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 supporting 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 supported 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 supported 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 supported maxillary bridges than with
removable prostheses.

Heydecke G et al, Within subject comparisons of maxillary fixed and removable ..,
Clin Oral Implants Res 2003;14:12530.

-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 support.
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 support 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 support, 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 support of the
restoration.
The difference in the two categories are
determined by the amount of implant
support.
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 supported
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
support or an RP-4 restoration, which is
completely supported, 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 terms implant-retained and

implant supported are inadequate and that the
prosthess is retained or supported solely by the
implants.

Stewarts Clinical Removable Prosthodontics, Fouth edition, Ch9, 259-277

In reality, implant-assisted removable partial

dentures are also supported by natural teeth
and/or soft tissues; retention also may involve
conventional clasping systems.
Implant can offer many benefits for removable
prosthesis, including improved support,
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 supported crown used as abutment, Implant Dent, 1998

Keltjens 1993, suggested implant supported

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