Treatment plan for restoring the edentulous maxilla with implant-supported

restorations: Removable overdenture versus fixed partial denture design

Nicola U. Zitzmann, Dr med dent,a and Carlo P. Marinello, Dr med dent, Prof, MSb
University of Basel, Basel, Switzerland
Statement of problem. Restoring the edentulous maxilla with a fixed complete denture or a removable
overdenture is a complex and challenging procedure.
Purpose. This article presents and discusses the crucial factors involved in deciding whether a fixed or
removable implant prosthesis should be planned in fulfilling the patient’s preference for optimal esthetics,
phonetics, comfort, and function.
Methods and material. A concept for treatment planning is presented that enables the practitioner to
check the decisive parameters during the first examination and to make the final decision with the help of
the reformatted computerized tomography scan.
Conclusion. If this treatment plan is followed, implants can be placed to comply with the selected pros-
thetic solution and compromised solutions can be avoided. The fixed design for implant prosthesis is only
appropriate for patients with minimal resorption of the alveolar bone and an optimal maxillomandibular
relationship. The removable overdenture may be indicated from the outset and is no longer restricted to
patients with a compromised situation in which fixed implant prostheses are not feasible. (J Prosthet Dent
1999;82:188-96.)

CLINICAL IMPLICATIONS
Applying a straightforward diagnostic planning procedure and checking the decisive
factors clinically and radiologically allows precise treatment planning even in the
edentulous maxilla and saves the practitioners time. The removable overdenture is con-
sidered as an equally good alternative treatment option to the fixed partial denture
design.

S everal designs of prostheses can be used to restore

the edentulous maxilla with implant-supported fixed or
removable complete dentures.1 By using the latter
means that it is possible to extend the denture base and
rely on the palatal and posterior denture-bearing areas.
Thus, the overdenture prosthesis can be designed as a
combined implant-retained and tissue-supported
restoration, which is indicated in compromised situa-
tions with 4 or less implants. When placement of a
sufficient number of implants of adequate length is fea-
sible, the superstructure can be purely implant-sup-
ported in construction. In such situations, one has to
make the choice between a fixed and a removable
superstructure design. However, firm criteria for plan-
ning and deciding on treatment appear to be lacking.
Many authors recommend not promising the patient a
fixed reconstruction until the final wax trial has been
accepted.2-4 However, changing the treatment plan
aAssistant
Professor, Clinic of Fixed and Removable Prosthodontics
and TMJ Disorders.
bProfessor and Chairman, Clinic of Fixed and Removable Prostho-
dontics and TMJ Disorders.
after implant placement can lead to improper implant
positioning and should be avoided.
It is the aim of this article to introduce criteria for
planning implant treatment, including the crucial fac-
tors involved in deciding whether a fixed or removable
prosthesis should be placed in the edentulous maxilla.
Checklists to aid treatment planning and graphs to
visualize the crucial parameters are given.
CHECKLIST FOR EXAMINATION
Most patients prefer a fixed restoration or want to
discard their removable prostheses.5 Thus, it is impor-
tant to check early in treatment whether this is feasible.
The recommended restoration should be discussed
with the patient and it may be necessary to convince
him or her that a removable overdenture might be
more convenient for his/her situation. Changing the
treatment plan from a fixed to a removable prosthesis
at a later timepoint is, first, disappointing for the
patient, and second, cumbersome for the prosthodon-
tist who has to deal with inadequate implant position-
ing. Therefore crucial design factors have to be consid-
ered from the outset, as they will determine the ideal

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ZITZMANN AND MARINELLO THE JOURNAL OF PROSTHETIC DENTISTRY

Table I. Treatment options for the edentulous maxilla

Fixed partial denture design Removable partial denture design

–Screw-retained (detachable) or –Overdenture with reduced palatal coverage or –Overdenture with full palatal
–Cemented Flange considerations: coverage
Palatal extension is detemined by
• Need for load distribution
• Phonetic improvement
Buccal extension is determined by
• Lip line
• Need for soft tissue support

6-10 implants 6-8 implants 4 (2) implants

Meticulously in optimal implant position
7-10 mm distance from center to center
ideally distributed over the arch or
anterior of the maxillary sinus for
premolar occlusion or optional sinus
elevation/augmentation
Bar retained with precision superstructure Bar retained (or single studs)
• Prefabricated bar and clip
• Individually milled bar
10-14 mm distance from center to center ideally
distributed over the arch or anterior of the
maxillary sinus or optional sinus elevation/
augmentation

Table II. Checklist for implant treatment: Patient’s history

Removable overdenture

Superstructure Fixed implant prostheses With reduced palatal coverage With full palatal coverage

Patient’s related factors

Patient’s preference Preferred 2nd choice 3rd choice
Phonation More problems Fewer problems Fewer problems
Excessive gag reflex Fewer problems More problems More problems
Ability to perform oral hygiene More demanding Easier Easier
Economics More expensive Less expensive Less expensive

Table III. Checklist for implant treatment: Extraoral examination (based on an acceptable existing prosthesis or an ideal wax-
trial denture)
Superstructure Fixed implant prostheses Removable overdenture

Extraoral factors
Facial support: h Unnecessary h Needed (evaluated with and without prosthesis)
Esthetic plane: h Convex profile h Concave profile
Maxillomandibular relationship
(Angle class): h Class I/II h Class III (to be compensated)
Lip support h Entire lip thickness displayed h Trapped, thin upper lip
Smile line (determined during h Low h Average
repose/speech/expanded smile) h High (alveolar ridge visible during speech)
Vestiblar space: h Little h Increased during smiling
Horizontal tooth display: h 6-10 teeth (no/1 cantilever possible) h 10-14 teeth (posterior soft tissue support possible)
Length of the upper lip h Long (26-30 mm) h Short (16-20 mm)
(subnasal to philtrum) ≈ 0.9 mm of upper central teeth visible ≈ 3.4 mm of upper central teeth visible
h Average (21-25 mm)
≈ 2.2 mm of upper central teeth visible

implant position (Table I). The practitioner can refer to
a checklist during the initial examination and check the
factors in the sagittal and vertical dimensions, which
can be well visualized in a transverse section (Tables II
through IV and Figs. 1 through 3).
EXTRAORAL FACTORS
Extraoral clinical examination addresses facial
parameters such as facial support, lip support, smile
line, and upper lip length (Table III and Fig. 2). Facial
support is a critical factor for decision making because

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Fig. 1. Sagittal and vertical factors affecting decision making. Fig. 2. Extraoral factors.

Table IV. Checklist for implant treatment: Intraoral examination (based on an acceptable existing prosthesis or an ideal wax-
trial denture). Determine free-way-space and incisal edge position (touching the vermillion border of the lower lip during “F”
sound)
Superstructure Fixed complete denture Removable overdenture

Intraoral factors
Mucosal quality:
Mucosal quantity:
Bone quantity:
Ridge palpation buccal and crestal:
Incisal papilla position:
Crown-bone relationship/interarch space
Length of the clinical crown: (mean
length of central incisors 10.5 mm)
Tooth size to arch size discrepancy:
Speech disruption (phonetic zone):
Bone quality:
(approximately assessed from
computed tomographic scan)
h Keratinized h Nonkeratinized
h Nonmovable h Movable
Soft tissue graft feasible: h Yes h No
h Thick (molding possible) h Thin
h Buccal (convex), crestal (rounded, wide) h Buccal (concave), crestal (thin, sharp)
Bone graft feasible: h Yes h No
h Palatal h Crestal h buccal
h Optimal (minimal vertical resorption) h Too long (to large vertical space)
Pink porcelain accepted: h Yes h No
h No h Yes
h No h Yes (needs adaptation of S-ridge)
h Type I (solely compact) h Type III (dense trabeculated/thin corticalis)
h Type II (dense trabeculated/thick corticalis) h Type IV (porous spongiosa)

soft tissue support can be obtained mainly by the buc-
cal flange of a removable restoration and the position of
the denture teeth. Facial support plays an important
role in patients with a retrognathic appearance of the
maxilla or for compensation of prognathism. Both can
be acquired because of the divergent resorption pattern
of the edentulous maxilla and mandible or are geneti-
cally caused by the skeletal growth pattern. Any need
for extraoral soft tissue support should be evaluated
with and without the existing prosthesis in place, and
with the patient facing forward and in profile (Fig. 4).
The relation of the upper and lower lips to the
esthetic plane (line from end of nose to chin) should be
checked for the “best balance of lips,” which is given
with equal distances or the lower lip slightly closer to
this plane.6 Patients with a concave profile may need
compensatory support. The thickness of the buccal
flange of an existing complete denture can also be
indicative of the necessary lip and cheek support.7,8 In
patients with prognathism and also in retrognathic
patients, it must be considered whether the intermaxil-
lary relationship can be changed to establish a normal
overjet and overbite.9
In the dentate maxilla, lip support is primarily
derived from the alveolar ridge shape and the cervical
crown contour of the maxillary incisors. In the edentu-
lous maxilla, the resorption pattern is cranially and
medially directed, so that a palatal position of the ante-
rior maxilla frequently appears.10,11 This entails the
incisors being located anterior to the alveolar ridge so

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Fig. 3. Intraoral factors. Fig. 4. Patient with upper lip length of 15 mm, in need of soft
tissue support.

as to display the entire lip thickness. Depending on the

discrepancy between the position of the clinical crown
and the alveolar ridge contour in the bucco-oral dimen-
sion, compensation with the denture base of a remov-
able reconstruction may be necessary.
The smile line is determined by the tonus of the oro-
facial muscles that influence the movement of the
upper lip during speech and smiling.12 Tjan et al13
described the average smile as having the position of
the upper lip such that 75% to 100% of maxillary
incisors and the interproximal gingiva are displayed
during smiling. This position was distinguished from
the high smile line where there is additional exposure
of part of the gingiva and from the low smile line, Fig. 5. Set up without buccal prosthesis flange.
where less than 75% of the maxillary anterior teeth are
displayed. In patients designated for implant treatment
in the maxilla, the evaluation of the smile line should be (0.25 mm display) and exposed 2.25 mm of the
performed without the denture in place. When even mandibular incisors. The smile line and lip length fac-
the alveolar ridge is displayed during smiling, the use of tors may be related to patient age, due to the decreas-
a buccal flange in a removable prosthesis may be advis- ing tonus of the perioral muscles of elderly patients.
able to prevent esthetic problems.4
INTRAORAL FACTORS
The upper lip length should be recorded during
examination as it influences the position of the maxil- During the intraoral examination, it is essential to
lary anterior teeth (Fig. 4).14 The length of the upper investigate the following parameters: quality and quan-
lip is measured from the base of the column (subnasal) tity of the mucosa, quantity and contour of the under-
to the philtrum location. In patients with a short upper lying bone, crown to bone relationship, interarch
lip, the maxillary anterior dentition will normally be space, and phonetic zone (Table IV and Fig. 3).
exposed in repose, whereas in patients with a long The mucosal quality and quantity can be assessed by
upper lip the incisors will, providing normal skeletal palpation, sounding, and/or with the help of radi-
growth has occurred, usually be covered. Grading ographs. A thick mucosa is easier to mold for a papil-
patients into 5 groups according to their upper lip lary-like interimplant trigonum than a thin mucosa.
length, Vig and Brundo15 found that almost 4 mm of Sufficient mucosal thickness helps to hide the abutment
the maxillary central incisors were exposed in patients margin and facilitates correct emergence profile of the
with short lips 10 to 15 mm in length combined with clinical crown. This is especially true for angulated
just 0.7 mm exposure of the mandibular incisors. Aver- abutments with its pronounced titanium collar. Palpa-
age lip lengths of 21 to 25 mm were related to 2.2 mm tion of the alveolar ridge allows assessment of bone
display in the maxilla and 1 mm display in the quantity and detection of any ridge collapse. The posi-
mandible. Extremely long upper lips (31 to 35 mm) tion of the incisal papilla related to the crest reflects the
covered almost the entire length of the incisors bone resorption in the sagittal dimension.

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THE JOURNAL OF PROSTHETIC DENTISTRY
Table V. Dimensions of the maxillary teeth16
Tooth Crown length Root length
Central 11 13
Lateral 9 13
Canine 10 17
Premolars 9 14
First molar 8 12/13**
Second molar 7 11/12**
*Axial inclination described as angle between the long axis of the tooth and the sagittal plane.
**Buccal/palatal.
Md: Mesiodistal; Bli: buccolingual.
Average values in millimeters, alignment in degrees.
Morphologic changes encountered with bone
resorption after tooth loss comprise a maxillary arch
becoming narrower and may lead to a intermaxillary
discrepancy in the intended clinical crown position.
This phenomenon is well-known from complete den-
tures in which the incisors are placed in front of the
alveolar ridge to maintain neutral occlusion and a
reverse articulation situation is established in the poste-
rior to ensure sufficient stability of the full denture in
function. For detailed assessment of the morphologic
situation and the changes due to bone resorption, it is
necessary to estimate the crown to bone relationship,
namely, the distance between the ideal position of the
clinical crowns and the underlying bone. If the tooth
position in an existing removable prosthesis is not
acceptable, a diagnostic setup is fabricated similar to the
wax trial for a complete denture. This can be prepared
without a buccal flange to analyze potential problems
of facial support, especially when a fixed restoration is
desired by the patient (Fig. 5).
The principles and rules of complete denture pros-
thesis rehabilitation are applied in detecting the vertical
dimension and in preparing the diagnostic setup. To
find the adequate arrangement of the denture teeth in
the anterior, the first step is to determine the incisal
edge position of the central incisors, which should con-
tact the vermilion border of the lower lip when an “F”
sound is produced. Depending on the lip length, 1 to
2 mm of the incisal edge should be displayed in repose,
while more is visible in E-position. Then the exposed
incisal part should correspond to half of the distance
recorded between the upper and lower lips during an
“E” sound. Once the incisal edge position has been
established, the length of the central incisors is deter-
mined. This is 10.5 mm on average (Table V),16 but
may be more in elderly patients, in whom some gingi-
val recession can be expected.
The axial inclination of the central incisor, which is
28 degrees to the sagittal plane on average, should be
placed so as to provide adequate support for the upper
lip. Once the crown length, angulation, and coronal
form have been determined, the distance between the
192
ZITZMANN AND MARINELLO
Md crown diameter At cervix Bli crown diameter At cervix Alignment*
9 7 7 6 28°
7 5 6 5 26°
8 6 8 7 16°
7 5 9 8 5°
10 8 11 10 6°
9 7 11 10 8°
prospective cervical crown margin and the residual
bone crest can be assessed. For a fixed complete den-
ture, the clinical crown should ideally end up at the soft
tissue level of the alveolar ridge. In this situation, only
minimal bone resorption and a limited interarch space
with an optimal tooth-lip relationship is present. When,
otherwise, a large vertical distance results between the
ideal positioned artificial teeth and the underlying tis-
sues, moderate to severe resorption of the maxilla may
have occurred. The degree of bone resorption and its
effect on the maxillomandibular relationship ideally
should be determined with the use of the wax trial. The
dimension of any tooth size to arch size discrepancy
will also become apparent.
Once the buccal crown contour has been estab-
lished, one can apply the adequate buccolingual width
of the incisors within the wax trial (6 mm on aver-
age16) and evaluate the distance between the cervical
crown margin and the underlying tissues on the palatal
arch. In this phonetic zone, it is essential to form an
adequate lingual anatomy so the contour of the
cingulum is correct, as the tooth-tongue contact is
needed for “T” and “D” sounds (Fig. 3). Excessive air
escape through the interproximal area with a fixed
prosthesis could cause speech problems; so any speech
disruption and “S” sound deficiencies (sigmatism,
lisping) have to be avoided. Tanaka17 demonstrated
that the zone in the anterior palatal region starts with
a shallow convexity in the sagittal plane. The curve has
an inflection located 11 to 13 mm behind the incisors
and 6 mm above their cervical margin. When this zone
has been involved in the resorptive processes, it may
be necessary to design a palatal extension to form a
correct S-ridge, which is, again, an indication for a
removable restoration.
Making a fixed complete denture in a situation with
advanced resorption would cause excessively long, buc-
cally flared teeth with large interproximal spaces or vis-
ible abutments entering the mucosa. Because facial sup-
port cannot be accomplished adequately, speech may
be disturbed and esthetics compromised. Although
pink porcelain can be used to hide the vertical distance,
VOLUME 82 NUMBER 2
ZITZMANN AND MARINELLO THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 6. Radiologic template with titanium markers. Fig. 7. Horizontal slices oriented perpendicular to markers
(CT scan).

it cannot ensure sufficient lip and cheek support, which

must be formed with the help of the buccal flange of a
removable prosthesis.
RADIOLOGIC DIAGNOSIS
For precise estimation of the available bone, which
affects implant position, angulation, and length, a com-
puterized tomograph (CT) scan with a radiographic
template is highly recommended.18 The acceptable
existing denture or the optimal diagnostic setup is
duplicated in clear acrylic resin. Radiopaque markers
(titanium pins) are incorporated into the template,
depicting ideal implant position and angulation for a
screw-retained fixed implant prosthesis. The incisal end
of the markers represent the optimal screw access hole
located at the cingulum or the central fossa. A survey- Fig. 8. Central image line manually drawn for Denta-scan.
or is used to find the optimal implant axes and to pre-
pare the holes for titanium pins of standardized length
(7 mm) in every possible tooth/implant position
(Fig. 6). A pin length of 7 mm is recommended to rep- The horizontal slices (1 to 2 mm sections) of the
resent the length and axis of the intended clinical computerized tomography have to be oriented perpen-
crown. dicular to the titanium pins (Fig. 7). Within a horizon-
The markers are oriented perpendicular to the tal section through the titanium markers, a curved line
occlusal plane and should end apically at the height of (“central image line”19) is drawn manually connecting
the prospective clinical crown margin. This allows the adjacent pins, except in the anterior region (canine to
relationship between the crown and the underlying canine) where this line should be placed 5 mm palatal-
bone in the vertical dimension to be assessed from the ly to the pins (Fig. 8), due to the palatal position of the
CT scan. Titanium is advantageous as it does not pro- anterior maxilla. A specialized software program
duce any artifacts, due to its atomic number (Ti 22), (Denta-scan, Philips, Eindhoven, The Netherlands)
which is similar to that of the neighboring materials processes cross-sectional reformations exactly perpen-
such as air, water, or dental hard tissues containing dicular to this curved line and also perpendicular to the
mainly carbon (C 6), nitrogen (N 7) and oxygen (O 8). horizontal slices (Fig. 9). Thus, the resultant transver-
Hence, titanium absorbs radiation similarly to the sur- sal images are parallel to the titanium pins, which rep-
rounding environment, whereas dental alloys such as resent the ideal implant axes. A radiologic transparency
amalgam fillings, gold restorations, crowns, or post and can serve as a guide for planning implant length.20 The
cores with higher atomic numbers (Hg 80, Ag 64, calculation can also be performed on a computer with
Au 79) cause some scattering. the SIM/Plant software (Columbia Scientific Inc,

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THE JOURNAL OF PROSTHETIC DENTISTRY ZITZMANN AND MARINELLO

Fig. 9. Ideal relation between titanium markers and underlying bone in anterior transversal
sections (Denta-scan).

Fig. 10. Large discrepancy between crown and alveolar ridge in anterior transversal sections.

Columbia, Md.). Preoperative or intraoperative aug-
mentation needs become evident with the CT scan and
can then be discussed with the patient.
TREATMENT PLANNING
When evaluating the transverse cross-sections, the
decisive question arises as to whether the available bone
allows for implant placement at an ideal angulation. For
a fixed restoration, it must be feasible to place implants
meticulously with respect to the correct prosthetically
driven position, which is represented by the titanium
markers (Fig. 9). If any buccal concavities in the ante-
rior are present, the implant angulation may have to be
altered to some degree, which means that the use of

194 VOLUME 82 NUMBER 2

ZITZMANN AND MARINELLO
angulated abutments is inevitable. However, if clinical
and radiologic diagnosis rule out a fixed reconstruction
and a removable overdenture is recommended, then
the selection of ideal implant sites is no longer restrict-
ed to the areas defined by the titanium markers
(Fig. 10). They still serve as guides for the location of
the prospective clinical crown and crown contour.
For a bar-retained overdenture prosthesis, distances
of 10 to 14 mm from implant center to center are
required depending on the favored bar and clip system.
If prefabricated systems (Hader, Lifecore Biomedical
Inc, Chaska, Minn., or Vario Soft, Bredent, Senden,
Germany) are used, every second tooth position can be
selected from the Denta-scan to allow the clips in-
between adjacent abutments to be arranged suitably.
However, if implant placement is restricted to particu-
lar areas because of advanced bone resorption and adja-
cent tooth positions have to be selected as implant posi-
tions, then a milled bar (with 2-degree taper) should be
planned. In these situations, the interimplant distance is
less critical because retention is derived from the fric-
tional fit of the implant borne superstructure and from
additional frictional pins or attachments (CEKA,
Antwerp, Belgium) that are incorporated into the bar.
For both fixed or removable restorations, the radio-
logic template should be used as a guide intraopera-
tively.21 The stent is modified by removing the pins and
part of the palatal base, keeping a palatal support for
intraoral positioning. The planned implant locations
are marked on the template to allow the implant posi-
tions to be easily transferred to the bony ridge during
surgery (Fig. 11).
SUMMARY
This article introduced a concept for treatment of
the edentulous maxilla with implant-supported restora-
tions. The crucial factors in deciding whether a fixed or
removable prosthesis should be planned will influence
the entire treatment plan, including implant position-
ing and flange considerations. Most factors, precluding
the use of a fixed implant–supported restoration, are
related to osseous and/or soft tissue deficiencies. The
resorptive processes can cause prognathism, the need
for facial support, speech disruption, and/or esthetic
problems. So any parameter that would rule out a fixed
reconstruction should be assessed in the sagittal and
vertical planes with the help of a wax try-in. The first
clinical diagnosis should be definitively verified within
the reformatted CT scan. If bone and soft tissue defi-
ciencies cannot be compensate for, a removable recon-
struction is the most desirable alternative solution.
If a fixed prosthesis is feasible in patients with mini-
mal resorption and limited intermaxillary space,
implants should be placed meticulously in the intended
tooth position. For a bar-retained overdenture prosthe-
sis, implants should be placed with an adequate inter-
AUGUST 1999
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 11. Modified template with selected positions marked
for intraoperative use.
implant distance of about 10 to 14 mm so that prefab-
ricated bar and clip systems can be used. Otherwise, an
individually milled bar has to be planned. The exten-
sion of the buccal and palatal flange is determined dur-
ing the setup try-in in relation to the smile line, the
need for facial support, and the phonetic requirements.
REFERENCES
1. Zitzmann NU, Marinello CP. Fixed or removable implant-supported
restorations in the edentulous maxilla. Review of the literature. Quintes-
sence Int [in press].
2. Lewis S, Sharma A, Nishimura R. Treatment of edentulous maxillae with
osseointegrated implants. J Prosthet Dent 1992;68:503-8.
3. Wicks RA. A systematic approach to definitive planning for osseointegrat-
ed implant prostheses. J Prosthodont 1994;3:237-42.
4. Taylor TD. Fixed implant rehabilitation for the edentulous maxilla. Int J
Oral Maxillofac Implants 1991;6:329-37.
5. DeBoer J. Edentulous implants: overdenture versus fixed. J Prosthet Dent
1993;69:386-90.
6. Ricketts RM. Esthetics, environment, and the law of lip relation. Am J
Orthod 1968;54:272-89.
7. Smedberg JI, Lothigius E, Nilner K, De Buck V. A new design for a hybrid
prosthesis supported by osseointegrated implants: 2. Preliminary clinical
aspects. Int J Oral Maxillofac Implants 1991;6:154-9.
8. Parel SM. Implants and overdentures: the osseointegrated approach with
conventional and compromised applications. Int J Oral Maxillofac
Implants 1986;1:93-9.
9. Watson RM, Davis DM, Forman GH, Coward T. Considerations in design
and fabrication of maxillary implant-supported prostheses. J Prosthodont
1991;4:232-9.
10. Atwood DA. Bone loss of edentulous alveolar ridges. J Periodontol
1979;50(4 Spec No):11-21.
11. Desjardins RP. Prosthesis design for osseointegrated implants in the eden-
tulous maxilla. Int J Oral Maxillofac Implants 1992;7:311-20.
12. Mecall RA, Rosenfeld AL. Influence of residual ridge resorption patterns
on fixture placement and tooth position, part III: presurgical assessment of
ridge augmentation requirements. Int J Periodontics Restorative Dent
1996;16:322-37.
13. Tjan AH, Miller GD, The JG. Some esthetic factors in a smile. J Prosthet
Dent 1984;51:24-8.
14. Goldstein RE. Esthetics in dentistry. 1st ed. Philadelphia: Lippincott; 1976.
p. 227-30.
15. Vig RG, Brundo GC. The kinetics of anterior tooth display. J Prosthet Dent
1978;39:502-4.
16. Ash MM. Wheeler’s dental anatomy, physiology and occlusion. 7th ed.
Philadelphia: WB Saunders; 1993. p. 128-273.
195
THE JOURNAL OF PROSTHETIC DENTISTRY ZITZMANN AND MARINELLO

17. Tanaka H. Speech patterns of edentulous patients and morphology of the Reprint requests to:
palate in relation to phonetics. J Prosthet Dent 1973;29:16-28. DR NICOLA U. ZITZMANN
18. Schwarz MS, Rothmann SL, Rhodes ML, Chafetz N. Computed tomogra- HEBELSTR. 3
phy: part II. Preoperative assessment of the maxilla for endosseous CH-4056
implant surgery. Int J Maxillofac Implants 1987;2:143-8. SWITZERLAND
19. Mecall RA, Rosenfeld AL. The influence of residual ridge resorption pat- FAX: 41-61-267-26-60
terns on fixture placement and tooth position, part II. Presurgical deter- E-MAIL: zitzmann@ubachu.unibas.ch
mination of prosthesis type and design. Int J Periodontics Restorative Dent
1992;12:32-51. Copyright © 1999 by The Editorial Council of The Journal of Prosthetic
20. Zitzmann NU, Schärer P. Oral Implantology. A clinical compendium. 1st Dentistry.
ed. Zurich: KBM; 1997. p. 14-16 and appendix. 0022-3913/99/$8.00 + 0. 10/97992
21. Murrell GA, Davis WH. Presurgical prosthodontics. J Prosthet Dent
1988;59:447-52.

Smoking and vascular density of healthy marginal gingiva.

Noteworthy Abstracts Persson L, Bergstrom J. Eur J Oral Sci 1998;106:953-7.
of the
Current Literature

Purpose. Smoking exerts a constrictive effect on microcirculatory vessels and causes a vasocon-
striction of oral mucosal vessels. This study used low-power stereophotography to evaluate
whether vascular characteristics in terms of vascular density in periodontally healthy individuals
are influenced by smoking.
Material and methods. Fourteen women (25-38 years of age), 7 smokers and 7 nonsmokers,
participated. Consumption of cigarettes per day for the smokers was between 10 and 25 with the
duration ranging from 8 to 18 years. All subjects were in self-reported good general health and
their gingival condition was clinically healthy as judged from the Löe and Silness gingival index.
Vascular density was evaluated according to a semiquantitative index based on the morphology
and number of vessels within a given area of the marginal gingiva. In the region under investiga-
tion, the clinical appearance and possible changes of the gingival vasculature were documented by
means of an image system consisting of a stereomicroscope and 2 camera housings designed for
synchronous exposure. Within the measurement zone, distinct vascular structure contrasting to
the surrounding tissue was counted and evaluated with regard to form and structure. Three types
of vascular structure were observed: (1) point, (2) single-limbed loop, and (3) double-limbed
loop.
Results. The differences between consecutive time points within nonsmokers were small, indi-
cating stability of vascular characteristics over time. Consecutive differences within smokers were
somewhat greater but there were no significant different between time points. There were no sta-
tistically significant differences between smokers and nonsmokers over time (P>.05).
Conclusions. The vascular density of the marginal gingiva was not influenced by moderate smok-
ing once healthy gingival conditions exist. 30 References.—ME Razzoog

196 VOLUME 82 NUMBER 2