Point your browser to http://www.journals. elsevierhealth.com/periodicals/ympr/home, follow the prompts to activate online access here, and follow the instructions. To activate your account, you will need your subscriber account number, which you can find on your mailing label (note: the number of digits in your subscriber account number varies from 6 to 10). See the example below in which the subscriber account number has been circled. Sample mailing label
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*********AUTO**SCH 3-DIGIT 001 1 V97-3 J010 12345678-9 J. H. DOE 531 MAIN ST CENTER CITY, NY 10001-001
Personal subscriptions to The Journal of Prosthetic Dentistry Online are for individual use only and may not be transferred. Use of The Journal of Prosthetic Dentistry Online is subject to agreement to the terms and conditions as indicated online.
Gonda et al
Clinical Implications This study suggests that an overdenture retained by either 1 implant or 2 implants is a treatment option for patients with an edentulous mandible, when considering denture fracture incidence.
The clinical trial from which the data for this study were generated was supported by the Canadian Institutes of Health Research (grant no. 58954), the ITI Foundation (grant no. 222), and Straumann Canada Ltd. a
Assistant Professor, Department of Prosthodontics and Oral Rehabilitation, Osaka University Graduate School of Dentistry. Professor, Department of Prosthodontics and Oral Rehabilitation, Osaka University Graduate School of Dentistry. c Professor, Department of Oral Health Sciences, Faculty of Dentistry, University of British Columbia. d Professor, Department of Oral Health Sciences, Faculty of Dentistry, University of British Columbia. b
The Journal of Prosthetic Dentistry
Gonda et al
179
March 2010 Implant-retained overdentures are standard treatment options for rehabilitating edentulous jaws.1,2 While 2 to 4 implants have been preferred to retain and stabilize an implantretained overdenture, some reports suggest a single implant is adequate for overdenture retention.3-6 Cordioli et al3 and Krennmair et al4 evaluated treatment with mandibular overdentures retained by single implants in a geriatric patient population. The authors concluded that oral rehabilitation using mandibular complete dentures retained by a single implant is an economical therapeutic alternative to conventional mandibular complete dentures, especially for older patients. Fracture of the acrylic resin denture base, whether for a conventional or implant prosthesis, can be an inconvenient complication, as the patient is generally unable to wear the denture until it is repaired. Information on denture fractures has been reported7-12; however, there is no information on the incidence of fractures when dentures are retained by a single implant. The objective of this study was to compare the fracture incidence of acrylic resin mandibular overdentures retained by 1 or 2 implants. The null hypothesis was that there would be no difference in fracture incidence for overdentures retained by 1 or 2 implants.
MATERIAL AND METHODS The present study included data from the Vancouver Implant Prosthesis (VIP) clinical trial, which ran from 2003 to 2008.6 The goal of the trial was to compare patient satisfaction,
component costs, and treatment and maintenance time associated with mandibular overdentures retained by 1 or 2 implants. This research was approved by the University of British Columbia’s Clinical Research Ethics Board. The clinical records of 85 patients (43 men and 42 women; mean age: 67 years) wearing a mandibular implant-retained overdenture for at least 1 year were examined. The dentures of all subjects had been made by dental students at the undergraduate clinic of the Faculty of Dentistry or by local clinicians. Dentures were accepted if judged technically satisfactory by a faculty-based prosthodontist. Implants (Solid screw, SLA surface; Straumann Canada Ltd, Burlington, Canada) were placed in either the mandibular midline for the singleimplant option, or bilaterally in the mandibular canine area for 2-implant situations. During a 6-week healing period, a healing abutment (Healing Cap; Straumann Canada Ltd) protected each implant, and a provisional reline material (COE-SOF T; GC America, Alsip, Ill) was placed in the mandibular denture. After a 3-month healing period, a ball abutment (Retentive Anchor; Straumann Canada Ltd) was placed on each implant, followed by a localized relining of the denture to attach the gold matrices (Gold Matrix; Straumann Canada Ltd). No reinforcement was added to the overdenture base. The follow-up period after denture relining varied from 481 to 1762 days, with a mean follow up of 3.23 years. Subjects who had experienced a fractured overdenture were identi-
fied from the clinical records. A fracture was considered as either a visible crack in the acrylic resin or a total separation of the denture parts. The same clinical records listed 3 denture fracture sites: over the implant, elsewhere (not over the implant), or unknown. A chi-square test with Yates’ continuous correction was used to compare the incidence of fracture (_=.05). Kaplan-Meier method and log-rank test were used to calculate and compare the survival rate until fracture or “time to fracture” of overdentures retained by 1 or 2 implants. In this study, a fractured denture was classified as not surviving.
RESULTS Forty-two subjects received a single implant, and 43 received 2 implants. In total, there were 17 fractures recorded for 13 subjects. Nine single-implant subjects experienced 11 denture fractures, while 4 double-implant subjects experienced 6 fractures. Comparing these results using a chi-square test with Yates’ continuity correction, this difference was not significant (P=.211) (Table I). The survival rate until fracture of overdentures retained by 1 implant was 81.0%, and of overdentures retained by 2 implants, 93.2%, using the Kaplan-Meier method (Fig. 1). There was no significant difference in survival rate between the 1 and 2-implant situations, according to the log rank test (P=.07). Twelve (70%) of the fractures occurred over the implant, 2 (12%) occurred elsewhere, and the locations of 3 (18%) fractures were not recorded. Over-the-implant fractures
Table I. Comparison of subjects with 1 and 2 implants who experienced overdenture fracture, using chi-square test with Yates’ continuity correction
Gonda et al
No Fracture
Fracture
Total
One implant
33 (78.6%)
9 (21.4%)
42
Two implants
39 (90.7%)
4 (9.3%)
43
Total
72 (84.7%)
13 (15.3%)
85
P
.211
180
Volume 103 Issue 3
Cumulative Survival Rate
1.00
0.75
0.50
0.25 One implant
0
0
500
1000
Two implants
1500
2000
Days after Reline 1 Survival curves to illustrate differences between time to fracture of overdentures retained by 1 or 2 implants, with Kaplan-Meier method.
Table II. Time (days) to fracture of denture after reline Subject
Days after Reline
A
139; 774
B
1392
C
14; 54
D
362
E
302
F
14
G
230
H
219
I
388
J
937
K
41
L
776
M
299; 340; 375
were distributed differently between the 2 groups, accounting for 64% of the single-implant denture fractures, versus 83% of the 2-implant denture fractures. Ten subjects experienced a fracture once, 2 experienced fractures twice, and 1 subject experienced fractures 3 times. The length of time from denture reline with implant retention to denture fracture varied from 14 to 1392 days, with a mean of just over 1 year (392 days) (Table II).
DISCUSSION In comparing subjects with dentures retained by 1 or 2 implants, the null hypothesis for incidence of denture fracture was not rejected, as the incidence of denture base fractures was not significantly different between the 1- and 2-implant situations. Like fractures of overdentures supported by natural teeth, fractures of overdentures retained by implants
The Journal of Prosthetic Dentistry
tend to occur where there is a concentration of stress, usually over the implant. Walton et al10 reported that 5.8% of removable implant-supported prosthesis repairs (n=137) involved fractures in the acrylic resin. However, this investigation could not be compared to the present study, as data from the study by Walton et al did not indicate the total number of fractures for all study subjects. Chaffee et al11 reported that 4 of 58 patients (6.9%) required 12 mandibular denture repairs due to fracture, primarily in the midline. This distribution of fractures is less than the findings (15.3%) of the present study, but the reasons for this difference are unclear. For example, the influence of denture base reinforcement is unknown, since it was not stated whether denture base reinforcement was used by Chaffee and colleagues. Reinforcement of the denture base over the implants may increase resistance to this concentration of stress, and this approach has been suggested to prevent fractures over both natural teeth8 and implants.7,9 An in vitro study12 using strain gauges suggested that acrylic resin reinforced with a cast chrome-cobalt framework strengthens the resistance to fracture of a denture base. However, a clinical trial comparing ball and bar attachments with mandibular overdentures retained by 2 implants did not demonstrate any difference in denture repairs, whether or not the denture base was reinforced with a cast framework embedded in the acrylic resin across the midline from premolar to premolar.2 Apparently, the number and variety of forces on a denture base in clinical function are more complex than those rendered in an in vitro study, which indicates that further research is necessary, preferably with a prospective design, to address the problem of fractures in overdentures. The small sample size was a limitation of this study, which may account for the lack of significance between the fractures of overdentures with single and double implants. Estimated
Gonda et al
181
March 2010 power of the chi-square test was 0.29, and that of the log-rank test was 0.28.
CONCLUSIONS The incidence of denture base fractures was not significantly different between overdentures retained by 1 or 2 implants; however, when fractures did occur, they tended to do so in areas adjacent to implants.
REFERENCES 1. Feine JS, Carlsson GE, Awad MA, Chehade A, Duncan WJ, Gizani S, et al. The McGill consensus statement on overdentures. Mandibular two-implant-overdentures as first choice standard of care for edentulous patients. Montreal, Quebec, May 2425, 2002. Int J Oral Maxillofac Implants 2002;17:601-2. 2. MacEntee MI, Walton JN, Glick N. A clinical trial of patient satisfaction and prosthodontic needs with ball and bar attachments for implant-retained complete overdentures: three-year results. J Prosthet Dent 2005;93:28-37.
3. Cordioli G, Majzoub Z, Castagna S. Mandibular overdentures anchored to single implants: a five-year prospective study. J Prosthet Dent 1997;78:159-65. 4. Krennmair G, Ulm C. The symphyseal single-tooth implant for anchorage of a mandibular complete denture in geriatric patients: a clinical report. Int J Oral Maxillofac Implants 2001;16:98-104. 5. Maeda Y, Horisaka M, Yagi K. Biomechanical rationale for a single implant-retained mandibular overdenture: an in vitro study. Clin Oral Implants Res 2008;19:271-5. 6. Walton JN, Glick N, MacEntee MI. A randomized clinical trial comparing patient satisfaction and prosthetic outcomes with mandibular implant overdentures retained by one or two implants. Int J Prosthodont 2009;22:331-9. 7. Naert I, De Clercq M, Theuniers G, Schepers E. Overdentures supported by osseointegrated fixtures for the edentulous mandible: a 2.5-year report. Int J Oral Maxillofac Implants 1988;3:191-6. 8. Langer Y, Langer A. Root-retained overdentures: Part I--Biomechanical and clinical aspects. J Prosthet Dent 1991;66:784-9. 9. Carlson B, Carlsson GE. Prosthodontic complications in osseointegrated dental implant treatment. Int J Oral Maxillofac Implants 1994;9:90-4.
10.Walton JN, MacEntee MI. Problems with prostheses on implants: a retrospective study. J Prosthet Dent 1994;71:283-8. 11.Chaffee NR, Felton DA, Cooper LF, Palmqvist U, Smith R. Prosthetic complications in an implant-retained mandibular overdenture population: initial analysis of a prospective study. J Prosthet Dent 2002;87:40-4. 12.Gonda T, Ikebe K, Dong J, Nokubi T. Effect of reinforcement on overdenture strain. J Dent Res 2007;86:667-71. Corresponding author: Dr Tomoya Gonda Department of Prosthodontics and Oral Rehabilitation Osaka University School of Dentistry 1-8 Yamadaoka Suita Osaka 565-0871 JAPAN Fax: +81-6-6879-2957 E-mail: [email protected] Acknowledgements The authors thank Dr Ross Bryant for his clinical management of the subjects in the trial, and Philip Feeley for assistance with data. Copyright © 2010 by the Editorial Council for The Journal of Prosthetic Dentistry.
Access to The Journal of Prosthetic Dentistry Online is reserved for print subscribers! Full-text access to The Journal of Prosthetic Dentistry Online is available for all print subscribers. To activate your individual online subscription, please visit The Journal of Prosthetic Dentistry Online. Point your browser to http://www.journals. elsevierhealth.com/periodicals/ympr/home, follow the prompts to activate online access here, and follow the instructions. To activate your account, you will need your subscriber account number, which you can find on your mailing label (note: the number of digits in your subscriber account number varies from 6 to 10). See the example below in which the subscriber account number has been circled. Sample mailing label
This is your subscription account number
*********AUTO**SCH 3-DIGIT 001 1 V97-3 J010 12345678-9 J. H. DOE 531 MAIN ST CENTER CITY, NY 10001-001
Personal subscriptions to The Journal of Prosthetic Dentistry Online are for individual use only and may not be transferred. Use of The Journal of Prosthetic Dentistry Online is subject to agreement to the terms and conditions as indicated online.
Gonda et al