Implants

Assessment of dentition
and treatment planning for
the edentulous situation

DR. R. Ramakrishna

PATIENT AND PROBLEM CENTRED

FIXED PARTIAL DENTURE

TREATMENT
DISADVANTAGES / LIMITATIONS

Reduction of Adjacent Tooth Structure

longevity depends on abutment
prognosis

REMOVABLE PARTIAL DENTURE

TREATMENT
DISADVANTAGES / LIMITATIONS
Inadequate retention,
stability
Unfavourable support area
Decreased psychological
comfort
Poor tissue tolerance

Implant Dentistry had opened the door for a

better functional and cosmetic results

FP1

Replacement of only anatomic crowns of the

missing natural teeth, minimal loss of hard and
soft tissue

FP2

Replacement of only anatomic crown

and a portion of the root of natural tooth. crown
contour appears normal in the occlusal half but is elongated or
hyper contoured in the gingival half

FP3

Replacement of natural teeth crowns and a

portion of soft tissue - use of hybrid prosthesis.

RP4

Restoration is completely supported by

implant and / or teeth

RP5

RP5 - a removable prosthesis combining

implant and soft tissue support

Prosthetic axiom
Provide the partially edentulous patient with
a fixed prosthesis whenever possible.

Teeth adjacent to implant site

Abutment options
Implants advantages
Caries free
No endo failure
Improved survival
Less plaque

Abutment options
Independent implant prosthesis
Distributes occlusal forces
Reduced stress
Dec. abutment screw loosening

Partially edentulous arch with Independent implant

prosthesis

Extract or maintain natural tooth?

0,5, 10 yr rule
Prognosis

Protocol

>10 yr keep tooth & restore as indicated

5- 10yrindependent implant restoration. If natural
tooth to be included with implants in
restoration, make
it a living pontic by adding
implants on each side and
splint together.
<5 yr extract tooth and graft site and/ or implant.

Transitional abutment
Maintain strategic teeth as interim restorations
Most common in full arch rehab.
Adv.- fixed prosthesis
healing site protected
Disad.- cost, time, site contamination

Transitional implants

Adjacent bone anatomy

Not ideal- bone graft or pontic.
Inadequate ht. next to natural tooth- ortho
extrusion along with graft.
Treatment options:
1.Graft if inadequate width to place Div. A or B imp.
2.Cantilever a pontic from two or more natural teeth
or two or more Div. A imp.
3.Fixed prosthesis with one pontic connecting an
imp. with one or two teeth.

Cantilevers
Moment loads or torque on abutments
Class I lever
Complication- uncementation of farthest
abutment
Ideal- mesially
Occlusion- no contact on excursions

Natural abutment movement

Most important determinant to splint with implant
Vertical Factors: no., length of roots, dia, shape & position, PDL
status
Tooth movt. 28 mic.
Imp. Movt.- 2-3 mic.
Horizontal
Posterior- 56-75 mic.
Anterior- 90-108 mic.
Muhleman- initial and secondary movt.

Implant movement
Mesio-distal- 40- 115 mic.( lack of cortical bone)
Labio-lingual- 12-67 mic.
Factors: load, bone density, elastic deformation of
bone

Splinting natural abutments

Natural tooth with 0 mobility splint with imp.
Since imp., bone and prosthesis compensate for
the slight tooth movt.
Observable clinical mobility- >90 mic.
Occlusion- initial contacts on natural tooth
No lateral forces.
Hence not with anteriors.

Splinting dental units

Overall prosthesis movt. decreased

Decreased load to individual teeth
Last tooth in splint should be rigid
Terminal abutments should not have poor
retention form

Non rigid connectors

No improvement in stress distribution

Migration of natural teeth( Misch,Tolman)
Cost, over contoured abutments, plaque
Intrusion of natural abutment

Fixed partial denture supported by natural tooth as

anterior abutment and an Implant as the posterior
abutment

Natural and implant pier abutments

Intermediate abutment
Less movt. than natural tooth, class I lever fulcrum
Uncementation
Better- place additional implants- independent
prosthesis
Not possible- non rigid connector
Natural tooth pier abt.- living abutment, no stress
breaker, proprioception.

Natural abutment evaluation

Abutment size
Crown/ root( implant) ratio
Endodontic status
Root configuration
Tooth position( in the arch)
Parallelism
Root surface area
Caries: restorability
Periodontal status

Abutment size

Molars more retentive than premolars

Wider implant abutments
Crown height
Customised larger dia abutment

Crown: Root Ratio

Lateral forces- class I lever 1:2 ideal (FPD) , 1:1.5- common, 1:1
minimum

Implant :crown ratio

Natural tooth- centre of rotation- two thirds on the
root surface
Implant- centre of rotation- crest of bone
Height of imp.- does not affect mobility, does not
affect resistance to lateral forces
Effect of crown height can't be reduced by
increasing length of imp.
Instead reduce cantilever lengths or reduce angled
forces

Tooth position
Anterior- greater mobility, lateral forces
Drifting of natural abutments- consider correction
Orthodontic movt. to correct inter arch or gross
occlusal correction.

Parallelism
Path of insertion of prosthesis with anterior and
posterior dental units requires more extensive
tooth preparation.
Rigid attachments in design, size and fabrication
Endo treatment to achieve parallelism

Caries
Eliminate all caries prior to implant placement
Obturation of endo treated teeth completed prior
to implant surgery

Root configuration
Determines the additional stresses the tooth can
withstand without complications.
Tapered or fused roots and blunted apexes( Max.
II molar)- decreased ability
Use additional implants rather than such teeth
Dilaceration, root curvature- increased support
max. canine- encroach on adj. available bone
Ovoid roots( max. premolar) - better abutment
than circular.

Root surface area

Greater the S A, greater the support.

Posteriors better than anteriors.
Antes law
Three adjacent pontics in a fixed prosthesis in the
posterior regions of the mandible contraindicated
maxilla- contraindicated
unless opposed by a RPD

Endodontic evaluation
Natural abutment have satisfactory pulpal
health or obturation , prior to implant
placement
Endodontic lesions treated prior to implant
Many imp. Failures can be attributed to adj.
Endodontic failure
But assessment of endo success prior to imp
placement is difficult (Esposito et al)

Periodontal status
Evaluation prior to placement
Periodontal therapy can be carried out at
time of imp placement
Oral prophylaxis and hygiene are scheduled
prior to imp placement
Tetracycline to reduce sulcular flora.

Classification and treatment plan

for partially edentulous arches

1
Implant dentistry bone volume classification
by Misch and Judy( 1987)
It builds on the four classes of partially
edentulism described in the Kennedy
Applegate system

25mm
>10mm
>10mm
>5mm

>5mm

>5mm

Edentulous area have abundant bone height (>10mm) and length (>7mm)
for endosteal implant(s).
Direction of load is within 30 degrees of implant body axis
Crown implant ratio is < 1
Root form implants and independent prostheses often are indicated

2.5-5mm

>10mm
>15mm

>10mm
2.5-5mm

>15mm

Edentulous area have a moderate available bone width (2.5-5mm) and at

least adequate bone height of (>10mm) and length of 15 mm.
Direction of load is within 20 degrees of implant body axis
Crown implant ratio is < 1
Surgical options include Osteoplasty, small diameter implants and / or
augmentation

 Edentulous area have deficient available bone for endosteal implants

for predictable result, because of too little bone width (C-w), length,
height (C-h or angulation offload )
Crown implant ratio is often > 1

 Surgical options for C-w include Osteoplasty or augmentation, for C-h

subperiosteal implants or augmentation.
Root forms may be considered with augmentation and / or nerve
repositioning.

 Edentulous areas have severely resorbed ridges involving a portion of

the basal supporting bone.
Crown implant ratio is > 5.
Surgical option usually require augmentation before implants can be
inserted.

PARTIALLY EDENTULOUS ARCH WITH UNILATERAL EDENTULOUS AREA

POSTERIOR TO REMAINING TEETH
Division A to D same as for Class I

>5mm
>10mm

>10mm
>5mm

>5mm

>5mm

PARTIALLY EDENTULOUS ARCH WITH UNILATERAL EDENTULOUS AREA

WITH NATURAL TEETH REMAINING ANTERIOR AND POSTERIOR
Division A to D same as for Class I

2.5-5mm
>10mm
>15mm

>10mm
2.5-5mm >15mm

PARTIALLY EDENTULOUS ARCH WITH EDENTULOUS AREA ANTERIOR

TO THE REMAINING NATURAL TEETH AND CROSSES THE MIDLINE
Division A to D same as for Class I

>5mm

>10mm
>5mm

>5mm

>10mm
>5mm

SA-1

SA-2

Uses conventional methods of implant insertion and sinus procedures as required

based on width of bone

SA-3

SA-4

Uses Tatum lateral wall approach for sinus grafting before implant insertion

Subantral treatment options exists in

posterior maxilla

Treatment Categories
TREATMENT

HEIGHT (mm)

PROCEDURE

SA-1

> 12

Division A root form placement

SA-2

10 - 12

Sinus lift; simultaneous Division

A root form placement

SA-3

5 - 10

Lateral wall approach sinus graft;

delayed Division A root from
placement

SA-4

<5

Lateral wall approach sinus graft;

delayed Division A root from
placement

> 5 mm width
> 10-13 mm height
>7 mm length
<30 degrees
angulation
C/I ratio < I

Division A root form

2.5-5 mm width
> 10-13 mm height
>12 mm length
<20 degrees
angulation
C/I ratio < I

OSTEOPLASTY
Division A root form
AUGMENTATION
Demanding esthetics
Great force factors
NARROW IMPLANT
Division B root form
Plate form

Unfavorable in:
Width (C-w)
Height (C-h)
Length
Angulation (C-a)
C/I ratio I

OSTEOPLASTY(C-w)
AUGMENTATION
Fixed prosthesis
Demanding esthetics
Great force factors
ENDOSTEAL
Root form
Ramus frame
SUBPERIOSTEAL
Arch form
Angulation
Cost
Time
TRANSOSTEAL

Severe atrophy
Basal bone loss
Flat maxilla
Pencil thin
mandible

AUGMENTATION
Treatment of choice
ENDOSTEAL
Root form
Ramus frame
SUBPERIOSTEAL

CLASSIFICATION
3 Types
DIVISION A
DIVISION B
DIVISION (C-w)
DIVISION (C-h)
DIVISION D

ABUNDANT BONE IN ALL THREE SECTIONS

ADEQUATE BONE IN ALL THREE SECTIONS

For placing of normal Root form

Change to Division A by Osteoplasty

INADEQUATE BONE WIDTH FOR IMPLANTATION

For Removable Prostheses

Osteoplasty is done to convert to C-h.
For FP1 - Autogenous onlay graft.

INADEQUATE BONE HEIGHT FOR

IMPLANTATION

Long term success not achieved with Fixed

Prosthesis.

For removable
RP4 - Complete subperiosteal Implants
RP5 - Anterior root form with posterior
soft tissue

AVAILABLE MINIMAL BONE

Bone Augmentation before Implant

placement

Conventional dentures considered.

ABUNDANT BONE IN THE ANTERIOR AND

ADEQUATE BONE IN THE POSTERIORS

ABUNDANT BONE IN THE ANTERIOR REGION AND

INADEQUATE BONE IN THE POSTERIORS

ANTERIOR SECTION - Larger Diameter Root form

POSTERIORS
Maxilla - Sinus Grafting + Endosteal Implants
Mandible - Grafts / Subperiosteal Implants

ABUNDANT BONE IN THE ANTERIOR REGION AND

MINIMAL BONE IN THE POSTERIORS

TWO MAIN TREATMENT OPTIONS

Anterior section changed to Division A by

Osteoplasty, treated same as Type II - Division A,C.
If Osteoplasty does not present sufficient height, posterior
division changed by Sinus grafts and treated as
Type I - Division B.

ABUNDANT BONE IN THE ANTERIOR, ADEQUATE BONE IN RIGHT

POSTERIOR AND INADEQUATE BONE IN THE LEFT POSTERIOR

Anterior root form implants are indicated.

ABUNDANT BONE IN THE ANTERIOR, ADEQUATE BONE IN RIGHT

POSTERIOR AND INADEQUATE BONE IN THE LEFT POSTERIOR

Right posterior-narrow diameter implants.

ABUNDANT BONE IN THE ANTERIOR, ADEQUATE BONE IN RIGHT

POSTERIOR AND INADEQUATE BONE IN THE LEFT POSTERIOR

If additional support needed, anterior root

forms are placed and splinted to the posteriors.

 Anterior root form implants are

indicated.
If additional support needed, grafts
are considered.

 Mandible-subperiosteal implants are

indicated.
Maxilla-augmentation with sinus grafts
and subnasal elevation.

Over denture treatment

options

Advantages

Bone loss prevented

Stability, retention, support, speech
Esthetics
Dec soft tissue abrasion
Inc chewing efficiency
Reduced prosthesis size

Disadvantages
Psychological
Crown height space required
Long term maintenance
attachments (change)
relines(RP-5)
new prosthesis every 7 years
Continued posterior bone loss
Food impaction
Movement(RP-5)

OVERDENTURE OPTION ONE (OD-1)

Implants placed in B and D
positions, independent of
each other.
Ideal anterior and posterior
ridge form.
Common type of attachment is
O-ring and the movement is PM-6.
DISADVANTAGE
Relatively poor implant support and stability.

OVERDENTURE OPTION TWO (OD-2)

Implants in the B and D position joined

rigidly by a bar.
Retentive element is O-ring or clip
design.
The bar can be Dolder or Hader and the
movement ranges from PM-3 to PM-6.

OVERDENTURE OPTION THREE (OD-3)

Type 1:

Implants in A, C and E
position rigidly joined by a
bar.
Posterior ridge form is good.
Movement ranges from
PM-2 to PM-6.

Type 2:

Implants in B, C and D
position joined by a rigid
bar.
Posterior ridge form is poor.
Movement ranges from
PM-3 to PM-6.

OVERDENTURE OPTION FOUR (OD-4)

Implants are placed in A,B, D and E positions.

Rigidly joined by cantilever extending
about 10mm.
Indications include poor posterior anatomy.
Movement ranges from PM-2 to PM-6.

OVERDENTURE OPTION FIVE (OD-5)

Implants are placed in A,B, C, D and E

positions. Rigidly joined by cantilever
extending about 15mm.
Indications include high demands and
desires of the patient.
Movement - PM-0.

In traditional
dentistry the
restoration reflects
the existing condition
of the patient. Implant
dentistry is unique
because additional
foundation can be
created for a desired
Prosthodontic result.

TWO SEPARATE PARTS

Super structure

Fixed

Fixed-detachable Overdenture

TWO SEPARATE PARTS

Mesostructure

Continuous
bar

Non continuous bars

Depending on
shapes

Round
Ovoid
Rectangular
Square

Simply resting on the

bar

Depending on
the
superstructure

Attached to the bar /

locked
under unique
attachment.
Supplementary
attachment
incorporated into/ onto

DEPENDING ON THE ARCH.

Curved

Straight

ANCHORAGE DEVICE
BIOLOGICAL

MECHANICAL

RETENTION
NUMBER OF ABUTMENTS
DISTRIBUTION OF ABUTMENTS IN THE RIDGE SEGMENT
CURVATURE OF THE RIDGE SEGMENT
SIZE AND TYPE OF ANCHORAGE DEVICE
LENGTH OF THE BAR AND NUMBER OF CLIPS
DEGREE OF JAW ATROPHY

ATTACHMENT
S

Magnets

ADVANTAGE

SHORT COMINGS

Questionable
Easy to repair retention
Poor lateral stability
No stress relief
Corrosive
Loosen or unthread
Expensive
Easy to use

ATTACHMENT
S
Ceka,
Octa-link

ADVANTAGE
Easy to use

SHORT COMINGS
Expensive

Easy to repair

requires frequent

Good retention maintenance

loosen or
Stressunthread
breaking

ATTACHMENT
S
ER
A

ADVANTAGE
Adjustable
retention
Easy to replace
Modest in cost

SHORT COMINGS
need
frequent
replacement

ATTACHMENT ADVANTAGE
S
Adjustable
Zest,
retention
O-Rings
Good retention
Stress
breaking
Easy to use

SHORT COMINGS
Abutments must
be parallel
Less rigid than
metal to metal
Wear more
quickly
than metal

ATTACHMENT
ADVANTAGE
S
Stress
Hader,
breaking
Dolde
r
Easy to repair
and replace
Easy to
maintain

SHORT COMINGS
Expensive

ATTACHMENT
S
PinLoc
k

ADVANTAGE
Easy to use
Easy to
maintain

SHORT COMINGS
Expensive

 Hygiene
Periodontal condition
Restorations present
Level of decay activity
Reasons for previous tooth
loss
Bone shape and quality
Patient motivation

Relation between natural dentition and Implant

supported prostheses
17

24

A minimum of 3mm edentulous space between

adjacent tooth and the fixture is needed to place
4mm diameter fixture.

FP-1

Fixed prosthesis; replaces only the crown; looks like a

natural tooth

FP-2

Fixed prosthesis; replaces only the crown and a portion of

root; crown contour appears normal in the occlusal half but
is elongated or hyper contoured in the gingival half

FP-3

Fixed prosthesis; replaces missing crowns and gingival

color and portions of the edentulous site; prosthesis most
often uses denture teeth and acrylic gingiva, but may be
porcelain to metal.

RP-4
RP-5

Removable prosthesis; overdenture completely supported

by implant.
Removable prosthesis; overdenture supported by both soft
tissue and implant.