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Introduction
The treatment of the edentulous jaws presents a difficult challenge requiring careful diagnosis and treatment planning to achieve an aesthetic and functional result.
Christopher Ho, Implant treatment planning for the edentulous jaws, Australasian Dental practice, April 2010, 126-132.
These patients, especially the fully edentulous mandible, suffer from poor function and consequently lack of self confidence, often being termed “dental cripples”.
Christopher Ho, Implant treatment planning for the edentulous jaws, Australasian Dental Practice, April 2010, 126-132.
The bone loss accelerates when the patient wears a poorly fitting soft tissue borne prosthesis.
Burns, mandibular implant overdenture treatment: consensus and contraversy, J Prosthod 2000, 9: 37-46
Almost 40% of denture wearer have been wearing an ill-fitting prosthesis for more than 10 years. 80% of dentures are worn both day and night, place greater forces on the hard and soft tissues, which accelerates bone loss.
Marcus PA, Joshi JA, Morgano SM ,Complete edentulism and dentures use for elders in New England. J. Prosth. Dent., 1996, 76: 260266.
In some cases, it is not possible to achieve optimal results using conventional complete denture treatment alone, and alternatives must considered.
Burns, mandibular implant overdenture treatment: consensus and contraversy, J Prosthod 2000, 9: 37-46
In the past, treatment solutions focused on providing increased ing tissue volume, such as, alveolar ridge augmentation, alveoloplasty and tissue extension procedures.
Burns, mandibular implant overdenture treatment: consensus and contraversy, J Prosthod 2000, 9: 37-46
These treatments have provided mixed long term success and have occasionally introduced significant complications and morbidity.
Burns, mandibular implant overdenture treatment: consensus and contraversy, J Prosthod 2000, 9: 37-46
Presently, some feel that complete denture prosthesis are below the standard of care and that the most basic restoration for edentulous mandible should be an implant retained overdenture with two implants placed in the anterior mandible. Feine J S, Carlsson G E, Awad M A et al. Mandibular two-implant overdentures as first choice standard of care for edentulous patients. Gerodontolog y 2002;19: 3-4.
The treatment options for the edentulous jaw can be either removable or fixed in nature. They range from removable dentures to implant retained dentures and fully fixed implant ed bridgework .
Christopher Ho, Implant treatment planning for the edentulous jaws, Australasian Dental Practice, April 2010, 126-132.
Literature Review
Tallgren,1972, reported the amount of bone loss occurring the first year after tooth loss is almost 10 times greater than the following years. Tallg ren A: The continuing reduction of the residual alveolar ridges ….. , J Prostl7et Dent 27:120-132, 1972.
Atwood, 1962, the posterior edentulous mandible resorbs at a rate about four times than the anterior edentulous mandible. Atwood DA, some clinical factors related to the rate of resorption …., JPD, 12:441450,1962
Blomberg & Lindquist 1983, implants provided improvement of quality of life for completely edentulous patients. Blomberg S & Lindquist LW, Psychological reactions to edentulousness and treatment 1983,251-262.
Schroeder et al. 1981, he suggested that overdentures ed by four implants should be used for the completely edentulous mandible. Schroeder A, et al, The reactions of bone, connective tissue, and epithelium to endosteal implants …, Journal of Maxillofacial Surgery 1981,9, 15-25.
Diagnosis
Extra Oral Examination Intra Oral Examination Radiologic Diagnosis
-Speech: Speech problems are mainly with fixed implant prostheses.
Difficulty is often seen with linguo-palatal consonants where the tongue approximates the convex plateau of the anterior palate.
Christopher Ho, Implant treatment planning for the edentulous jaws, Australasian Dental practice, April 2010, 126-132.
Lundqvist et al (1992) reported that 60% of the
patients in a clinical trial had distorted speech soon after treatment and 3 years later, the rate was still 30%.
Lundqvist S et al, Speech before and after treatment with bridges on osseointeg rated implants in the upper jaw. Clin Oral Implants Res 1992a;3:57-62.
Heydecke et al (2004) in a within-subject
comparison of maxillary fixed and removable prostheses found more speech errors with implant ed maxillary bridges than with removable prostheses.
Heydecke G et al, Within subject comparisons of maxillary fixed and removable ….., Clin Oral Implants Res 2003;14:125–30.
-Thickness of the mucosa: - Often in edentulous patients the interdental papillae is absent.
- When papillae are lost it is very difficult if not impossible to regenerate it.
S. Jiviraj et al, Treatment planning of the edentulous maxilla, Br. Dent J, 2006, 201(5): 261-79
-Bone quality and quantity: The clinicians ability to evaluate the maxillary bone quantity and quality makes this one of the most challenging sites for successful implant placement.
Lekholm U, Zarb GA. Patient selection and preparation. In Branemark P-I, Zarb G A, Albrektsson T (Eds). Tissue integ rated prostheses: Osseointeg ration in clinical dentistry. pp 199-209. Chicago: Quintessesnce, 1985.
-Inter arch space: The limiting factor in edentulous patients is the available interarch space. An efficient method of evaluating inter arch space in a patient with an edentulous maxillary arch is to construct a diagnostic putty cast. Wicks R A. A systematic approach to definitive planning for osseointeg rated implant prostheses. J Prosthodont 1994; 3: 237-242.
-Incisal edge position: On average the length of the central incisors is 10.5 mm, this can be more in elderly patients who exhibit gingival recession. To determine if a fixed or removable restoration would be appropriate a wax try in is done without flange.
Ash M M. Wheelers dental anatomy, physiolog y and occlusion. 7th ed. pp 128-273. Philadelphia: WB Saunders, 1993.
Treatment planning
In treatment planning the following factors must be considered: 1. Aesthetics and patient desires. 2. Type of . 3. Amount of resorption and interarch space. 4. Number of implants. 5. Implant distribution. 6. Economics.
S. Jiviraj et al, Treatment planning of the edentulous maxilla, Br. Dent J, 2006, 201(5): 261-79
b. Anticipated force to be placed on the restoration. Bruxers often present with a pronounced antegonial notch and this can be indicative of the likely force to be placed on the restorations. In these types of patients it is wise to ‘over engineer’ and place additional implants for added and distribution of force.
S. Jiviraj et al, Treatment planning of the edentulous maxilla, Br. Dent J, 2006, 201(5): 261-79
PROSTHETIC OPTIONS
PROSTHETIC OPTIONS In 1989, Misch proposed five prosthetic options for implant dentistry. The first three options are fixed prostheses (FPs). These options depend on the amount of hard and soft tissue structures replaced and the aspects of the prosthesis in the esthetic zone. Car Mish, ch5, Prosthetic options in implant dentistry, Third edition, 2007, 92-103
Two types of final implant restorations are removable prostheses (RPs); they depend on the amount of implant , not the appearance of the prosthesis.
Car Mish, ch5, Prosthetic options in implant dentistry, Third edition, 2007, 92-103
Removable Prostheses There are two kinds of the removable prostheses, based upon of the restoration. The difference in the two categories are determined by the amount of implant . Car Mish, ch5, Prosthetic options in implant dentistry, Third edition, 2007, 92-103
Edentulous Maxilla Treatment Options
Maxillary Fixed Prosthesis Options The arch form of the maxilla influences the treatment plan of the edentulous premaxilla. Three typical dental arch forms for the maxilla : -Square. -Ovoid -Tapering. Carl Misch, ch17, Maxillary arch implant considerations …, Third edition, 2007, 367-387
Maxillary Overdenture Options Fewer reports have been published for maxillary overdentures compared with the mandible. Engquist et al, 1988, reported 6% to 7% implant failure for mandibulat implants ed overdentures and 19% to 35% failure for maxillary implant overdentures. Carl Misch, ch17, Maxillary arch implant considerations …, Third edition, 2007, 367-387
Only two treatment options are available for the maxillary implant overdentures, As such, the two treatment options provide an RP-5 restoration with some posterior soft tissue or an RP-4 restoration, which is completely ed, retained, and stabilized by implants.
Carl Misch, ch17, Maxillary arch implant considerations …, Third edition, 2007, 367-387
Edentulous Mandible Treatment Options
Mandibular Fixed Prosthesis Options Mandibular Dynamics The mandible between the mental foraminae is stable. Distal to the foraminae, the mandible exhibits movement toward the midline on opening. Caused by the attachment of internal pterygoid muscles on the medial ramus of the mandible. Carl Misch, ch15, Treatment plan for fixed restorations …, Third edition, 2007, 314-324
IMPLANT ASSISTED REMOVABLE PARTIAL DENTURES
Stewarts Clinical Removable Prosthodontics, Fouth edition, Ch9, 259-277
The more widely used implant-retained and implant ed are inadequate and that the prosthess is retained or ed solely by the implants.
Stewarts Clinical Removable Prosthodontics, Fouth edition, Ch9, 259-277
In reality, implant-assisted removable partial dentures are also ed by natural teeth and/or soft tissues; retention also may involve conventional clasping systems. Implant can offer many benefits for removable prosthesis, including improved , retention, comfort, and esthetic.
Stewarts Clinical Removable Prosthodontics, Fourth edition, Ch9, 259-277
Jackson 1990, the earliest reports of implantassisted removable partial dentures involved splinting of natural teeth to implants.
Jackson TR, Removable partial overdenture with natural…, Dent Clin North Am, 1990
Ganz 1991, splinted two maxillary implants to the remaining natural teeth to provide a bar retained removable partial overdenture.
Ganz SD, Combination natural tooth and implant borne removable…, JPD, 1991
Yang 1998, first use of a single implant as a RPD abutment.
Yang Y, Tarnow D, Single implant ed crown used as abutment…, Implant Dent, 1998
Keltjens 1993, suggested implant ed distal extension RPD may be the most reasonable cost effective treatment option for patient opposing edentulous maxillae. Keltjens et al, Distal extension removable partial dneutre …., JOMI , 1993
Mitrani et al 2003, published a 1 to 4 years retrospective study of 10 patients treated with implant assisted RPD. All patients reported significantly improved satisfaction following implant placement. Mitrani R, et al, Posterior implant for distal …, IJPRD, 2003
Treatment Planning Considerations As might be expected, extension base RPD represent the most challenging situations in RPD therapy. Common complaints includes lack of stability, inadequate retention, esthetically objectionable clasp display and discomfort upon occlusal loading. Stewarts Clinical Removable Prosthodontics, Fourth edition, Ch9, 259-277
Classification of Implant-assisted Removable partial denture The letter I added to the original Kennedy designation would communicate the change from the conventional tooth tissue- borne situation to one that is now tooth-implant-borne.
Stewarts Clinical Removable Prosthodontics, Fourth edition, Ch9, 259-277
CASES
CASE 6
CASE 7
CASE 8
CASE 9
CASE 10
The treatment of the edentulous jaws presents a difficult challenge requiring careful diagnosis and treatment planning to achieve an aesthetic and functional result.
Christopher Ho, Implant treatment planning for the edentulous jaws, Australasian Dental practice, April 2010, 126-132.
These patients, especially the fully edentulous mandible, suffer from poor function and consequently lack of self confidence, often being termed “dental cripples”.
Christopher Ho, Implant treatment planning for the edentulous jaws, Australasian Dental Practice, April 2010, 126-132.
The bone loss accelerates when the patient wears a poorly fitting soft tissue borne prosthesis.
Burns, mandibular implant overdenture treatment: consensus and contraversy, J Prosthod 2000, 9: 37-46
Almost 40% of denture wearer have been wearing an ill-fitting prosthesis for more than 10 years. 80% of dentures are worn both day and night, place greater forces on the hard and soft tissues, which accelerates bone loss.
Marcus PA, Joshi JA, Morgano SM ,Complete edentulism and dentures use for elders in New England. J. Prosth. Dent., 1996, 76: 260266.
In some cases, it is not possible to achieve optimal results using conventional complete denture treatment alone, and alternatives must considered.
Burns, mandibular implant overdenture treatment: consensus and contraversy, J Prosthod 2000, 9: 37-46
In the past, treatment solutions focused on providing increased ing tissue volume, such as, alveolar ridge augmentation, alveoloplasty and tissue extension procedures.
Burns, mandibular implant overdenture treatment: consensus and contraversy, J Prosthod 2000, 9: 37-46
These treatments have provided mixed long term success and have occasionally introduced significant complications and morbidity.
Burns, mandibular implant overdenture treatment: consensus and contraversy, J Prosthod 2000, 9: 37-46
Presently, some feel that complete denture prosthesis are below the standard of care and that the most basic restoration for edentulous mandible should be an implant retained overdenture with two implants placed in the anterior mandible. Feine J S, Carlsson G E, Awad M A et al. Mandibular two-implant overdentures as first choice standard of care for edentulous patients. Gerodontolog y 2002;19: 3-4.
The treatment options for the edentulous jaw can be either removable or fixed in nature. They range from removable dentures to implant retained dentures and fully fixed implant ed bridgework .
Christopher Ho, Implant treatment planning for the edentulous jaws, Australasian Dental Practice, April 2010, 126-132.
Literature Review
Tallgren,1972, reported the amount of bone loss occurring the first year after tooth loss is almost 10 times greater than the following years. Tallg ren A: The continuing reduction of the residual alveolar ridges ….. , J Prostl7et Dent 27:120-132, 1972.
Atwood, 1962, the posterior edentulous mandible resorbs at a rate about four times than the anterior edentulous mandible. Atwood DA, some clinical factors related to the rate of resorption …., JPD, 12:441450,1962
Blomberg & Lindquist 1983, implants provided improvement of quality of life for completely edentulous patients. Blomberg S & Lindquist LW, Psychological reactions to edentulousness and treatment 1983,251-262.
Schroeder et al. 1981, he suggested that overdentures ed by four implants should be used for the completely edentulous mandible. Schroeder A, et al, The reactions of bone, connective tissue, and epithelium to endosteal implants …, Journal of Maxillofacial Surgery 1981,9, 15-25.
Diagnosis
Extra Oral Examination Intra Oral Examination Radiologic Diagnosis
-Speech: Speech problems are mainly with fixed implant prostheses.
Difficulty is often seen with linguo-palatal consonants where the tongue approximates the convex plateau of the anterior palate.
Christopher Ho, Implant treatment planning for the edentulous jaws, Australasian Dental practice, April 2010, 126-132.
Lundqvist et al (1992) reported that 60% of the
patients in a clinical trial had distorted speech soon after treatment and 3 years later, the rate was still 30%.
Lundqvist S et al, Speech before and after treatment with bridges on osseointeg rated implants in the upper jaw. Clin Oral Implants Res 1992a;3:57-62.
Heydecke et al (2004) in a within-subject
comparison of maxillary fixed and removable prostheses found more speech errors with implant ed maxillary bridges than with removable prostheses.
Heydecke G et al, Within subject comparisons of maxillary fixed and removable ….., Clin Oral Implants Res 2003;14:125–30.
-Thickness of the mucosa: - Often in edentulous patients the interdental papillae is absent.
- When papillae are lost it is very difficult if not impossible to regenerate it.
S. Jiviraj et al, Treatment planning of the edentulous maxilla, Br. Dent J, 2006, 201(5): 261-79
-Bone quality and quantity: The clinicians ability to evaluate the maxillary bone quantity and quality makes this one of the most challenging sites for successful implant placement.
Lekholm U, Zarb GA. Patient selection and preparation. In Branemark P-I, Zarb G A, Albrektsson T (Eds). Tissue integ rated prostheses: Osseointeg ration in clinical dentistry. pp 199-209. Chicago: Quintessesnce, 1985.
-Inter arch space: The limiting factor in edentulous patients is the available interarch space. An efficient method of evaluating inter arch space in a patient with an edentulous maxillary arch is to construct a diagnostic putty cast. Wicks R A. A systematic approach to definitive planning for osseointeg rated implant prostheses. J Prosthodont 1994; 3: 237-242.
-Incisal edge position: On average the length of the central incisors is 10.5 mm, this can be more in elderly patients who exhibit gingival recession. To determine if a fixed or removable restoration would be appropriate a wax try in is done without flange.
Ash M M. Wheelers dental anatomy, physiolog y and occlusion. 7th ed. pp 128-273. Philadelphia: WB Saunders, 1993.
Treatment planning
In treatment planning the following factors must be considered: 1. Aesthetics and patient desires. 2. Type of . 3. Amount of resorption and interarch space. 4. Number of implants. 5. Implant distribution. 6. Economics.
S. Jiviraj et al, Treatment planning of the edentulous maxilla, Br. Dent J, 2006, 201(5): 261-79
b. Anticipated force to be placed on the restoration. Bruxers often present with a pronounced antegonial notch and this can be indicative of the likely force to be placed on the restorations. In these types of patients it is wise to ‘over engineer’ and place additional implants for added and distribution of force.
S. Jiviraj et al, Treatment planning of the edentulous maxilla, Br. Dent J, 2006, 201(5): 261-79
PROSTHETIC OPTIONS
PROSTHETIC OPTIONS In 1989, Misch proposed five prosthetic options for implant dentistry. The first three options are fixed prostheses (FPs). These options depend on the amount of hard and soft tissue structures replaced and the aspects of the prosthesis in the esthetic zone. Car Mish, ch5, Prosthetic options in implant dentistry, Third edition, 2007, 92-103
Two types of final implant restorations are removable prostheses (RPs); they depend on the amount of implant , not the appearance of the prosthesis.
Car Mish, ch5, Prosthetic options in implant dentistry, Third edition, 2007, 92-103
Removable Prostheses There are two kinds of the removable prostheses, based upon of the restoration. The difference in the two categories are determined by the amount of implant . Car Mish, ch5, Prosthetic options in implant dentistry, Third edition, 2007, 92-103
Edentulous Maxilla Treatment Options
Maxillary Fixed Prosthesis Options The arch form of the maxilla influences the treatment plan of the edentulous premaxilla. Three typical dental arch forms for the maxilla : -Square. -Ovoid -Tapering. Carl Misch, ch17, Maxillary arch implant considerations …, Third edition, 2007, 367-387
Maxillary Overdenture Options Fewer reports have been published for maxillary overdentures compared with the mandible. Engquist et al, 1988, reported 6% to 7% implant failure for mandibulat implants ed overdentures and 19% to 35% failure for maxillary implant overdentures. Carl Misch, ch17, Maxillary arch implant considerations …, Third edition, 2007, 367-387
Only two treatment options are available for the maxillary implant overdentures, As such, the two treatment options provide an RP-5 restoration with some posterior soft tissue or an RP-4 restoration, which is completely ed, retained, and stabilized by implants.
Carl Misch, ch17, Maxillary arch implant considerations …, Third edition, 2007, 367-387
Edentulous Mandible Treatment Options
Mandibular Fixed Prosthesis Options Mandibular Dynamics The mandible between the mental foraminae is stable. Distal to the foraminae, the mandible exhibits movement toward the midline on opening. Caused by the attachment of internal pterygoid muscles on the medial ramus of the mandible. Carl Misch, ch15, Treatment plan for fixed restorations …, Third edition, 2007, 314-324
IMPLANT ASSISTED REMOVABLE PARTIAL DENTURES
Stewarts Clinical Removable Prosthodontics, Fouth edition, Ch9, 259-277
The more widely used implant-retained and implant ed are inadequate and that the prosthess is retained or ed solely by the implants.
Stewarts Clinical Removable Prosthodontics, Fouth edition, Ch9, 259-277
In reality, implant-assisted removable partial dentures are also ed by natural teeth and/or soft tissues; retention also may involve conventional clasping systems. Implant can offer many benefits for removable prosthesis, including improved , retention, comfort, and esthetic.
Stewarts Clinical Removable Prosthodontics, Fourth edition, Ch9, 259-277
Jackson 1990, the earliest reports of implantassisted removable partial dentures involved splinting of natural teeth to implants.
Jackson TR, Removable partial overdenture with natural…, Dent Clin North Am, 1990
Ganz 1991, splinted two maxillary implants to the remaining natural teeth to provide a bar retained removable partial overdenture.
Ganz SD, Combination natural tooth and implant borne removable…, JPD, 1991
Yang 1998, first use of a single implant as a RPD abutment.
Yang Y, Tarnow D, Single implant ed crown used as abutment…, Implant Dent, 1998
Keltjens 1993, suggested implant ed distal extension RPD may be the most reasonable cost effective treatment option for patient opposing edentulous maxillae. Keltjens et al, Distal extension removable partial dneutre …., JOMI , 1993
Mitrani et al 2003, published a 1 to 4 years retrospective study of 10 patients treated with implant assisted RPD. All patients reported significantly improved satisfaction following implant placement. Mitrani R, et al, Posterior implant for distal …, IJPRD, 2003
Treatment Planning Considerations As might be expected, extension base RPD represent the most challenging situations in RPD therapy. Common complaints includes lack of stability, inadequate retention, esthetically objectionable clasp display and discomfort upon occlusal loading. Stewarts Clinical Removable Prosthodontics, Fourth edition, Ch9, 259-277
Classification of Implant-assisted Removable partial denture The letter I added to the original Kennedy designation would communicate the change from the conventional tooth tissue- borne situation to one that is now tooth-implant-borne.
Stewarts Clinical Removable Prosthodontics, Fourth edition, Ch9, 259-277
CASES
CASE 6
CASE 7
CASE 8
CASE 9
CASE 10
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