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Inside Implant Dentistry

Contemporary Treatment of Mandibular Edentulism

by Lyndon F. Cooper, DDS, PhD, Kuang-Han Chang, DDS, and Ingeborg De Kok,
DDS

Edentulism remains prevalent in the United States among individuals older than 65
years of age. It results in a wide range of local anatomical, physiological, and
psychosocial changes that include continued residual ridge resorption, reduced
masticatory function, altered facial esthetics associated with changes in vertical
dimension and muscular function, and deterioration in self-reported social
functions. It is a condition with broad physiological and psychosocial impact, which
can be managed effectively using endosseous dental implants.

An obvious result of edentulation is alveolar bone loss and a reduction in

mandibular function (Figure 1 View Figure). A recent review of residual ridge
resorption acknowledged the multifactorial etiology and suggested that
combinations of anatomical, metabolic, mechanical, and yet-to-be-analyzed factors
contribute to it. Denture use remains a controversial factor contributing to residual
ridge resorption. Carlsson concluded that an excellent method to avoid jawbone
resorption was preventive dental care to maintain dental health and avoid total
extraction.1 For the hopeless dentition or the already edentulous jaws, the insertion
of an implant-supported prosthesis can reduce bone loss and may even promote
bone growth.

Prosthetic treatment using a complete denture is associated with additional

complications, which may add to patient dissatisfaction. Commonly observed
problems include denture stomatitis and denture sores as well as functional
problems affecting phonetics and mastication. Conventional dentures are clearly not
an ideal treatment for mandibular edentulism. When considering contemporary
treatment of the edentulous patient, endosseous dental implants for the treatment of
edentulism offers an alternative treatment to complete denture therapy. Key among
the advantages of mandibular implants are the improvement in mandibular
function, the prevention or reversal of alveolar bone loss, and the measurable
improvement in self-reported satisfaction with treatment.2 Yet, complete treatment
of the edentulous patient extends beyond considerations of improved prosthesis
function.

Contemporary Treatment of the Edentulous Patient

There are at least six aspects of care that contribute to a contemporary approach to
the treatment of the edentulous population (Table 1). Primary among these is
acknowledgement of the extent of the edentulism and the importance of
encouraging routine oral examination of all edentulous patients, which is is the basis
for ensuring oral health and the keystone to ensuring a high-quality prosthesis.
Clinicians should be motivated to prescribe endosseous dental implant-supported
prostheses for every patient with an edentulous mandible.

Routine Oral Examination of the Edentulous Patient

Edentulism is more prevalent among older individuals and more common in rural
communities. Other oral diseases, notably oral cancers, are also more prevalent in
the older US population. The reported incidence of oral cancer is not diminishing
and early diagnosis is among the most important factors affecting prognosis and
treatment.3 Other oral mucosal diseases also affect the edentulous patient, including
infectious diseases (eg, candidiasis) and autoimmune disorders, including mucosal
disorders (eg, lichen planus). In addition, salivary diseases such as Sjögren’s
syndrome have a direct impact on the ability of the edentulous patient to use
dentures comfortably and effectively. The consequences of edentulism and denture
use have further impact on the oral structures and merit continuous monitoring
(Figure 2 View Figure). The denture sore that is innocuous in the healthy individual
may lead to osteonecrosis in the cancer survivor receiving systemic bisphosphonate
chemotherapy. 4 Management of the oral health needs of the edentulous patient has
great relevance in the context of complex medical treatment of today’s older patient.

The edentulous oral condition is a prognostic factor that affects the difficulty of
denture construction and may affect therapy outcomes. The Prosthodontic
Diagnostic Index 5 is an effective means of characterizing the complexity of the
edentulous oral condition and offers tiered diagnostic levels that infer potential
limitations of treatment and outcomes. The opportunities for patient referral to
prosthodontists, oral pathologists, and oral surgeons for preprosthetic and
prosthetic consultation or treatment should be pursued to maximize individual care.

Replace Dentures within 5 Years with a Renewed Focus on Esthetics

Denture satisfaction is multifactorial, and includes perceived function, fit, and
appearance. Constructing new dentures or modifying existing ones by reline or
rebase techniques is required to address the physical changes that occur with
edentulism (residual ridge resorption, loss of vertical dimension of occlusion) as
well as the physical deterioration of dentures (Figure 3 View Figure).

Poorly fitting dentures should be directly treated. In a clinical study of 21 patients

with poorly fitting dentures, Garrett and colleagues 6 confirmed the general
assumption that patients perceive improvements when ill-fitting dentures are
relined or replaced by new dentures (Figure 4 View Figure).

Another aspect of denture use is denture cleanliness (Figure 5 View Figure). One
study indicated that the majority of patients were not satisfied with the cleanliness
of their dentures and, importantly, older dentures were associated with a higher
incidence of denture stomatitis.7

Beyond health and physiologic function, dentures also have social functions. Several
investigations have underscored the social significance of denture quality to the
edentulous patient, 8 and the social significance of dentures requires current
emphasis. Given the present focus on esthetics in dental therapy for the dentate
subject, denture esthetics should be an integral part of this growth in dentistry
(Figure 6 View Figure). In fact, esthetic principles can find their roots in the classic
prosthodontic literature addressing denture esthetics9 (Figure 7A and Figure 7B
View Figure).

Prescribe Mandibular Dental Implants for All Edentulous Patients

There is compelling data to support the clinical posture that mandibular implants
should be prescribed for all edentulous patients. Prospective investigations of 5, 10,
and 15 years demonstrate that at the patient level, implant and prosthesis survival is
> 90%. The original description by Adell and coworkers 10 of the Brånemark dental
implant system revealed that at 15 years there was > 95% implant and prosthesis
survival. Many investigators worldwide have reported that the success of dental
implants for the treatment of mandibular edentulism is high (> 90% after 5 years).11
Discrepancies exist between study designs and reporting criteria;12 however, a wide
body of evidence indicates that endosseous dental implants placed in the
parasymphyseal mandible survive to support prosthesis function for many years
(Figure 8 View Figure).

Clinicians must also be motivated to maintain the endosseous dental implants of

edentulous patients. Local peri-implant inflammation is observed when plaque and
calculus form on the abutment and adjacent prostheses. Annual examinations
should be performed (Figure 9A and Figure 9B View Figure). Removal of the
prostheses may be required to perform peri-implant mucosal probing. Early signs of
inflammation and increased peri-implant mucosal sulcus depth should be addressed
by increasing hygiene through education and minor prosthesis modification.
Evidencing the established criteria for success (> 0.2 mm annually) may be
addressed by interceptive therapy. 13

Prosthesis stability for mandibular implant-supported fixed dentures is also high.14

Yet there are complications associated with treatment. Primary among these
complications are bridge screw loosening and fracture, abutment screw loosening
and fracture, prosthesis fracture and prosthetic tooth wear (Figure 10 View Figure).
Tooth wear is a complication that must be addressed intermittently. The increased
functional capacity imparted to the implant-supported fixed denture patient is
clearly observed by prosthetic tooth wear. The biologic consequences of tooth wear
include loss of vertical dimension of occlusion and the attendant sequelae. The
mechanical consequences of tooth wear is the disruption of the designated occlusal
scheme, typically resulting in marked vertical overjet and increased lateral tooth
contacts, which may contribute to high nonaxial forces acting at the bridge screws.
Although the rate of tooth wear will vary among materials and patients, experience
indicates that the need for restoration of the occlusal scheme and vertical dimension
of occlusion for acrylic denture teeth should be considered approximately every 3 to
5 years. These factors must be accounted for and included in the patient’s
calculations of treatment cost over the long term. It is important to recognize that
the majority of the complications associated with implant therapy are minor,
mechanical or prosthetic in nature, and associated with little morbidity. However,
they often represent unanticipated and relatively expensive interruptions in
otherwise trouble-free prosthetic rehabilitation of the edentulous mandible.

A recent review of the complete denture literature suggests that many edentulous
patients are satisfied with complete denture therapy and may not seek dental
implant treatment.1 Every patient will not consent to receive dental implants.
MacEntee and colleagues 2 suggested that pain, the perception of poor chewing
function and speech, and dissatisfaction with appearance motivate patients to
choose dental implants. Irrespective of the status of the edentulous patient,
treatment using endosseous dental implants should be discussed in terms of
potential improvement of limitations in measured and self-reported outcomes.

There are few absolute contraindications for treatment of the edentulous mandible
using dental implants. Because edentulism is most prevalent in the older
population, the complexity of treatment because of existing medical conditions (eg,
diabetes or anticoagulant therapy) must not be underestimated. Sugerman and
Barber15 concluded that there was little published information regarding the long-
term outcome of implants in patients with diverse systemic diseases. Weyant and
Burt16 reported greater implant failure in individuals with contributory medical
histories. Although there appear to be few absolute medical contraindications for
dental implant therapy, occasional patient-specific limitations are encountered and a
comprehensive knowledge regarding each individual patient is therefore essential.

Local factors for implant placement in the parasymphyseal are typically favorable.
In a large majority of patients, this region of the mandible offers sufficient bone for
treatment without prerequisite grafting. The edentulous patient may be categorized
according to the anatomic representation of the mandibular and maxillary residual
alveolar ridges. Earlier reports concerning the use of endosseous dental implants
suggested that they would benefit the most severely resorbed mandible,17 although
later investigations demonstrated that patients with both severe and moderately
resorbed mandibles derived benefit from dental implant-supported protheses. 18

Several classification systems are helpful in assessing the extent of alveolar

resorption19 as well as residual bone volume and bone quality.20 A broader
understanding of the denture patient is required and a classification system for
edentulous patients can provide insight into the difficulty of denture treatment.5
Implants are not only reserved for the most severely resorbed mandibles or the most
difficult denture patients. As the extent of treatment increases to meet the
complexities associated with systemic disease, marked alveolar ridge resorption,
neuromuscular dysfunction, local tissue factors, and patient demands, the
opportunities for multi disciplinary care expand and should be explored to ensure
individual patient success and satisfaction.

There are risks specifically associated with dental implant treatment of the
parasymphyseal mandible. These are less commonly reported risks of treatment and
include placement of an implant near the inferior alveolar nerve or severing of the
inferior alveolar nerve leading to dysesthesia or paresthesia, mandibular fracture
after implant placement, or life-threatening bleeding from the lingual artery. These
risks can be reduced by careful planning as well as the rare exclusion of select
patients based on current illness or past medical history. Guided surgeries using
computed tomography analyses (Figure 11 View Figure) and more recent
innovations using CAD/CAM surgical guides offer additional potential benefit in
careful implant placement. 21

The most common risk facing the patient who receives careful treatment planning
and prosthesis evaluation before implant placement is the risk of early implant
failure (before loading). Delayed failures are reported to be less common. Implant
fracture is reported to occur infrequently (approximately 1% of all failures). 22

A spectrum of treatment modalities and protocols ranging from overdenture

therapy using a two-stage procedure to implant-supported fixed denture therapy
provided by immediate loading are available to the vast majority of edentulous
patients. A simple designation of treatment options for the edentulous mandible is
to consider the majority of patients for treatment using either two implants with ball
abutments for overdentures (Figure 12A and Figure 12B View Figure) or four
implants supporting a fixed denture constructed using a metallic bar veneered with
resin or porcelain (Figure 13 View Figure).

Additionally, six to eight implants can be used to support porcelain-fused-to-metal

(PFM) fixed partial dentures. There are advantages and disadvantages for each
treatment opportunity and the cost of treatment represents a major distinguishing
characteristic among these three different approaches to therapy.

Overdentures Using Two Implants without Prosthetic Bars or Superstructures

Implant-retained overdentures have been reported to be the minimal standard of
care for the treatment of mandibular edentulism.23 There are excellent reviews that
discuss the advantages and disadvantages of this treatment 24 and most succinctly,
the implant-retained mandibular overdenture using ball abutments as retentive
elements represents a cost-efficient prosthesis that offers physiological advantages of
maintained alveolar bone mass and improved masticatory function, psychosocial
advantages of improved self-image and social function, and benefits of access for
oral hygiene. The controversy regarding the use of gold bars and clips vs ball
abutments with retainers as retentive elements for the overdenture can be
summarized by recognizing that there is a lack of evidence that splinting of
implants improves osseointegration outcomes or that the bar offers better retention
of the overdenture. The presence of the bar can result in increased plaque retention
and peri-implant inflammation. Both bar-retained and ball-retained prostheses
require regular maintenance and the expense of this maintenance should be
explained to patients at the consultation visit.

The presently stated preference for simplicity using two-implant–retained

overdentures may involve the use of ball attachments or the recently introduced
Locator™ (Zest Anchors, Inc, Escondido, CA) attachment system. Like the Locator
abutment, ball abutments should be used with resilient attachments (eg, Preci-
Clix™ attachments, Preat Corporation, Santa Ynez, CA) that preclude abutment
wear during function. The stated advantages of the Locator system include reduced
vertical dimension of the components, adaptation of divergent implants, and simple
modification of retention by selection of resilient attachments. These advantages
should not serve as excuses for poor treatment planning. When compared to more
complex prosthetic reconstruction for overdentures such as three- or four-implant–
supported bar overdentures, Van Kampen et al 25 measured retention of ball vs bar
attachments for 18 overdenture patients and found little difference, thereby
confirming the laboratory result of Petropoulos et al.26

The two-implant–supported overdenture can be used for a wide range of

mandibular edentulous patients. A minimum residual ridge height of 10 mm is
recommended. The presence of the inferior alveolar nerve at the ridge crest of
markedly resorbed ridges should be acknowledged and addressed by denture relief,
but should not preclude the provisional prescription of a two-implant overdenture.

Planning for parallel implants facilitates restoration and the use of ball abutments.
Planning must also include the provision for sufficient occlusogingival dimension
measured from the plane of occlusion (or the incisal edge) to the residual ridge crest.
This dimension represents the space that will be filled by the prosthetic teeth, the
denture acrylic, the ball housing, and the abutment. A minimum of 10 mm is
recommended to accommodate 4 mm of incisor length above the denture resin, 2
mm of acrylic resin to support the retainer, 1 mm for the thickness of the retainer
above the ball abutment, and a minimum of 3 mm for a ball abutment beyond the
crest of bone. Therefore, when a panoramic radiograph and clinical examination
reveal that the residual anterior mandible is > 15 mm to 18 mm in height,
encroachment on this restorative space may occur and should be compensated for
by an alveolectomy preceding implant placement. This aspect of treatment planning
allows an esthetic and robust denture to be made that will avoid many of the
complications commonly encountered with mandibular overdentures.

It is possible to place two implants in the parasymphyseal mandible using

tomography to guide a flapless surgical procedure. When this is possible, the
implants and two ball abutments may be placed and a denture can be inserted at
the time of surgery (immediate provisionalization). To permit osseointegration to
occur without excessive loading of the implants, the intaglio surface of the denture
must be relieved circumferentially around the abutments and relined in this
relieved region using a soft, resilient liner. After 6 to 8 weeks of healing, the
retainers can be connected by a reline procedure or direct pick-up method using
autopolymerizing denture repair resin. After the connection procedure, it is prudent
to perform a remount procedure to refine the denture occlusion. The ultimate
success for the overdenture therapy is reliant upon osseointegration success of the
implants as well as the overall clinical success of conventional denture therapy.
Long-term success is critically dependent on recall evaluation, patient compliance
with oral and denture hygiene, and consideration of reline therapy throughout the
lifetime of the overdenture prosthesis.

Four Implants and an Implant-Supported Fixed Denture

The implant-supported fixed denture revolutionized the treatment of mandibular
edentulism.10 There are also excellent reviews that discuss the advantages and
disadvantages of this treatment.27 The biological capacity of the parasymphyseal
mandible to support implant function is great. Simplification using fewer implants
(four vs five or six) and immediate loading protocols have emerged. 28 The potential
advantages for this simplification are reduced component costs, prosthetic
construction simplification, and improved access for hygiene. When there is
elevated concern for osseous support using only four implants (eg, residual
mandible height of 8 mm to 9 mm) or there is concern for marked function (eg, in a
well-known bruxer), an additional implant can be provided.

A minimum residual ridge height of 8 mm is recommended. When dysesthesia is

marked as a result of the presence of the inferior alveolar nerve at the ridge crest,
this treatment approach may be preferred when compared to the overdenture.
When oral hygiene may be questioned or restricted for physical reasons, the
implant-supported fixed denture may be dissuaded in favor of an overdenture
prosthesis.

Planning for implant placement for an implant-supported fixed denture also

requires concern for occlusogingival dimension. To ensure an esthetic, phonetic,
hygienic, and mechanically robust prosthesis, an absolute minimum of 10 mm of
occlusogingival dimension is recommended to accommodate 4 mm of incisor length
above the metallic bar, 4 mm for the prosthetic cylinders, metallic bar and retaining
screws, and 2 mm to account for the transmucosal dimension of the abutment
beyond the crest of bone. After examining mandibular casts mounted to oppose the
established maxillary dentition at the correct vertical dimension of occlusion, any
occlusogingival dimensional discrepancies should be addressed by consideration of
an alveolectomy at the time of implant placement.

To further ensure the mechanical integrity of the final prosthesis, the distance
between the most anterior and most posterior implants (ie, the A-P spread) must
also be defined and maximized (Figure 14A and Figure 14B View Figure). In simple
terms, the A-P spread must be > 10 mm to accommodate a prosthetic cantilever of
15 mm (the dimension of two mandibular bicuspids). A recent development
involves axial displacement of terminal implants in the “all-on-four” concept29 and
is now widely advocated using several different implant systems.

The construction of the implant-supported fixed denture requires great attention to

detail. The fabrication of the metallic framework of the prosthesis must be achieved
with precision to ensure passive fitting at all four of the abutment/prosthesis
interfaces. This ensures proper bridge screw mechanics that will preclude the
majority of screw loosening and screw fracture incidents. Several new technologies
including CAD/CAM machining (Procera®, Nobel Biocare, Yorba Linda, CA) and
laser welding adaptation (Cresco™, Astra Tech, Inc, Waltham MA), offer direct
solutions to precision of fit. The veneering of prosthetic teeth can be planned as a
PFM prosthesis or as an acrylic-wrapped denture tooth prosthesis. Although there
may be advantages of esthetics and wear resistance to the PFM prosthesis, the initial
cost and potential cost of repairs must be considered. Acrylic denture teeth
processed to the metal framework has the disadvantage of wear and delamination
or tooth fracture, but the advantages of initial cost and planned tooth replacement
have been acknowledged.

Evaluate for Biologic and Prosthetic Complications on a Regular Basis

The recall of patients and maintenance of implant-supported fixed dentures is
required. Biological consequences of implant placement in the parasymphyseal
mandible include bone accrual in the mandible. This is considered to be a clinical
manifestation of Wolff’s Law (the bone’s response to physical loading). Bone
responses adjacent to the implant are controlled by mechanical as well as biological
effectors. Local inflammation at the implant abutment resulting from biofilm
accumulation should be monitored and addressed. Periodontal probing at the recall
appointment of the dental implant abutments will reveal changes in tissue
dimensions and show inflammation by bleeding. It may be necessary to remove the
prosthesis annually to accurately perform probing measurements and thoroughly
clean the prosthesis. Reversing local peri-implant mucosal inflammation is possible
by the removal of plaque and the reinforcement of hygiene measures by instruction
or modification of the prosthesis to permit greater access. Periodic recall should
include radiographic assessment of the implant–bone interface with particular
emphasis of the marginal bone response. Albrektsson and Zarb 30 suggested that
marginal bone loss should not exceed 0.2 mm annually after the first year of bone
adaptation. Bone loss of 1 mm in a year indicates an inflammatory process that
should be intercepted. Lang and colleagues suggested a protocol for intervention.13
Cupping bone loss around an implant has been reported to suggest mechanical
overloading31 and intervention may include alteration of the prosthesis, perhaps by
first evaluating the bilateral symmetry of centric occlusal contacts, second by
identifying marked excursive contacts, and third by considering the cantilever
length of the prosthesis. Intervention at the prosthesis level should accompany any
attempt to recover from cupping bone loss.

Screw loosening or screw fracture is the most common prosthetic complication

associated with the implant-supported fixed denture. Mechanical loading is
suggested to be the cause of this problem and may be due to bending moments
experienced by the bridge screw or the abutment screw. The rate of such
complications has been suggested to be high. For example, early investigations
reported greater than 20% incidence of screw complications.32 However, there may
be advantages to contemporary implant designs that involve interference fits and
internal tapered connections. As an example, treatment of 109 patients with implant-
supported fixed dentures resulted in no screw loosening or fracture during a 5-year
prospective investigation. 33 Component systems that protect the assembly screw(s)
from functional overloading contribute to improved therapeutic outcomes.

Six to Eight Implants and an Implant-Supported Fixed Partial Denture

This treatment alternative is reserved for individuals with little residual ridge
resorption or the desire for toothlike restorations, which are supported by the
patience and financial means to achieve this result. Implant-supported fixed
dentures fabricated using either porcelain or acrylic veneers, alternatively, can be
provided. The promise of toothlike restorations should not be taken lightly by the
clinician. Therefore, it is suggested that this treatment be reserved for individuals
with ideal residual ridge morphology or those who are willing to undergo bone
grafting procedures and accept the risks and potential limitations of vertical and/or
horizontal ridge augmentation procedures.

The key limitation to this treatment is ideal implant placement. Toothlike

restorations require ideal implant placement, which is wholly dependent on
presurgical prosthetic planning using fully waxed diagnostic casts and well-formed
surgical guides. Subsequent peri-implant tissue morphology may be limited, but the
lower lip typically shelters this limitation and its impact is not a key factor in
treatment acceptance as it often is for the edentulous maxilla.
When this treatment is performed using segmented fixed partial dentures, the
opportunities for long-term maintenance appear good. The potential for prosthetic
failure can be isolated to only a few implants and a relatively small prosthesis,
which simplifies possible repair or replacement. The same is true for implant failure
with segmented fixed partial dentures. If an early or late implant failure is
encountered, there is an opportunity for provisionalization during the period of time
that implant placement is repeated.

CONCLUSION
Edentulism remains prevalent in the United States and a renewed focus on the
edentulous patient is indicated by demographics. Dental implant therapy is effective
and successful. The associated complications require a lifetime of recall evaluation
for prevention and dutiful maintenance. Clinicians should actively encourage
edentulous patients to attend annual recall evaluations, to consider denture
replacement in a timely manner, and to consider the potential use of endosseous
dental implants as an effective means of improving their own perceptions of
function, appearance, and image.

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Figure 1 Residual ridge resorption is
often severe. This panoramic
radiograph illustrates complete
resorption of alveolar bone with a
residual mandible that is just 6 mm
to 8 mm high. Although the
prognosis for denture use is poor,
dental implant treatment is possible
and the resulting prosthesis
prognosis would be enhanced.
Figure 3 Dentures are often used
without timely replacement.
Although the period of usefulness
of complete dentures is not fully
defined, esthetic deficiencies
because of wear, whitening,
staining, or repair (shown) as well
as tooth wear (shown) and ill-fitting
intaglio surfaces are all reasons for
denture replacement.
Figure 5 The quality of existing
dentures is often related to denture
hygiene. This denture illustrates a
20-year-old denture displaying
Figure 2 Denture use is associated
with many common sequelae,
including denture stomatitis and
denture-related ulceration of the
mucosa. These ulcerations are often
self-limiting after adjustment of
denture occlusion or denture flange
impingement.
Figure 4 Denture reline procedures
can be useful for diagnostic,
therapeutic or impression-making
purposes. A number of soft reline
materials provide a rapid way to
interrogate tissue responses to new
denture bases and improve denture
base/ tissue relationships. The reline
procedure can be integrated into the
earliest stages of denture and
implant-retained overdenture
therapies.
Figure 6 The quality of new
dentures should reflect
contemporary interest in dental
esthetics. Tooth shades and gingival
complete wear of the occlusal
surface of the molar through the
denture base and extreme biofilm
accumulation. Patient education is
key to prevention.
morphologies can be arranged and
processed to model ideal dentitions.
(Shown here are BlueLine™ teeth,
Ivoclar Vivadent, Amherst, NY,
which were processed using
custom- stained acrylic resin.
Dentures processed by Donald J.
Yancey.)

Figure 7A and Figure 7B Denture Figure 8 Routine oral examination

esthetic determinants are part of
facial esthetics and should be
organized around general defined
principles. (A)The preoperative,
existing denture is associated with
reduced vertical dimension of
occlusion and poor lip support.
There is limited incisal display and
an inverted smile line because of
tooth attrition and fracture. (B) At
denture try-in, the possible tooth
arrangement is considered in terms
of facial esthetics and dental
esthetics.
of the edentulous patient should be
scheduled every 6 to 12 months and
include a comprehensive oral
examination of all of the oral soft
tissues. The implants should be
probed and the local tissues
carefully interrogated. Intervention
when peri-implant inflammation is
observed should be provided and
referral to a periodontist may be
indicated. It is equally important to
evaluate the overall health of the
denture-supporting tissues and
adjacent oral mucosa, tongue, and
pharyngeal region.

Figure 9A and Figure 9B Implant-supported fixed dentures are associated

with long-term function and implant success. (A) A 9-year postoperative
radiograph illustrates the peri-implant bone levels at five 8-mm x 3.5-mm
dental implants supporting an implant-supported fixed denture. (B) At 9
years, new acrylic denture teeth were processed on the original cast gold
bar and the maxillary denture was replaced to restore the worn prosthesis
and revitalize the esthetic appearance of the existing prosthesis.
Figure 10 Prosthetic complications
occur and are often complex in
nature. Broken abutment and bridge
screws (shown) create soft tissue
complications and prosthetic
complications that often require
surgical intervention, identification,
purchase and acquisition of
appropriate components, and
prosthetic repair. Patients must be
informed of the potential cost and
limitations of repair.
Figure 12A and Figure 12B Two
implants offer a simple solution to
mandibular overdenture function.
(A) Two ball abutments 5 years after
placement and loading with a
mandibular overdenture. This status
typifies the successful outcome
reported in many clinical studies.
(B) Newer abutments such as the
Locator (shown with housing and
spacer before chairside pickup) and
new ball attachments such as Preci-
Clix offer improved clinical
management of the two-implant
overdenture patient.
Figure 14A and Figure 14B
Contemporary concepts for implant-
supported fixed dentures include
the routine use of four implants to
support the prosthesis. (A) As
shown in this occlusal view, the
axial displacement of implants
enables greater anterior-posterior
spread and enhanced biomechanical
stability of the prosthesis at the
abutment screw and bridge screw
level. (B) Panoramic radiographic
representation of treatment reveals
the strategic distribution of the four
implants medial to the mental
foramen.
Figure 11 In many situations, a
computed tomographic image of the
bone and prosthesis offers the
advantage of defining the
relationship of vital structures (such
as the inferior alveolar nerve) to the
designated dental implant position
Additional treatment information is
available when the location of the
prosthesis can be simultaneously
observed.
Figure 13 When the image of a
complete mandibular denture is
superimposed over the panoramic
radiograph of two implants and ball
abutments, the dimensional
requirements for successful denture
construction are clearly illustrated.
When there is < 10 mm between the
alveolar crest (the
implant/abutment interface) and
the planned occlusal plane, there is
often insufficient space to house the
implant abutment and the
attachment housing in a sufficient
thickness of acrylic resin (> 2 mm as
shown) to preclude complications.
About the Authors
Lyndon F. Cooper, DDS, PhD
Stallings Distinguished Professor
Director of Graduate Prosthodontics
School of Dentistry
University of North Carolina at Chapel Hill
Chapel Hill, North Carolina

Kuang-Han Chang, DDS

Resident
Graduate Prosthodontics
School of Dentistry
University of North Carolina at Chapel Hill
Chapel Hill, North Carolina

Ingeborg De Kok, DDS

Assistant Professor
Department of Prosthodontics
School of Dentistry
University of North Carolina at Chapel Hill
Chapel Hill, North Carolina