This document discusses various prosthetic options in implant dentistry. It begins by introducing different treatment options for completely and partially edentulous patients, noting that implant dentistry provides more options compared to traditional dentistry. It then covers Misch's classification system for prosthetic options (FP1-FP3, RP4-RP5), which are determined by the amount of hard and soft tissue replacement needed. The document discusses different prosthesis types for complete and partial edentulism in detail. It also covers considerations for prosthesis design such as crown height space, bone width, implant positioning and restorative materials. In conclusion, the optimal prosthetic option depends on the patient's existing oral condition and treatment goals.

1. Prosthetic Options In
Implant Dentistry
NAMITHA AP
2ND MDS
DEPT.OF PROSTHODONTICS

2. Contents
 Introduction
 Completely edentulous prosthesis design
 Removable implant supported prosthesis
 Fixed restorations in completely or partially
edentuous patients
 Partially edentulous prosthesis design
 Misch’s prosthetic options in implant
dentistry
1. FP1
2. FP2
3. FP3
4. RP4
5. RP5
 CLASSIFICATION OF PROSTHEIS
MOVEMENT
1. PM0
2. PM2
3. PM3
4. PM4
5. PM6
 OVERDENTURE OPTIONS
 CONCLUSION
 RELATED ARTICLES
 REFERENCES

3. Implant
dentistry
Diagnosis of the
patient’s
condition
Many
treatment
options
Introduction
Traditional dentistry
Completely
edentulous patients
Limited options- CD
Partial edentulism
More options exits
there are limitations because
the dentist cannot add
abutments
Restoration design is directly
related to the existing oral
condition.
provide a range of abutment
locations in either completely or
partially edentulous patients
BONE
AUGMENTATION
ADDS MORE
OPTIONS
Implant
dentistry
Maximum
options
Treatment
plan of
choice
PROBLEMPATIENT
Misch CE. Dental Implant Prosthetics-E-Book.
Elsevier Health Sciences; 2004 Sep 20.193

4. Patients are missing teeth,
not implants!
 ideal goals of implant dentistry are to replace a patient’s
missing teeth to
 regardless of the previous atrophy, disease, or injury of the
stomatognathic system
 It is the final restoration, not the implants, that accomplishes
these goals
Blueprints indicate the finest details
for buildings and are fabricated
before the actual construction
begins
The end result should be clearly identified
before the project begins and even
before foundation requirements are
established.
BLUEPRINTS
NORMAL
CONTOUR
COMFORT
FUNCTION
ESTHETICS
SPEECH HEALTH
Misch CE. Dental Implant Prosthetics-E-Book. Elsevier Health Sciences; 2004 Sep 20.193

5. historically
Predetermined
implant
bone available for
implant insertion
dictated the
number and
locations of dental
implants
The prosthesis was determined
Reintroduced with computed tomography
technology directed toward finding existing
bone locations for implant insertion.
Misch CE. Dental Implant Prosthetics-E-Book. Elsevier Health Sciences; 2004 Sep
20.193
To satisfy predictably a patient’s needs and desires,
the prosthesis should first be designed.

6. FIXED RESTORATIONS IN COMPLETELY OR
PARTIALLY EDENTUOUS PATIENTS
edentulous patients often believe the implant teeth are
better than their experience with compromised natural
teeth.
INDICATIONS
patient has abundant bone and implants have already
been placed, the lack of crown height space
fewer complications than overdentures
Misch CE. Dental Implant Prosthetics-E-Book. Elsevier
Health Sciences; 2004 Sep 20.194

7. Crown height space
 Key vertical parameter in treatment planning for
the implant restorations.
distance from the occlusal plane to the crest of the
alveolar ridge in the posterior region
distance from the incisal edge of the arch in question in
the anterior region
BARIUM SULFATE
RADIO OPAQUE
TEMPLATE

8. visualize the final restoration at
the onset with a fixed-implant
restoration
individual areas of ideal or key
abutment support are
determined
The patient’s force factors and
bone density in the region of
implant support are evaluated
The additional implants to
support the expected forces on
the prosthesis designed
implant size and design
selected to match force and
area conditions
available bone evaluated to
assess whether it is possible to
place the implants to support
the intended prosthesis
inadequate bone or implant
abutment situations, the
existing oral conditions must be
improved
The mind
of the patient must be
modified to accept a
different prosthesis
type and its limitations.

11. PARTIALLY EDENTULOUS PROSTHESIS
DESIGN
 The fewer natural teeth missing, the better the indication for
a fixed partial denture.
 Fixed partial denture is completely implant supported rather
than joining implants to teeth leads to the use of more
implants in the treatment plan.
 Cost disadvantage BUT significant intraoral health
benefits.
 added implants in the edentulous site results in fewer
pontics, more retentive units in the restoration, and less
stress to the supporting bone.
 complications are reduced, and implant and prosthesis
longevity are increased
Misch CE. Dental Implant Prosthetics-E-Book. Elsevier
Health Sciences; 2004 Sep 20.195

13. cost were the
primary factor in
establishing a
treatment plan
Most do not
express serious
concerns whether
the restoration is
fixed or removable
as long as specific
problems are
addressed
Some patients have a
strong psychological
need to have a fixed
prosthesis (FP) as
similar to natural
teeth as possible.
COMPLETELY EDENTULOUS
PROSTHESIS DESIGN
Misch CE. Dental Implant Prosthetics-E-Book. Elsevier Health Sciences; 2004 Sep 20.194
predictable Cost effective
Patients
anatomical needs
Personal desires
Axiom of implant
treatment

14. REMOVABLE IMPANT SUPPORTED PROSTHESES
soft tissues are also used to
support the prosthesis
implants are inserted into the anterior
regions of the jaws (improved retention
and stability )
chance of food entrapment
Attachments need replacement
acrylic denture teeth wear faster than porcelain to metal
Misch CE. Dental Implant Prosthetics-E-Book. Elsevier Health Sciences; 2004 Sep 20.194

15. The anterior mandible has the greatest bone
height in any region of the jaws.
The incisal edge of a tooth is usually more
facial, hence the implant often engages the
lingual plate of bone.
(more available bone in height
than the posterior regions)
Misch CE. Dental Implant Prosthetics-E-Book. Elsevier
Health Sciences; 2004 Sep 20.319
Posterior regions of the jaws also
resorb four times or faster than anterior
regions

17. Misch CE. Dental Implant
Prosthetics-E-Book. Elsevier
Health Sciences; 2004 Sep
20.194
maxillary denture and a
mandibular overdenture
with two implants.
COMMON OPTION
When available bone dimension is lost more difficulty with retention and
stability of the restoration in either arch
Patients should be made aware of future compromises in bone loss and its
associated problems with minimal treatment options

18. Prosthetic options  In 1989, Misch
 used to communicate the appearance of the final prosthesis to
all of the implant team members, including the laboratory and
patient.
replace partial (one
tooth or several) or
total dentitions and
may be cemented or
screw retained
depend on the
amount of implant
support, retention,
and stability, not the
appearance of the
prosthesis
inability of the patient to remove
the prosthesis
These options depend on the
amount of hard and soft tissue
structures replaced and the aspects
of the prosthesis in the esthetic zone.

20. Fixed prosthesis
FP 1
 to replace only the anatomical crowns of the
missing natural teeth.
 minimal loss of hard and soft tissues
 The volume and position of the residual bone
must permit ideal placement of the implant in
a location similar to the root of a natural
tooth
 Final restoration appears very similar in size
and contour
 most traditional FPs used to restore or replace
natural crowns of teeth.
Misch CE. Dental Implant Prosthetics-E-Book. Elsevier Health Sciences; 2004 Sep 20.195

21.  most often desired in the maxillary
anterior region (esthetic zone during
smiling )
Cervical diameter
Natural teeth
6.5-10.5 mm
Oval to triangular
in cross section
Implant abutment
4-5 mm
Round in cross
secton
Misch CE. Dental Implant
Prosthetics-E-Book. Elsevier Health
Sciences; 2004 Sep 20.196
Thin labial bone lying over the
facial aspect of a maxillary
anterior root remodels after tooth
loss and the crest width shifts to
the palate, decreasing 40% within
the first 2 years.

22. OCCLUSAL TABLE OF CROWN
 modified in unesthetic regions to conform to the
implant size and position and to direct vertical
forces to the implant body
 Eg. posterior mandibular implant-supported
prostheses have narrower occlusal tables at the
expense of the buccal contour because the
implant is smaller in diameter and placed in the
central fossa region of the tooth.
 Maxillary posterior teeth often have reduced
occlusal tables from the palatal aspect because
the buccal cusp is often within the esthetic zone
Misch CE. Dental Implant Prosthetics-E-Book. Elsevier Health Sciences; 2004 Sep 20.197

23.  difficult to achieve when more
than two adjacent teeth are
missing.
Misch CE. Dental Implant Prosthetics-E-Book. Elsevier Health Sciences; 2004 Sep 20.197
• The width or height of the
crestal bone is frequently
lacking after the loss of
multiple adjacent natural
teeth
BONE
AUGMENTATION
• no interdental papillae in
edentulous ridges - required
to improve the interproximal
gingival contour
SOFT TISSUE
AUGMENTATION
open “black” triangular spaces
(where papillae should usually be
present) when the patient smiles.

24. RESTORATIVE MATERIAL
 A single tooth FP-1 crown may use aluminum
oxide cores and porcelain crowns or ceramic
abutments and porcelain crowns.
Misch CE. Dental Implant Prosthetics-E-Book.
Elsevier Health Sciences; 2004 Sep 20.197
• Can easily be separated and soldered
• in contact with implants corrode less
than nonprecious alloys.
Noble
metal
• Any history of exudate around a
subgingival margin will dramatically
increase the corrosion effect between
the implant and the base metal.
Base
metal
Substructure
in case of a
nonpassive
fit at the
metal try-in
material of choice - porcelain to noble-
metal alloy
risk of fracture may increase because impact
forces are greater on implants than natural
teeth
improve the
accuracy of the
casting because
nonprecious metals
shrink more during
the casting process

25. FP2
 Volume and topography of
the available bone are more
apical compared with the
ideal bone position of a
natural root (1–2 mm below
the cement–enamel junction)
An FP-2 fixed prosthesis appears to restore the
anatomical crown and a portion of the root of
the natural tooth.
Misch CE. Dental Implant Prosthetics-E-Book. Elsevier
Health Sciences; 2004 Sep 20.198
Incisal edge of the restoration is
in the correct position
gingival third of the crown is
overextended, usually apical and
lingual to the position of the
original tooth
Restorations
are similar to
teeth
exhibiting
periodontal
bone loss
and gingival
recession

26.  Esthetic zone of
a patient is
established
during smiling
in the maxillary
arch.
 The number of
teeth displayed
in a smile is
variable.
Misch CE. Dental Implant Prosthetics-E-Book. Elsevier
Health Sciences; 2004 Sep 20.198
Only 4% of
patients display
almost all the
maxillary teeth
during a smile
Tjan AH, Miller GD, The JG: Some esthetic factors in a smile,
J Prosthet Dent 51:24-28, 1984.)
Almost 50% of patients
display the teeth up to a
first premolar.
If the teeth do not show during smiling
or speech, an FP-2 restoration is not a
compromise.

27.  The low lip position is evaluated during sibilant
sounds of speech (e.g., Mississippi).
 It is not unusual for patients to show less lower
anterior teeth during smiling, especially in
younger patients.
 Older patients are most likely to show the
anterior teeth and gingiva during speech, with
men showing more than women
Misch CE. Dental Implant Prosthetics-E-Book. Elsevier
Health Sciences; 2004 Sep 20.199

28.  As the patient
becomes older, the
maxillary esthetic zone
is altered.
 Whereas only 10% of
younger patients do
not show any soft
tissue during smiling
 30% of 60-year-old
adults and 50% of 80-
year-old adults do not
display gingival
regions during smiling
If the high lip line during
smiling or the low lip line
during speech does not display
the cervical regions; longer
teeth are usually of no esthetic
consequence
Misch CE. Dental Implant
Prosthetics-E-Book. Elsevier
Health Sciences; 2004 Sep
20.199

29.  The low lip position of the
mandibular lip during speech is not
affected as much as the maxillary lip
during the high smile line.
 Rarely do younger or middle-age
patients show the lower gingival
during speech.
 Only 10% of older patients show the
mandibular soft tissue during
speech.
 Hence, FP-2 restorations in the
mandible are common and usually
of no compromise
Misch CE. Dental Implant Prosthetics-E-Book. Elsevier Health Sciences; 2004 Sep 20.199
BONE WIDTH ANGULATION
HYGIENIC
CONSIDERATIONS
IMPLANT
POSITION
IN FP 2
IN FP1-
ESTHETIC
DEMANDS

30.  If this occurs, the incisal two thirds of
the two crowns should be ideal in
width,as though the implants were not
present.
 Only the cervical region is
compromised.
 It should be placed in the correct facial
lingual position to ensure that contour,
hygiene, and direction of forces are not
compromised
Misch CE. Dental Implant Prosthetics-E-Book. Elsevier Health Sciences; 2004 Sep 20.199
MESIO DISTAL
POSITIONING OF
IMPLANT – NOT
SPECIFIC
implant may even be placed in an
embrasure between two teeth.
RESTORATIVE MATERIAL OF CHOICE – PRECIOUS METAL
TO PORCELAIN
The amount and contour of the metal work is
different than for an FP-1 restoration
Amount of additional volume of tooth
replacement increases the risk of unsupported
porcelain in the final prosthesis, when the metal
is undercontoured.

31. FP3
 As with the FP-2 prosthesis, the original
available bone height has decreased by natural
resorption or osteoplasty at the time of
implant placement.
 To place the incisal edge of the teeth in proper
position for esthetics, function, lip support,
and speech, the excessive vertical dimension
to be restored requires teeth that are
unnatural in length.
 Patient may have a normal to high maxillary lip
line during smiling or a low mandibular lip line
during speech.
Misch CE. Dental Implant
Prosthetics-E-Book. Elsevier
Health Sciences; 2004 Sep 20.200
Pink-colored restorative materials to replace a
portion of the soft tissue, especially the interdental
papillae

32.  The ideal high smile line occurs in almost 70% of the population
and the maxillary lip displays the interdental papilla of the
maxillary anterior teeth but not the soft tissue above the
midcervical regions
 Approximately 7% of men and 14% of women have a high smile or
“gummy” smile and display the interdental papillae and at least
some of the gingival tissues above the free gingival margin of the
teeth.
 Patients in both of these categories of high lip line should have
the soft tissue replaced by either the prostheses or the patient’s
soft tissue Misch CE. Dental Implant Prosthetics-E-
Book. Elsevier Health Sciences; 2004 Sep
20.200,201

33.  The patient may also have greater
esthetic demands even when the teeth
are out of the esthetic smile and speech
zones.
 Patients complain that the display of
longer teeth appears unnatural even
though they must lift or move their lips
in unnatural positions to see the covered
regions of the teeth.
Misch CE. Dental Implant Prosthetics-E-Book. Elsevier Health Sciences; 2004 Sep 20.200,202

34. The addition of gingival-tone acrylic or porcelain for a more natural
FP appearance is often indicated with multiple implant abutments
because bone loss is common with these conditions, and the soft
tissue drape is more difficult to appear ideal
Misch CE. Dental Implant Prosthetics-E-Book. Elsevier Health Sciences; 2004 Sep 20.200,203

35.  There are basically two approaches for an FP-3 prosthesis:
(1) a hybrid restoration of denture teeth and acrylic with a metal substructure
(2) a porcelain–metal restoration
 An FP-3 porcelain-to-metal restoration is more difficult to fabricate for the laboratory technician
than an FP-2 prosthesis.
 The pink porcelain is harder to make appear as soft tissue and usually requires more baking
cycles.
 This increases the risk of porosity or porcelain fracture.
Misch CE. Dental
Implant Prosthetics-
E-Book. Elsevier
Health Sciences;
2004 Sep 20.200,203

36. primary factor that determines the restoration material is the amount of crown height space
EXCESSIVE
CROWN HEIGHT
SPACE
porcelain–metal
restoration will
have a large
amount of metal in
the substructure
• PORCELAIN THICKNESS
NOT > 2mm
increase in
porcelain fracture
acts as a heat sink and
complicates the
application of porcelain
during the fabrication
of the prosthesis.
as the metal
cools after
casting, the
thinner regions
of metal cool
first and create
porosities in the
structure.
Misch CE.
Dental Implant
Prosthetics-E-
Book. Elsevier
Health Sciences;
2004 Sep
20.200,203
fracture of
the
framework
after
loading
when the casting is reinserted into
the oven to bake the porcelain, the
heat is maintained within the
casting at different rates; thus, the
porcelain cool-down rate is variable,
which increases the risk of porcelain
fracture
weight
and
cost

38. Hybrid restoration
 An alternative to the traditional porcelain–metal
FP
 A smaller metal framework, with denture teeth
and acrylic to join these elements together.
 Less expensive
 highly esthetic because of the premade denture
teeth and acrylic pink soft tissue replacements.
 Intermediary acrylic between the denture teeth
and framework may reduce the impact force of
dynamic occlusal loads.
 easier to repair in the case of porcelain fracture
because the denture tooth may be replaced with
less risk than adding porcelain to a traditional
porcelain–metal restoration Fatigue of acrylic is greater than the traditional
prosthesis; therefore, repair of the restoration is
more commonly needed.

39.  Implants placed too facial or lingual or in
embrasures
 when vertical bone has been lost
 greater crown heights allow the correction of
incisal edge positions
 extremely high smile lip line
Misch CE. Dental Implant Prosthetics-E-Book. Elsevier
Health Sciences; 2004 Sep 20.200,203
Greater moment of force is placed on the
implant cervical regions, especially during
lateral forces (e.g., mandibular excursions or
with cantilevered restorations).
INDICATIONS FOR FP2/FP3
In the maxillary arch, wide open
embrasures between the implants
may cause food impaction or
speech problems.
often extended or
juxtaposed to the
maxillary soft tissue
so that speech is not
impaired

40. There are two types of RPs based on
support, retention, and
stability of the restoration
 Patients are able to remove
the restoration but not the
implant supported
superstructure attached to the
abutments.
Misch CE. Dental Implant Prosthetics-E-Book. Elsevier
Health Sciences; 2004 Sep 20.200,203,204

41.  The most common removable implant
prostheses are overdentures for
completely edentulous patients.
Misch CE. Dental Implant
Prosthetics-E-Book.
Elsevier Health Sciences;
2004 Sep 20.575
VERSUS NORMAL CD

42. RP 4  RP completely supported by the
implants, teeth, or both.
 The restoration is rigid when
inserted: overdenture attachments
usually connect the RP to a low-
profile tissue bar or superstructure
that splints the implant abutments.
 Usually five to seven implants in
the mandible and six to eight
implants in the maxilla are
required to fabricate completely
implant supported RP-4
prostheses in patients with
favorable dental criteria
Misch CE. Dental Implant Prosthetics-E-Book. Elsevier
Health Sciences; 2004 Sep 20.200,204

43. IMPLANT PLACEMENT CRITERIA FOR
RP4 PROSTHESIS
 Different than that for an FP
 Denture teeth and acrylic require more prosthetic
space for the removable restoration.
 A superstructure and overdenture attachments must
often be added to the implant abutments.
 This requires a more lingual and apical implant
placement compared with the implant position for an
FP.
Misch CE. Dental Implant Prosthetics-E-Book. Elsevier
Health Sciences; 2004 Sep 20.200,204

44.  Position of an attachment on the superstructure or prosthesis may also
affect the amount of spacing between the implants.
 For example, a Hader clip requires the mesiodistal implant spacing to be
greater than 6 mm from edge to edge and as a consequence reduces the
number of implants that may be placed between the mental foramina.
Misch CE. Dental Implant Prosthetics-E-Book. Elsevier
Health Sciences; 2004 Sep 20.200,204
The implants in an RP-4 prosthesis (and an FP-2 or FP-3
restoration) should be placed in the mesiodistal position
for the best biomechanical and hygienic situation

45.  The RP-4 prosthesis may have the same appearance
as an FP-1, FP-2, or FP-3 restoration.
 A porcelain-to-metal prosthesis with attachments in
selected abutment crowns can be fabricated for
patients with the cosmetic desire of an FP.
 The overdenture attachments permit improved oral
hygiene or allow the patient to sleep without the
excess forces of nocturnal bruxism on the prosthesis.
 The prosthesis is very similar to traditional
overdentures supported by natural teeth
Misch CE. Dental Implant Prosthetics-E-Book. Elsevier
Health Sciences; 2004 Sep 20.200,204,332

46. RP 5
 RP-5 is an RP combining implant and soft tissue support.
 amount of implant support is variable.
 A completely edentulous mandibular overdenture may have
(1) two of three anterior implants independent of each other
primarily for retention
(2) splinted implants in the canine regions to enhance
retention and stability
(3) three splinted implants in the premolar and central incisor
areas to provide improved retention and lateral stability
(4) four or five implants splinted with a cantilevered bar to
improve retention, stability, and support which reduces
soft tissue abrasions and limits the amount of soft tissue
coverage needed for prosthesis support.
Misch CE. Dental Implant Prosthetics-E-Book. Elsevier
Health Sciences; 2004 Sep 20.204

47. CLASSIFICATION OF PROSTHESIS
MOVEMENT (MISCH 1985)
 Evaluates the directions of
movement of the implant-
supported prosthesis
 An overdenture is by definition
removable, but in function or
parafunction, the prosthesis may
not move.
 The dentist determines the
amount of PM the patient desires
or the anatomy may tolerate
Misch CE. Dental Implant Prosthetics-E-Book. Elsevier Health Sciences; 2004 Sep 20.580
PM-0
•does not have movement during function
PM-2
•with hinge motion
PM-3 •Apical and hinge motion
PM-4
•Movement in 4 directions
PM-6
•Movement in all directions

48. PM 0
 If the prosthesis is rigid when in place but
can be removed, the PM is labeled PM-0
regardless of the attachments used.
 O-rings may provide motion in six different
directions.
 But if four O-rings are placed along a
complete arch bar and the prosthesis rests
on the bar, the situation may result in a PM-
0 restoration

49. PM 2
 hingelike PM permits
movement in two planes
(PM-2) and most often
uses a hingelike
attachment
 Dolder bar and clip
without a spacer or Hader
bar and clip are the most
commonly used hingelike
attachments.
• EGG shaped in cross
section
• A clip attachment may
rotate directly on the
Dolder bar
• Flexes to a power of 3
DOLDER
BAR
• ROUND in cross section
• More flexible
• Flex to the power of four
HADER
BAR
contribute to unretained
abutments or bar
fracture
apron is added to the
tissue side of the Hader
bar to limit metal flexure

50. Hader bar
may be used for a
PM-2 when
posterior ridge
shapes are favorable
and soft tissue is
firm enough to limit
prosthesis rotation.
A cross-section of the Hader bar and clip system
reveals that the apron, by which the system gains
strength compared with a round bar design
Transforms the
prosthesis and
bar into a more
rigid assembly

51. PM 3 PM 4 PM 6
OCCLUSAL,GINGIVAL,MESIAL,DIS
TAL,FACIAL,BUCCAL AND
LINGUAL
MESIAL,DISTAL FACIAL
AND LINGUAL
O RING
ATTACHMENT
MAGNETS
DOLDER BAR
WITH SPACER
AND CLIP
FACIAL,LINGUAL AND
GINGIVAL

52. Dolder bar

53. Misch CE. Dental Implant Prosthetics-E-
Book. Elsevier Health Sciences; 2004 Sep
20.579
MANDIBULAR
OVERDENTURE
TREATMENT OPTIONS

54. Overdenture option 1
O-ring or Locator design.

55. stability and support
of the prosthesis
are gained primarily
from the anatomy of
the mandible and
prosthesis design,
which is similar to a
complete denture.

56. Disadvantages Poor implant support
and stability
Decrease in occlusal
force
Increase in prosthetic
maintenance
appointments
Posterior bone
resorption
A, A panoramic radiograph of two
independent implants in a division
D mandible. B, One
implant failed, and the mandible
fractured through the
failed implant site.
two-mandibular implant
overdenture
should oppose a complete
denture.
Otherwise, instability and sore
spots are common related to
the implant overdenture.
The support requirements of the posterior regions of the mandible are
reduced when opposing a complete denture

57.  The ultimate goal in the treatment plan is to
convert OD-1 patients to a RP-4 or fixed
prosthesis with more implant support and
stability before the loss of the posterior bone
in the mandible occurs behind the foraminae.
 As soon as the patient can afford two more
implants, the implants should be placed in the
A and E position, and all four ABDE implants
should be connected with a bar that may be
cantilevered to the posterior and help reduce
the posterior bone loss.

58. Overdenture option 2
O-ring attachments are also
positioned equal distance
off the midline.
Attachments are placed parallel
to each other and at the some
occlusal height.

59.  Reduced loading forces are exerted on two anterior implants when splinted with a bar
compared with individual implants.
 The bar is designed to position the attachments an equal distance off the midline parallel to
each other at the same occlusal height and in a similar angulation to provide added
retention

60. The ideal distance between the implants is in the 14- to 16-mm range or B and D positions.
Implants placed closer than the B, D position will result in reduced prosthesis stability during function
whether they are connected or independent units.
The connecting bar should not be cantilevered to the distal from the two implants

61. Implants in the A, E position were
splinted together with a bar. The
prosthesis screw
became loose on the A implant,
which resulted in a
long cantilever on the E implant,
which then failed.

62. Overdenture option 3
 Three root form implants are placed in the A, C,
and E positions
 A superstructure bar connects the implants but
with no distal cantilever
 The A-C-E implant and bar position is much
more stable than the B-D position for the
prosthesis.

63. In the future convert it in to RP 4 OR any FP

64. Overdenture option 4
 The cantilevered superstructure is a feature of the
four or more implant treatment options in a
completely edentulous arch for three reasons:
1. increase in implant support compared with OD-1 to
OD-3.
2. biomechanical position of the splinted implants is
improved in an ovoid or tapering arch form
compared with OD-1 or OD-2.
3. additional retention provided by the fourth implant
for the superstructure bar, which limits the risk of
prosthetic screw loosening and other related
complications of cantilevered restorations.

65. A-P spread between implants in the A, E and D, B
positions is greater and therefore permits a longer distal cantilever.
This A-P spread is usually 8 to 10 mm in these arch forms
and therefore often permits a cantilever up to 10 mm from the
A and E positions

66. Advantages
 Greater occlusal load support, lateral
prosthesis stability, and improved
retention.
 The prosthesis loads the soft tissue over
the buccal shelf and the first and second
molars and retromolar pad regions.
 amount of occlusal force on the implant
system is reduced (compared with a
fixed restriction or RP-4 prosthesis)
because the bar does not extend to the
molar position, where the forces are
greater.
Disadvantages
 The OD-4 treatment option is the
lowest treatment rendered when the
patient has maxillary teeth.
 The greater vertical and horizontal
forces to the mandibular IOD require
anterior disclusion in excursions to
decrease the bite force.
 As such, more anterior implants are
required under these conditions
The next treatment plan option for the patient with a moderate financial budget is to add an additional
implant in the future in one of the first molar positions (preferred) or the C position.
Both of these options increase the A-P spread to fabricate a RP-4 prosthesis with an enhanced implant
system support. The goal is to convert all patients eventually to a RP-4 or fixed restoration,
to prevent posterior bone loss and its associated disadvantages (including esthetics of the posterior facial
regions).

67. Overdenture option 5
 The amount of the distal bar cantilever is related (in part) to
the A-P distance.

68. Arch shape affects the
anteroposterior (A-P) distance.
A, The square arch
form is less than 5 mm. B, The
ovoid arch form
often has an A-P distance of 5
to 8 mm. C, A
tapered arch form has the
greatest A-P distance,
larger than 8 mm.
The mandibular arch form may be square, tapering, or
ovoid.
Square arch forms limit the A-P spread between implants
and may not be able to counter the effect of a distal
cantilever.
Therefore, rarely are distal cantilevers designed for square
arch forms

69.  completely implant-supported
prostheses often increase the
amount of posterior bone height
even when no posterior implants
are inserted.
maxillary arch has natural
teeth (especially in a
young patient or male
patient)
patient desires a RP-4 or
fixed restoration
IndicationsNo prosthetic load on
posteriors
Avoid load on posterior
residual ridge
Resorption process is
delayed
Posterior
implants
Cantilevered bar and overdenture
INCREASE
ANTEROPOSTERIOR
SPREAD

70. CONCLUSION
Gives a desired
prosthodontics result
• Additional foundation units
Patient factors • Psychological and anatomical needs and desires of the patient
Design prosthesis
• That satisfies these goals and eliminates the existing problems
Benefits of implant
dentsitry • realized only when the prosthesis is first discussed and
determined
• An organized treatment approach based on the prosthesis
permits predictable therapy results.
Prosthesis may
be fixed or
removable for
completely
edentulous
patients, fixed
restorations are
planned for
most partially
edentulous
patients
Misch CE.
Dental Implant
Prosthetics-E-
Book. Elsevier
Health Sciences;
2004 Sep
20.205

71. FP-1 prosthesis, when desired, may have
a narrow implant inserted rather than an
osteoplasty and a larger diameter
implant
Amount of
support
required for
an implant
prosthesis
FP3/FP
FP1
Prosthetic
option
first factor to
determine
overall implant
treatment plan
Misch CE. Dental Implant Prosthetics-E-Book. Elsevier Health Sciences; 2004 Sep 20.205

72. “Combination Syndrome” in an Upper/
Lower Implant Overdenture Patient: A
Clinical Report
 An upper/lower overdenture case, which presented with clinical entities
commonly associated with the combination syndrome, is described.
 clinical presentations reminding of combination syndrome features were
described in patients wearing upper complete dentures opposing lower
implant retained/ supported overdentures
 main observation was related to increased bone loss in the anterior maxilla
RELATED ARTICLES

73. 2 O Ring attachments in
sites #5 and #12, 1 Locator attachment
#2, and 1 extracoronal resilient
attachment in site #15. The
attachments were worn out

74. 1
Disproportioned
bone loss can
occur in various
extents in patients
treated with
prostheses having
mixed support
(implants/
tissue).
Regular recalls are
paramount,
to preserve the
health of
supporting
tissues and
improve the
longevity of
restorations.

75. Rehabilitation of Maxillofacialtrauma Patient with Dental
Implants: A Case Report

77. Patient-reported outcome measures of edentulous
patients restored with implant-supported
removable and fixed prostheses: A systematic review
 Overall, the OHRQoL and satisfaction of edentulous patients were
significantly improved after wearing implant-supported prosthesis compared
to their OHRQoL and satisfaction ratings before treatment.
 These improvements can be found in almost all domains, including comfort,
function, aesthetics, speech, self-esteem
 When comparing between IOD and IFCD, however, the reported outcomes
were inconsistent.
 The majority of the reviewed studies reported that IFCD performed better in
the aspects of overall satisfaction and OHRQoL
 IOD being easier to maintain oral hygiene
 IFCD needs to have a design that allows access for efficient oral hygiene and
that patients, who receive such reconstructions, must be adequately trained
for their particular prosthesis

78. How many implants are necessary to
stabilise an implant-supported
maxillary overdenture?
 Twenty-eight studies were included in the systematic review.
 The survival rate of implants appeared to be higher when at least four
implants were placed to support the overdenture, compared to less than
four implants.
 Patient satisfaction were not influenced by the number of implants.
 The metanalysis could only be performed to compare the implant survival
rate of a four splinted implants group and more than 4 splinted implants
group, without significant differences between both groups
Guenin C, Martín-Cabezas R
Evidence-Based Dentistry. 2020 Mar;21(1):28-9.

79. References
 Misch CE. Dental Implant Prosthetics-E-Book. Elsevier Health Sciences; 2004 Sep
20.
 Oda K, Kanazawa M, Takeshita S, Minakuchi S. Influence of implant number on the
movement of mandibular implant overdentures. The Journal of prosthetic
dentistry. 2017 Mar 1;117(3):380-5.
 Yao CJ, Cao C, Bornstein MM, Mattheos N. Patient‐reported outcome measures of
edentulous patients restored with implant‐supported removable and fixed
prostheses: A systematic review. Clinical oral implants research. 2018 Oct;29:241-
54.
 Guenin C, Martín-Cabezas R. How many implants are necessary to stabilise an
implant-supported maxillary overdenture?. Evidence-Based Dentistry. 2020
Mar;21(1):28-9.
 Gandhi N, Gandhi S, Kurian N, Mehdiratta S. Rehabilitation of maxillofacialtrauma
patient with dental implants: A case report. CHRISMED Journal of Health and
Research. 2018 Jan 1;5(1):80.
 Oh SH, Kim Y, Park JY, Jung YJ, Kim SK, Park SY. Comparison of fixed
implant‐supported prostheses, removable implant‐supported prostheses, and
complete dentures: patient satisfaction and oral health‐related quality of life.
Clinical oral implants research. 2016 Feb;27(2):e31-7.

80. THANK YOU!