CONSENSUS

REPORT
Recommendations for Implant-Supported
Full-Arch Rehabilitations in Edentulous
Patients: The Oral Reconstruction Foundation
Consensus Report
Frank Schwarz, Prof Dr Med Dent
Department of Oral Surgery and Implantology, Goethe University, Carolinum, Frankfurt, Germany.

Alex Schär, PhD

Oral Reconstruction Foundation, Basel, Switzerland.

Katja Nelson, DDS, PhD

Tobias Fretwurst, DDS, PhD
Department of Oral and Craniomaxillofacial Surgery, Translational Implantology, Center for Dental
Medicine, University Medical Center Freiburg, Freiburg, Germany.

Tabea Flügge, DDS, PhD

Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität
zu Berlin, Department of Oral and Maxillofacial Surgery, Berlin, Germany.

Ausra Ramanauskaite, DDS, Dr Med Dent, PhD

Georgina Trimpou, Dr Med Dent
Department of Oral Surgery and Implantology, Goethe University, Carolinum, Frankfurt, Germany.

Irena Sailer, Prof Dr Med Dent

Duygu Karasan, DDS, PhD
Vincent Fehmer, MDT
Division of Fixed Prosthodontics and Biomaterials, Clinic of Dental Medicine, University of Geneva,
Geneva, Switzerland.

Fernando Guerra, PhD

Ana Messias, PhD
Pedro Nicolau, DMD, PhD
Dentistry Department, Faculty of Medicine, University of Coimbra, Coimbra, Portugal.

Konstantinos Chochlidakis, DDS, MS

Alexandra Tsigarida, DDS, MS
Eastman Institute for Oral Health, University of Rochester, Rochester, New York, USA.

Florian Kernen, Dr Med Dent, MSc

Department of Oral and Craniomaxillofacial Surgery, Translational Implantology, Center for Dental
Medicine, University Medical Center Freiburg, Freiburg, Germany.

Thomas Taylor, DDS, MSD

Department of Reconstructive Sciences, University of Connecticut, School of Dental Medicine,
Farmington, Connecticut, USA.

Konstantinos Vazouras, DDS, MPhil, MDSc

Postgraduate Prosthodontics, Department of Prosthodontics, Tufts University School of Dental
Medicine, Boston, Massachusetts, USA.

Correspondence to: Insa Herklotz, Dr Med Dent

Dr Frank Schwarz Department of Prosthodontics, Geriatric Dentistry and Craniomandibular Disorders, Charité –
Department of Oral Surgery
Universitätsmedizin Berlin, Berlin, Germany.
and Implantology
Goethe University, Carolinum
Frankfurt am Main, Germany
Robert Sader, Prof Dr Med, Dr Med Dent, Dr Med Habil
Fax: +49 69 6301 3829 Department for Oral, Cranio-Maxillofacial and Facial Plastic Surgery, Medical Center of the Goethe
Email: f.schwarz@ University Frankfurt, Frankfurt, Germany.
med.uni-frankfurt.de

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 Consensus Report

The tasks of Working Groups 1 to 6 at the 4th Consensus Meeting of the Oral Reconstruction Foundation were to
elucidate clinical recommendations for implant-supported full-arch rehabilitations in edentulous patients. Six systematic/
narrative reviews were prepared to address the following subtopics: (1) the influence of medical and geriatric factors
on implant survival; (2) the prevalence of peri-implant diseases; (3) the influence of material selection, attachment type,
interarch space, and opposing dentition; (4) different interventions for rehabilitation of the edentulous maxilla; (5)
different interventions for rehabilitation of the edentulous mandible; and (6) treatment choice and decision-making in
elderly patients. Consensus statements, clinical recommendations, and implications for future research were determined
based on structured group discussions and plenary session approval. Int J Prosthodont 2021;34(suppl):s8–s20. doi:
10.11607/ijp.consensusreport

T
he rehabilitation of edentulous patients by means 6. Full-Arch Removable vs Fixed Implant Restorations:
of implant-supported prostheses is still considered A Literature Review of Factors to Consider
to be a major challenge in daily clinical practice.1,2 Regarding Treatment Choice and Decision-Making
This is due to various potential systemic and site-specific in Elderly Patients (Vazouras and Taylor)
risk factors that may be commonly associated with el-
derly patients,3 thus complicating implant therapy. A total of 65 clinicians and researchers with a special
The scope of this consensus meeting was therefore focus on implant therapy participated in this consensus
to comprehensively evaluate the available evidence on meeting.
the following key topics: (1) the influence of medical and At the beginning of the meeting, the authors pre-
geriatric factors on implant survival; (2) the occurrence sented the methodology, results, and conclusions of their
of biologic complications and anatomical and esthetic respective reviews in group sessions. The experts were
considerations; (3) the influence of material selection, split into six working groups. Within the group discus-
attachment type, interarch space, and opposing denti- sions and the formulation of consensus statements, clini-
tion; (4) different interventions for rehabilitation of the cal recommendations and implications for future research
edentulous maxilla; (5) different interventions for rehabili- were each directed by one chairperson and one secretary,
tation of the edentulous mandible; and (6) guidance for who were appointed in advance. All statements and rec-
treatment choice and decision-making in elderly patients. ommendations were presented and discussed in plenary
sessions and revised until final approval was obtained.
GROUP DISCUSSIONS AND CONSENSUS
WORKING GROUP 1
An international expert meeting was organized and held
in Prague, Czech Republic, from March 8–9, 2019. In Objectives
advance of the consensus meeting, the following six The literature review by this working group (Fig 1) ad-
systematic/narrative reviews were prepared: dressed the following questions: (1) is age (> 75 years) a
1. Influence of Medical and Geriatric Factors on risk factor for implant survival?; (2) is diabetes mellitus a
Implant Success: An Overview of Systematic risk factor for implant survival?; and (3) is antiresorptive
Reviews (Fretwurst et al) therapy a risk factor for implant survival?
2. Prevalence of Peri-implant Diseases in Patients
with Full-Arch Implant-Supported Restorations: A Major Findings and Conclusions
Systematic Review (Ramanauskaite et al) An older age (> 75 years) does not affect implant survival
3. The Influence of Patient-Related Factors and in the short term (follow-up of 1 to 5 years).
Material Selection on the Clinical Outcomes of Fixed Current studies demonstrated that diabetes mellitus
and Removable Complete Implant Prostheses: An is not a risk factor for implant survival in the short term,
Overview on Systematic Reviews (Karasan et al) but there is no information on appropriate perioperative
4. Different Interventions for Rehabilitation of the treatment (medication) and wound closure. There is little
Edentulous Maxilla with Implant-Supported evidence in the literature on the success of bone grafting
Prostheses: An Overview of Systematic Reviews and progressive loading protocols in diabetic patients.
(Messias et al) Low-dose oral bisphosphonate (BP) treatment for os-
5. A Comparison Between Fixed and Removable teoporosis does not affect implant survival in the short
Mandibular Implant-Supported Full-Arch Prostheses: term, but can lead to medication-related osteonecrosis
An Overview of Systematic Reviews (Tsigarida and of the jaw (MRONJ).
Chochlidakis) There is no information on implant survival with low-
dose antibody therapy (denosumab) for osteoporosis.

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 Consensus Report

Fig 1   Members of Working Group 1 (medical and geriatric factors). From left to right: Tobias Fretwurst (Rapporteur), Tabea Flügge (Secre-
tary), Torsten E. Reichert, Wilfried Wagner, Katja Nelson (Chairperson), Bilal Al-Nawas, and András Huszák.

The same implant healing as in low-dose BP patients Clinical Recommendations

is assumed. High-dose BP and antibody therapy leads BPs and antiresorptive medication
to the highest incidence of MRONJ. There are no treat- • Low-dose oral BP intake for osteoporosis treatment
ment regimens available for patients with peri-implantitis does not compromise implant survival, but might
receiving antiresorptive medication. cause MRONJ.
• No information is available concerning implant
Consensus Statements survival on low-dose antibody treatment
Age (denosumab) of osteoporosis. The same implant
• An older age does not itself affect implant survival healing as in BP patients is assumed.
in the short term (follow-up of 1 to 5 years), but • High-dose BP and antibody treatment has led to
consideration of health status in these patients the highest incidence of MRONJ. Therefore, implant
is important. Common systemic diseases and therapy cannot be recommended in these patients.
concomitant polypharmacy should be carefully • No regime for patients with peri-implantitis under
addressed in this patient group. antiresorptive medication is available.
Diabetes mellitus Complications
• Current studies indicate that diabetes mellitus is • In patients with comorbidities, the impact of
not a risk factor for implant survival, but there is no specific, severe, and even rare complications should
information concerning appropriate perioperative be considered rather than implant survival.
management (ie, medication) and wound closure. • Study results should be interpreted cautiously due
• Low-quality evidence exists in the literature for to patient selection and surgical and perioperative
the success of bone grafting procedures and management.
progressive loading protocols in diabetic patients.4 • Careful and targeted patient history is mandatory
Therefore, complex surgical procedures should be and might require referral to a specialist.
regarded carefully.

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 Consensus Report

Fig 2   Members of Working Group 2 (biologic complications/anatomical and esthetic considerations). From left to right: Rémy Tanimura,
Ausra Ramanauskaite (Rapporteur), Laurens Wiggers, Frank Schwarz (Chairperson), Florian Beuer, Georgia Trimpou (Secretary), Christian
Hammächer, Karl-Ludwig Ackermann,* Ferhan Ahmed, Rae’d M. Abutteen. Not pictured: Pavel Kriz and Vojtech Slezacek. *Dr Ackermann
has since passed.

WORKING GROUP 2 20.3% of the implants, while the corresponding values

among patients with at least one edentulous arch were
Objectives 0% to 25% and 0% to 7.2%, respectively.
A search protocol was developed to answer the fol- It was concluded that edentulous patients (ie, fully
lowing focus question: What is the prevalence of peri- edentulous patients or patients with at least one edentu-
implant diseases in edentulous patients rehabilitated lous arch) restored with either fixed or removable restora-
with implant-supported fixed or removable restorations? tions were frequently affected by peri-implant disease.
This working group (Fig 2) also had to prepare a narra-
tive review (unpublished data) considering anatomical Consensus Statements
factors and esthetic outcomes associated with full-arch Biologic complications
implant-supported restorations. • Edentulous patients (ie, fully edentulous patients
or patients with at least one edentulous arch) were
Major Findings and Conclusions frequently affected by peri-implant disease.
A total of 18 studies (3 randomized controlled trials • Fully edentulous patients exhibited a higher
[RCTs], 1 nonrandomized controlled trial, and 14 pro- frequency of peri-implantitis at the implant level
spective studies) were included. According to a single compared to patients with at least one edentulous
study, the prevalence of peri-implant mucositis in fully arch (2.1% to 20.3% vs 0% to 7.2%).
edentulous patients was 57%, corresponding to 47% of • Maintenance care is also essential in edentulous
the implants. The prevalence of peri-implant mucositis patients, and their individual requirements must be
among patients with at least one edentulous arch ranged considered.
from 0% to 13.7% of the patients and from 0% to 20% • It is not possible to assess whether prosthetic design
of the implants. In fully edentulous patients, the preva- (removable or fixed), time of loading (immediate
lence of peri-implantitis was found to range between or conventional), implant location (maxilla or
1.5% and 29.7% of the patients and between 2.1% and mandible), implant site grafting, or time of implant

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 Consensus Report

placement have any influence on the occurrence of abutment designs, attachment of the prosthesis on
peri-implant diseases in patients restored with full- the implant/abutment complex, cleaning procedures
arch, implant-supported restorations. of the abutments).
Implant loss • The potential of zirconia to reduce plaque
• Implant loss in the edentulous maxilla was accumulation needs to be further elucidated in
influenced by the type of restoration, the number well-controlled clinical studies.
of implants supporting removable prostheses, and • Future clinical trials should focus on appropriate
surface roughness. Higher rates of implant failure abutment cleaning to maintain peri-implant health.
were noted for removable compared to fixed
prostheses and for machined compared to rough- Further Consensus Statements and Clinical
surface implants. Removable restorations supported Recommendations
by fewer than four implants were associated with Anatomical factors in the mandible
higher rates of implant loss. The loss of machined • The evaluated publications commonly report
implants was particularly high at grafted sites. implant placement in the interforaminal region.
• Implant loss in the edentulous mandible did not • The interforaminal region is compromised by the
differ between rough-surface and machined presence and extension of the anterior loop, incisive
implants. canal, and lingual foramina.5
• Preoperative CBCT scans might reduce the risk
Clinical Recommendations for anatomical damage and should be part of
Biologic complications treatment planning when placing implants in the
• Considering the primary and secondary outcomes edentulous mandible.
assessed in the present review, the clinician may • From the prosthetic perspective, long cantilevers
choose between/among different abutment should be avoided, and posterior implants should be
characteristics. taken into consideration. In the atrophic mandible,
• Peri-implant health or disease is mainly influenced this may be accomplished by short implants.
by plaque accumulation rather than abutment Anatomical factors in the maxilla
characteristics. • Unlike in the mandible, implants were commonly
• The clinician is advised to support the patient in placed in anterior and posterior positions in the
maintaining oral hygiene procedures. In addition, maxilla.
the design of either prefabricated or customized • The ongoing pneumatization of the maxillary sinus
abutments (and suprastructures) should consider necessitates subantral grafting procedures to avoid
plaque retention as a relevant factor inducing peri- penetration of the implant in the sinus.
implant mucosal inflammation (ie, bleeding on • Short implants might overcome sinus grafting;
probing). however, their performance has not been
• The need for sterilization of the abutment to investigated in the edentulous maxilla.
prevent the onset of peri-implant diseases cannot • The proximity to the nasal cavity, as well as
be substantiated based on the available evidence. the extension of the incisive canal, may also
However, a proper abutment cleaning protocol is compromise implant placement in the anterior
advised to reduce potential contamination from the region of the atrophic maxilla.5
abutment prior to its insertion. • Preoperative CBCT scans might reduce the risk
Implant loss for anatomical damage and should be part of
• Rough-surface implants should be favored for treatment planning when placing implants in the
rehabilitation of the edentulous maxilla, especially edentulous maxilla.
when bone grafting is needed. Anatomical factors in the mandible and maxilla
• Removable prostheses should be supported by • Bone quality was not assessed prior to or during
at least four implants placed in the anterior and implant placement in the evaluated studies. It is
posterior positions. understood that bone quality has a direct clinical
impact on healing periods/loading protocols and on
Implications for Future Research the selection of implant design/dimensions.
• Prospective clinical data on the potential effects of Timing of implant placement in edentulous arches
abutment characteristics on peri-implant soft tissue • Implant placement in the edentulous arch was
health or disease need to be established. mainly investigated at 2 to 7 months following
• Study designs should carefully consider the tooth extraction.
exclusion of confounding factors with major clinical • Data on immediate and early placement protocols
relevance to the primary outcomes assessed (eg, are scarce.

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 Consensus Report

Bone augmentation outcomes of RCIPs. The influence of opposing dentition

• Bone augmentation procedures, along with implant and the required prosthetic space were not investigated
placement in edentulous arches, have been rarely sufficiently.
investigated (ie, one study on sinus floor elevation,
two studies on lateral grafting). Consensus Statements and Clinical Recommenda-
• It is anticipated that bone augmentation/ tions for Fixed Complete Implant Prostheses
regeneration in edentulous arches may follow the Prosthetic material selection
same pattern as noted in partially edentulous areas. • The clinical outcomes in terms of survival and total
Nevertheless, bone augmentation procedures need technical complication rates have proven to be similar
further investigation to elucidate the most suitable for all types of prosthetic materials used for FCIPs.
protocols for edentulous patients. Nevertheless, it should be kept in mind that the
Esthetic outcomes follow-up periods for zirconium oxide (ZrO2) FCIPs
• There are no data on esthetic outcome measures are limited (up to 8 years) compared to conventional
in edentulous patients with implant-supported FCIP prosthetic materials (ie, metal-acrylic resin).
restorations. Moreover, the technical complication types may
• There is a need to establish an esthetic index differ based on the prosthetic material used.
for edentulous patients with implant-supported • FCIPs revealed high survival rates but also high
restorations, with a particular emphasis on specific technical complication rates. Chipping was one of the
anatomical features such as lip support, smile line, major complications for bilayered prostheses, namely
transition line, and skeletal relations. metal-ceramic, metal-acrylic, and veneered ZrO2.
• As noted in partially edentulous patients,6 a lack of • Due to the high chipping rates of veneered ZrO2
keratinized tissue (< 2 mm) was also associated with and metal-ceramic FCIPs, monolithic or minimally
a higher rate of biologic complications. veneered (only nonfunctional areas, such as facial
• It is recommended to establish a sufficient amount of and pink ceramic veneering) use of high strength
keratinized tissue along with full-arch fixed/removable ZrO2 might be a promising alternative for FCIPs.
prostheses to maintain peri-implant health. However, the data on their clinical performance
remain scarce.
WORKING GROUP 3 • The prosthetic material selection should be done
based on the required mechanical stability of the
Objectives prosthesis and the workflow that will be adopted
The aim of this working group (Fig 3) was to analyze (completely or partially digital vs analog).
systematic reviews reporting on the influence of mate- Prosthetic space
rial selection, attachment type, interarch space, and • Reports on clinical requirements for different
opposing dentition on the prosthetic outcomes of fixed prosthetic materials, namely required prosthetic
and removable complete implant prostheses (FCIPs and space, are lacking. Better quantification and
RCIPs, respectively). documentation of all possible parameters are
therefore required to improve treatment instructions
Major Findings and Conclusions and objective guidelines for a follow-up protocol.
A total of 22 systematic reviews (FCIP: n = 11; RCIP: n • Limited prosthetic space may be considered as a
= 10) were evaluated. High overall prosthesis survival reason for increased risk of failure.
rates for 5 to 10 years were obtained with both FCIPs • Based on the minimum material thicknesses
and RCIPs (93.3% to 100% and 96.9% to 100%, re- required in order to achieve required mechanical
spectively). Chipping/fracture of the veneering material stability, the following estimation can be done for
was the most frequent technical complication for FCIPs, the overall vertical space needed for FCIPs: 10 mm
and attachment-related complications were the main from the implant platform level to the occlusal
technical problems for RCIPs. The effect of prosthetic plane for metal-ceramic/metal-resin FCIPs; and 12
material of FCIPs was revealed as not significant for the mm from the implant platform level to the occlusal
technical complications or survival rates. No studies were plane for ZrO2 FCIPs.
identified that provided direct information on the effect • Phonation and esthetics also need to be considered
of interarch space for FCIPs or RCIPs. as limiting factors for prosthetic space for
It was concluded that both FCIPs and RCIPs obtained rehabilitation of the edentulous maxilla.
high overall survival rates, but technical complications Opposing dentition
cannot be avoided. No prosthetic material can be • With a moderate certainty of evidence, natural
considered as the material of choice over another. At- maxillary dentitions opposed by FCIPs do not affect
tachment type has no influence on the overall clinical long-term survival rates differently than other

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 Consensus Report

Fig 3   Members of Working Group 3 (prosthetic material selection). From left to right: Vincent Fehmer (Secretary), Óvári Zoltán, Duygu
Narin-Karasan (Rapporteur), Andreas Kunz, Irena Sailer (Chairperson), Carsten Fischer, Eric Normand, Attila Kámán, Cuneyt Karabuda,
Kerem Dedeogluk.

maxillary prosthetic designs, such as removable made based on patient-related factors; otherwise,
partial dentures (RPDs) or RCIPs; however, natural incorrect selection of an attachment may result in
dentition or fixed restorations as an antagonist may higher maintenance needs and complication rates.
increase the risk of technical complications. Prosthetic space requirement and opposing
dentition.
Consensus Statements and Clinical Recom- • There is no agreement in the literature regarding
mendations for Removable Complete Implant the effect of opposing dentition on complication
Prostheses rates of RCIPs, but it was addressed as an
Attachment types accounting factor for increased complication and
• Similar survival rates were reported for splinted and failure rates.
free-standing attachment systems. However, the • Fixed dentition, either a fixed prosthetic restoration
technical complication types differed between the or natural dentition, as antagonist can presumably
two attachment systems. create higher occlusal forces and may lead to
• Each attachment system comes with its own clinical increased complication rates. Moreover, limitations
prerequisites and has different indications. Existing in vertical space for the prosthetic components and
prosthetic space, interimplant distance, implant matrix are suggested to be more common in the
position and angulation, and number of implants maxilla, which may lead to higher complication and
can be considered as the factors that dictate the failure rates.
implant attachment of preference. • Amid the statements indicating that interarch space
• It was shown that clinicians often make the and opposing dentition can be accounting factors for
attachment selection based on subjective criteria, increased risk of failure for RCIPs, no evidence-based
such as expertise, personal comfort, the dental results can be obtained from the current literature.
technician’s preference, or based on the influence • Based on the minimum material thickness required
of marketing strategies. These decisions need to be in order to achieve mechanical stability, the

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 Consensus Report

Fig 4   Members of Working Group 4 (edentulous maxilla). From left to right: Jacques Vermeulen, Stephan Beuer, Ben Derksen, Kimmo
Vähätalo, Ana Messias (Secretary), Kristian Thesbjerg, Fernando Guerra (Chairperson), George Pynadath, Stefan Wolfart, Sigmar Schnuten-
haus, Frederic Hermann, Pedro Nicolau (Rapporteur), Stefan Ulrici, Jan Klenke.

following estimation can be done for the overall maxillae with sufficient bone to place implants; (2) ad-
vertical space needed for full-arch restorations; dressing maxillae with insufficient bone to place im-
free-standing attachments: 10- to 11-mm vertical plants; and (3) comparing different types of prostheses,
distance from the implant platform level to the number of implants, patient-reported outcomes, and
incisal edge of the RCIP; splinted attachments: economic evaluations.
13- to 14-mm vertical distance from the implant The literature indicates that in cases of severe atrophy
platform level to the incisal edge of the RCIP. of the edentulous maxilla, bone augmentation procedures
such as onlay bone grafts, lateral sinus floor elevation, ver-
WORKING GROUP 4 tical distraction osteogenesis, and Le Fort I interpositional
grafting are valid procedures. The use of extra-alveolar
Objectives implants (zygomatic and pterygoid) to overcome severe
The objective of this working group (Fig 4) was to syn- maxillary atrophies should be prescribed with caution.
thesize evidence derived from systematic reviews on Short implants can be used in conjunction with standard
different interventions for rehabilitation of the eden- implants in splinted configurations to overcome situations
tulous maxilla with implant-supported restorations. A of moderate atrophy of the maxillary sinus.
protocol-oriented search was established to address the The use of mini-implants in the completely edentulous
focus question: What is the current evidence regarding maxilla is not advisable for permanent implant-supported
rehabilitation of the edentulous maxilla with different restorations.
implant-supported prostheses in terms of implant and No implant-supported rehabilitation of the edentulous
prosthesis survival? maxilla (fixed or removable) should be supported on
fewer than four implants. One-piece full-arch fixed den-
Major Findings and Conclusions tal prostheses can be supported on a minimum of two
The final selection process led to the inclusion of 34 anterior axial plus two posterior distally tilted implants
systematic reviews that were grouped as: (1) addressing or on six to eight axial implants symmetrically distributed

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 Consensus Report

Edentulous maxilla

Removable Fixed or Fixed

removable?

Bone Bone
volume? volume?
Insufficient Sufficient Insufficient Sufficient

Graft? Graft?

Yes No Yes No

Tilted Tilted
4–6 SDI implants 4–6 SDI* > 6 SDI 6 SDI implants > 6 SDI* 6 SDI*

4: 2 anterior 4–6: 2–4

Splinted/ One-piece/ One-piece/
Splinted axial + 2 free- One-piece anterior axial One-piece
posterior standing segmented + 2 posterior segmented
distally tilted distally tilted

4–6: 2–4 4–6: 2–4

non-axial non-axial
(zygomatic or (zygomatic or
pterygoid) + pterygoid) +
2–4 axial 2–4 axial

Splinted One-piece

Fig 5  Decision tree for prosthetic rehabilitation of the edentulous maxilla—fixed or removable? *Includes the possibility of combining
standard-diameter implants (SDI) with axially placed short implants and/or Category III narrow-diameter implants in one-piece (fixed) or
splinted (removable) options.

through the posterior and anterior regions of the arch. • Four to six implants should be considered necessary
Four to six implants is the advised number to support an for both fixed and removable prosthetic options
overdenture. Both splinted and free-standing anchorage in the edentulous maxilla to achieve support,
systems are advocated. retention, and stability for predictable longevity.
The currently available data do not allow a cost-effective- • Regardless of the prosthetic option, implants should
ness analysis for rehabilitation of the edentulous maxilla. be maximally distributed across the arch (anterior
and posterior) according to anatomical situation.
Consensus Statements and Clinical • In cases of a fixed prosthesis and insufficient bone
Recommendations volume (vertical and horizontal) in the posterior
• General statements about cost-effectiveness are maxilla, two to four anterior parallel implants
not possible because of many different influencing and two posterior distally tilted implants are an
factors; for example, bone quality and quantity, alternative to bone grafting.
individual patient characteristics, prosthetic • Zygomatic implants are another alternative in cases
considerations, time of loading, longevity of the of a fixed prosthesis and insufficient bone volume
restoration and implants, and lack of scientific data. (vertical and horizontal) in the posterior maxilla. The
• Though four is the minimum recommended number expected complication rate is similar to the other
of implants for fixed or removable rehabilitation of the options, but more severe when either an implant is
maxilla, the lower the number of implants, the higher lost or a prosthesis is compromised or even lost due
the risk of a combined implant/prosthesis failure. to implant failure.

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 Consensus Report

Fig 6   Members of Working Group 5 (edentulous mandible). From left to right: Konstantinos Chochlidakis (Rapporteur), Jean-Claude Imber,
Gerhard Iglhaut, Florian Kernen (Secretary), Alexandra Tsigarida (Rapporteur), Alex Schär, Robert Sader (Chairperson), Gerald Krennmair,
Helfried Hulla, Maciej Stupka.

• Studies that compare the performance of tilted WORKING GROUP 5

and axial implants placed in regenerated bone are
urgently needed. Objectives
• In compromised bone situations where a removable The objectives of this working group (Fig 6) were to
prosthesis is the treatment option, the use of more evaluate the current literature related to the number
than five splinted implants (for example, short implants of implants, implant characteristics, loading protocols,
in the posterior region, preferably in combination with survival rates, biologic and mechanical complications,
standard anterior implants) should not be ruled out to patient satisfaction, and financial considerations for
reduce the risk of implant loss (Fig 5). mandibular implant full-arch prostheses.
• Regular follow-up appointments should be
scheduled for all implant patients. Follow-up Major Findings and Conclusions
intervals should be individualized according to High survival rates for implants and prostheses have been
prosthetic and clinical parameters. reported with fixed and removable implant full-arch pros-
• Removable prosthetic options are expected to require theses in the mandible. Immediate loading procedures
more maintenance than their fixed counterparts, present with high survival rates for both fixed and remov-
particularly during the first year of service (Fig 5). able prostheses. There are differences in the number of im-
plants, implant characteristics, complications, and financial
Implications for Future Research implications between these two types of prostheses, which
• RCTs should include more comprehensive clinical clinicians need to account for as part of the treatment.
evidence, including patient-reported outcome In cases where both treatment options are indicated,
measures (PROMs), in order to conduct cost- patient expectations and cost should be the determining
effectiveness evaluations to compare treatment factors for selecting a treatment modality.
options.

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 Consensus Report

Consensus Statements and Clinical Recommendations • For mandibular full-arch zirconia IFCDs, more long-
for Implant Fixed Complete Dentures term studies are needed for definitive conclusions.
Number of implants • Complications were not reported according to
• Two-implant fixed complete dentures (FCDs): Not a number of implants.
viable treatment option due to inadequate evidence, Patient satisfaction/quality of life
short follow-up, and high bias. • High patient satisfaction and quality of life (QoL)
• Three-implant FCDs: Literature exists, but more long- have been reported for mandibular IFCDs in terms
term studies are needed for definitive conclusions. of stability, retention, and ease of chewing.
• Four- to five-implant FCDs: Clinically and • There was no significant difference in overall patient
scientifically documented with high survival rates. satisfaction or QoL when compared to mandibular
• If four implants are used, an anteroposterior spread removable full-arch implant prostheses.
should be considered for implant positioning (ie,
tilted vs axial implant placement). Consensus Statements and Clinical Recommenda-
• The patient’s financial situation dictates the type of tions for Removable Implant Overdentures
prosthesis, and the type of prosthesis dictates the Number of implants
number of implants and the distribution. • One-implant overdentures (OVDs) may be used
• Six (or more)-implant FCDs: It is unclear from the under certain conditions.
current evidence whether there is an indication for • Two-implant OVDs are considered the minimum
more than six implants. With six or more implants, standard of care treatment. There is adequate
fixed implant prostheses can be segmented. evidence for successful outcomes.
Short implants (≤ 8 mm) vs augmentation • Four-implant OVDs have been successfully used for
• Short-implant mandibular FCDs may be a viable mandibular implant OVDs (IOVDs).
treatment option, but there is insufficient evidence Mini-diameter implants vs augmentation
for definitive conclusions. • There is no clear evidence of treatment success for
Loading protocols mini-implants.
• All loading protocols have been clinically and • Mini-implants may be an alternative treatment
scientifically documented for mandibular implant when standard treatment is not possible due to
fixed complete dentures (IFCDs). anatomical or medical issues considering four mini-
• Clinicians should be aware of the influencing factors implants for a mandibular IOVD.
for immediate loading (case selection, insertion Loading protocols
torque, primary stability, rough surface). • Although all three loading protocols provided
Survival/success rates high survival rates, early and conventional loading
• Two-implant FCDs: High survival rates (> 98% at protocols are still better documented than
1 year), but not a viable treatment option due to immediate loading.
inadequate evidence and high bias. Survival/success rates
• Three-implant FCDs: High survival rates (> 98% at • High survival rates (> 95% at 5 years) have been
3 years); further studies with longer follow-up times reported in the literature for implants and prostheses.
are needed for conclusive results. Complications
• Four (or more)-implant FCDs: High survival rates • Most of the prosthetic complications were
have been reported (implant: 97% at 5.5 years, associated with the attachment system (53%),
prosthesis: 99% at 5.5 years). followed by the need for reline (25%).
Complications • The most common biologic complication was
• Even though high survival rates have been reported reported as mucosal hyperplasia (31%).
with mandibular IFCDs, prosthetic and biologic • The implant number and type seem to have no
complications are still frequent. clear effect on complications.
• For mandibular IFCDs, the prosthodontic Patient satisfaction/QoL
complication rates represented 68% of the total • There was no significant difference in overall patient
complications. Chipping of veneering material was satisfaction and QoL when compared to IFCDs.
the most common. • The “easy to clean” rating was significantly higher
• Biologic complication rates represented 32% of the with IOVDs compared to IFCDs.
total complications. Peri-implant inflammation was • Patient satisfaction does not seem to be affected by
the most common. the number of implants or prosthesis retention system.

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 Consensus Report

Fig 7   Members of Working Group 6 (decision-making). From left to right: Rodrigo Andrés, Fumihiko Watanabe, Hanae Saito, Joaquin Tabuenca,
Insa Herklotz (Secretary), Konstantinos Vazouras (Rapporteur), Thomas Taylor (Chairperson), Pieter van Elsas, Frank Leusink, Marzena Dominiak.

WORKING GROUP 6 • Patient expectations will be paramount in treatment

decision-making.
Objectives • Prior experience with prosthodontic restorations will
Implant treatment of complete edentulism in elderly peo- influence treatment choices.
ple involves removable as well as fixed rehabilitations. The • Patient information about complications and
literature is not clear on which option might be better and treatment options must be accurately presented
why. The available literature was therefore reviewed and and discussed.
analyzed by Working Group 6 (Fig 7) in an effort to bring • Regardless of a fixed or removable decision,
some guidance to the decision-making process. prosthesis design must facilitate adequate personal
oral hygiene procedures, and patients who receive
Major Findings and Conclusions such restorations must be adequately trained for
The decision-making pathway for determining what their particular prosthesis.
type of implant-supported prosthesis is preferable for • Analysis of the patient’s general health is critical
edentulous patients is complicated by many variables (including extreme frailty or mental disability,
that must be considered in treatment planning to provide periodontitis, smoking history, history of snoring
the maximum benefit for the patient. Detailed explana- and/or sleep apnea, and xerostomia).
tion of potential outcomes, complications, difficulties, • In patients of advanced age, converting a prosthetic
and benefits of therapeutic options is mandatory. Proper solution from fixed to removable may be indicated.
assessment of patients’ expectations and desires before • In elderly patients, severe alveolar atrophy indicates
treatment is critical for a successful outcome. a removable solution.
• Facial esthetics and lip dynamics may drive the
Consensus Statements and Clinical Recommendations decision related to the prosthetic outline.
• Financial means will drive decision-making for • Clinical decision-making must not only be based
treatment choice and long-term maintenance. on the survival rate, but rather on the patient’s
subjective gain in QoL, comfort, and overall

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 Consensus Report

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ACKNOWLEDGMENTS

This consensus meeting was organized and supported by the Oral

Reconstruction Foundation, Basel, Switzerland. The authors and
members of the working groups declare that they have no conflict
of interests related to this consensus report. Fernando Guerra, Robert
Sader, Irena Sailer, Alex Schär, and Thomas Taylor are members of the
Oral Reconstruction Foundation Boards, and Alex Schär is employed
by the Foundation.

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