PROSTHETIC OPTIONS

FOR
COMPLETELY EDENTULOUS
CASES
CLASSIFICATION OF EDENTULOUS
ARCHES
 Misch Classification
A: Abundant Bone

B: Adequate bone to place narrow implants

C: Inadequate bone width or height (Compromised bone)

D: Severely atrophied bone (Deficient bone)

Misch Classification
 Type 1
 The division of bone is similar in the three
segments

Type 1 Division A
 Type 1

Type 1 Division C Type 1 Division D

 Type 2
 The posterior sections are the same but the
anterior is different

Type 2 Division A,B

 Type 2

Type 2 Division B,C

 Type 3
 The three edentulous segments has
different divisions

Type 3 Division A,B,D

 Type 3

Type 3 Division C,D,C

 PROSTHETIC OPTIONS FOR
TREATMENT OF COMPLETELY
EDENTULOUS CASES
 VS
Fixed Removable
Factors Affecting selection of treatment
options
Retention

inter-arch bone

hygiene implants

Para-
patient
Functional

cost Esthetics
Fixed VS Removable
Esthetics
 Fixed VS Removable
Quality of soft tissues surrounding the implants
Fixed VS Removable
Oral Compliance
Fixed VS Removable
Oral Hygiene
 Fixed VS Removable

 Fewer implants
 Interarch Space

 More than 15mm so

overdentures or hybrid

 Less than 15 mm so we

can used PFM Restorations

Factors Affecting selection of treatment
options
Retention

inter-arch bone

hygiene implants

patient Esthetics

Para-
cost Functional
PROSTHETIC OPTIONS FOR
MANDIBULAR IMPLANT
OVERDENTURE
 Advantages of implant overdenture

 Improves Retention  Decrease soft tissue abrasion

 improved Stability
 Reduced prosthesis size
 Improved esthetics

 Improved phonation
 Decrease bone loss
 Improved chewing

efficiency
 Disadvantages Of Overdenture

 More routine maintenance

 Continued posterior bone loss

 crown height space

 Food Impaction
 Overdenture Movements

PM-O PM-2 PM-3 PM-4 PM-6

 Overdenture Movements
 PM-0: No Movement

 PM-2: Hinge Movement

 PM-3: Apical & Hinge

movement
 Overdenture Movements
 PM-4: Allow movement

in 4 directions

 PM-6: All range of

Movement
Mandibular implant site selection
Overdenture Treatment Options
 OD1
 Implants in the B &D positions
 First Option OD1
Indications:
i. Anatomical conditions

are good to excellent

ii. Minimum patients

needs and desire

iii. Cost is a primary factor

iv. Tapered Arch form

 OD1 Ideal Implants Placement:

 Parallel

 Perpendicular to O.P

 Same Height

 Equidistant
 B&D OR A&E Positions????

 B&D position reduce the

anterior movement of the
prosthesis

 Splinting ??????
 Second Option OD2

 Implants placed in the B&D positions and

rigidly joined by a bar
 OD2
Indications:
i. Anatomical conditions

are good to excellent

ii. Minimum patients

desire

iii. Patient can afford a

prosthesis and a bar

 Ideal Implant Placement:
• They are at least 16-20 mm

apart

• Too close implants will affect

stability during function

• They exit through the crest of

the ridge.
 OD2
Can we placed splinted implants in the A&E
Positions
 Disadvantages of placing Implants in
A&E positions
 Greater bar flexibility

 Anterior denture tipping

 Greater Lateral load

 Compromise the

attachment system

 Difficult speech
 Design of the Tissue Bar
 Parallel to the plane of occlusion

 Perpendicular to the midline

 There should be ample space beneath the Bar

Occlusal
plane

Midline
Design of the Tissue Bar
Possible Complications of tissue bar
Possible Complications of tissue bar
 Overdenture Option 3 OD3
 Implants in the A,C&E positions and rigidly joined by a
bar with no distal cantilever

 It is the first option for patient concerned with retention

and stability and can afford the moderate cost
 OD3
Advantages of having an
extra implant:
i. Less bar flexure

ii. Better stress distribution

iii. Greater surface area

iv. Less prosthesis movement

v. Tripod distribution
Can we place them in BCD Position??
Overdenture option 4 (OD4(

Implants are placed in A,B,D &E and joined by

a bar with a distal cantilever about 10 mm
 Indications of OD4
 Moderate to poor posterior

anatomy

 Complaint of lack of retention

stability and tissue abrasion

 More demanding patient than

previous options
 Why Distal Cantilever Now ??

 Increased implant support

 Additional retention Stability

provided from the bar

 Biomechanical advantage

due to good A-P spread

Anteroposterior Spread

Cantilever
Length
A-P Spread and implant number

A-P Spread

A-P Spread
A-P Spread & Arch form
 Other Factors that controls the
cantilever length
1. Occluding Force

2. Crown Height

3. Para-functionals Stress Factors

4. Opposing Arch

5. Age &Gender
 OD4Design Considerations
 The tissue bar requires more bulk between the implants
because of the increased forces delivered.

 Hygiene access between the implants and beneath the bar is

required
 OD4Design Considerations
 Bite force of patients with implant supported prostheses is greater

 Therefore it may be advisable to provide metal reinforcement

particularly if interocclusal space is compromised

Prosthesis Movement
Prosthesis Movement
Overdenture Option 5 (OD5)
 5 implants placed in A,B,C,D and E rigidly
joined by a bar with distal cantilever about
15 mm
 Indications of OD5

i. Severe problems with

dentures
ii. Demanding patients
iii. Poor Anatomical
conditions
iv. Problems with function
speech and stability
v. Need to stop posterior
bone loss
Treatment of the severely resorbed mandible
Treatment of the severely resorbed mandible
Treatment of the severely resorbed mandible
 Hidden Cantilever

The portion of the cantilever that extend

beyond the connecting bar
 Single implant placed in the midline

 Overdenture retained with an “O”

ring type of attachment

 Patient satisfaction appears to be equivalent to the 2 implant retained

overdenture (Walton et al, 2009)

 Some clinicians have reported a high risk of the acrylic resin fractures

overlying the single implant (Harder et al, 2001).

Mini implants
FIXED PROSTHETIC OPTIONS FOR
EDENTULOUS MANDIBLE
 Mandibular Dynamics
1. Medial movement

 The mandible (distal to the mental

Foramen) exhibit medial movement

during opening and protrusive

movement .

 The amplitude of this flexure

increases as the position moves

dsital
 Mandibular Dynamics
2. Torsion

 Twisting of the mandible

twisted on the working side

during unilateral molar biting

and parafunctional habits

The torsion of the mandible is more powerful than the medial flexure

The body of the mandible flexes more when the size of the bone decreases
 Mandible Dynamics

 The more rigid splinting of distal segment( distal to

2nd premolar) from one side to another the greater
the risk the mandibular dynamics may influence
the prosthesis prognosis
 The influence mandibular dynamics

 Bone loss

 Screw loosening

 Material fracture(Implant or
prosthesis)

 unretained restoration

 Pain on opening
 Advantages of Fixed Restoration

 Feels like natural teeth

 Less food entrapment

 Less regular maintenance

 Lasts more than overdentures

 Stop or decrease the atrophy of the posterior edentulous

ridge
 Porcelain fused to metal prosthesis
 Advantages
 Excellent esthetics

 Nonporous materials

 Little or no wear of occlusal surfaces

 Disadvantages
 Expensive to fabricate
 Time consuming
 Requires a high level of technical
expertise
 Prone to cracks and fractures
PFM TREATMENT
OPTIONS
 Treatment Option 1
(Branemark Approach 4 - 6)
All On 4 Concept
All On 4 Concept
 Treatment Option 2
(5-7 )
 The same as the first option but additional
implants above the mental foramen For:
i. Number of implants is increased
ii. Increased A-P spread
Treatment Option 2
(5-7(
 Treatment Option 3
(6-7 implants)
 Additional implants are
placed in the 1st molar or
2nd premolar region on
one side connected to 4-5
inter foraminal implants

 Adv:
i. Only one cantilever
ii. Better A-P spread
 Treatment Option 4
(6-9 Implants)
 All implants in one
posterior segment are
splinted for 9 unit FPD
 The other posterior
segment is restored
independently

 This Option eliminates

any cantilever
Treatment Option 5
(6-9 Implants)
FIXED HYBRID PROSTHESIS
 Fixed hybrid prosthesis

Components
Cast metal framework

Acrylic resin

Denture teeth
 Fixed hybrid prosthesis
Advantages
• Less costly
• Easier to maintain and repair
• Acrylic flange provides better lip
support
Disadvantages
• The acrylic resin retaining the
denture teeth is porous
• Wear of the denture teeth
 Fixed Hybrid Prosthesis
 The mandibular prosthesis
requires the placement of
4-6 implants anterior to the
mental foramen.

 Occlusion could be
provided to the first molar
area using a distal
cantilever of 15 mm or less
 Fixed Hybrid Prosthesis

Passive Fit
Porosity Causes Fracture
CAD – CAM Frameworks
Milled from Solid Titanium Alloy