PROSTHETIC OPTIONS IN

IMPLANT DENTISTRY.

Presented by,
Chaithra Prabhu B
Final year P.G

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 CONTENTS
INTRODUCTION
COMPLETELY EDENTULOUS PROSTHETIC DESIGN

PARTIALLY EDENTULOUS PROSTHETIC DESIGN

PROSTHETIC OPTIONS
CONCLUSON
REFERENCES

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 INTRODUCTION

TRADITIONAL DENTISTRY

COMPLETE PARTIAL
LIMITED OPTIONSEDENTULISM
EDENTULISM

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 RANGE OF WIDE
IMPLANT ABUTMEN RANGE O
DENTIST T TREATME
RY LOCATION NT
S OPTIONS
Ideal goals of IMPLANT DENTISTRY are to
replace patient’s missing teeth to normal contour,
comfort, function, esthetics, speech and health
regardless of previous atrophy, disease or injury to
stomatognathic system.

Dental implant prosthetics; Carl E Misch: 2 nd

edition

63
• Dental implantology : term used today to describe anchoring
of alloplastic material into the jaws to provide support and
retention for prosthetic replacement of teeth that has been lost.

• The patient’s function when wearing a conventional complete

denture prosthesis may be reduced to 60% of that formerly
experienced with natural dentition.
• Implant prosthesis offers a predictable treatment course than
the traditional restorations.

Dholam KP, Gurav SV. Dental implants in irradiated jaws: A literature review. J
Cancer Res Ther 2012;8 Suppl 1:S85-93

Misch CE. Dental Implant Prosthetics. 2nd ed. Amsterdam,

Netherlands: Elsevier Health Sciences; 2014.

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 COMPLETELY EDENTULOUS
PROSTHESIS DESIGN

COMPLETELY
EDENTULOUS PATIENTS

Strong psychological need Specific problems being

to have fixed prosthesis addressed

An axiom of implant treatment, is to provide the most

predictable, cost effective treatment that will satisfy
patient’s anatomical needs and personal desires.

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 REMOVABLE IMPLANT
ADVANTAGES OF REMOVABLE IMPLANT
SUPPORTED PROSTHESIS IN COMPLETELY
SUPPORTED PROSTHESIS
EDENTULOUS PATIENTS.

1. Treatment is less expensive: related to fewer implants

required.

2. Less bone augmentation: as implants are placed in anterior

region.

3. Facial esthetics can be enhanced with labial flanges and

denture teeth.

4. Daily home care easier.

Dental implant prosthetics; Carl E Misch: 2 nd
edition

63
5. Prosthesis can be removed at night to
manage nocturnal parafunction.

6. Long term treatment of complications is

facilitated.

Dental implant prosthetics; Carl E Misch: 2 nd

edition

63
 FIXED IMPLANT
RESTORATIONS
ADVANTGES OF FIXED RESTORATIONS IN
COMPLETELY OR PARTIALLY EDENTULOUS PATIENTS;
1. Psychological(feels more like natural teeth).
2. Abundant bone and inadequate crown height for RP.
3. Longevity.
4. Less maintenance.
5. Chances for food entrapment are less as compared to removable
overdenture.

Dental implant prosthetics; Carl E Misch: 2 nd

edition

63
 VISUALIZATION OF THE FINAL RESTORATION AT THE ONSET WITH A
FIXED IMPLANT RESTORATION.

INDIVIDUAL AREAS OF KEY ABUTMENT SUPPORT ARE DETERMINED TO

ASSESS PLACEMENT OF IMPLANTS.

PATIENT’S FORCE FACTORS AND BONE DENSITY ARE EVALUATED.

ONLY THEN IS THE AVAILABLE BONE EVALUATED TO ASSESS WHETHER

IT IS POSSIBLE TO PLACE IMPLANTS TO SUPPORT INTENDED PROSTHESIS.

Dental implant prosthetics; Carl E Misch: 2 nd

edition

63
• IN INADEQUATE BONE OR IMPLANT ABUTMENT
SITUATIONS,THE EXISTING ORAL CONDITIONS
MUST BE IMPROVED OR THE NEEDS AND
DESIRES OF THE PATIENT MUST BE REDUCED.

• EITHER THE MOUTH MUST BE MODIFIED BY

AUGMENTATION TO PLACE IMPLANTS OR THE
MIND OF THE PATIENT MUST BE MODIFIED TO
ACCEPT DIFFERENT PROSTHESIS TYPE.

Dental implant prosthetics; Carl E Misch: 2 nd

edition

63
PARTIALLY EDENTULOUS
PROSTHESIS DESIGN
• A common axiom in traditional prosthodontics for partial
edentulism

FIXED PARTIAL DENTURE

IDEALLY FIXED PARTIAL DENTURE COMPLETELY

IMPLANT SUPPORTED.

THE ADDED IMPLANTS RESULT IN:

 FEWER PONTICS
 MORE RETENTIVE UNITS
 LESS STRESS TO SUPPORTING BONE.

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 PROSTHETIC
•
OPTIONS
In 1989, Misch proposed 5 prosthetic options for implant
dentistry.

• THESE OPTIONS DEPEND ON THE AMOUNT OF HARD

AND SOFT TISSUE STRUCTURES REPLACED AND THE
ASPECTS OF THE PROSTHESIS IN THE ESTHETIC
ZONE. AND ALSO DEPEND ON THE AMOUNT OF
IMPLANT SUPPORT, RETENTION AND STABILITY

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63
 FP-1

• An FP-1 is a fixed restoration and

appears to the patient to replaces only
the anatomical crowns of the missing
natural teeth.
• The final restoration appears very
similar in size and contour to most
traditional FPs used to restore or replace
natural crowns of teeth.

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Healthy natural teeth. Ideal hard and
Bone and soft tissues must be Ideal
soft tissues.
in volume and position to obtain FP-
1.

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FP-1 most often desired in the maxillary anterior region.

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Implant abutment can rarely be treated as a natural tooth
prepared for a full crown.

1. Cervical diameter of natural tooth 6.5 to 10.5mm, oval to

triangular in cross section.
Implant abutment 4 to 5 mm in diameter round in cross
section.
2. Placement of implant rarely corresponds exactly to the
crown-root position of original tooth.
Thin labial bone Remodels Crest width shifts to
palate, decreasing 40% in 2years.

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3. The occlusal table of crown should be
modified in unesthetic regions to conform to
implant size and to direct vertical forces to
implant body.

Posterior mandibular implant supported

prosthesis narrower occlusal tables at the
expense of buccal contour implant is
smaller in diameter and placed in central fossa
region of tooth.
Maxillary posterior teeth have reduced occlusal
tables from palatal aspect.

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4. Bone augmentation is often required before implant
placement to achieve natural looking crowns in the
cervical region.

5. Soft tissue augmentation is often required to improve

the interproximal gingival contour. Ignoring this BLACK
triangular spaces can appear.

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6. Restorative material of choice for an
FP-1 prosthesis is PORCELAIN to
NOBLE-METAL alloy.

Noble metal in contact with implant

corrode less than non precious alloys.

A single tooth FP-1 may use aluminium

oxide cores and Porcelain crowns or
ceramic abutments and porcelain
crowns.

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 FP-2
• The volume and topography of the available bone are more
apical compared with ideal bone position.
• Restores the anatomical crown and a portion of the root of
the natural tooth.
• Incisal edge of the restoration is in correct position but
gingival third of crown is overextended.

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The esthetic zone of
a patient is
established during
smiling in the
maxillary arch.

Some esthetic factors in a smile;Tjan AH,Miller D;Jprosthet

Dent;1984.

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 If the teeth do not
show during smiling or
speech ,a FP-2
restoration is not a
compromise.

A smile that shows interdental

papillae but no cervical tissues
is ideal and is found in 70% of
patients.

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• A multiple unit FP-2 restoration does
not require as specific an implant
position in mesial or distal position as
cervical contour is not displayed during
function.

• Implant position may be chosen in

relation to bone width, angulation or
hygienic consideration.

• If the implant is not positioned in an

ideal mesiodistal position,it should be
placed in correct faciolingual position to
ensure that contour, hygiene,and
direction of forces is not compromised.
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• MATERIAL CHOICE:

• Precious metal to porcelain.

• The amount of metal work is different than for FP-1 and

is more relevant in a FP-2 prosthesis because the
additional volume of tooth replacement increases the
risk of unsupported porcelain in final prosthesis, when
the metal work is undercontoured

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 FP-3
• Replaces the natural teeth crowns and has pink coloured
restorative materials to replace a portion of the soft tissue ,
especially in interdental papilla.

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 • Unlike the FP-2 prosthesis, the patient may
have a high maxillary lip line during smiling
or a low mandibular lip line during speech

• As a consequence, the soft tissue drape should

also be replaced

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Patients this category of high lip line should have the soft tissue
replaced
 by the prostheses
 soft tissue agumentation

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 2 BASIC APPROACHES FOR FP-3
PROSTHESIS

1.HYBRID RESTORATION 2.PORCELAIN METAL

Denture teeth and acrylic RESTORATION
with a metal substructure. An FP-3 porcelain to metal
restoration (more difficult to
fabricate)

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• The selection between Hybrid and traditional porcelain metal
restoration depends on Crown Height Space (CHS)

The crown height space determination for a hybrid versus

the traditional porcelain–metal restoration is 15 mm from
the bone to the occlusal plane. When less than this
dimension is available, a porcelain-to-metal restoration is
suggested. When a greater crown height space is present,
a hybrid restoration is often fabricated.

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 An excessive intrearch space means a traditional porcelain-metal
restoration will have a large amount of metal in the substructuture,
so the porcelain thickness will not be greater than 2 mm
As the metal cools after casting, the thinner regions of metal cool
first and create porosities in the structure. This may lead to fracture
of the framework after loading

However, the large amount of metal in the substructure acts as a

heat sink and complicates the fabrication of the prosthesis

Furthermore, when the casting is reinserted into the oven to bake

the porcelain, the heat is maintained within the casting at different
rates, so the porcelain cool-down rate varies, which increases the
risk of porcelain fracture

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 In addition, the amount of precious metal in
the casting adds to the weight and cost of the
restoration

Precious metals are indicated for implant

restorations to decrease the risk of corrosion and
improve the accuracy of the casting because
nonprecious metals shrink more during the
casting process

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• Alternative to
traditional
HYBRID
porcelain metal RESTORATION
FP.

• Uses smaller
metal framework
with denture
teeth and acrylic
to join these
elements.

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• ADVANTAGES OF HYBRID RESTORATION:
1. Less expensive to fabricate and highly esthetic.
2. Intermediary acrylic between the denture teeth and
framework may reduce the impact force of occlusal forces.
3. Easier to repair.

The crown height space determination for a hybrid versus

the traditional porcelain metal restoration is 15mm from
bone to occlusal plane.

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63
 REMOVABLE PROSTHESIS
• There are 2 types of RPs based on SUPPORT, RETENTION
and STABILITY of the restoration.

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• RP-4 has complete implant support in
both anterior and posterior regions.
• In MANDIBLE superstructure bar is
often cantilevered from implant
positioned between the foramina.
• MAXILLARY RP-4 usually has more
implants and no cantilever.

• RP-5 has primarily anterior implant

support and posterior soft tissue
support.

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 RP-4
• Overdenture attachments usually connect RP to low profile tissue
bar or superstructure that splints implant abutments.

• 5 to 7 implants in mandible and 6 to 8 implants in maxilla are

required.

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 IMPLANT PLACEMENT
CRITERIA FOR RP-4
• Denture teeth and acrylic require more prosthetic space.
• A superstructure and overdenture attachments must
often be added to implant abutments.
• Requires more lingual and apical placement compared
with FP.

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 RP-5
• RP combining implant and soft tissue
support.
• A complete edentulous mandible
overdenture may have:
1. 2 or 3 anterior implants independent of
each other.
2. Splinted implants in canine region to
enhance retention.
3. 3 splinted implants in premolar and
central incisor region.
4. 4 or 5 implants splinted with a
cantilevered bar to improve
retention,stability and support.
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 • The primary ADVANTAGE of RP-5

• Reduced cost as fewer implants may be inserted compared

with fixed restoration.

• Less demand for bone augmentation.

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 • The doctor and the patient should realize that the bone
will continue to resorb in the soft tissue–borne regions of
the prosthesis.

• Relines and occlusal adjustments every few years are

common maintenance requirements of an RP-5
restoration.

• Bone resorption with RP-5 restorations may occur 2 to 3

times faster than the resorption found with full dentures.

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63
The mandibular overdenture requires at least 12 mm between the soft
tissue and the occlusal plane to provide sufficient space (15 mm from
bone level to occlusal plane) for the bar, attachments, and teeth.
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FIXED VS REMOVABLE FP3
VS RP4

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 Bone Density: Influence on
Prosthetic
Treatment Planning
• The strength of the bone supporting the endosteal
implant is directly related to its density.

Misch bone density classification

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• As the bone density decreases, the biomechanical loads on
the implants must be reduced. This can be accomplished in
several ways by considering the following prosthetic design.
• 1. Angle of load on the implant body should be more
axial and offset loads minimized.
• 2. Narrower occlusal tables should be designed.
• 3. Splinting the crowns of adjacent implants.
• 4. Cantilever length may be shortened or eliminated in
case of full-arch restorations for edentulous patients,

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 RP-4 rather than FP prosthesis may be considered in
edentulous patients to reduce nocturnal parafunctional forces.

RP-5 prosthesis may be considered to permit the soft tissue to

share the occlusal force.

Night guards and acrylic occlusal surfaces distribute and

dissipate the parafunctional forces on an implant system.

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 OCCLUSAL SCHEME IN
BRIEF
FIXED NATURAL DENTITION MUTUALLY
FIXED IMPLANT
IMPLANT PROSTHESIS
FIXED IMPLANT PROTECTED
PROSTHESIS PROSTHESIS OCCLUSION
(FP)
IMPLANT SUPPORTED
REMOVABLE
OVERDENTURE (RP-4)
CONVENTIONAL BILATERAL
DENTURE BALANCED
REMOVABLE OCCLUSION
OVERDENTURE (RP-5)

Resnik RR . Principles of implant occlusion : part 3– reccomendations for removable implant prostheses. Chairside magazine 12(1)

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 GRAFTLESS PROCEDURES

1. ALL ON 4 CONCEPT
2. ALL ON 6 CONCEPT
3. TILTED IMPLANTS
4. PTERYGOID IMPLANTS
5. ZYGOMATIC IMPLANTS
6. TUBEROSITY IMPLANTS
7. MINI IMPLANTS
8. SHORT WIDE IMPLANTS

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 ALL ON 6 CONCEPT

• full-arch rehabilitation on six

endosseous implants

• all-on-six - decrease
cantilever length by
introducing inclined implants
in the distal positions.

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 ALL ON 4 CONCEPT
In 1998 Dr. Paulo Malo successfully treated the first
patient with the All-on-4® treatment concept

The All-on-4® treatment concept is a cost-efficient,

graftless solution that provides patients with a fixed
full-arch prosthesis on the day of surgery. 
Characteristics include:

•Full-arch rehabilitation with only four implants 

Two straight anterior implants and two implants
tilted up to 45º in the posterior

•Immediate Function (fixed provisional bridge)

For patients meeting criteria for immediate loading
of implants

•Graftless procedure
Bone grafting is avoided by tilting the posterior
implants, utilizing available bone 63
 Conclusion

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 REFERENCES
• Misch CE. Dental Implant Prosthetics.
2nd ed. Amsterdam,Netherlands:
Elsevier Health Sciences; 2014
• Dholam KP, Gurav SV. Dental implants
in irradiated jaws: A literature review.
• Leles CR, Freire Mdo C. A sociodental
Thank you
approach in prosthodontics treatment
decision making. J Appl Oral Sci
2004;12:127-32 63