CH 3

3
Treatment Planning Complications

Randolph R. Resnik, Carl E. Misch
The introduction of the dental implant has greatly expanded the two are removable and are based on the amount of support
scope of services that clinicians can provide to restore patients for the restoration.1
to optimal form, function, and esthetics. Patients presenting The amount of support required for an implant prosthesis
with missing teeth or pathology that necessitate tooth extraction should initially be similar to that used in traditional tooth-
now have a wide range of treatment options beyond ixed supported restorations. After the intended prosthesis is
bridges or removable prosthetics. The progressive loss of bone designed, the implants and treatment surrounding this spe-
as a consequence of tooth extraction can now be minimized. ciic result can be established. The prosthetic option is the irst
Implant technology has allowed clinicians to come much closer factor to determine in the overall implant treatment plan.
to the ideal goal of restoring patients’ dental health.
Patients present to dental ofices every day with either an Not Understanding and Communicating
edentulous condition or pathology that necessitates tooth the Types of Prostheses
removal. Prior to the beginning of treatment, the clinician Complication. When treatment planning for a ixed pros-
has an ethical and legal obligation to educate the patient as thesis, many inherent complications may occur. It is crucial
to the advantages and disadvantages of every therapeutic for the clinician to have a thorough understanding of how
option available. The goal of this chapter is to provide clini- the inal ixed prosthesis is directly related to the amount of
cians with a comprehensive treatment protocol for the major hard and soft tissue remaining, position of the implant, and
edentulous conditions, including advantages and disadvan- the anatomic area of the oral cavity. If this is not understood,
tages of each. By informing the patient of each option avail- miscommunication may result leading to possible esthetic,
able (including no treatment), the dental professional can aid biomechanical, or periodontal issues.
the patient in forming an educated choice for treatment that
meets their needs and values. Prevention
In this chapter the various aspects of treatment planning Prosthesis treatment planning irst. To satisfy predictably a
will be discussed. These include the prosthesis type, available patient’s needs and desires, the prosthesis should irst be
bone, key implant positions, implant size, and force factors. designed. In the stress treatment theorem postulated by Misch,
the inal restoration is irst planned in a way similar to an archi-
tect designing a building before setting the foundation.2 Implant
TYPE OF PROSTHESIS dentistry is analogous to constructing a building. Prior to con-
struction, detailed blueprints are obtained that explain in detail
TREATMENT PLANNING every aspect of the project. Similar guidelines should be used in
In implant dentistry, when a speciic prosthetic result is implant dentistry treatment planning. Only after the prosthesis
desired, additional foundation units (support) may be created is envisioned and determined can the inal abutments, implant
to obtain the end result. Both the psychologic and anatomic size and location, and available bone requirements be deter-
needs and desires of the patient should be irst evaluated and mined to support the speciic predetermined restoration.
determined. The prosthesis that satisies the intended goals Treatment plan according to inances. Patients are too often
and expectations may then be designed. treated as though cost is the primary factor in establishing a
Complications often arise when only one implant approach treatment plan. Patients should be presented with all viable
is used for all patients because the same surgical and pros- treatment plans, regardless of cost. To determine the ideal inal
thetic scenarios and laws are invariably repeated. The bene- prosthetic design, the existing anatomy is evaluated after it has
its of implant dentistry can be realized only when the been determined whether a ixed or removable restoration is
prosthesis is irst discussed and determined in detail by the required to address the patient’s desires. An axiom of implant
clinician and patient. An organized treatment approach based treatment is to provide the most predictable, treatment that will
on the prosthesis permits predictable therapy results. Misch satisfy the patient’s anatomic needs and personal desires.
has postulated there are basically ive various prosthetic Patient should be educated on all viable treatment plans.
options available in implant dentistry. Three restorations are It is the clinician’s obligation to educate the patient on the
ixed and vary in the amount of hard and soft tissue replaced; various treatment plans that are possible. In edentulous cases,
54
CHAPTER 3 Treatment Planning Complications 55
TABLE 3.1 Prosthodontic Classiication

Type Deinition
FP-1 Fixed prosthesis; replaces only the clinical
crown; looks like a natural tooth with ideal
contours
FP-2 Fixed prosthesis; replaces the clinical crown and
a portion of the root; crown contour appears
normal in the occlusal half but is elongated or
hypercontoured in the gingival half
FP-3 Fixed prosthesis; replaces missing clinical crown
12 mm
and gingival color and a portion of the
edentulous site; most common prosthesis is
zirconia 4 mm 18 mm
RP-4 Removable prosthesis; overdenture supported 10 mm
completely by implants (usually with a
superstructure bar) that is completely implant
supported with no soft tissue support
RP-5 Removable prosthesis; overdenture supported
by both soft tissue (primary support) and
implants, which may or may not have a
superstructure bar (secondary support)
ixed vs. removable should be explained. It is imperative that

patients understand the advantages and disadvantages of
each of these treatment modalities. In this way, patient expec-
tation complications will be prevented. A good source of
FIG 3.1 Fixed restorations have three categories: FP-1, FP-2,
providing this information is via presentation books, videos,
and FP-3. The restoration type is related to the contour of the
and online information. The education process should be restoration. (FP-1 is ideal, FP-2 is hypercontoured, and FP-3
documented and be part of the patient’s records. replaces the gingiva drape with pink porcelain or acrylic.) The
Understand the differences between the types of prosthe- difference between FP-2 and FP-3 most often is related to
ses. To prevent treatment planning complications, the the high maxillary lip position during smiling or the mandibular
implant clinician must understand there are three types of lip position during sibilant sounds of speech. FP-2 and FP-3
ixed prostheses and two types of removable prostheses, as restorations often require more implant surface area support
postulated by Misch in 1989. When evaluating ixed prosthe- by increasing implant number or size. (From Misch CE: Dental
ses, the three options may be used to replace one tooth implant prosthetics, 2e, St Louis, 2015, Mosby.)
or multiple teeth and may be cemented or screw retained.
These types of ixed prostheses depend on the amount of Implant Criteria. The FP-1 prosthesis is most often desired
hard and soft tissue structures replaced and the aspects of the in the maxillary anterior region, especially in the esthetic
prosthesis in the esthetic zone. Common to all ixed options zone during smiling. The inal FP-1 restoration appears to the
is the inability of the patient to remove the implant prosthesis patient to be similar to a crown on a natural tooth. However,
(Table 3.1 and Fig. 3.1). the implant abutment can rarely be treated exactly as a natural
tooth prepared for a full crown. The cervical diameter of a
FIXED PROSTHESES natural tooth is approximately 6.5 to 10.5 mm with an oval-
triangular cross-section. However, the implant abutment is
FP-1 usually 4 to 5 mm in diameter and round in cross section. In
Deinition. An FP-1 is a ixed restoration and appears to the addition, the placement of the implant rarely corresponds
patient to replace only the anatomic crowns of the missing exactly to the crown–root position of the original tooth. For
natural teeth (clinical crown). To fabricate this restoration example, the thin labial bone lying over the facial aspect of a
type there must be minimal loss of hard and soft tissues. The maxillary anterior root remodels after tooth loss, and the
volume and position of the residual bone must permit ideal crest width shifts to the palate, decreasing 40% within the irst
placement of the implant in a location similar to the root of 2 years.
a natural tooth. The inal restoration appears very similar in
size and contour to the clinical crown or most traditional FPs Complication. The most common complication with a
used to restore or replace natural crowns on teeth (Figs. 3.2 patient requesting a FP-1 prosthesis is not recognizing pre-
and 3.3). operatively the limitations of the hard and soft tissue anatomy.
56 CHAPTER 3 Treatment Planning Complications
FP-1 FP-2 FP-3
FP-1 FP-2 FP-3
FIG 3.2 The Misch prosthesis classiication is dictated by the amount of clinical crown height,
hard and soft tissue replacement. FP-1 replaces the ideal clinical crown, FP-2 replaces the clinical
crown + a hypercontoured replacement of the lost hard and soft tissue, and FP-3 that replaces
the clinical crown + signiicant hard and soft tissue replacement (pink porcelain, acrylic, zirconia).
(From Misch CE: Dental implant prosthetics, 2e, St Louis, 2015, Mosby.)
If the inal implant position is nonideal, it will be almost replaced. In a buccal-lingual position, the implant should be
impossible to obtain a FP-1 prostheses without hard and soft in a plane slightly lingual to the incisal edge of the tooth being
tissue grafting. replaced. In the apicocoronal plane, the implant should be
approximately 3 mm apical to the free gingival margin of the
Prevention. The bone loss and lack of interdental soft tissue adjacent teeth, provided that the adjacent teeth have ideal
complicate the inal esthetic result, especially in the cervical hard and soft tissue anatomy.
region of the crowns. FP-1 prostheses are especially dificult
to achieve when more than two adjacent teeth are missing FP-2
because of the need for hard tissue augmentation, soft tissue Deinition. An FP-2 ixed prosthesis restores the anatomic
augmentation, and optimal implant positioning. crown and a portion of the root of the natural tooth and, there-
Hard tissue augmentation. The width or height of the fore, is hypercontoured. The incisal edge of the restoration is in
crestal bone is frequently insuficient after the loss of multiple the correct position, but the gingival third of the crown is over-
adjacent natural teeth, and bone augmentation is often extended, usually apical and lingual to the position of the origi-
required before implant placement to achieve natural-looking nal tooth. These restorations are similar to natural teeth
crowns in the cervical region. exhibiting periodontal bone loss and gingival recession. In most
Soft tissue augmentation. Because there are no interden- situations an FP-2 is an acceptable prosthesis for patients.
tal papillae in edentulous ridges, soft tissue augmentation is However, in the esthetic zone or in a patient with a high smile
often required to improve the interproximal gingival contour. line, this may pose complication issues because the prosthesis
Ignoring this crucial step will result in open “black” triangular may be deemed unesthetic by the patient (Fig. 3.4).
spaces (where papillae should usually be present) when the
patient smiles. Implant Criteria. The volume and topography of the avail-
Ideal implant positioning. To obtain an FP-1 prostheses, able bone are more apical compared with the ideal bone
the implant must be positioned ideally in the mesial-distal, position of a natural root (1–2 mm below the cement-enamel
buccal-lingual, and apicocoronal planes. The center of the junction) and dictate a more apical implant placement com-
osteotomy should be midway between the mesial-distal dis- pared with the FP-1 prosthesis. This most commonly occurs
tance, provided the available space is ideal for the tooth being because of implant placement in Division B ridges, and
B
FIG 3.3 FP-1 prosthesis. (A) Preoperative image of missing #
10 (maxillary left lateral incisor); (B) Postoperative, depicting
inal prosthesis that is normal size to the adjacent clinical
crowns.
because of the lack of bone width, the inal implant position

will be too far apical in comparison to the adjacent teeth. C
FIG 3.4 (A) and (B), FP-2 Prosthesis showing a hypercontoured
Complication. The most common complications that occur or elongated tooth in comparison to the adjacent clinical
with a FP-2 prosthesis are a result of not informing the patient crowns. (C), FP-2 prosthesis showing associated complica-
of the hypercontouring of the inal prosthesis or the need for tions of bone loss and loss of papilla from implant positioning
the use of pink porcelain. Especially in the maxillary anterior too deep or apical.
region, this may pose an esthetic issue with the patient. The
use of pink porcelain also increases laboratory expenses.
informed consent should be modiied to explain and fully
Prevention inform the patient of the overcontoured prostheses (FP-1 vs.
Patient communication. The patient should be well FP-2) (Fig. 3.5).
informed prior to the initiation of treatment that the inal Preoperative smile zone evaluation. The esthetic zone of
FP-2 prosthesis will appear longer than healthy natural teeth a patient is established during smiling in the maxillary arch.
(without bone loss). The patient should be shown photo The number of teeth displayed when a patient smiles is highly
images or diagrams of an FP-2 prosthesis compared to an variable. Less than 10% of the population limits their smile
FP-1 prosthesis prior to treatment. Additionally, the surgical to the anterior six teeth. Almost 50% of people show up to
Consent for Implant Surgery

1. I have been informed and afforded the time to fully understand the purpose and the nature of the implant surgery
procedure. I understand what is necessary to accomplish the placement of the implant under the gum or in the bone.
2. My doctor has carefully examined my mouth. Alternatives to this treatment have been explained. I have tried or consid-
ered these methods, but I desire an implant to help secure the replaced missing teeth.
3. I have further been informed of the possible risks and complications involved with surgery, drugs, and anesthesia. Such
complications include pain, swelling, infection and discoloration. Numbness of the lip, tongue, cheek, or teeth may occur.
The exact duration may not be determinable and may be irreversible. Also possible are thrombophlebitis (inflammation
of the vein), injury to teeth present, bone fractures, sinus penetration, delayed healing, allergic reactions to drugs or
medications used, etc.
4. I understand that if nothing is done any of the following could occur: bone disease, loss of bone, gum tissue inflammation,
infection, sensitivity, looseness of teeth followed by necessity of extraction. Also possible are temporomandibular joint
(jaw) problems, headaches, referred pain to back of the neck and facial muscles, and tired muscles when chewing. In
addition, I am aware that if nothing is done an inability to place an implant at a later date due to changes in oral or medical
conditions could exist.
5. My doctor has explained that there is no method to predict accurately the gum and bone healing capabilities in each
patient following the placement of an implant.
6. It has been explained that in some instances implants fail and must be removed. I have been informed and understand
that the practice of dentistry is not an exact science; no guarantees or assurances as to the outcome of the results of
treatment or surgery can be made. I am aware that there is a risk that the implant surgery may fail, which might result in
further corrective surgery or the removal of the implant with possible corrective surgery associated with the removal.
7. I understand that any amount of smoking, alcohol, or elevated blood sugar may effect gum and bone healing and may
limit the success of the implant. I agree to follow my doctor’s home care instructions. I agree to report to my doctor any
complications and maintain regular examinations as instructed.
8. I agree to the type of anesthesia, depending on the choice of the doctor. I agree not to operate a motor vehicle or hazard-
ous device for at least 24 hours or more until fully recovered from the effects of the anesthesia or drugs given to me for
my care.
9. To my knowledge, I have given an accurate report of my physical and mental health history. I have also reported any
prior allergic or unusual reactions to drugs, food, insect bites, anesthetics, pollens, dust, blood or body diseases, gum or
skin reactions, abnormal bleeding or any other conditions related to my health.
10. I Have Been Informed And Understand The Existing Anatomy (Bone And Tissue) Which May Place Limitations On The
Final Implant Crown Height And Position. The Implant Crown Will Most Likely Be Higher (Longer) Than The Adjacent
Teeth (FP-2), With Lack Of Gum Tissue On Each Side. Pink Porcelain May Also Need To Be Used In Conjunction With
The Final Crown.
11. I agree to notify the doctor’s office of any and all changes to my address and/or telephone number within a reasonable
time frame (two to four weeks)
12. I request and authorize medical/dental services for myself, including bone grafts and other surgery. I fully understand the
contemplated procedure, surgery, or treatment conditions that may become apparent, which warrant, in the judgment of
the doctor, additional or alternative treatment pertinent to the success of comprehensive treatment. I also approve any
modifications in design, materials, or care, if it is felt this is for my best interest. If an unforeseen condition arises in the
course of treatment which calls for performance of procedures in addition to or different from that now contemplated
I further authorize and direct my doctor, associate, or assistant, to do whatever they deem necessary and advisable
under the circumstances, including the decision not to proceed with the bone graft procedure.
_______________________________________________ _______________________
Signature of Patient Date
_______________________________________________ _______________________
Signature of Witness Date
_______________________________________________ _______________________
Signature of Doctor Date
FIG 3.5 Consent form for FP-2 or FP-3 prosthesis.
FIG 3.7 A splinted image of #8-#9 implants with pink porce-

lain. An FP-2 or FP-3 may not be indicated when a high smile
line exists.
B
FIG 3.6 High smile line. (A) Unfavorable smile line showing FP-3
the entire clinical crown and tissue. This type of smile may
Deinition. The FP-3 ixed restoration appears to replace the
contraindicate implant placement because of esthetic related
natural teeth crowns and has pink-colored restorative mate-
issues. (B) Favorable smile line showing only one-half of the
clinical crown and no tissue. This type of smile line is ideal rial (acrylic or pink porcelain) to replace a portion of the soft
for an FP-2 or FP-3 prosthesis. tissue, especially the interdental papillae. This is most com-
monly indicated when severe bone resorption has occurred.
the irst premolar and approximately 4% of our patients Implant Criteria. As with the FP-2 prosthesis, the original
display almost all the maxillary teeth during a smile.3 The low available bone height has decreased by natural resorption or
lip position is ideally evaluated during sibilant sounds of osteoplasty at the time of implant placement. To place the
speech (e.g., Mississippi, sixty-six). It is not unusual for incisal edge of the teeth in ideal position for esthetics, func-
patients to show fewer lower anterior teeth during smiling, tion, lip support, and speech, the excessive vertical dimension
especially in younger patients. Older patients are most likely to be restored requires teeth that are unnatural in length. The
to show the anterior teeth and gingiva during speech, with soft and hard tissue loss requires replacement with pink por-
men showing more than women. Likewise, if the high lip line celain or acrylic (Fig. 3.7).
during smiling or the low lip line during speech does not
display the cervical regions, the longer teeth are usually of no Complication. The main complication associated with an
esthetic consequence, provided that the patient has been FP-3 prosthesis is patient acceptance because of the hyper-
informed before treatment (Fig. 3.6). contoured crowns (i.e., pink porcelain or acrylic). Addition-
Ideal implant position. A multiple-unit FP-2 restoration ally, the clinician must be aware of the added laboratory
does not require as speciic an implant position in the mesial costs associated with an FP-3 prosthesis. Most laboratories
or distal position as does an FP-1 prosthesis. This is because will charge a signiicantly higher fee for the application of
the cervical contour is not displayed during function. The pink porcelain. However, the clinician should be aware
implant position may be chosen in relation to bone width, there exist various shades of pink porcelain. It is recom-
angulation, or hygienic considerations rather than purely mended that the color of the tissue be evaluated similar to
esthetic demands (compared with the FP-1 prosthesis). On tooth shade. Many pink shade guides are available for use in
occasion, because of available bone, the implant may even be implant dentistry today (Fig. 3.8).
placed in an embrasure between the two teeth. This often
occurs when replacing mandibular anterior teeth with a full- Prevention
arch ixed restoration. If this occurs, the incisal two thirds of Patient communication. The patient should be well
the two crowns should be ideal in width, as though the informed prior to any treatment that the inal FP-3 prosthetic
implants were not present. Only the cervical region is com- teeth will appear longer and also have pink restorative mate-
promised (i.e., this is most likely out of the esthetic zone). rial associated with the prosthesis to replace the loss of hard
Although the implant is not positioned in an ideal mesiodis- and soft tissue. Photos or examples of the pink prosthesis
tal position, it should be placed in the correct facial-lingual should be shown to the patient.
position to ensure that contour, hygiene, and direction of Understanding of smile zone variations. The ideal high
forces are not compromised. smile line (i.e., not showing excessive soft tissue) occurs in
almost 70% of the population. The maxillary lip displays the Color of the pink tissue. Because the color characteristics
interdental papilla of the maxillary anterior teeth, but not the of patient’s gingiva vary greatly, the implant clinician
soft tissue above the mid cervical regions. A high smile or should use a laboratory that has the capability to use a pink
“gummy” smile will usually display the interdental papillae porcelain shade guide to match the tissue. However, patients
and at least some of the gingival tissues above the free gingival should be informed of the tissue color changes that occur
margin of the teeth. Patients in both of these categories of over time.
high lip line should have the soft tissue replaced by either the Understand the two types of FP-3 prostheses. There are
prostheses or augmentation. Additionally, the appearance of basically two approaches for an FP-3 prosthesis. (1) A hybrid
the mandibular teeth may be evaluated during sibilant sounds restoration of denture teeth and acrylic with a metal substructure.
(Fig. 3.9). The complications associated with this type of prosthesis are
excessive wearing of the denture tooth or debonding from the
prosthesis. (2) A porcelain–metal/zirconia restoration. An FP-3
porcelain-to-metal/zirconia restoration is more dificult to fab-
ricate for the laboratory technician than an FP-2 prosthesis.
The pink porcelain is more dificult to appear as soft tissue and
usually requires more porcelain iring cycles. This increases the
risk of potential porosity or porcelain fracture (Fig. 3.10).
Spacing of multiple implants. For edentulous arches or
larger spaces, implants should be placed a minimum of 3
millimeters apart. If they are less than 3 millimeters apart,
dificulty with hygiene will result along with the possibility
that bone loss on one will extend to the other, compromising
A both implants.
Tissue space. In the maxillary arch, wide open embrasures
between the implants may cause food impaction or speech
problems. These complications may be solved by using a
removable soft tissue replacement mask or make the overcon-
toured cervical restorations. The maxillary FP-3 prosthesis is
often extended or juxtaposed to the maxillary soft tissue so that
speech is not impaired. However, this results in hygiene issues,
which place the prostheses at risk. The mandibular FP-3 resto-
rations may be left above the tissue, similar to a sanitary pontic.
This facilitates oral hygiene in the mandible, especially when
the implant is exposed through the soft tissue drape and is not
B visible during speech. However, if the space below the restora-
FIG 3.8 Pink tissue shading. (A) Pink shade guides. (B) Exam- tion is too great, the lower lip may lack support in the labio-
ples of pink porcelain and pink stained zirconia. mental region.
Appearance of mandibular teeth in

facial positions among women
70
60
50
% Subjects
40 Resting
30 Speaking
20 Smiling
10
0
20-29 30-39 40+
Age (years)
FIG 3.9 The appearance of the lower anterior teeth is primarily evaluated during sibilant sounds
of speech, and older patients show more teeth than younger patients. (From Misch CE: Dental
implant prosthetics, 2e, St Louis, 2015, Mosby.)
RP-5
RP-4
RP-4
RP-5
A
FIG 3.11 Removable restorations have two categories based
on implant support. RP-4 prostheses have complete implant
support in both the anterior and posterior regions. In the
mandible, the superstructure bar often is cantilevered from
implants positioned between the foramina. The maxillary
RP-4 prosthesis usually has more implants and no cantilever
(usually no palate present). An RP-5 restoration has primarily
anterior implant support and posterior soft tissue support in
the maxilla or mandible. Often fewer implants are required,
and bone grafting is less indicated. (From Misch CE: Dental
B
Patients are able to remove the restoration but not the
implant-supported superstructure or attachments to the
abutments. The difference in the two categories of removable
restorations are not in appearance (as it is in the ixed catego-
ries). Instead, the two removable categories are primarily
determined by the amount of implant and soft tissue support
(Fig. 3.11).
RP-4
C Deinition. An RP-4 removable prosthesis is completely sup-
FIG 3.10 FP-3 prostheses. (A) acrylic/denture tooth construc- ported by implants with no soft tissue support. The RP-4
tion; (B) pink porcelain; (C) pink zirconia. prosthesis is primarily a totally implant-supported prosthesis.
The restoration is rigid when inserted, and the overdenture
attachments usually connect the RP to single implant attach-
ments or a low-proile tissue bar with attachments (Fig. 3.12).
REMOVABLE PROSTHESES
Implant Criteria. The implant placement criteria for an
When treatment planning, the patient’s prosthetic requirements RP-4 prosthesis are different than that for an FP prosthesis.
should be fully understood and an evaluation of the patient’s Denture teeth and acrylic require more prosthetic space for
anatomy is a priority. The most common removable implant the removable restoration in comparison to a ixed prosthesis.
prostheses are overdentures for completely edentulous patients. The implants in an RP-4 prosthesis (and an FP-2 or FP-3
Complete removable overdentures have been reported with restoration) should be placed in the mesiodistal position for
predictability and a high success rate for many decades; however, the best biomechanical and hygienic situation. Usually, in the
there is much confusion concerning this type of prosthesis mandible, implants are inserted between the two mental fora-
because of the inherent variations.4,5 Most often, patients do not mens in the A, B, C, D, and E positions.
understand the associated movement with overdentures (i.e.,
dependent on number of implants, attachments, A-P spread, Complication. The most common complication occurring
posterior ridge form) because they don’t understand the associ- with a RP-4 prosthesis is lack of adequate implant support
ated biomechanical factors with an overdenture prosthesis. The (e.g., insuficient number of implants) and food impaction.
complications that may a occur may be signiicant. In the mandibular RP-4 prosthesis, because there exists no
There exist two types of removable prostheses that are peripheral seal, often food becomes impacted underneath the
based on support, retention, and stability of the restoration. prosthesis.
apicocoronal dimension, adequate interocclusal space is

needed to allow for at least 2 mm of acrylic to retain the
denture teeth with overdentures; approximately 15 mm is
needed from the crest of the bone to the incisal edge.
Implant number. For a totally implant-supported prosthe-
sis (RP-4), four to ive implants are required in the mandible
and six to eight implants in the maxilla. Fewer implants being
utilized to support a RP-4 prosthesis will result in possible
overloading of the prosthesis and/or implants leading to
complications.
RP-5
Deinition. RP-5 is a removable prosthesis combining
A
implant and soft tissue support. Predominately, the soft tissue
is the primary support (primary stress-bearing areas) and
implants are used for secondary support. The advantage of
an RP-5 restoration is the reduced cost because fewer implants
may be inserted compared with a RP-4 or ixed restoration.
Additionally, there is less demand for bone augmentation,
which decreases cost.
Implant Criteria. Implants in the mandible are inserted

within the mandibular interforaminal space with two, three,
or four implants. These correspond to the Overdenture Treat-
ment Planning options (e.g., OD-1–OD-5). In the maxilla,
usually four to six implants are recommended depending
upon force factors.
B
FIG 3.12 (A) RP-4—totally implant-supported prosthesis with Complication. The most common complication occurring
no soft tissue support, note the lack of peripheral seal. with an RP-5 prosthesis is the associated movement. A
(B) RP-5 prosthesis—soft tissue–supported with secondary
common misconception of patients is they believe that
implant support and peripheral seal.
implants, independent of the number, should have no associ-
ated movement. Because an RP-5 relies on the soft tissue for
Prevention support, there will be inherent movement within the prosthe-
Patient communication. The patient should have a thor- sis. Additionally, with an RP-5 prosthesis, because of the
ough understanding of the differences between a RP-4 and a primary implant support, soft tissue pressure is present, which
RP-5 prosthesis. There exist distinct differences between RP-4 may cause sore spots. If a patient’s initial complaint is chronic
and RP-5 prosthesis with respect to number of implants, type posterior sore spots, an RP-5 is not the best prosthetic option.
of support, and prosthesis movement.
Treatment denture. A preimplant treatment denture may Prevention
be fabricated to evaluate the occlusal vertical dimension and Patient communication. The patient should have a thor-
ensure the patient’s esthetic satisfaction. This technique is ough understanding of the differences between an RP-4 and
especially indicated for patients with demanding needs and an RP-5 prosthesis. A common problem with an RP-5 pros-
desires regarding the inal esthetic result or with severely thesis is the possible associated movement, which some
reduced vertical dimensions with their present prosthesis. patients may not tolerate or expect. A preoperative explana-
The implant dentist may also use the treatment denture as a tion must allow the patient a full understanding of the advan-
surgical guide for implant placement and for use during the tages and disadvantages of the two types of prostheses. A
healing stage. After the implants are uncovered, the super- common analogy is the use of a chair. A two-implant over-
structure or prosthetic design is fabricated within the guide- denture is similar to a chair with only two legs. The chair may
lines of the existing treatment restoration. be stabilized; however, it can easily be moved. A three-implant
Implant position. The positioning of implants for an RP-4 overdenture is similar to a three-legged chair because it is
overdenture is critical to the successful outcome of the pros- more stable than two-implant overdenture; however, it will
thesis. For example, a Hader clip requires the mesiodistal still have some degree of movement. A four- to ive-implant
implant spacing to be greater than 6 mm from edge to edge of overdenture is similar to a four-legged chair, which is associ-
the implant bodies. Because of this space requirement, the ated with minimal movement (Fig. 3.13).
number of implants is reduced, especially if placed between Treatment denture. A preimplant treatment denture may
the interforaminal space of the mandible. Additionally, in the be fabricated to determine position and prosthesis thickness.
However, this is usually less important than in a RP-4 type so they fully understand the limitations of this type of
prosthesis. prosthesis.
Posterior ridge form. If the patient has a poor posterior Implant position. The positioning of implants for an RP-5
ridge form (mandible), especially in the posterior area, an overdenture is critical to the successful outcome of the pros-
RP-5 prosthesis might not be the ideal treatment option. thesis. When a bar is not going to be utilized, great care should
In these cases, patient education and consent is mandatory be exercised to make sure that adequate spacing between the
implants is present. Lack of space between implants (<3 mm),
will result in prosthetic attachment complications. Addition-
ally, the implants should be placed at approximately the same
height and as parallel as possible to prevent path of insertion
complications.
Implant number. For a totally implant-supported prosthe-
sis, a minimum of two to four implants is required in the
mandible and four to six implants in the maxilla. Fewer
implants will result in additional mobility of the prosthesis
or occlusal overloading.
Continuous residual ridge bone loss. The clinician and
the patient should realize that the residual bone will continue
to resorb in the soft tissue–borne regions of the prosthesis.
Relines and occlusal adjustments every few years are common
maintenance requirements of an RP-5 restoration. Bone
C A resorption in the posterior regions with RP-5 restorations
Rotates front may occur two to three times faster than the resorption found
to back
with full dentures.6 This may be a determining a factor when
considering this type of treatment in younger patients despite
the decreased cost and lower failure rate (Fig. 3.14).
Rotates toward
B missing leg
DIVISIONS OF AVAILABLE BONE
FIG 3.13 Overdenture type analogy; (A) Two-legged chair
(2-implants) will rotate anterior and posterior, (B) Three-legged QUANTITY OF AVAILABLE BONE
chair (3-implants) which is more stable than 2-implants,
however still has movement, (C) Four-legged chair (4-5 After the type of prosthesis is determined, the available bone
implants) is the most stable with no movement. for implant placement is evaluated to determine the surgical
5 IMPLANTS 2 IMPLANTS
A B C D E A B C D E
A B
3 IMPLANTS 4 IMPLANTS
A B C D E A B C D E
C D
FIG 3.14 Mandibular RP-4/RP-5 prosthesis treatment plans. (A) RP-4; 5 implants between the
mandibular foramen regions. (B) RP-5; 2 implants. (C) RP-5; 3 implants. (D) RP-5; 4 implants.
A B C D
H
E
G F
FIG 3.16 The height of available bone is measured from the

crest of the edentulous ridge to the opposing landmark. The
opposing landmark may be in the maxillary canine region (A),
loor of the nares (B), maxillary sinus (C), tuberosity (D), man-
dibular canine region (G), anterior mandible (F), or bone above
the inferior mandibular canal (E). (From Misch CE: Dental
L
FIG 3.15 Available bone is measured in height (H), width (W),
and length (L). Also considered are crown height space and
angulation of bone (which is related to the direction of force bone to insert dental implants (Fig. 3.17). However, the
to the implant body). (From Misch CE: Dental implant pros- crown height of the prosthesis may be extensive (e.g., FP-2,
thetics, 2e, St Louis, 2015, Mosby.) FP-3) because of the loss of bone. This region often has the
most available bone but also may have the greatest crown
height space.
approach necessary (i.e., bone augmentation, implant inser- The anterior bone region in the mandible extends between
tion, or both) to support the intended prosthesis. The avail- the right and left mental foramens. The mental foramen is
able bone concept describes the amount of bone in the most often found in close proximity to the two premolars.
edentulous area considered for implantation. Available bone The anterior region of bone extends beyond the canines and
is measured in width, height, length, and angulation and to the irst premolar region most often. The initial mandibu-
crown height space (CHS) in relation to the remaining bone lar bone height is inluenced by skeletal anatomy, with Angle
(Fig. 3.15). If the bone is inadequate to predictably support Class II patients having shorter mandibular height and Angle
an implant, a bone graft is considered in the ideal site(s), or Class III patients exhibiting the greatest height.
alternative sites may be considered when additional implant The opposing landmarks for both the maxilla and man-
numbers are necessary. dible of the initial available bone height are more limiting in
the posterior regions distal to the irst premolar. In the maxil-
Not Understanding the Parameters lary posterior jaw region, there is usually greater bone height
of the Available Bone in the irst premolar than in the second premolar, which has
To avoid complications in assessing the available bone present, greater height than the molar sites because of the concave
the implant clinician must understand the correct parameters morphology of the maxillary sinus loor. As a consequence,
in determining the bone height, width, and length. the existing bone anatomy of the implant patient often
requires modiication (e.g., sinus augmentation) to enhance
Available Bone Height. The available bone height is irst long-term implant success (Fig. 3.21).
determined by radiographic evaluation (preferably cone The posterior height of bone in the mandibular region is
beam computed tomography [CBCT]) in the edentulous reduced because of the presence of the mandibular canal,
region by measuring from the crest of the edentulous ridge situated approximately 12 mm above the inferior border of
to the opposing anatomic landmark. The anterior regions of the mandible (Fig. 3.18). Generally, less available bone is
the jaws have the greatest height due to the pneumatization present in the higher force areas of the posterior mandible
of the maxillary sinus and the inferior alveolar nerve limits and maxilla; however, many treatment plans include shorter
this dimension in the mandibular posterior regions. The and fewer number of implants. Oikarinen et al found that
maxillary canine eminence region, just lateral to the lateral more than 6 mm of bone height is found in less than 50% of
piriform rim of the nose, often offers the greatest height of posterior mandibles and 40% of posterior maxillae in par-
available bone in the maxillary anterior (Fig. 3.16).7 tially edentulous patients.8
As a general rule, the anterior mandible has the greatest In the literature, the suggested minimum bone height for
bone height. There is more bone apical to the mandibular predictable long-term endosteal implant survival approaches
anterior teeth than any other region. Even after the resorption 12 mm. Failure rates reported in the literature for implants
of the residual ridge after tooth loss, there is usually adequate shorter than 9 mm tend to be higher, independent of the
FIG 3.17 The anterior mandible has the greatest bone height of any region of the jaws. However,
because of the variable osseous angulation in the anterior mandible, the implant often engages
the lingual plate of bone.
than height, so even when the width is inadequate for implant

placement, bone grafting may be used to create a site ideal for
restorative and implant insertion requirements.
Available Bone Width. The width of available bone is mea-

sured between the facial and lingual plates at the crest of the
potential implant site. The crestal aspect of the residual ridge
in the mandible is often cortical in nature and exhibits greater
density than the underlying trabecular bone regions. This
mechanical advantage permits immediate ixation of the
implant, provided this cortical layer has not been removed by
osteoplasty.
The crest of the edentulous ridge is most often supported
by a wider base in the anterior mandible. In most mandibular
situations, because of this triangular cross-section, an osteo-
plasty provides greater width of bone, although of reduced
height (Fig. 3.19).
It should be noted that crest reduction (osteoplasty) affects
the location of the opposing landmark, with possible surgical
consequences, including implant size selection, implant posi-
FIG 3.18 The posterior mandible has less bone height tion, and inal prosthesis design. This is particularly impor-
because the variable position of the inferior alveolar canal
tant when a FP-1 prosthesis is planned, with the goal of
which dictates the size and positioning of the implant.
obtaining a normal contour and proper soft tissue drape
around a single tooth replacement.
Unlike the anterior mandible, the anterior maxilla often
manufacturer design, surface characteristic, and type of does not follow the triangular anatomy. The palatal plate
application.9,10 of bone is more parallel to the facial plate in the maxilla
The available bone height in an edentulous site is the most (Fig. 3.20). In addition, many edentulous ridges exhibit a
important dimension for implant consideration because it labial concavity in the incisor area, with an hourglass conigu-
affects both implant length and associated crown height. ration. As a result, osteoplasty does not increase the width of
Crown height space directly affects force factors and esthetics. bone as much as in the mandible. As a consequence, bone
In addition, bone augmentation is more predictable in width augmentation for width is more often indicated in the maxilla.
After adequate height is available, the next most signiicant

factor affecting the long-term survival of endosteal implants
is the width of the available bone. Root form implants with
crestal diameters of 4 mm usually require more than 6 mm
of bone width to ensure suficient bone thickness and blood
supply around the implant for predictable survival. This
dimension provides more than 1 mm of bone on each side
of the implant at the crest. Because the bone usually widens
apically in the mandible, this minimum dimension rapidly
increases. For root form implants, the minimum bone thick-
ness is located in the midfacial and midlingual contours of
A B the crestal region exclusively (Fig. 3.21).
FIG 3.19 (A) The anterior mandible usually has a wider base
than the crest of the ridge and often forms a triangular-shaped Available Bone Length. The mesiodistal length of available
cross-section. (B) An osteoplasty to the narrow ridge in the
bone in an edentulous area is often limited by adjacent teeth
anterior mandible increases the width of crestal bone (and
or implants. As a general rule, the implant should be at least
reduces the available bone height). (From Misch CE: Dental
implant prosthetics, ed 2, St Louis, 2015, Mosby.) 1.5 to 2.0 mm from an adjacent tooth and 3 mm from an
adjacent implant. This dimension not only allows minor sur-
gical error but also compensates for the width of an implant
or tooth that acquires a crestal defect, which is usually less
than 1.4 mm. As a result, if bone loss occurs at the crest
module of an implant or from periodontal disease with a
tooth, the vertical bone defect will not spread to a horizontal
1 2 3 4 5 defect and cause bone loss on the adjacent structure.11 In the
case of a single-tooth replacement, the minimum length of
available bone necessary for an endosteal implant depends on
the width of the implant. For example, a 5-mm–diameter
implant should have at least 8 mm of mesiodistal bone, so
1.5 mm is present on each side of the implant. A minimum
mesiodistal length of 7 mm is usually suficient for a 4-mm–
diameter implant.
The diameter of the implant is also related to the width of
available bone and, in multiple adjacent sites, is primarily
FIG 3.20 The anterior maxilla most often has the palatal wall limited in this dimension. For example, a width of bone of
of bone parallel to the facial cortical plate. Osteoplasty is less 4.5 mm without augmentation requires a 3.5-mm or smaller
effective to increase the bone width. Augmentation proce- implant, with inherent compromises (e.g., less surface area
dures are most often warranted. (From Misch CE: Dental and greater crestal stress concentration under occlusal loads
implant prosthetics, ed 2, St Louis, 2015, Mosby.) on abutment screw and marginal bone). In narrow ridges, it
3.0mm
A B
FIG 3.21 Available bone length. (A) Evaluation of available bone length between two teeth is
most accurately determined with axial views. (B) In determining available bone length, a minimum
of 3 mm is required for hard and soft tissue health.
is often indicated to place two or more adjacent narrow- the second premolar region the angulation may be 10 degrees
diameter implants (when possible) to obtain suficient to a horizontal plane; in the irst molar areas, 15 degrees; and
implant–bone surface area to compensate for the deiciency in the second molar region, 20 to 25 degrees.
in width of the implant. Because the implants should be The limiting factor of angulation of force between the
3 mm apart and 1.5 to 2.0 mm from each tooth, 13 mm or body and the abutment of an implant is the width of
more in available bone mesiodistal length may be required bone. In edentulous areas with a wide ridge, wider root
when the narrower implant dimensions are used to replace a form implants may be utilized. Implants may allow up to
posterior tooth. 30 degrees of divergence with the adjacent implants, natural
The ideal implant mesiodistal width for single-tooth teeth, or axial forces of occlusion with minimum compro-
replacement is often related to the natural tooth being mise. However, angled loads to an implant body increases the
replaced in the site. The tooth has its greatest width at the crestal stresses to the implant components and bone, but the
interproximal contacts, is narrower at the cementoenamel greater-diameter implant decreases the amount of stress
junction (CEJ), and becomes even narrower at the initial transmitted to these structures. In addition, the greater width
crestal bone contact, which is 2 mm below the CEJ.12 The of bone offers some latitude in angulation at implant place-
ideal implant diameter corresponds to the width of the ment. The implant body may often be inserted so as to reduce
natural tooth, which may be measured 2 mm below the CEJ the divergence of the abutments without compromising the
of the adjacent tooth. In this way the implant crown emer- permucosal site.
gence (emergence proile) through the soft tissue may be An acceptable bone angulation in the wider ridge may be
similar to that of a natural tooth. For example, a maxillary as much as 30 degrees. The narrow yet adequate width ridge
irst premolar is approximately 8 mm at the interproximal often requires a narrower design root form implant. Com-
contact, 5 mm at the CEJ, and 4 mm at a point 2 mm below pared with larger diameters, smaller-diameter designs result
the CEJ. A 4-mm–diameter implant (at the crest module) in greater crestal stress to the system (abutment screws, crestal
would be the ideal if it is positioned at least 1.5 mm from the bone) and may not offer the same range of custom abut-
adjacent roots (2 mm below the CEJ). ments. In addition, the narrower width of bone does not
permit as much latitude in placement regarding angulation
Available Bone Angulation. Bone angulation is the fourth within the bone. This limits the acceptable angulation of
determinant for the evaluation of available bone. The alveolar bone in the narrow ridge to 20 degrees from the axis of the
bone angulation represents the natural tooth root trajectory adjacent clinical crowns or a line perpendicular to the occlu-
in relation to the occlusal plane. Ideally, this angulation is sal plane (Fig. 3.22).
perpendicular to the plane of occlusion, which is aligned with
the forces of occlusion and is parallel to the long axis of the Crown Height Space. The crown height space (CHS) is
prosthodontic restoration. The incisal and occlusal surfaces deined as the vertical distance from the crest of the ridge to
of the teeth follow the curve of Wilson and curve of Spee. As the occlusal plane. It affects the appearance of the inal pros-
such, the roots of the maxillary teeth are angled toward a thesis and may affect the amount of movement force on the
common point. The mandibular roots lare, so the anatomic implant and surrounding crestal bone during occlusal
crowns are more lingually inclined in the posterior regions loading. Esthetically, the prosthesis is less likely to replace the
and labially inclined in the anterior area compared with the sole anatomic crowns of natural teeth when a greater CHS is
underlying roots. The irst premolar cusp tip is usually verti- present.
cal to its root apex. The CHS may be considered a vertical cantilever. Any
The maxillary anterior teeth are the only segment in either direction of load that is not in the long axis of the implant
arch that does not receive a long-axis load to the tooth roots will magnify the crestal stresses to the implant-bone interface
but instead are usually loaded at an approximate 12-degree and to the abutment screws in the restoration. The greater
angle. As such, their root diameter is greater than the the CHS, the greater the moment force or lever arm with any
mandibular anterior teeth. In all other regions of the mouth, lateral force or cantilever (Fig. 3.23).
the teeth are loaded perpendicular to the curves of Wilson
and Spee.
Rarely does the bone angulation remain ideal after the loss
of teeth, especially in the anterior edentulous arch. In this
region, labial undercuts and resorption after tooth loss often
mandate greater angulation of the implants or correction of
the site before insertion (osseous augmentation). For example,
in the anterior mandible, the implant insertion often engages
the lingual cortical plate, rather than the inferior border of
the mandible, as a consequence of the position of the incisal
edge and the angulation of bone. In the posterior mandible, FIG 3.22 As bone resorbs from the buccal, the mandible will
the submandibular fossa mandates implant placement with become more angled toward the lingual, resulting in an angu-
increasing angulation as it distally progresses. Therefore, in lation complication for implant placement.
A B
A B
FIG 3.24 (A) Division A bone. (B) Treatment plan includes
FIG 3.23 Crown height space. (A) Lateral CBCT view of max- placement of conventional size implant.
illa and mandibular edentulous areas in relation to the incisal
edge. The incisal edge does not change position; however,
as bone loss advances, the CHS increases leading to greater
potential for force-related complications. (B) Ideal crown
BOX 3.1 Division A Bone Dimensions
height space varies with respect to the intended prosthesis Width >6 mm
(i.e., FP-3, RP-4, RP-5). Height >12 mm
Mesiodistal length >7 mm
Angulation of occlusal load (between occlusal plane and
implant body) <30 degrees
Crown height space ≤15 mm
The absence of a periimplant ligament means that the (From Misch CE: Dental implant prosthetics, ed 2, St Louis,
bone-implant stresses cannot be reduced by increasing the 2015, Mosby.)
implant height. Therefore, as the CHS increases and a canti-
lever or a lateral load is planned on the restoration, a greater
number of implants or wider implants should be inserted to
counteract the increase in stress. For an ideal treatment plan, and 12 mm or longer in height (length). A larger-diameter
the CHS should be equal to or less than 15 mm under ideal implant is suggested in the molar regions (5 to 6 mm in
conditions. diameter). Longer implants are suggested in immediate
loading treatment options or when an implant is immediately
Not Understanding the Divisions of Bone: inserted after the extraction of the tooth. As a general rule,
Division A (Abundant Bone) Division A bone should not be treated with smaller-diameter
The Division A edentulous ridge exhibits abundant bone in implants for the inal prosthesis, unless dictated by the spe-
all dimensions of height, width, and length. Division A root ciic tooth replacement (e.g., maxillary lateral incisors or
form implants are optimal and most often used as indepen- mandibular incisors) (Fig. 3.24). There are several advantages
dent support for a ixed or removable prosthesis. Division A to the use of implants equal to or greater than 4 mm in diam-
bone is the ideal type of bone to provide a natural looking eter compared with smaller-diameter implants (Box 3.2).
FP-1 prosthesis.
Prosthetic Treatment
Criteria Division. Division A bone corresponds to abundant Fixed. FP-1 restorations require a Division A ridge.
available bone in all dimensions; the height of 12 mm or However, a FP-2 prosthesis most often also requires a Divi-
more, width of >6 mm, angulation <30 mm, and crown sion A bone. A FP-2 restoration is the most common poste-
height space of <15 mm. Osteoplasty may often be performed rior restoration supported by multiple adjacent implants in
to obtain additional bone width in the mandible when a partially edentulous patients because of either bone loss or
larger diameter implant is desired. In rare instances, an angle osteoplasty prior to implant placement. A FP-3 prosthesis is
abutment will be required; however, the direction of load is most often the option selected in the anterior Division A
not excessive (Box 3.1). bone when multiple adjacent teeth are missing and the maxil-
lary smiling lip position is high, or a mandibular low lip line
Surgical Treatment. The implant choice in Division A bone during speech exposes regions beyond the natural anatomical
is a Division A root form that is 4 mm or greater in diameter crown position.
BOX 3.2 Division A Root Form

Implant Advantages
• The larger the diameter of an implant, the greater the surface D D
A
area and the less stress distributed through the crestal bone C C
B B A
region.
• The larger-diameter implants are closer to the lateral corti-
A A
cal plates of bone, which have greater density and
B B
increased strength, modulus of elasticity, and bone-implant
contact percentages. C-h
C-h
• The larger-diameter implants are less likely to fracture D
because the strength of the material is increased by a power Bone loss D
of four related to the radius of the implant (e.g., a 4-mm-diam-
FIG 3.25 The resorption of bone in the maxilla results in the
eter implant is 16 times stronger than a 2-mm-diameter
ridge becoming more narrow because it resorbs toward the
implant).
midline. The initial mandibular bone loss also resorbs toward
• The smaller-diameter implants are often one-piece implants
the midline. However, moderate to severe bone loss condi-
to decrease the risk of fracture.
tions result when the mandible is wider than the original
• The one-piece implants require an immediate restoration
mandibular crest. (From Misch CE: Dental implant prosthet-
rather than a submerged or one-stage approach. As such,
ics, ed 2, St Louis, 2015, Mosby.)
micromovement may occur at the bone-implant interface,
with an increased risk of crestal bone loss and implant
failure.
• The emergence proile angle of the crown is related
to the implant diameter. The larger-diameter teeth
can be most esthetically restored with a wider-diameter Complications. Complications with Division A bone are
implant. minimal. The most common complication is not assessing
• The larger the implant diameter, the less stress applied to the crown height space, which may impinge on the prosthetic
the abutment screw, and complications such as screw rehabilitation. Many clinicians fail to educate the patient
loosening or fracture are less likely.
about the rapid decrease in bone volume width and the con-
• The larger-diameter abutment provides greater cement
sequences of delaying treatment. When the bone volume is
retention for the inal restoration crown.
• Oral hygiene procedures are more compromised around
Division A, there is a decrease in treatment costs, with a
smaller-diameter implants restored with greater emer- reduction in the number and complexity of surgeries to the
gence proile angles and over contoured restorations. edentulous area (Fig. 3.25).
• The crest module and crestal portion of many two-
piece, smaller-diameter implants are smooth metal to
Not Understanding the Divisions of Bone:
increase the interbody wall thickness, thus creating shear Division B (Barely Suficient Bone)
loads to the crestal bone and an increased risk of bone The decreased width and surface area usually require addi-
loss. tional implants to be included in the inal prosthesis design.
• Implant costs to the patient are related to implant number, Division B may be changed to Division A by augmentation
not diameter. Increases in implant numbers for smaller-
or osteoplasty. The treatment options may be selected in light
diameter implants increase the cost to the patient (and
of the area to be treated. For example, in the anterior maxilla,
clinician).
• Division A root form implants can provide the greatest
augmentation is most often selected because of esthetics. In
range of prosthetic options. the anterior mandible, osteoplasty is common because of the
available bone height and low esthetic concerns. In the
(From Misch CE: Dental implant prosthetics, ed 2, St Louis, posterior mandible, multiple Division B implants may be
2015, Mosby.)
used when the bone density is favorable, the available bone
height is limited, and esthetics are not a primary factor. When
stress factors are a concern, bone augmentation precedes
Division B root form implants regardless of the anatomic
Removable. For removable implant overdentures in Divi- location (Box 3.3).
sion A bone, the inal position of the tooth and superstruc- As the bone resorbs, the width of available bone irst
ture bar must be evaluated before surgery. A limited CHS decreases at the expense of the facial cortical plate because
is more common in Division A bone, and an RP-4 or RP-5 the cortical bone is thicker on the lingual aspect of the alveo-
restoration may require osteoplasty before implant place- lar bone, especially in the anterior regions of the jaws. This
ment. Division A bone may represent a contraindication for may result in a 25% decrease in bone width the irst year and
high-proile O-ring attachments or superstructures placed a 40% decrease in bone width within the irst 1 to 3 years
several millimeters above the tissue. This may result in difi- after tooth extraction.13 The resulting narrower ridge is often
culty in prosthesis fabrication, esthetics, hygiene, adequate inadequate for most 4-mm-diameter root form implants
strength of the prosthesis. (Box 3.4).
Complications
BOX 3.4 Disadvantages of Division B
Division B root forms. Division B bone offers suficient Root Forms
available bone height with compromised bone width. The
Division B available bone width may be further classiied into 1. Almost twice the stress is concentrated at the top crestal
region around the implant.
ridges 4 to 6 mm wide and B minus width (B−w) 2.5 to 4 mm
2. Reduced overall surface area results in increased lateral
wide, where bone grafting is indicated most likely (Fig. 3.26).
loads causing three times greater stress on the implant in
Because the ridge width and implant diameter are narrower, comparison to Division A root form implants. This means
and forces increase as the angle of load increases, the angula- the lateral loads on the implant are tripled.
tion of occlusal load is also less and should be ideally within 3. Fatigue fractures of the implant, abutment, and abutment
20 degrees from the axis of the adjacent teeth or occlusal screw post are increased, especially under lateral loads.
plane. A CHS of 15 mm or less (similar to Division A) is • The crown emergence proile is less esthetic (except for
necessary in Division B to decrease the moment of forces with maxillary lateral or mandibular incisors).
lateral or offset loads, especially because of the smaller width 4. Periodontal conditions for daily care are compromised
dimension. around the cervical aspect of the crown.
5. The implant design is most often poor in the crestal region.
To increase implant body wall thickness and to reduce
fracture, no threads or compressive force design are
present; however, this further increases stress and the
amount of shear loads to bone.
BOX 3.3 Division B Dimensions 6. The angle of load must be reduced to less than 20 degrees
2.5–6 mm wide to compensate for the small diameter biomechanical
B+: 4–6 mm disadvantage.
B−w: 2.5–4 mm 7. Two implants are often required for proper prosthetic
Height >12 mm support unless anterior single-tooth replacement for maxil-
Mesiodistal length >6 mm lary laterals or mandibular incisors, thus surface area will
Angulation <20 degrees be greater because of implant number, not diameter.
Crown height space <15 mm 8. Implant costs are not related to diameter, so an increase
in implant number results in greater cost to the doctor and
(From Misch CE: Dental implant prosthetics, ed 2, St Louis, patient.
2015, Mosby.)
A B B–w C–w C–h D

FIG 3.26 In 1985 Misch and Judy presented a classiication of available bone (Divisions A, B, C,
D), which is similar in both arches. Implant, bone-grafting methods, and prosthodontic-related
treatment was suggested for each category of bone. A, Abundant; B, barely suficient; C, com-
promised; D, deicient; h, inadequate height; w, inadequate width. (From Misch CE: Dental
implant prosthetics, ed 2, St Louis, 2015, Mosby.)
Not understanding the need for modiication. Three treat- mandible, where bone density is good and esthetic require-
ment options are available for the Division B edentulous ments are limited.
ridge: 3. The third alternative treatment for Division B bone is to
1. Modify the existing Division B ridge to Division A by change the Division B ridge into a Division A by grafting
osteoplasty to permit the placement of root form implants the edentulous ridge with autogenous bone or allogenic
4 mm or greater in width. When more than 12 mm of bone (Fig. 3.29). A disadvantage of this treatment plan
bone height remains after osteoplasty, the Division B bone
is converted to Division A. When less than 12 mm of bone
height remains after osteoplasty, a biomechanical disad- FP-1 FP-3
vantage results due to the ridge being changed to a Divi-
sion C−h (Fig. 3.27).
2. The second treatment option is the placement of a narrow
diameter implant (3–4 mm diameter and 12 mm or more
in length; Fig. 3.28). Smaller-diameter root form implants
(3.0–3.5 mm) are designed primarily for Division B avail-
able bone. Because Division B bone is compromised in
width, there exists less margin of error in the ideal place-
ment. The Division B root form implants present several
inherent disadvantages compared with the larger-diameter
implants.14 As a result of these concerns for the Division
B root form, this option is most often used for single-tooth
replacement of a maxillary lateral incisor or mandibular
incisors, where the restricted available bone is in mesio-
distal width, or with multiple implants in the posterior
FIG 3.28 Options to treat a Division B ridge in the anterior

mandible include a narrow implant with a inal prosthesis
closer to anatomic dimensions (FP-1) (left), or osteoplasty
with Division A root forms and extended crown heights (FP-2
or FP-3) (right). (From Misch CE: Dental implant prosthetics,
ed 2, St Louis, 2015, Mosby.)
B
FIG 3.27 Changing Division B to Division A. (A) Because of FIG 3.29 Ideal Division B option. A Division B bone may be
the resorptive process, compromise in width occurs rather modiied to Division A by doing a bone augmentation. This
quickly. (B) Conversion to Division A via osteoplasty in the treatment option is most often required for a FP-1 prosthesis.
anterior mandible acquiring a minimum of 6 mm of width for (From Misch CE: Dental implant prosthetics, ed 2, St Louis,
placement of a 4 mm diameter implant. 2015, Mosby.)
includes the need for adequate bone healing. The emer- Not Understanding the Divisions of Bone:
gence proile angle of the inal crown, which does not Division B−w (B Minus Width)
compromise hygiene, requires a Division A root form The distinction between Division B and Division B−w is espe-
implant (with the exception of maxillary lateral incisors cially important when augmentation is the method of choice.
or mandibular incisors). Stress factors may also dictate the Bone augmentation is more predictable when the volume to
augmentation approach to Division B bone in order to augment is minimal and is for width and least predictable
utilize larger-diameter implants. In the presence of unfa- when additional bone height is desired. For example, a width
vorable stress factors, the number and width of abutments increase of 1 to 2 mm may be obtained with an alloplast and
should be increased without increasing the CHS to provide guided bone regeneration, but more than 2 mm of width is
a greater surface area of resistance to the magniied forces, more predictable with autologous bone as part of the graft.
which most likely will require augmentation. To accom-
plish this goal, augmentation is most ideal in Division Complications
B bone. More bone augmentation required. The Division B−w
Modiication from Division B to Division A may lead to a ridge will usually require more than 2 mm of width increase,
change in prosthesis. When a Division B ridge is changed to and therefore autologous bone or an autologous/allogenic graft
a Division A by osteoplasty procedures, the inal prosthesis is beneicial to predictably grow the additional bone width. If
design has to compensate for the increased CHS. For example, the Division B−w ridge contour requires alteration altered for
before surgery, the available bone height may be compatible improved prosthodontic relationships, an onlay particulate or
with an FP-1 prosthetic design. If, at the time of surgery, the block graft of autogenous bone is indicated. The autograft may
ridge is found deicient in width for implant placement, it is be harvested from an intraoral region (e.g., the mandibular
not unusual to remove crestal bone before reaching a Divi- symphysis or ramus) and placed along the lateral aspect of the
sion A width. This means the inal restoration will require an ridge that corresponds to ideal arch form. The implant place-
additional height. It may result in an extended tooth (FP-2, ment is usually delayed for 4 to 6 months after the augmenta-
FP-3) restoration, which may not be acceptable to the patient. tion process to permit ideal implant placement and to ensure
Insuficient osteoplasty. The most common approach complete bone formation before placing the implant.
to modify the narrower Division B ridge into another bone Bone resorption progression. The patient delaying treat-
division by osteoplasty is when the inal restoration is a man- ment with a Division B bone situation should be informed
dibular implant overdenture. Because of the resorptive of the future bone volume resorption that presents from
process that occurs in the anterior mandible, an osteoplasty disuse atrophy. The augmentation of bone in height is much
is usually indicated to allow for adequate bone width if the less predictable and requires more advanced techniques than
CHS is less than 15 mm; this maybe be advantageous for a augmentation of bone width alone (Fig. 3.31). For example,
ixed prosthesis and problematic for a removable prosthesis. the patient may not be experiencing problems with a maxil-
When a RP-4 or RP-5 is planned, care should be noted to lary denture, but the Division B bone will resorb in height
make sure adequate CHS is available. If insuficiency osteo- and decrease the stability and retention of the removable soft
plasty is performed, lack of space will be available for the tissue–supported prosthesis. When treatment is delayed until
prosthesis, which may lead to prosthesis fracture, tooth frac- patient problems begin, the overall result may be more dif-
ture, or tooth delamination. Ideally, greater than 2 mm of icult to achieve and more costly to the patient.
acrylic is required to secure an attachment or a denture tooth
(Fig. 3.30).
Bone loss over time
A
B
Bone loss
C–w
C–h
D
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Time (years)
(anterior maxilla and mandible)
FIG 3.31 Bone rapidly resorbs from Division A to Division B

then plateaus for many years before it is Division C−w. From
Division C−w to C−h, it resorbs rapidly. Long plateaus are
FIG 3.30 Mandibular overdenture with inadequate osteo- found for both Division B and Division C−h. (From Misch CE:
plasty leading to decreased crown height space. Dental implant prosthetics, ed 2, St Louis, 2015, Mosby.)
Final prosthesis. The inal prosthesis type for Division B grafting procedures will be more challenging after the height
ridges is dependent on the surgical option selected. Whereas has been reduced.
grafted ridges will more often be used when a ixed prosthesis After the C−h ridge is augmented, it is treated with the
is desired, ridges treated with osteoplasty before implant options available in the acquired bone division. A patient who
placement are likely to be supporting removable prostheses. desires a ixed prosthesis often requires an autogenous graft
The treatment option may be inluenced by the region to be before implant placement to acquire proper lip support and
restored. For example, in a partially edentulous anterior ideal crown height.
maxilla, augmentation is most often selected because of Augmentation of C−w is most often used when prosthetic
esthetics, and the parallel bony anatomy of the residual ridge guidelines require a ixed restoration or excess force factors
is not conducive for osteoplasty to gain bone width. In the require greater surface area implants and improved biome-
edentulous anterior mandible, osteoplasty is common. In the chanics for the prosthesis (Fig. 3.32).
premolar region of the posterior mandible, Division B root
form implants are often used because the bone density is Complications of C−w
adequate, available bone height is limited and may be reduced More dificult surgery. The C−w augmentation is more
after osteoplasty, and esthetics are often not a major factor. dificult than for Division B bone because the need for bone
volume is greater, yet the recipient bed is more deicient.
Not Understanding the Divisions of Bone: Because less host bone is present, more dificulty in using
Division C (Compromised Bone) ixation screws results. Additionally, there exists a decreased
The Division C edentulous ridge exhibits moderate resorp- blood supply, which may compromise healing. Usually, block
tion and presents more limiting factors for predictable end- bone grafts are indicated with the use of bone graft factors.
osteal implant placement. The decision to restore with Soft tissue complications, such as incision line opening, are
endosteal implants or to change to a more favorable bone also more common in C−w augmentations than Division B
division via augmentation before implant placement is inlu- because of compromised attached tissue (Fig. 3.33).
enced by the prosthesis, patient force factors, and patient’s Fast resorption. The clinician must be aware that the C−w
desires. bone will resorb to a C−h ridge as fast as A resorbs to B and
The Division C ridge is deicient in one or more dimen- faster than B resorbs to C−w. In addition, without implant or
sions (width, length, height, or angulation) (Box 3.5) regard- bone graft intervention, the C−h available bone will eventu-
less of the position of the implant body into the edentulous ally evolve into Division D (severe atrophy). Care should be
site. The resorption pattern of bone occurs irst in width and noted to prevent excessive force or pressure on the ridge via
then in height. As a result, the Division C ridge continues to a removable prosthesis.
resorb in width, until it becomes inadequate for any design
of endosteal implant. Division C-h
The Division C-h bone exhibits moderate to advanced
Division C−w atrophy vertical height of bone of 7 to 9 mm, or the crown
The Division C-w is signiicantly compromised in width, and
usually requires augmentation (facial and lingual) or osteo-
plasty to convert the ridge to C−h (adequate height). On
occasion, the C−w ridge may be treated by osteoplasty in the
anterior mandible, which converts the ridge to C−h and, in
the anterior mandibular region, most often to a width suit-
able for root form implants. The most common available
bone division after osteoplasty of C−w is C−h available bone,
not Division A, because the CHS is greater than 15 mm. On
occasion, the C−w osteoplasty may convert the ridge to Divi-
sion D, especially in the posterior mandible or maxilla, which
most likely contraindicates implant placement. Care should
be exercised to prevent this from occurring because bone
BOX 3.5 Division C Bone

Width (C−w bone): 0–2.5 mm
Height (C−h bone) <12 mm
Angulation of occlusal load (C−a bone) >30 degrees
Crown height space >15 mm
(From Misch CE: Dental implant prosthetics, ed 2, St Louis,

A B
2015, Mosby.) FIG 3.32 (A) and (B) Division C−w.
A B C
D E
FIG 3.33 Division C augmentation. (A) Preoperative Division C defect. (B) Recipient site prepara-
tion. (C) Augmentation. (D) Five-month postoperative depicting bone growth on the buccal and
lingual. (E) Ideal implant placement.
height space of greater than 15 mm. Moderate to advanced which may cause chronic tissue-related issues. During swallow-
atrophy may be used to describe the clinical conditions of ing, it may prolapse over the residual crest and implant sites,
Division C. The posterior maxilla and mandible are common causing constant irritation of the permucosal implant posts and
areas for Division C−h bone. This is due to vital structures impairing proper design of the prosthetic superstructures.
such as the maxillary sinus or mandibular canal, which limits Short implants. In C−h ridges, a common treatment
vertical height sooner than the opposing cortical plates in the option is the use of short implants. A C−h root form implant
anterior regions. is usually 4 mm or greater in width at the crest module and
The Division C edentulous ridge does not offer as many 10 mm or less in height. Several studies indicate that implant
elements for predictable endosteal implant or prosthesis survival is decreased when an implant is less than 10 mm in
success as in Divisions A or B. Anatomic landmarks to deter- height. For example, a large multi-center study of 31 different
mine implant angulations or positions in relation to the sites and six different implant designs observed 13% failure
incisal edge are usually not present, and greater surgical skill with 10-mm implants, 18% failure with 8-mm implants, and
is required. The clinician must realize that Division C ridge 25% failure with 7-mm implants.15 The implant failure did
implant–supported prostheses are more complex and have not occur after surgery but rather after prosthetic delivery.
slightly more complications in healing, prosthetic design, or The loading failure is most likely due to an inadequate
long-term maintenance. On the other hand, the patients will implant support combined with a magniication of force
usually have greater need for increased prosthodontic support. resulting from excessive CHS.
Despite the reduced bone volume, modiications of the treat- When endosteal root form implants are used in Division
ment plan and prosthesis that decrease stress can provide C−h bone with greater crown heights, additional implants
predictable, long-term treatment (Fig. 3.34). should be placed to increase the overall implant-bone surface
area, and the prosthesis should load the implants in an
Complications C−h axial direction. Additionally, a narrow occlusal table is indi-
Mandible-loor of mouth. When the anterior mandible is cated to decrease force-related complications. Because the CHS
C−h, the loor of the mouth is often level with the residual is most likely greater than 15 mm, the design of a removable
mandibular crest of the ridge, which present many potential prosthesis should often reduce or eliminate cantilever length
complications. Additionally, less attached tissue is present, and incorporate a stress relief mechanism. Reduced long-term
FIG 3.35 Division C−a.

A
Additionally, muscle pull from the buccinator muscles along

with compromised interocclusal space make this area one of
the most dificult to restore with dental implant prostheses.
Fixed prosthesis: excessive crown height space. A ixed
restoration in the Division C−h mandible may require both
anterior and posterior implant support when force factors are
greater than usual. The ixed prosthesis in Division C−h bone
with greater than 15 mm CHS is most often a hybrid device,
with denture teeth attached to a precious metal substructure
with acrylic resin. In this way, the complications and costs of
a porcelain-metal ixed restoration may be reduced and repair
is easier. Additionally, ixed prosthesis with excessive CHS
tend to be much heavier, which leads to common patient
complaints.
Biomechanical disadvantages. In general, Division C−h
B presents less favorable biomechanical factors to the implant
support. Additional implants, cross-arch stabilization, soft
FIG 3.34 Division C−h. (A) Posterior maxilla depicting minimal tissue support, or an opposing removable prosthesis, often
bone below the sinus. (B) Posterior mandible, premolar area
need to be considered in the prosthetic design to improve the
depicting minimal bone above the mandibular canal.
long-term prognosis. The treatment of Division C−h ridges
require greater clinician experience and training because the
surgical and prosthetic principals are much different than
predictability is usually expected if additional implants or less Division A and B.
stressful prostheses are not used because a greater moment
force is transmitted to the implants and/or prosthesis. Division C−a
Posterior maxilla: implant placement without sinus graft. In the Division C−a category, available bone is adequate in
In addition to the residual alveolar bone resorption, the max- height and width, but angulation is greater than 30 degrees.
illary sinus expands after tooth loss (pneumatization). As a Mraiwa et al found that 28% of edentulous anterior mandi-
result, the available bone height is decreased from both the bles had an angulation of 67.6 ± 6.5 degrees.16 This condition
crestal and apical regions. Placing implants in the posterior is not uncommon and should be evaluated prior to any treat-
maxilla predisposes the patient to increased morbidity and ment. When present, this excessive angulation condition is
possible displacement of the implant into the maxillary sinus. most often found in the anterior mandible. Root form
Sinus grafting is often prescribed before placing endosteal implants placed in this bone category may have the abut-
implants in the C−h posterior maxilla. ments positioned within the loor of the mouth and compro-
Posterior mandible: vertical bone grafting. In adequate mise prosthetic reconstruction, speech, and comfort. Other
available bone, height is often found in the posterior man- less observed regions for Division C−a include the maxilla
dible because of residual bone loss and the position of the with severe facial undercut regions or the mandibular second
mandibular nerve (i.e., especially with type 1 nerve position). molar with a severe lingual undercut (Fig. 3.35).
Complications C−a Not Understanding the Divisions of Bone:

Malpositioned lingually. When the anterior bone angula- Division D (Deicient Bone)
tion is unfavorable, root form implants may be positioned The Division D edentulous ridge corresponds to basal bone
too far lingually for prosthodontic support, speech, or loss and severe atrophy, resulting in dehiscent mandibular
hygiene. The patient will often complain of lack of tongue canals or a completely lat maxilla. The patient often requires
space and chronic tissue inlammation and soreness. augmentation with autogenous bone before implant and
Perforate lingual plate. Another complication related to prosthodontic reconstruction. Severe atrophy describes the
the Division C–a is placement of implants that perforate the clinical condition of the Division D ridge.
bony plates. The Division C−a anterior mandible is angled
more than 30 degrees. If the clinician is unaware of this angu- Division D Maxilla. The Division D maxilla occurs when
lation, the implants may perforate the lingual plate and irri- 6 mm or less of bone exists in the anterior maxilla below the
tate the tissues of the loor of the mouth or cause signiicant loor of the nose, or less than 6 mm of posterior bone is
bleeding episodes. If the clincian places the implants within present below the maxillary sinus. In the maxilla, basal bone
the bone, they may enter the crest of the ridge at the loor loss eventually results in a completely lat maxilla. The par-
of the mouth and make it almost impossible to restore tially or completely edentulous patient with a posterior Divi-
(Fig. 3.36). sion D maxilla and healthy anterior teeth or implants may
Dificult prosthetic rehabilitation. The prosthetic options undergo sinus augmentation procedures to increase bone
for Division C ridges more often consist of removable pros- volume for implant placement. The CHS may be insuficient
theses in the completely edentulous maxillary arch. A maxil- for onlay grafts in the posterior maxilla despite a lack of avail-
lary overdenture in a Division C ridge supports the upper lip able bone height because the sinus expands faster than the
without hygiene compromise. Ideally, an RP-5 prosthesis (full crest of the ridge resorbs. Endosteal implants of adequate
palate) is recommended to decrease biomechanical forces on height can rarely be positioned in the posterior maxilla with
the implants. In the Division C mandible, the greater CHS Division D bone without a sinus graft. After 6 months post–
often mandates an overdenture design with some soft tissue sinus graft, the Division D posterior maxilla is restored to
support (RP-5). With the buccal shelf mandibular support, Division A or C−h, and root form implants may be inserted
less force will be placed on the implant prosthesis. for posterior prosthodontic support (Box 3.6 and Fig. 3.37).
Complications – maxilla. The anterior maxilla rarely pro-
vides suficient support in the Division D ridge for implants
BOX 3.6 Division D Bone

Severe atrophy
Basal bone loss
Flat maxilla
Pencil-thin mandible
>20 mm crown height

2015, Mosby.)
A
B
FIG 3.36 (A) Implant placed lingually in poorly angled man-
dible (e.g., sublingual undercut), which may lead to severe
bleeding episodes. (B) Implant attachments protruding lin-
gually in poor position for prosthetic rehabilitation and result- FIG 3.37 Division D maxilla. Coronal CBCT image depicting
ing in tongue impingement. no available bone below the sinus.
of any design. Autogenous iliac crest bone grafts to improve fracture during surgery or from implant failure or removal is a
the anterior Division D are strongly recommended before any more likely complication than in other bone divisions. Clini-
implant treatment is attempted.73 After autogenous bone cians treating anterior Division D mandibles should be able to
grafts are completed and allowed to heal for 5 or more manage future complications, which may be extensive.
months, the bone division is usually Division C−h (or pos- Implants without bone grafting. Endosteal root form
sible Division A), and endosteal implants may be inserted. implants without autogenous grafts may be used on rare occa-
The autogenous bone grafts are not intended for improved sions in the anterior Division D mandible when the remaining
denture support (without future implant placement). If soft bone is dense and the opposing arch is edentulous. Care must
tissue–borne prostheses are fabricated on autogenous grafts, be taken during placement because mandibular fracture at
the bone will resorb at an accelerated rate. Additional augmen- insertion or during postoperative healing is a possible compli-
tation to compensate for this resorption is not indicated. cation. Under these conditions the CHS is very great, and the
Repeated relines, highly mobile tissue, sore spots, and patient number of implants is often four or fewer. Implant failure
frustration are all consequences. However, autogenous bone after loading is a greater risk. Implant failure results with cir-
grafts are maintained long term in conjunction with implant cumferential bone loss, which may be associated with man-
placement. Because of the stimulation of the augmented bone, dibular fracture through the implant site. An RP-5 removable
bone supporting the implants will be maintained. The com- restoration is usually indicated for Division D with only ante-
pletely lat anterior Division D maxilla should not be aug- rior implants. However, the RP-5 restoration allows continued
mented with only hydroxyapatite (nonresorbable) to improve bone resorption and atrophy to continue in the posterior
denture support. Inadequate ridge form usually exists to guide regions. The prudent therapy is to educate the patient as to the
the placement of the material. As a result, migration of the graft risks of the situation and offer an autologous bone graft and
at the time of surgery or in the future after soft tissue loading implants to support a RP-4 restoration (Fig. 3.38).
is a frequent sequela leading to signiicant complications. Lack of early treatment. The Division D arch requires
greater clinician training and results in more frequent com-
Division D Mandible plications related to grafting, early implant failure, and soft
Complications – mandible. In the Division D mandible, tissue management, and treatment options include a more
the superior genial tubercles become the most superior aspect guarded prognosis. It should be the goal of every clinician
of the ridge. The mentalis muscle loses much of its attach- to educate and treat the patient before a Division D bone
ment, even though the superior portion of the muscle attaches
near the crest of the resorbed ridge. In the posterior mandible,
the buccinator muscle may approach the mylohyoid muscle
and form an aponeurosis above the body of the mandible.
The mandibular arch also presents with mental foraminae
and portions of the mandibular canal dehiscent. It is not
infrequent that these patients develop neurosensory impair-
ment of the lower lip, especially during mastication. The CHS
is usually greater than 20 mm, which results in a signiicant
force multiplier and can rarely be reduced enough to render
A
long-term success of the prosthesis.
Prosthesis type. The prosthetic result for anterior ridges
with Division D without augmentation is the poorest treat-
ment outcome of all the divisions of bone. Fixed restorations
are nearly always contraindicated because the CHS is so sig-
niicant resulting in a biomechanical disadvantage. When
treated without augmentation, completely implant-supported
overdentures are indicated whenever possible to decrease the
soft tissue and nerve complications. An RP-5 restoration is
not suggested because bone loss will continue in the soft
tissue–supported region of the overdenture; usually there is
lack of a buccal shelf (primary stress bearing area).
Pathologic fracture. The mandibular completely edentu-
lous Division D patient is the most dificult to treat in implant
dentistry. Beneits must be carefully weighed against the risks
associated with augmentation procedures. Although the clini-
cian and patient often regard this condition as the most desper-
ate, these patients may easily end up with pathologic fracture B
complications. If implant failure occurs, the patient may become FIG 3.38 Division D Mandible: (A) Panoramic image. (B) Ceph-
a dental cripple—unable to wear any prosthesis. Idiopathic alometric image showing minimal available bone.
condition develops. For example, the profession treats peri- Misch has postulated four general guidelines to determine
odontal diseases before pain in the region occurs, and carious key implant positions for a ixed prosthesis in the edentulous
lesions are removed from teeth before abscess formation. site with multiple adjacent teeth missing:17
Bone loss is monitored around teeth in millimeters and 1. Cantilevers on prostheses designed for partially edentu-
requires continued care to reduce the risks of future tooth lous patients or completely edentulous maxillae should
and bone loss. Likewise, prudent practitioners monitor bone preferably be eliminated; the terminal abutments in the
loss in edentulous sites and offer education and treatment restoration are key positions.
before deleterious effects occur. 2. Three adjacent pontics should not be designed in the pros-
thesis, especially in the posterior regions of the mouth.
3. When the canine is missing, the canine site is a key posi-
KEY IMPLANT POSITION tion, especially when other adjacent teeth are missing.
4. When the irst molar is missing, the irst molar site is a key
TREATMENT PLANNING implant position for all partially edentulous patients and
Implant positions are an important component of the dental completely edentulous maxillae.
implant treatment planning process, which is crucial to
reduce force reduction to the implant system. The maximum No Cantilevers
number of potential implants that may be used in a ixed The irst rule for ideal key implant positions is that no can-
prosthesis is usually determined by allowing 1.5 to 2.0 mm tilever should be designed in the ixed prosthesis for partially
or more from each natural tooth and a 3-mm space between edentulous patients or full-arch maxillary ixed restorations
each implant and adding the diameter of the implant (Fig. (unless favorable force factors). Cantilevers are signiicant
3.39). This results in dividing the length of the span by 7 mm force magniiers, which result in excessive force to the cement
for the maximum number of implants (when the implants or prosthesis screws, prosthesis superstructure, abutment
are 4 mm in diameter − 14 mm space divided by 7 = 2 × screws, implant-bone interface, and the implants.18
4.0 mm implants). Hence, a 21- to 27-mm span may have Cantilevers on ixed partial dentures (FPDs) supported by
three implants, and a 28- to 34-mm span may have four teeth have a higher complication rate than prostheses with
implants. The key implant positions are more important sites terminal abutments.19 The primary causes of traditional
than the others to reduce biomechanical forces. When uti- three-unit FPD failure with natural tooth abutments are
lized, the key implant abutment locations will decrease bio- caries and endodontic complications (often related to the
mechanical complications. tooth preparation or decay). The 5-year survival rate of the
traditional FPD is often above 95%.20 However, when a can-
tilevered three-unit FPD supported by two teeth is used to
replace a missing tooth, the failure rate is over 25% within
the irst 5 years, and the complication rate increases to 40%
by 10 years; the primary cause of failure is biomechanics.21
When a load is placed on the cantilever portion of a prosthe-
sis, the abutment farthest from the cantilevered pontic has a
tensile and shear force applied to the cement seal because the
tooth adjacent to the pontic acts as a fulcrum (Fig. 3.40). Cements
are 20 times weaker to tension and shear compared with forces
in compression.22 Therefore, with a cantilevered prosthesis, the
cement seal breaks on the most distal abutment, and then the
abutment often decays. The abutment closest to the cantilever
becomes mobile or fractures (especially when endodontics was
performed) because it is the only retained abutment for the
Z Y X prosthesis. These biomechanical-related complications usually
occur in a relatively shorter period of time compared with bio-
logic complications (e.g., decay or periodontal disease).
1.5 mm 3 mm 3 mm 1.5 mm One Missing Tooth

Ideal placement. When one tooth is replaced with an
d implant, the implant should be inserted into the mesiodistal
d = 1.5 mm + ØZ + 3 mm + ØY + 3 mm + ØX + 1.5 mm center of the site. If the implant is positioned in the mesial-
FIG 3.39 The maximum number of implants in an edentulous distal center, a cantliever will result. As a general rule, the
span may be determined by allowing 1.5 mm or more from implant should be 1.5 to 2 mm from an adjacent tooth. Care
an adjacent tooth and 3 mm between each implant and should be exercised to decrease the possibility of placing the
adding the diameter of the implants. (From Misch CE: Dental implant too far from the natural teeth. This will also result in
implant prosthetics, ed 2, St Louis, 2015, Mosby.) a cantilevered prosthesis.
Implant size. A 4-mm implant requires 7 mm of space Two Missing Teeth. When two adjacent teeth are missing,
(4 mm + 1.5 mm + 1.5 mm). When a molar (∼10–12 mm) is two implants should ideally support the implant restoration.
replaced, the implant should be larger in diameter to decrease As a result, whenever two adjacent teeth are missing and the
the mesial and distal cantilever and placed in the mesiodistal space is 12 mm or more, two adjacent implants should be
center of the edentulous site. This decreases the biomechanical- inserted, even in the esthetic zone.
related risks to the implant system. A common treatment To enforce the rule of no cantilever, the key implant posi-
planning problem is when the implant size is selected on the tions indicate one implant per tooth when one or two adja-
available bone with no emphasis on the space being replaced cent teeth are missing with a span of more than 12 mm (when
(Figs. 3.41 and 3.42). the implant diameter is 3 mm), 13 mm (when one implant
is 3 mm and the other 4 mm), and so on (Fig. 3.43).
When one of the two (or more) missing teeth include a
molar, one of the terminal implants should be positioned
1.5 mm from the anterior adjacent tooth and the other ter-
minal implant at the distal of the last molar, not in the middle
of the molar. In this fashion, the 3-mm cantilever from the
midmolar to the marginal ridge is eliminated when the
implants are splinted together. When the implant is not posi-
tioned in the distal molar position, the size of the last molar
should be reduced to eliminate the cantilever. The clinician
should be aware that the last molar should ideally be a
premolar-size crown when the distal implant is positioned in
the mesial to midmolar position.
Lower incisor option. When missing two mandibular inci-
sors, usually one implant may be placed interproximally,
slightly lingual with a screw-retained prosthesis. If all four
lower incisors are missing, two implants may be placed inter-
proximally, distributing the cantilever amount equally (Fig.
3.44). This area involves lower force factors.
FIG 3.40 When a compressive force is placed on a cantilever Three Missing Teeth. When three adjacent teeth are
from two (or more) natural teeth, the closest tooth acts as a
missing, the key implant positions include the two terminal
fulcrum, and the distal tooth from the cantilever has a shear
and tensile load applied to the cement seal. In this example, abutments, one on each end of the prosthesis (Fig. 3.45).
the compressive load is applied to a irst premolar, the second A three-unit prosthesis may be fabricated with only these
premolar acts as a fulcrum, and the shear and tensile load is abutments when most of the force factors are low to moder-
applied to the irst molar. (From Misch CE: Dental implant ate and the bone density is favorable. A cantilevered restora-
prosthetics, ed 2, St Louis, 2015, Mosby.) tion on multiple splinted implants may be compared to a
A B
FIG 3.41 (A) An implant was placed in the distal position to restore a irst molar. A mesial 7-mm
cantilever was used to restore the crown. (B) The irst molar implant fractured within a few
years. Two implants should have been used to replace a molar tooth this large. (From Misch CE:
Dental implant prosthetics, ed 2, St Louis, 2015, Mosby.)
A B
FIG 3.42 Cantilever. (A) Implant distally placed in mandibular right irst molar position that
resulted in a mesial cantilever. (B) Focre-related fatigue resulted in fracture of the implant body.
with a cantilever or extension of 20 mm, the mechanical

advantage is 2 (20 mm/10 mm). In this example, a 25-lb force
on the cantilever results in a 50-lb tensile force on the farthest
abutment from the cantilever (25 lb × 2 = 50 lb). The abut-
ment closest to the cantilever (fulcrum) receives a compres-
sive force equal to the sum of the other two forces, or, in this
example, 75 lb (25 lb + 50 lb). In other words, the force on
the cantilever increases the force on the implants by two to
three times (Fig. 3.46). Cantilevers magnify forces to all the
abutments supporting the prosthesis.
When a cantilevered force exists, a greater load to the
implant farthest from the cantilever results in a tensile or
shear type of force, and any part of the implant system is at
4 4 an increased risk of biomechanical failure (e.g., porcelain
fracture, uncemented prosthesis, abutment screw loosening,
crestal bone loss, implant failure, implant component or body
fracture). This is especially observed when parafunction or
1.5 mm 3 mm 1.5 mm
increased CHS exists.
FIG 3.43 When two adjacent teeth are missing in the esthetic
To eliminate posterior cantilevers, bone augmentation is
zone, the implants should be 1.5 mm from the teeth and
3 mm (or more) apart. This means a 12-mm space is required often indicated to increase bone volume for implant place-
when the implants are 3 mm in diameter, and 14 mm is ment. However, there does exist disadvantages of bone aug-
required for two 4-mm-diameter implants. A-P, anteroposte- mentation procedures. Bone augmentation often requires an
rior. (From Misch CE: Dental implant prosthetics, ed 2, additional surgery before implant placement. Additional
St Louis, 2015, Mosby.) training is required to learn bone augmentation procedures,
the learning curve is longer, and it is more dificult to become
accomplished in these techniques. Complications related to
class I lever.18 The extension of the prosthesis from the last bone augmentation are more common than implant surgery
abutment is the effort arm of the lever. The last abutment in existing bone volumes and may be more extensive and even
next to the cantilever acts as a fulcrum when a load is applied debilitating to the patient. However, cantilevered implant
to the lever. The distance between the last abutment and the prostheses have a more frequently observed biomechanical
farthest abutment from the end of the cantilever represents risk than the surgical risks of augmentation, and these risks
the resistance arm, and the distance between the implants can cause the loss of the entire implant support and prosthe-
may be called the anteroposterior distance, or A-P spread. sis. Additionally, bone loss and resultant defects from implant
The length (usually in millimeters) of the cantilever (effort failure may make the following bone augmentation proce-
arm) divided by the resistance arm represents the mechanical dures even more dificult to perform than when treatment
advantage. Therefore when two implants are 10 mm apart was rendered in the original condition.
A B
FIG 3.44 Mandibular anterior treatment planning. (A) Missing two mandibular incisors are ideally
restored with a single implant. (B) Missing four mandibular incisors are ideally replaced with two
implants and a screw-retained prosthesis.
25 lb 20 10 50 lb
75 lb
FIG 3.45 A three-unit prosthesis has key implant positions at
each terminal end of the restoration. If force factors are high,
a third implant is recommended.
FIG 3.46 A cantilever on two implants may be considered a

Four or More Adjacent Teeth Missing. When four adjacent class I lever. When the implants are 10 mm apart, with a
teeth are missing, the terminal abutments are the key implant 20-mm cantilever, a mechanical advantage of 2 is created.
positions (Fig. 3.47). Most often, one to two additional A load on the cantilever will be multiplied by 2 on the most
implants are required, especially when the missing teeth distal implant, and the implant close to the cantilever receives
include a canine, a posterior teeth or when the bone density the sum total stress of the two other loads. (From Misch CE:
is poor. Restorations of 5 to 14 units require the key terminal Dental implant prosthetics, ed 2, St Louis, 2015, Mosby.)
positions plus additional abutments regardless of force factors
or bone density. The number of additional abutments is
determined by many biomechanical factors such as arch
form, bone density, opposing occlusion, parafunctional treatment option because of available anatomy. For example,
habits, available bone, and type of prosthesis. in a completely edentulous mandible, available bone in the
posterior regions may be insuficient for root form implant
Cantilever Options. The ideal implant treatment plan placement without advanced procedures (e.g., nerve reposi-
should eliminate cantilevers in partially edentulous patients tioning, iliac crest bone grafts).
and in complete arch maxillae. However, in completely eden- In addition, the dynamics of bone movement during
tulous mandibles, a cantilever is often the most prudent opening and function is different for a mandible and maxilla.
FIG 3.47 When four adjacent teeth are missing, the two FIG 3.49 A posterior ixed prosthesis with three (or more)
terminal abutments are the key implant positions. Most pontics is contraindicated with natural teeth abutments.
often, one or two additional implants are required. (From Misch CE: Dental implant prosthetics, ed 2, St Louis,
2015, Mosby.)
No Three Adjacent Pontics

In most prostheses designs, three adjacent pontics are contra-
indicated on natural tooth abutments in the posterior regions
of the mouth (Fig. 3.49). The adjacent abutments are sub-
jected to considerable additional force when they must
support three missing teeth, especially in the posterior regions
of the mouth. When three adjacent posterior teeth are missing
between remaining teeth (and the third molar is absent), the
terminal abutments are the second molar and the canine. The
forces in the posterior regions are three to four times greater
than the anterior region, and the force on the canine is
two times greater than on the anterior region. In addition,
the canine receives a lateral load in most excursions. The
lateral load increases the intensity of the force and places the
cement seal and porcelain/zirconia under more tensile and
shear loads.
FIG 3.48 The mandibular bone has dynamic movement In addition to the greater loads applied to the abutment
during function. Upon opening, the mandible lexes toward teeth, all pontic spans between abutments lex under load.
the midline. Parafunction or heavy biting on one posterior The greater the span between abutments, the greater the lex-
side results with a torsion of the mandible with the inferior ibility of the metal in the prosthesis. In a one-pontic prosthe-
border rolling buccal and the crest moving toward the tongue. sis, minimal lexure results (8 µm or less with precious metal
(From Misch CE: Dental implant prosthetics, ed 2, St Louis, under a 25-lb load). In comparison, a two-pontic span lexes
2015, Mosby.) eight times more than a one-pontic span, all other variables
being equal. Although the metal lexure is more for the two-
pontic prosthesis, the failure rate of three- or four-unit pros-
Upon opening, the mandible lexes distal to the mental thesis supported by natural teeth is similar for the irst 5 years
foramen toward the midline (mandibular lexure). During because the cause of failure is mostly biologic (e.g., caries).
heavy biting on the side of the jaw, the bottom of the man- The metal between abutments for a three-pontic span
dible rotates to the buccal, and the crest slightly rolls toward lexes 27 times more than that of a one-pontic span if all other
the lingual, again, distal to the mental foramen (Fig. 3.48).23 factors are equal (Fig. 3.50).24 In addition, the greater the
As a consequence of this lexure, splinting a molar implant load, the greater the lexure. With parafunction patients, the
across the arch to the contralateral molar may cause discom- lexure is even greater, with an increased shear and tensile
fort and lateral forces on the implant sites. With implant force on the abutments. The greater the lexure, the greater
prostheses, uncemented restorations, bone loss, and even the risk of porcelain fracture, uncemented prostheses, and
implant failure have been observed when there was cross-arch abutment screw loosening. As a result, not only is the mag-
splinting of molars. nitude of the force increased to the adjacent abutments when
x
A
.
V
2x
B
.
V
A 5 units, 3 key abutments
3x
C
V
.
FIG 3.50 (A) A one-pontic ixed partial denture (FPD) has
minimal lexure of the metal. (B) A two-pontic FPD lexes
eight times more than a one-pontic span. (C) A three-pontic
FPD has 27 times more lexure than a one-pontic span. (From B 6 units, 3 key abutments
Misch CE: Dental implant prosthetics, ed 2, St Louis, 2015,
Mosby.)
the prosthesis has three pontics (because they are supporting

two abutments and three pontics) but the lexure of the metal
also increases to a point that the incidence of complications
makes the treatment plan contraindicated, especially when C 7 units, 3 key abutments
forces are greater (as in the posterior region). As a result, a FIG 3.51 When ive to seven adjacent teeth are missing,
three–adjacent-pontic prosthesis has an increased failure rate there are three key implant positions: the terminal abutments
compared with a one- or two-pontic ixed prosthesis. The and another implant to limit the edentulous span to two
increased failure rate of long-span ixed prostheses is due teeth. Note additional implants are usually required, espe-
largely to the increase in biomechanical complications (e.g., cially for six or seven missing teeth (translucent implants).
unretained restorations and fracture). As a consequence, it is
well accepted in the literature that three pontics in the pos-
terior regions are contraindicated for natural teeth. and additional pier or intermediary abutments are indicated
The lexure of materials in a long span is more of a problem to limit the pontic spans to two premolar-size pontics.
for implants than natural teeth. Because natural roots have Following this rule, a ive- to seven- premolar–size unit pros-
some mobility both apically and laterally, the tooth acts as a thesis has three key abutments (two terminal and one pier)
stress absorber, and the amount of material lexure may be (Fig. 3.51).
reduced. Because an implant is more rigid than a tooth (and An 8- to 10-premolar–size unit prosthesis has four key
has a greater modulus of elasticity than a natural tooth), the implant positions (two terminal and two pier). An 11- to
risk for complications of increased load and material lexure 13-unit prosthesis has ive key abutments (two terminal and
are greater for an implant prosthesis. Because three posterior three pier), and a 14-unit prosthesis has six key abutment
pontics are contraindicated in a natural tooth–ixed prosthe- positions. In addition to these key abutments, additional
sis, it is even more important not to have three pontics in an abutments may be required to address patient force factors
implant restoration. and bone density. Rarely is the force factor situation favorable
The span of the pontics in the ideal treatment plan should and bone density ideal enough in a maxilla to be fulilled with
be limited to the size of two premolars, which is 13 to 16 mm. solely key abutments for a ixed prosthesis replacing more
When a molar is one of the teeth missing between existing than ive teeth.
teeth, the missing molar space alone may be 10 to 13 mm
long. As a result, when a large second premolar and irst Three-Pontic Options. Angled forces to the premaxilla
molar are missing, this edentulous span is often treatment magnify the amount of the force to the implant system in
planned to replace three teeth, rather than two, and an addi- both centric and excursive occlusal forces. Therefore, most
tional implant is warranted in this span. This is especially maxillary anterior prostheses should also limit the number
appropriate for greater patient forces (i.e., moderate to severe of pontics in the restoration. The exception to the no three-
parafunction) or softer bone types (i.e., D3 and D4). pontic rule is most often the anterior mandible, when the
To limit the effect of the complications of three adjacent three adjacent missing teeth are mandibular incisors. As long
premolar-size pontics, additional intraimplant key positions as implants are placed in the canine position, the number of
are indicated in prostheses missing ive or more adjacent pontics may be increased because of the long axis angle of
teeth. When 5 to 14 missing adjacent teeth are to be replaced, force, the reduced bite force, and the good bone quality.
key implant positions are located in the terminal abutments, However, when the dentate arch position is tapered and the
BOX 3.7 Arch Position: Canine

• Most surface area of any anterior tooth
• Canine-guided excursion of the mandible reduces mastica-
tory muscle contraction
• Canine and anterior teeth farthest from the temporoman-
dibular joint (less force magnitude)
• Adjacent teeth are less ideal for additional force

2015, Mosby.)
FIG 3.52 In a dental arch, the two most important biome- mandibular adjacent incisor is one of the weakest teeth in the
chanical positions are represented by the canine and the irst mouth, and the irst premolar is often one of the weakest
molars. (From Misch CE: Dental implant prosthetics, ed 2, posterior teeth. As a consequence, when a canine is missing,
St Louis, 2015, Mosby.)
a single tooth implant replacing the canine is the ideal treat-
ment of choice (Box 3.7).
When two adjacent teeth are missing and include a canine,
433 431
(2.4) (2.4)
two implants are required. Even when a canine and lateral
450 incisor are in the esthetic zone, it is better to reduce the size
400 of the implants and place two implants with no cantilever
350 273 rather than place a larger implant with a cantilever. The
300 (1.5) 234 implants should be at least 3 mm apart so the base of the
220
205 (1.3)
250 179 (1.2) interimplant papilla can support the soft tissue drape.
(1.1)
(1.0)
200 A traditional ixed prosthetic axiom on natural teeth indi-
150 cates it is contraindicated to replace a canine and two or
100 more adjacent teeth.24 If a patient desires a ixed prosthesis,
50 implants are required whenever the following adjacent teeth
0 are missing in either arch: (1) the irst premolar, canine, and
FIG 3.53 The canine has more root surface area than any lateral incisor; (2) the second premolar, irst premolar, and
anterior tooth and the irst molar more area than any other canine; and (3) the canine, lateral, and central incisors.
posterior tooth. (From Misch CE: Dental implant prosthetics, Whenever these combinations of teeth are missing, implants
ed 2, St Louis, 2015, Mosby.) are required to restore the patient because (1) the length of
the span is three adjacent teeth, (2) the lateral direction of
force during mandibular excursions increases the stress to the
three anterior pontics are cantilevered to the facial, an addi- prosthesis, (3) the magnitude of the bite force is increased in
tional implant is indicated even in the anterior mandible. the canine region compared with the anterior region, and (4)
an implant in the canine region with implant-protected
Canine Rule occlusion (mutually protected occlusion) distributes reduced
In any arch, certain positions are more important sites than lateral loads during mandibular excursions.
others. In the dental arch, these more important positions are The canine is the most important position for the occlusal
represented by the canine and the irst molar (Fig. 3.52).25 scheme of the patient. Canine guidance or mutually protected
The canine root has more surface area in either arch com- occlusion is the primary occlusal format in most ixed
pared with any other anterior tooth, and the molar has more implant reconstructions or completely implant-supported
root surface area than any posterior teeth (Fig. 3.53).26 The removable restorations. The angled force of approximately 22
canine is a particularly interesting tooth. When a lateral force to 25 degrees in excursions should not be magniied on a
is placed on the natural canine and no posterior teeth are in canine pontic with an implant prosthesis supported by fewer
contact, two thirds of the masseter and temporalis muscles implants.27 Although the force reduction in excursions is not
do not contract, and the resultant force on the anterior teeth as great with an implant as with a natural canine tooth, there
is less. In addition, because the mandible acts as a class III still is some force reduction as a consequence of the class III
lever, with the temporomandibular joint behind the muscles lever effect.28 Whenever the canine and two or more adjacent
of mastication, the force applied to the anterior teeth is less teeth are missing, the canine is a critical site along with the
when the posterior teeth do not occlude. Therefore, both terminal positions of the span (Fig. 3.54).
biologic and biomechanical factors make the canine position When the three adjacent teeth are the irst premolar,
an important site in the dental arch. canine, and lateral incisors, the key implant positions are the
A ixed restoration replacing a canine is at greater risk than irst premolar, the canine, and the lateral incisor when the
nearly any other restoration in the mouth. The maxillary or overall intratooth space is greater than 19 mm because three
C L C
R L
FIG 3.54 A panoramic radiograph of a patient missing a maxillary right canine, lateral incisor, and
central incisor. The key implant positions are the canine and central incisor to support a three-unit
ixed partial denture. (From Misch CE: Dental implant prosthetics, ed 2, St Louis, 2015, Mosby.)
implants with no cantilever reduce any increased force factor First Molar Rule
risks. The minimum implant sizes are usually 3.5 mm for the The molars have the most root surface area of any natural
premolar and canine and 3 mm for the lateral incisor. tooth in the mouth and have two or three roots. The biome-
When the irst premolar, canine, and lateral incisor are chanical rationale for this condition is that the bite force
missing and the intratooth span is less than 19 mm, only two doubles in the molar position compared with that of the
implants are used to support the prosthesis. In this scenario, premolar position in both the maxilla and mandible. In addi-
it is better to place terminal abutments and have a canine tion, the edentulous span of a missing irst molar is usually
pontic, especially when the prosthesis is within the esthetic 10 to 12 mm compared with a 7-mm span for a premolar. As
zone. The size of the implants is slightly increased to com- a result, the irst molar is also a key implant position.17
pensate for the angled forces during a lateral excursion. In As previously presented, cantilevers should not be used in
addition, the amount of the incisal vertical overbite is partially edentulous patients to replace a irst molar, espe-
reduced to decrease the leverage effect on the canine. The cially when patient force factors are moderate to great (e.g.,
incisal guidance should be as shallow as possible to decrease parafunction, opposing arch). The cantilever further increases
the force during excursions. However, it must be steep the force of the molar region to the splinted abutments. As a
enough to separate the posterior teeth in the mandibular result, uncemented restorations, bone loss, and failure are at
excursions. greater risk.
When there are multiple missing teeth on each side of the When a irst molar is missing, a 5- to 6-mm-diameter
canine site, the canine edentulous site is a key pier abutment implant is indicated in the mid mesiodistal position of the
position. The canine position is a key implant position to help edentulous site when the molar is less than 12 mm wide.
disocclude the posterior teeth in mandibular excursions. When a irst molar implant is indicated in the maxilla, a sinus
As a result, when four or ive adjacent teeth are missing, bone graft is most always required. The maxillary sinus
including a canine and at least one adjacent posterior premo- expands rapidly after tooth loss. More often than not, the
lar tooth, the key implant positions are the terminal abut- sinus loor should be altered and grafted in conjunction with
ments and the canine position. For example, when the irst a irst molar implant insertion.
premolar, canine, lateral, and central incisor are missing, the When two adjacent teeth are missing, including a irst
key implant positions are the irst premolar and central molar, the key implant positions include the terminal abut-
incisor (terminal abutments) and the canine (canine rule) ments, including the distal molar position. When three pos-
(Fig. 3.55). terior teeth are missing and include a irst molar, a irst molar
When six or more adjacent teeth are missing, which implant is included. For example, in a patient missing the
include both canines, additional pier abutments (which limit second premolar, irst molar, and second molar, three key
the pontics’ spans to no more than two teeth) are also indi- implant positions are required to restore the full contour of
cated. For example, when the irst premolar to irst premolar the missing molars teeth: the second premolar and second
are missing, ive key implants are indicated, especially in the molar terminal abutments and the irst molar pier abutment
maxillary arch—the terminal abutments, the canines, and an (Fig. 3.57). A similar scenario is present when all four poste-
additional implant in one of the central incisor positions. The rior teeth are missing—irst premolar, second premolar, irst
same ive key implant positions exist for the one-tooth span molar, and second molar. The key implant positions are the
of second premolar to second premolar (Fig. 3.56). terminal abutments (irst premolar and second molar) and
A B
C D
E F
FIG 3.55 (A) The patient is missing a maxillary central incisor, lateral incisor, canine, and irst
premolar. There is inadequate bone volume in the canine position. (B) A block bone graft is
positioned primarily in the canine region. (C) The block bone graft matures for 6 months. (D) The
key implant positions are the central incisor, canine, and irst premolar. (E) An additional implant
was positioned in the lateral incisor region. (The patient is a man with deep vertical overbite.)
(F) A four-unit ixed partial denture was cemented in place. (From Misch CE: Dental implant
prosthetics, ed 2, St Louis, 2015, Mosby.)
the irst molar (Fig. 3.58). In the maxilla, a sinus graft is Four to six implants in the anterior maxilla have been
most always indicated to replace these four adjacent teeth suggested in the complete edentulous maxilla, with posterior
(Fig. 3.59). When one implant replaces a molar (with a span cantilevers (Fig. 3.60). Full-arch restorations for the edentu-
of 10–13 mm), the implant should be at least 5 mm in diam- lous maxillary arch should also have a irst molar implant. In
eter. When a smaller-diameter implant is selected in a molar general, density of bone in the maxilla is less than the man-
space of 14 mm or more, the molar may be considered the dible in both the anterior and posterior regions. The anterior
size of two premolars, and two smaller-diameter implants maxillary implants receive an angled load (compared with
may be selected.29 Text continued on p. 91
P2 P1 P1 P2
C L C C L C
R L
FIG 3.56 A panoramic radiograph of 10 anterior teeth missing. There are ive key implants posi-
tions for this ixed prosthesis: the second premolars, the canines, and an anterior implant to limit
the pontics to no more than two. (From Misch CE: Dental implant prosthetics, ed 2, St Louis,
2015, Mosby.)
B
FIG 3.57 (A) A panoramic radiograph of a patient missing the second premolar, irst molar, and
second molar. There is inadequate bone height because of the pneumatization of the maxillary
sinus. (B) A sinus graft restores the bone height to favorable limits for future implants in the
second premolar, irst molar, and second molar. Continued
C D
E
FIG 3.57, cont’d (C) Three implants are inserted: the second premolar and the second terminal
implants and a irst molar implant. (D) The three implants after integration. (E) A three-unit ixed
partial denture supported by three implants. Only the mesial half of the second molar is restored
because there is no opposing mandibular second molar. (From Misch CE: Dental implant pros-
thetics, ed 2, St Louis, 2015, Mosby.)
B C
D
FIG 3.58 (A) A panoramic radiograph of a patient missing mandibular irst premolar to second
molar. (B) Four implants were used to restore the missing teeth. (C) The key implant abutments
are the irst premolar and second molar (no cantilever) and the irst molar. (D) The four-unit
splinted ixed partial denture restores the missing teeth. (From Misch CE: Dental implant pros-
thetics, ed 2, St Louis, 2015, Mosby.)
2 15
3 14
4 13
5 6 12
31 7 8 9 10 11 18
30 19
29 20
28 27 26 25 24 23 22 21
Rule 1: No cantilever
Rule 3: Canine and first molar
FIG 3.59 A panoramic radiograph replacing the irst premolar to second molar. A sinus graft is
most always required to place the molar implants. (From Misch CE: Dental implant prosthetics,
FIG 3.60 (A) Four implants in an edentulous maxilla

are suggested in the literature to support a ixed
prosthesis. (B) The ixed prosthesis supported by
four anterior implants most often cantilevers the
molars. In addition, there is also an offset cantilever
to the facial in both the anterior and posterior
regions. (C) The failure rate of the maxillary implants
usually causes additional bone loss. The maxilla
may be unable to be restored without advanced
bone grafts, more implants, and a new prosthesis.
(From Misch CE: Dental implant prosthetics, ed 2,
B
C
2 15
3
4
5 13 14
12
6 7 11 18
31 8 9 10
30 19
29 28 20
27 26 25 24 23 22 21
Key implant positions - 2 first molars, 2 canines, and a central incisor
FIG 3.61 The key implant positions for an edentulous maxilla to support a ixed prosthesis (or
RP-4 prosthesis) are the bilateral molars, the bilateral canines, and an implant in one of the central
incisor positions. (From Misch CE: Dental implant prosthetics, ed 2, St Louis, 2015, Mosby.)
the anterior mandible) in both centric and mandibular excur- and the apical 4 mm of the zygomatic process (passing
sions. The anterior maxillary arch usually has shorter implants through the maxillary sinuses) (Fig. 3.62). This treatment
than the anterior mandible because the vertical height of option does not consider the force magniiers of CHS or the
bone is less compared with the anterior mandible. The shorter A-P spread of the implants in relationship to the anterior
implants have less surface area and higher stresses, especially cantilever replacing the anterior teeth. In addition, when four
in soft bone. Maxillary ixed restorations most often oppose implants support a 12-unit ixed prosthesis, the position of
an implant prosthesis (usually ixed) or natural teeth. This the implants cannot follow the four key implant position
increases the force to the maxillary prosthesis. Therefore, the rules, and there are often no implants in the canine positions
biomechanical risks associated with full-arch maxillary pros- and more than three pontics between the anterior implants
theses with a molar cantilever are greater than for mandibular or three pontics cantilevered from the most distal implants.
restorations. A literature review of full-arch prostheses reports In full-arch prostheses, studies comparing six implants
an implant failure rate three times higher in full-arch maxil- to four- and three-implant abutments show better distribu-
lary implant ixed restorations than with mandibular full- tion and reduced stress on the six-implant system compo-
arch implant restorations.30 The treatment plan should be nents (crown, cement, abutment, abutment screw, marginal
different for the two arches. bone, implant-bone interface, and implant components)
The key implant positions for an edentulous maxilla are (Fig. 3.63).32 Silva et al evaluated, with three-dimensional
the distal of the irst molars bilaterally, the bilateral canines, inite element analyses, the difference in four vs. six implants
and an implant in one of the central incisor positions between to support a full-arch cantilevered prosthesis.29 The cantilever
the canines. This permits the ive sections of an arch to be length and crown height were similar in both models. The
splinted together and take advantage of the biomechanics of six-implant support model reduced the stress to the implant-
an arch (Fig. 3.61). bone regions between 7% to 29%, depending on the direction
and position of the applied load.
In rare cases, four implants in the mandible between the
IMPLANT NUMBER foramen may be used to support a full-arch implant-supported
prosthesis—ixed or RP-4. The implants are typically positioned
TREATMENT PLANNING in the irst to second premolar positions, and the canines.
In the past, the number of implants most often was deter- However, the other patient force factors should be low (e.g., no
mined in relation to the amount of available bone. This moderate to severe parafunction, crown height space less than
concept became popular in the mid 1980s, when the Bråne- 15 mm, older woman, and opposing a maxillary complete
mark philosophy of osseointegrations was introduced for denture). In addition, the bone density should be favorable (D2).
completely edentulous arches. In an edentulous arch, four to When all of these conditions are not present, consideration is
six anterior implants were used in available bone situations given to the ive key implant positions, and more implants are
between the mental foramina in the mandible and anterior indicated when stress factors are moderate to severe.
to the maxillary sinuses in the maxilla for a full-arch ixed When a full-arch ixed implant restoration is the treatment
prosthesis. The prosthesis cantilevered the molars from the for a maxillary arch, the suggested number of implants by
anterior implant positions. Four implants were used in mod- some authors is often the same as the mandible. For example,
erate to severe atrophic ridges for a ixed full-arch prosthe- “all on four” is a common treatment option presented to the
sis.31 This concept has been expanded to include zygomatic profession in either arch along with similar fees for either
implants in the posterior regions, which engage the palate arch to the patient (Fig. 3.64).33 Yet a literature review reveals
B
FIG 3.62 (A) A panoramic radiograph of four zygomatic implants supporting a ixed prosthesis
in the maxilla. (B) The full-arch maxillary prosthesis is cantilevered to the facial, and there are six
adjacent pontics in the anterior region, including a canine position. (From Misch CE: Dental
14
6/5 supporting implants
12 4 supporting implants
Bending moment (N-cm)
10 3 supporting implants
0
Distal Medial Mesial
Implants
FIG 3.63 The more implants supporting a ixed prosthesis,
the lower the bending movement and stress in the support
system. (From Misch CE: Dental implant prosthetics,
2e, St. Louis, 2015, Mosby; Data from Duyck J, Van FIG 3.64 Full-arch implant ixed restoration by many authors
Doosterwyck H, Vandersloten J, et al: Magnitude and distri- uses the same number of implants in the maxilla and man-
bution of occlusal forces on oral implants supporting ixed dible. However, three times greater failure rates are observed
prostheses: an in vivo study, Clin Oral Implants Res 2:465– in the maxillary arch. (From Misch CE: Dental implant pros-
475, 2000.) thetics, ed 2, St Louis, 2015, Mosby.)
the failure rate of the full-arch maxillary restoration is three TABLE 3.2 Implants vs. Prosthesis
times greater than the mandible.30 The hardness of the bone Success: Four Implants per Prosthesis
is related to its strength. The mandible more often has hard for 25 Patients (100 Implants for
(strong) bone, and the maxilla more often has softer bone. In 25 Prostheses)
fact, the posterior maxillary bone may be 5 to 10 times weaker
Implant Number Prosthesis Prosthesis
than the hard bone of the anterior mandible.34 As a result,
Success Rate Number Success Rate
more implants should be used in the poorer-quality bone
found in the maxilla. Increasing the implant number decreases 100% 25 100%
the periimplant bone stress. 90% 15 60%
The maxillary anterior arch receives a force at a 12- to 80% 5 20%
15-degree angle during occlusion and up to a 30-degree angle 75% 0 0%
in excursions. A 15-degree angled force increases the force (From Misch CE: Dental implant prosthetics, ed 2, St Louis,
component on the implant by 25.9%, and a 30-degree 2015, Mosby.)
force increases the force by 50%.35 This is a biomechanical
rationale for why maxillary anterior teeth are larger than the
mandibular anterior teeth. Hence, the size or number of TABLE 3.3 Implants vs. Prosthesis
implants in the anterior maxilla should be greater than an Success: Eight Implants per Prosthesis
anterior mandible. for 25 Patients (200 Implants for
The excursive forces in a maxillary restoration come from 25 Prostheses)
within the arch to push outside the arch. This force direction
on the maxillary arch is more detrimental than in the man- Implant Number Prosthesis
Success Rate Number Success Rate
dible. The mandible receives a force from outside of the arch
toward the inside of the arch, which is the mechanism of force 100% 25 100%
the Roman or gothic arch was designed to resist. As a result 87.5% 25 100%
of these biomechanical issues, more implants should be used 75% 25 100%
in maxillary compared with mandibular restorations. It is (From Misch CE: Dental implant prosthetics, ed 2, St Louis,
probably not a coincidence that there are more roots for the 2015, Mosby.)
teeth in the maxillary arch compared with those in the man-
dibular arch.
The minimum number of implants used to support a prosthesis, providing more abutments for greater retention
restoration should include all of the key implant positions. of the restoration, with reduced risk of screw loosening or
Yet the number of implants in a treatment plan should rarely uncemented prosthesis. As a general rule, it is better to err on
be the minimum. There is no safety factor if an implant fails: the side of safety in numbers than on the side of too few
the prosthesis becomes partially unretained, or the patient implants. When in doubt, add an additional implant to the
has a parafunctional episode. For example, if 25 patients treatment plan.
receive four implants to support a ixed prosthesis, there
would be 25 ixed prostheses and 100 implants in the report. Inluence of Patient Force Factors
This type of treatment planning may initially be less expen- on Implant Number
sive for the patient, but an implant failure any time after The additional number of implants, after the key implant
implant surgery places the patient’s restoration at consider- sites are established, are related to the patient force factors
able risk. If each patient lost one implant with this implant and the bone density.18 Five patient force factors determine
number per prosthesis, the overall implant success would be the amount of stress transmitted to the prosthesis. They are:
75%, but there would only remain three implants in each 1. Parafunction
patient. As a result, all 25 ixed prostheses would be at risk of Bruxism (severe, moderate, mild, absent; this is the most
overload failure. If 20% of the implants fail (with one failure important stress factor)
per patient), only 5 of the 25 patients would have four Clenching (force magnitude may be as great as bruxism)
implants to support the restoration (only 20% of the patients 2. Masticatory muscle dynamics
would be restored with a ixed prosthesis) (Table 3.2).17 Sex (men have greater force)
If the 25 edentulous patients in this example have eight Age (younger patients have greater force and live longer)
implants to support a full-arch, 12-unit ixed prosthesis, the Size (larger patients have greater force)
risk of prosthesis failure is signiicantly reduced (Table 3.3). 3. Crown height space
If each patient loses one implant, most likely all patients Double the crown height and double the force with any
would still be able to function with their original prosthesis. angled load or cantilever (mesial, distal, facial, or lingual)
Even if all 25 patients lost two implants, the 25 restorations 4. Arch position
may still function without risk (depending on the implant a. Anterior regions: low forces
failure location). The additional implants also reduce the can- b. Canine and premolar: medium forces
tilever length and reduce the number of pontics in the c. Posterior regions: high forces
5. Opposing dentition
a. Denture: lowest force
b. Natural teeth: intermediate force
c. Implant ixed prosthesis: higher forces
Not all patient force factors have the same risk.
In conclusion, whenever the patient force factors are greater
than usual, additional implants should be added to support
the prosthesis. Of the patient force factors, severe bruxism
is the most signiicant followed by clenching and CHS, region
of the mouth, masticatory dynamics, and the opposing arch.
Inluence of Bone Density on Implant Number

FIG 3.65 The anteroposterior (A-P) spread of implants is deter-
The additional number of implants after the key implant sites mined by drawing a line from the distal of the last implant on
are established is also related to the density of bone. The each side and a parallel line through the middle of the most
softest bone type (D4) has (1) the lowest strength and may anterior implant.
be 10 times weaker than the strongest bone type on a scale of
1 to 10 for bone strength (D4 bone is a 1 or 2); (2) the greatest
biomechanical mismatch with its modulus of elasticity com-
pared with titanium; (3) the lowest bone-implant contact
(≈25%) and higher stresses (stress = force/area); and (4) force factors and poor bone density (D4 bone) in the implant
strains in the bone are transmitted not only at the crest but sites may also require this many implants.
also along the entire bone-implant surface.
The soft bone type (D3) has (1) a low bone strength, which Implant Number: Full-Arch Mandibular
is 50% weaker than hard bone (D2) (on a 10-point scale, Fixed Prosthesis
its strength is a 3 to 4); (2) intermediate difference of modulus As a general observation, the number of implants to replace
of elasticity compared with titanium; (3) low bone-implant all of the mandibular teeth ranges from ive to nine, with at
contact (≈50%); and (4) strain patterns at the crestal half of the least four between the mental foraminae. When the implants
implant. are limited to sites anterior to the mental foraminae to
The hard bone (D2) has (1) ideal strength (a 7 to 8 on a support a ixed prosthesis, a cantilever must be designed.
10-point scale), (2) high bone-implant contact (≈75%), (3) Cantilevers in the mandible should ideally be projected in
more stiff modulus of elasticity, and (4) strain patterns pri- only one posterior quadrant to increase the A-P distance and
marily at the crestal region of the implant. The hardest bone reduce the force to the implants (Fig. 3.65). Whenever pos-
(D1) has the best biomechanical features of (1) strength (9 sible, at least one implant should be positioned in a irst
to 10 on a 10-point scale), (2) highest bone-implant contact molar site. When implants are positioned in four of the ive
(above 85%), (3) stiffest modulus of elasticity, and (4) strain open pentagon positions in the mandible, a cantilever is at a
values above the irst thread. reduced risk of overload because of favorable dynamics of an
As the bone quality is reduced, the number of implants to arch, increased A-P distance, and usually a more favorable
support the prosthesis should increase. The risk factor scale bone density. When seven or more implants are used in the
for bone density is inversely related to the strength of the edentulous mandible with bilateral molar implants, two sepa-
bone scale. D4 bone is a 10, D3 bone is an 8, D2 bone is a 4, rate restorations may be fabricated with no posterior cantile-
and D1 bone is a 2. When the implants are inserted into D4 ver to permit mandibular lexure and torsion. Usually, the
bone, a larger-diameter or another implant is suggested, second molar is not replaced in the edentulous mandible.
depending on the number of teeth replaced. A full-arch ixed
restoration in the mandible with D2 bone may often have ive Implant Number: Full-Arch Maxillary
implants, but in D4 bone, nine implants may be appropriate. Fixed Prostheses
The total number of implants is related to the key implant The edentulous maxillary ixed prosthesis should usually
positions plus the inluence of the patient force factors and not have a cantilever. The irst seven ideal sites are often the
the quality of bone. bilateral irst molars, bilateral second premolars, bilateral
In conclusion, the decision for the number of implants in canines, and one implant between the canine positions
the treatment plan begins with the implants in the ideal key (Fig. 3.66). These positions satisfy the key implant positions
positions. Additional numbers are most often required and and add an implant in the posterior region because the bone
are primarily related to the patient force factors or to bone density is often poor. Additional implants in the bilateral
density in the edentulous sites. For example, a young, large second molar sites are a beneit to increase the A-P distance
man who bruxes severely with greater-than-normal CHS in of the implants, which counters the anterior bite forces that
the posterior regions of the mouth opposing an implant res- may be increased from parafunction and so on (Fig. 3.67). A
toration will require one implant for each missing root (two greater number of implants are generally required in the
implants for each molar). Likewise, patients with moderate maxilla to compensate for the less dense bone and more
unfavorable biomechanics of the premaxilla and range from General Complications

7 to 10 implants with at least three implants from canine to The lack of rigid ixation during implant healing may be a
canine (Fig. 3.68). result of parafunction on soft tissue–borne prostheses overly-
ing the submerged implant (e.g., interim prosthesis). The
most common cause of both early and late implant failure
FORCE-RELATED ISSUES after successful surgical ixation is the result of parafunction.
Such complications occur with greater frequency in the
PARAFUNCTION maxilla because of a decrease in bone density and an increase
in the moment of force. The presence of these parafunctional
Deinition conditions must be carefully noted during the early phases of
Parafunctional forces on teeth or implants are characterized treatment planning.
by repeated or sustained occlusion (e.g., habitual movements)
and have long been recognized as harmful to the stomato- Classiication
gnathic system. These same forces, when applied to implant The classiication of parafunction involves (1) bruxism, (2)
prostheses, have been shown to be very harmful. clenching, and (3) tongue thrust or increased size. The dental
literature usually does not identify bruxism and clenching
as separate entities. Although several aspects of treatment
are similar, their diagnosis and treatment are in some ways
different.
Bruxism and clenching are the most critical factors to
evaluate in any implant reconstruction. Long-term success
will not be achieved with severe parafunction of bruxism or
clenching. The implant clinician should always try to diag-
nose the presence of these two conditions.
This does not mean that patients with moderate and
severe parafunction are absolute contraindications to implant
treatment. Because patients with moderate to severe para-
function represent so many additional risks in implant den-
tistry, one must be aware of these conditions and the methods
to reduce their noxious effects on the entire implant-related
system. Unfortunately, parafunction may be a dificult entity
FIG 3.66 In an edentulous maxilla, the most common addi- to diagnose, especially if the patient is completely edentulous
tional implant site is in the second premolar region. Seven and is wearing a recently fabricated prosthesis.
implants (or more) are most often used to support a ixed (or
RP-4) prosthesis. (From Misch CE: Dental implant prosthet- Bruxism. Bruxism primarily concerns the horizontal, non-
ics, ed 2, St Louis, 2015, Mosby.) functional grinding of teeth. The forces involved are in
Implant positions: key locations

5 to 14 units
Secondary
2
3 14 15
4 5 12 13
31 6 7
8 10 11 18
30 9 19
29 28 20
27 26 25 24 23 22 21
Key implant positions - 2 first molars, 2 canines, a central incisor

Secondary implant positions: extreme force factors
FIG 3.67 In the maxillary arch, secondary implants may be positioned to decrease the stress
in soft bone or in patients with high force factors. (From Misch CE: Dental implant prosthetics,
B C
D
FIG 3.68 (A) A panoramic radiograph of a maxillary bilateral sinus graft and maxillary and man-
dibular iliac crest bone grafts. Eight implants were used in the maxilla and seven implants in the
mandible. (B) An intraoral view of the maxillary and mandibular implants. (C) FP-3 ixed restora-
tions in situ. (D) A panoramic radiograph of the implants and ixed restorations. (From Misch CE:
signiicant excess of normal physiologic masticatory loads. treatment planning. The irst step is to recognize the condi-
Bruxism may affect the teeth, muscles, joints, bone, implants, tion before the treatment is rendered. The symptoms of this
and prostheses. These forces may occur while the patient is disorder may be ascertained by a dental history and may
awake or asleep and may generate increased force on the include repeated headaches, a history (or presence) of frac-
system several hours per day. Bruxism is the most common tured teeth or restorations, repeated uncemented restora-
oral habit and may be dificult to diagnosis. tions, or jaw discomfort upon awakening. When the patient
The maximum biting force of bruxing patients is greater is aware of muscle tenderness or the spouse is conscious of
than average. Fortunately, the bite force does not continue the noise of bruxism during sleep, the diagnosis is readily
to increase in most bruxing patients. When muscles do not obtained. However, many patients do not attribute these
vary their exercise regimen, their size and function adjust to problems to excessive forces on the teeth and report a nega-
the dynamics of the situation. As a result, the higher bite tive history. A lack of these symptoms does not negate the
forces and muscle size usually do not continue in an unend- possibility of bruxism (Box 3.8).
ing spiral. Clinical signs. Fortunately, many clinical signs of bruxism
Diagnosis. Bruxism does not necessarily represent a con- warn of excessive grinding. The signs of bruxism include an
traindication for implants, but it does dramatically inluence increase in size of the temporalis and masseter muscles. These
BOX 3.8 Bruxism

Symptoms
Frequent headaches – Pain on opening/closing
History or presence of fractured teeth and/or restorations
Repeated uncemented restorations
Jaw tension and discomfort upon awakening
Muscle soreness and tenderness
Spouse awareness during sleep
BOX 3.9 Bruxism: Clinical Signs

of Bruxism
1. Increase in muscle size of temporalis and masseter
muscles
2. Temporalis, masseter, or external pterygoid muscles A
tender to palpation
3. Mandibular deviation while opening
4. Limited occlusal opening
5. Tooth mobility
6. Cervical abfraction of teeth
7. Fracture of teeth or restorations
8. Uncemented crowns or restorations
9. Wearing (attrition) of natural teeth
10. Tooth sensitivity
muscles and the external pterygoid may also be tender during

palpation. In addition, other signs include deviation of the
lower jaw on opening, limited occlusal opening, increased
mobility of teeth, cervical abfraction of teeth, fracture of teeth
or restorations, and uncemented crowns or ixed prostheses B
(Box 3.9). FIG 3.69 (A) Mild bruxism. Note the wear facet on the man-
Clinical exam. A physical examination for the implant dibular canine and the slight notch in the maxillary lateral
candidate should include palpation of the muscles of masti- incisor. (B) Patients often grind their teeth in a speciic,
cation including the masseter, temporalis, and internal and repeated movement of the mandible, called an engram.
external pterygoid muscles. Hyperactive or hypertrophied When the opposing wear facets of the teeth are in contact,
muscles are the most common sign of bruxing. The lateral one should note the occlusal position of the teeth. The patient
pterygoid muscle is more often overused by the bruxing shown in A has a working contact on the mandibular premolar
patient and is often dificult to palpate. The ipsilateral medial with the maxillary canine in this engram position. The slight
pterygoid muscle provides more reliable information in this cervical abfraction of the mandibular irst premolar is a con-
sequence of the parafunction. The patient’s posterior teeth
region. It acts as the antagonist to the lateral pterygoid in
should not occlude in this position to decrease the amount
hyperfunction and, when tender, provides a good indicator
of force on the anterior teeth. (From Misch CE: Dental implant
of overuse of the lateral pterygoid.36 However, the most effec- prosthetics, ed 2, St Louis, 2015, Mosby.)
tive method to diagnose bruxism is to evaluate the wearing
of the natural teeth. Nonfunctional wear facets on the incisal
edges occur most often on natural teeth rather than on
crowns made of porcelain or metal occlusal, especially in the anterior teeth but is not a cosmetic compromise (Fig. 3.69).
anterior mandible and maxillary canines. Enamel opposing Moderate bruxism has obvious anterior incisal wear facets
enamel causes more occlusal material wear than almost any but no posterior occlusal wear pattern (Fig. 3.70). Severe
other combination (e.g., enamel opposing metal, metal bruxism has an absence of incisal guidance as a result of the
opposing metal, etc.).37 As a result, in a partially edentulous excessive wear, and posterior wearing of the teeth is obvious
patient, enamel wear is easily observed in the bruxing patient. (Fig. 3.71).
Not only is enamel wear the easiest method to determine Complications
bruxism in a dentate patient but Misch has noted the disorder Posterior wear facets. Tooth wear is most signiicant
may also be classiied as absent, mild, moderate, or severe. when found in the posterior regions and changes the intensity
No anterior wear patterns in the teeth signiies an absence of bruxism from the moderate to the severe category. Poste-
of signiicant bruxism. Mild bruxism has slight wearing of rior wear patterns are more dificult to manage because they
A B
FIG 3.70 (A) Moderate bruxism of the central incisors (there is an esthetic consequence).
(B) The engram position placed the mandibular anterior teeth anterior to the maxillary incisal
edge and caused the wear of the central incisors. (From Misch CE: Dental implant prosthetics,
FIG 3.72 This patient exhibits an engram pattern of bruxism

FIG 3.71 This patient has severe bruxism because occlusal primarily toward the left premolar to central incisors. The right
wear is both anterior and posterior (right). The incisal guid- canine and lateral incisor have far fewer wear facets. Incisal
ance should be reestablished before a maxillary arch ixed guidance should be restored before any left posterior restora-
reconstruction. (From Misch CE: Dental implant prosthetics, tion. This “pathway of destruction” is speciic. (From Misch
ed 2, St Louis, 2015, Mosby.) CE: Dental implant prosthetics, ed 2, St Louis, 2015, Mosby.)
are usually related to a loss of anterior guidance in excursions, primarily on one side of the arch or even on only a few teeth
and when the posterior teeth contact in excursive jaw posi- (Fig. 3.72). This engram pattern usually remains after treat-
tions, greater forces against the teeth are generated.38 The ment. If the restoring dentist reestablishes incisal guidance on
masseter and temporalis muscles contract when posterior teeth severely affected by an engram bruxing pattern, the
teeth contact. With incisal guidance and an absence of pos- incidence of complications on these teeth will be increased.
terior contact in a lateral excursion of this jaw, two thirds of If the patient wears an occlusal guard, it is usually easy to see
these muscles do not contract and, as a consequence, the the repeatable excursive movements.
bite force is dramatically reduced. However, when the poste- Component fracture. Because patients that exhibit
rior teeth maintain contact, the bite forces are similar in bruxism have increased occlusal force, and much of the force
excursions, as during posterior biting. In a patient with results in lateral (nonaxial) loading, this may be very damag-
severe bruxism, the occlusal plane or the anterior incisal guid- ing to the implant system. An increased probability of crestal
ance may need modiication to eliminate all posterior con- bone loss, implant fracture, abutment screw loosening, por-
tacts during mandibular excursions before the implant celain fracture, or unretained restorations.17
restoration.
Repeatable movement. Bruxing patients often repeat the Clenching. Clenching is a habit that generates a constant
same mandibular movements, which are different from force exerted from one occlusal surface to the other without
border movements of the mandible and are in one particular movement. The habitual clenching position does not neces-
direction. As a result the occlusal wear is very speciic and sarily correspond to centric occlusion. The jaw may be
positioned in any direction and position before the static BOX 3.10 Clenching: Clinical Signs
load; therefore a bruxing and clenching combination may
exist. The clench position most often is in the same repeated • History or presence of temporalis, lateral pterygoid, or
masseter muscle tenderness (often upon awakening)
position and rarely changes from one period to another. The
• Tooth sensitivity
direction of load may be vertical or horizontal. The forces
• Tooth mobility
involved are in signiicant excess of normal physiologic loads • Temporalis, lateral pterygoid, or masseter muscle
and are similar to bruxism in amount and duration; however, hypertrophy
several clinical conditions differ in clenching.39 • Deviation of mandible during opening
Diagnosis. Many clinical symptoms and signs warn of • Limited opening – pain on opening
excessive grinding. However, the signs of clenching are often • Stress lines in enamel
less obvious. The forces generated during clenching are usually • Cervical abfraction
directed more vertically to the plane of occlusion, at least in • Material fracture (enamel pits, restorations) – porcelain
the posterior regions of the mouth. Wearing of the teeth is fracture
usually not evident, and clenching often is not diagnosed • Scalloped border of tongue – presence of antegonial notch
at the angle of the mandible
during the intraoral examination. As a result, the clinician
must be more observant to the diagnosis of this disorder.
Clinical signs. Many of the clinical signs of clenching
resemble bruxism. When a patient has a dental history or and is very important if an implant may be placed in the
presence of muscle tenderness (often upon awakening) or region of the mobile teeth. The rigid implant may receive
tooth sensitivity to cold, parafunction is strongly suspected. more than its share of occlusal force when surrounded by
In the absence of tooth wear, clenching is the prime suspect. mobile teeth. Fremitus, a vibration type of mobility of a
Tooth mobility, temporalis, lateral pterygoid, or masseter tooth, is often present in the clenching patient. To evaluate
muscle tenderness or hypertrophy, deviation of the mandible this condition, the dentist’s inger barely contacts the facial
during occlusal opening, limited opening, stress lines in surface of one tooth at a time and feels for vibrations while
enamel, cervical abfraction, and material fatigue (enamel, the patient taps the teeth together. Fremitus is symptomatic
enamel pits, porcelain and implant components) are all asso- of a local excess of occlusal loads.
ciated clinical signs of clenching.40 When the clinical signs of Cervical erosion is often a sign of parafunctional clenching
excessive force appear on the teeth, muscles, or joint in the (Fig. 3.73). The notched appearance of the cervical portion
absence of incisal wear, clenching is strongly suspected. of the tooth directly correlates with the concentration of
A most common clinical inding of clenching is a scal- forces shown in three-dimensional inite analysis and photo-
loped border of the tongue. The tongue is often braced against elasticity studies.43 Abfraction of teeth was also observed in
the lingual surfaces of the maxillary or mandibular teeth cats, rats, and marmosets and was described in the literature
during clenching, exerting lateral pressures and resulting in as early as 1930. A study of a noninstitutionalized older
the scalloped border. This tongue thrust position may also be human population revealed that cervical abrasion was present
accompanied by an intraoral vacuum, which permits a clench in 56% of the participants.44
to extend for a considerable time, often during sleep. When Complications
the clinician asks the patient to open wide to evaluate Postoperative care. A common cause of implant failure
maximum occlusal opening (while palpating the temporo- during healing is parafunction in a patient wearing a soft
mandibular joint [TMJ]), the lateral tongue contour is tissue–supported prosthesis over a submerged implant. The
observed to notice any scalloped border (Box 3.10). tissue overlying the implant is compressed during the para-
Clinical exam. Muscle evaluation for clenching (and function episode. The premature loading may cause micro-
bruxism) includes deviation during opening of the jaw, movement of the implant body in the bone and may
limited opening, and tenderness of the TMJ. Deviation to one compromise osteointegration. When an overlying soft tissue–
side during opening indicates a muscle imbalance on the borne restoration exerts pressure as a result of parafunction,
same side.36 Limited opening is easily evaluated and may indi- pressure necrosis causes soft tissue dehiscence over the
cate muscular imbalance or degenerative joint disease. The implant. This condition is not corrected by surgically cover-
normal opening should be at least 40 mm from the maxillary ing the implant with soft tissue, but the soft tissue support
incisal edge to the mandibular incisal edge in an Angle Class region of the prosthesis over the implant should be gener-
I patient, taking into consideration an overjet or overlap. If ously relieved during the healing period whenever parafunc-
any horizontal overjet or overlap exists, its value in millime- tion is noted. With metal-free partial dentures, this may
ters is subtracted from the 40-mm minimum opening mea- weaken the prosthesis leading to possible fractures.
surement.41 The range of opening without regard for overlap
or overjet has been measured in the range of 38 to 65 mm for
men and 36 to 60 mm for women from incisal edge to edge.42 Treatment Planning for Parafunction Patients
Increased mobility of teeth may be an indication of a force (Clenching/Bruxism)
beyond physiologic limits, bone loss, or their combination. Progressive Bone Loading. The time intervals between
This requires further investigation in regard to parafunction prosthodontic restoration appointments may be increased to
number of implants (i.e., greater surface area) should be

treatment planned.
Occlusion. With parafunctional habits, the occlusion must

be strictly designed and monitored. Ideally, the patient should
be maintained in a canine guided occlusion, as long as the
canines are healthy. Mutually protected occlusion, with addi-
tional anterior implants or teeth distributing forces, is devel-
oped if the implants are in the canine position or if this tooth
is restored as a pontic. The anterior teeth may be modiied to
recreate the proper incisal guidance and avoid posterior inter-
ferences during excursions.
The elimination of posterior lateral occlusal contacts (i.e.,
nonaxial loading) during excursive movements is recom-
A mended when opposing natural teeth or an implant or tooth-
supported ixed prosthesis. This is beneicial in two aspects:
(a) because lateral forces dramatically increase stress at the
implant-bone interface, the elimination of posterior contacts
diminishes the negative effect of angled forces during bruxism,
and (b) the presence of posterior contacts during excursions,
and almost all ibers of the masseter, temporalis, and the
external pterygoid muscles contract and place higher forces
on the anterior teeth and implants. On the contrary, during
excursions in the absence of posterior contacts, fewer ibers
of the temporalis and masseter muscles are stimulated, and
the forces applied on the anterior implant–teeth system are
B reduced by as much as two thirds.
Prosthesis Design. The prosthesis may be designed to

improve the distribution of stress throughout the implant
system with centric vertical contacts aligned with the long
axis of the implant whenever possible. Narrow posterior
occlusal tables to prevent inadvertent lateral forces and to
decrease the occlusal forces are beneicial. Enamoplasty of the
cusp tips of the opposing natural teeth is indicated to
help improve the direction of vertical forces within the guide-
lines of the intended occlusion (i.e., improve plane of
occlusion) newer occlusal materials (e.g., zirconia). Wider
C
implant bodies, harder cement types (e.g., zinc phosphate vs.
FIG 3.73 Clenching habits are more dificult to diagnose zinc oxide), titanium alloy implant bodies, and more implants
because occlusal wear is often absent. (A) A common sign splinted together are all beneicial.
is scalloping of the tongue, which results from tongue protru-
sion during clenching. (B) Antegonial notch, which results
Occlusal Guard. The most important treatment for a
from massetter hypertrophy. (C) Prosthesis fracture resulting
patient with parafunctional habits is the use of an occlusal
from excessive biomechanical force.
guard. Ideally, patients should wear a hard, processed acrylic
occlusal guard at night. The guard will absorb the majority
of the parafunctional forces, reducing the damaging forces to
provide additional time to produce load-bearing bone around the implant system. Patients should also be instructed to
the implants through progressive bone-loading techniques.45 wear the guard during any time they might exhibit parafunc-
By utilizing the progressive bone loading technique, poorer tion, such as stressful time periods, driving, and working at a
bone density is transformed into better quality bone, which is computer.
more ideal for excessive occlusal loads.
Tongue Thrust and Size. Parafunctional tongue thrust is the
Greater Surface Area. Anterior implants that are subjected unnatural force of the tongue against the teeth during swal-
to parafunctional forces are problematic because they are lowing. A force of approximately 41 to 709 g/cm2 on the ante-
usually nonaxial or shear forces. To counteract this excessive rior and lateral areas of the palate has been recorded during
force the use of wider-diameter implants or additional swallowing.46 These forces may cause clinical complications.
BOX 3.11 Parafunction: Tongue Thrust

and Size
1. Tongue thrust
a. Less force than bruxism or clenching
b. Is constant
c. Horizontal direction
2. Several types possible
a. Anterior
b. Intermediate
c. Posterior unilateral or bilateral
3. Incision line opening after surgery
4. Early loading risk for one stage or immediate restorations
5. Prosthetic complications

FIG 3.74 Patient with anterior openbite secondary to tongue 2015, Mosby.)
thrust. Because of the openbite, the patient has no anterior
guidance with mandibular excursions.
Types. Several different types of tongue thrust have been Tooth movement. A tongue-thrust habit may lead to
identiied; anterior, intermediate, posterior, and either unilat- tooth movement or mobility, which is of consequence when
eral or bilateral, which may be found and in almost any implants are present in the same quadrant. If the remaining
combination (Fig. 3.74). To evaluate anterior tongue thrust, teeth exhibit increased mobility, the implant prosthesis may
the doctor holds the lower lip down, squirts water into the be subject to increased occlusal loads.
mouth with the water syringe, and asks the patient to swallow. Inadequate tongue room. A potential prosthetic com-
A normal patient forms a vacuum in the mouth by position- plication for a patient with a lateral tongue thrust is the
ing the tongue on the anterior aspect of the palate and is able complaint of inadequate room for the tongue after the
to swallow without dificulty. A patient with an anterior mandibular implants are restored. A prosthetic mistake is to
tongue thrust is not able to create the vacuum needed to reduce the width of the lingual contour of the mandibular
swallow when the lower lip is retracted because the seal and teeth to give the tongue more space. The lingual cusp of the
vacuum for the patient are achieved between the tongue and restored mandibular posterior teeth should follow the curve
the lower lip. As a consequence, the patient is unable to of Wilson and have a proper horizontal overjet to protect
swallow while the lower lip is withdrawn. the tongue during function. A reduction in the width of the
A posterior tongue thrust is evaluated by retracting one mandibular posterior teeth often increases the occurrence
cheek at a time away from the posterior teeth or edentulous of tongue biting and may not dissipate with time. When the
region with a mouth mirror, injecting water into the mouth lingual surface of the mandibular restoration is reduced, the
with a water syringe and asking the patient to swallow. entire prosthesis may need to be refabricated. The restoring
Visual evidence of the tongue during deglutition may also be dentist should identify the tongue position before treatment
accompanied by pressure against the mirror and conirms a and inform the patient about the early learning curve for
lateral force. the tongue once the teeth are delivered on the implants
Complications (Fig. 3.75).
Early loading. Although the force of tongue thrust is of Complication prevention. Even in the absence of tongue
lesser intensity than in other parafunctional forces, it is hori- thrust, the tongue often accommodates to the available space,
zontal and can increase stress at the permucosal site of the and its size may increase with the loss of teeth. As a result, a
implant. This is most critical for one-stage surgical approaches patient not wearing a mandibular denture often has a larger-
and immediate restoration of implants in which the implants than-normal tongue. The placement of implants and pros-
are in an elevated position at initial placement and the thetic teeth in such a patient results in an increase in lateral
implant interface is in an early healing phase. If the natural force, which may be continuous. The patient then complains
teeth in the region of the tongue thrust were lost as a result of inadequate room for the tongue and may bite it during
of an aberrant tongue position or movement, the implants function. However, this condition is usually short lived,
are at increased risk during initial healing and early prosthetic and the patient eventually adapts to the new intraoral condi-
loading (Box 3.11). tion. However, it has been observed a ixed restoration is
Incision line opening. The tongue thrust may also con- more advantageous for this type of patient. If the patient has
tribute to incision line opening after bone grafting or implant a RP-5 prosthesis, it should be turned into an RP-4: An RP-5
surgery, which may compromise both the hard and soft restoration is much less stable in patients with tongue thrust
tissues. This is especially noteworthy in a bone augmentation or size issues, and patient complaints are more common with
procedure. removable restorations in general.
BOX 3.12 Crown Height Space

• The CHS is measured from the occlusal plane to the crest
of the bone.
• CHS does not have a speciic ideal dimension. With ixed
restorations, the acceptable range for CHS is between 8
and 12 mm.
• Removable implant restorations often require a CHS of
12 mm or more, especially when a bar connects the indi-
vidual implants.
• An increase in prosthetic complications occurs with either
limited or excessive CHS.
CHS, crown height space.

2015, Mosby.)
FIG 3.75 In a patient with missing teeth and no prosthetic
replacement, such as a complete or partial denture, the
tongue often increases in size. The tongue does not transfer
an active lateral force during swallowing. This tongue type anterior regions of the mouth, the presence of a vertical over-
will adapt most often to a mandibular posterior implant pros- bite means the CHS is larger in the maxilla than the space
thesis. (From Misch CE: Dental implant prosthetics, ed 2, from the crest of the ridge to the opposing teeth incisal edge.
St Louis, 2015, Mosby.) In general, when the anterior teeth are in contact in centric
occlusion, there is a vertical overbite. The anterior mandibu-
lar CHS is usually measured from the crest of the ridge to the
mandibular incisal edge. However, the anterior maxillary
> 1 mm occlusal clearance
Occlusal table
CHS is measured from the maxillary crestal bone to the max-
illary incisal edge, not the occlusal contact position.
8 mm
The ideal CHS needed for a ixed implant prosthesis
5 mm cement
retention should range between 8 and 12 mm. This measurement
accounts for the “biologic width,” abutment height for cement
Prosthetic platform retention or prosthesis screw ixation, occlusal material
<1 mm
Bone level
1 mm subgingival strength, esthetics, and hygiene considerations around the
CT + JE = 2 mm abutment crowns. Removable prostheses often require a CHS
greater than 12 mm for denture teeth and acrylic resin base
strength, attachments, bars, and oral hygiene considerations
(Box 3.12).48
Complications
Increased Force. By deinition, force magniiers are situa-
tions or devices that increase the amount of force applied to
a system and include a screw, pulley, incline plane, and lever.18
FIG 3.76 The crown height space is measured from the The biomechanics of CHS are directly related to lever
occlusal plane to the crest of the bone. The ideal space for a
mechanics. The properties of a lever have been appreciated
FP-1 prosthesis is between 8 mm and 12 mm. CT, Connec-
tive tissue attachment; JE, junctional epithelial attachment.
since the time of Archimedes 2000 years ago. (“Give me a
(From Misch CE: Dental implant prosthetics, ed 2, St Louis, lever and a fulcrum and a place to stand and I can move the
2015, Mosby.) world.”) The complex issues of cantilevers and implants have
been demonstrated in the edentulous mandible, where the
length of the posterior cantilever directly related to complica-
tions or failure of the prosthesis.49 Rather than a posterior
CROWN HEIGHT SPACE (CHS) cantilever, the CHS is a vertical cantilever when any lateral or
cantilevered load is applied and is also a force magniier
DEFINITION
(Fig. 3.77). As a result, because CHS excess increases the
The crown height space or interarch distance is deined as the amount of force, any of the mechanical complications related
vertical distance between the maxillary and mandibular to implant prostheses may also increase, including unce-
dentate or dentate arches under speciic conditions (e.g., the mented prosthesis, screw loosening (prosthetic or abutment),
mandible is at rest or in occlusion).47 The CHS for implant overdenture attachment complications, and so on.
dentistry is measured from the crest of the bone to the plane
of occlusion in the posterior region and the incisal edge of Cantilevers. When the direction of a force is in the long
the arch in question in the anterior region (Fig. 3.76). In the axis of the implant, the stresses to the bone are not
magniied in relation to the CHS (Fig. 3.78). However, when the crown height is increased from 10 to 20 mm, two of six
the forces to the implant are on a cantilever or a lateral force of these moments are increased by approximately 200%.
is applied to the crown, the forces are magniied in direct A cantilevered force may be in any direction: facial, lingual,
relationship to the crown height. Bidez and Misch evaluated mesial, or distal. Forces cantilevered to the facial and lingual
the effect of a cantilever on an implant and its relation to direction are often called offset loads. Because bone resorption
crown height.50 When a cantilever is placed on an implant, proceeds from buccal to lingual and results in decreased
there are six different potential rotation points (i.e., width. Unless bone augmentation is completed, implants will
moments) on the implant body (Fig. 3.79; Table 3.4). When be often placed more lingual than the center of the natural
FP-1 FP-3 25
25
FIG 3.77 The crown height space is a vertical cantilever to

any angled load or cantilever. The FP-3 on the right will deliver
greater stresses to the implant compared with the implant
on the left. A wider-diameter implant is of beneit to support FIG 3.78 When a long axis load is applied to an implant, the
the implant restoration on the right. (From Misch CE: Dental crown height does not magnify the load. The implant on the
implant prosthetics, ed 2, St Louis, 2015, Mosby.) left will have similar stress to the one on the right because
the load is in the long axis. (From Misch CE: Dental implant
Vertical axis
Lingual-transverse
Occlusal
movement
movement
Mesiodistal Faciolingual axis

plane
Transverse
plane
Mesiodistal axis
Facial
movement
Lingual
movement
Facial-transverse
Apical movement
movement Faciolingual
plane
FIG 3.79 Moment loads tend to induce rotations in three planes. Clockwise and counterclock-
wise rotations in these three planes result in six moments: lingual-transverse, facial-transverse,
occlusal, apical, facial, and lingual. (From Misch CE: Dental implant prosthetics, ed 2, St Louis,
2015, Mosby.)
TABLE 3.4 Moment Load at Crest, When Subjected to Forces Shown in Fig. 3.79
INFLUENCES ON MOMENT IMPOSED MOMENTS (N/mm) AT IMPLANT CROWN-TO-CREST INTERFACE
Occlusal Height Cantilever Length
(mm) (mm) Lingual Facial Apical Occlusal Facial Transverse Lingual Transverse
10 10 100 0 50 200 0 100
10 20 100 0 50 400 0 200
10 30 100 0 50 600 0 300
20 10 200 0 100 200 0 100
20 20 200 0 100 400 0 200
20 30 200 0 100 600 0 300
(From Misch CE: Dental implant prosthetics, ed 2, St Louis, 2015, Mosby.)
FIG 3.81 Crown height is a force magniier to any lateral load

FIG 3.80 In the past, treatment plans included more and or horizontal cantilever. When available bone height decreases
longer implants in abundant bone (top) but fewer and shorter with a greater crown height, more implants should be inserted
implants in less available bone (bottom). However, crown and cantilever length reduced. (From Misch CE: Dental
height increases as bone height decreases, and this approach implant prosthetics, ed 2, St Louis, 2015, Mosby.)
creates unfavorable mechanics when the bone height is
reduced. (From Misch CE: Dental implant prosthetics, ed 2,
tooth root. This often results in a inal restoration cantile- prosthesis and implant height. Moderate bone loss before
vered to the facial. When the crest of the ridge resorbs, avail- implant placement may result in a crown height–bone height
able bone height is also decreased, and the CHS is increased. ratio greater than 1, with greater lateral forces applied to the
The potential length of the implant is often reduced in exces- crestal bone than in abundant bone (in which the crown
sive CHS conditions (i.e., because of vital structures), and the height is less). A linear relationship exists between the applied
more lingual implant position results in offset loads (i.e., load and internal stresses within the bone.51 Therefore, the
biomechanical disadvantage). greater the load applied, the greater the tensile and compres-
The vertical distance from the occlusal plane to the oppos- sive stresses transmitted at the bone interface and to the pros-
ing landmark for implant insertion is typically a constant in thetic components. And yet many implant treatment plans
an individual (with the exception of the posterior maxilla are designed with more implants in abundant bone situations
because the sinus cavity expands more rapidly than crestal and fewer implants in atrophied bone volume. The opposite
bone resorption in height). As the bone resorbs, the crown scenario should ideally exist. The available bone present, the
height becomes larger, but the available bone height decreases greater the crown height and the greater the number of
(Fig. 3.80). An indirect relationship is found between the implants indicated (Fig. 3.81).
Treatment of Excessive Crown Space interpositional bone grafts, and distraction osteogenesis. A
Crown height space greater than 15 mm is considered exces- staged approach to reconstruction of the jaws is often pre-
sive and is primarily the result of the vertical loss of alveolar ferred to simultaneous implant placement, especially when
bone from long-term edentulism. Other causes may include large-volume gains are required. Signiicant vertical bone aug-
genetics, trauma, and past implant failure. Treatment of exces- mentation may even require multiple surgical procedures.
sive CHS before implant placement includes orthodontic and In case of excessive CHS, bone augmentation may be pre-
surgical methods. Orthodontics in partially edentulous ferred to prosthetic replacement, especially in type C−h or D
patients (i.e., especially in the growth and development state) bone volumes. Surgical augmentation of the residual ridge
is the method of choice because other surgical or prosthetic height reduces the CHS and improves implant biomechanics
methods are usually more costly and have greater risks of by both position and number. Augmentation often permits
complications. Several surgical techniques may also be the placement of wider-body implants with the associated
considered, including block onlay bone grafts, particulate beneit of increased surface area (Fig. 3.82). Prosthetics is the
bone grafts with titanium mesh or barrier membranes, most commonly used option to address excess CHS; however,
C
FIG 3.82 (A) A panoramic radiograph of a severely resorbed maxilla and mandible. (B) An autolo-
gous bone graft may be used to increase the available bone height and reduce the crown height
in a Division C or D bone volume. (C) A panoramic radiograph after the iliac crest bone graft to
the maxilla and mandible. Continued
D E
F G
I
FIG 3.82, cont’d (D) Implants may be inserted into the bone graft after 6 months. (E) The
implants are prepared to support a cemented prosthesis. (F) A FP-3 ixed restoration is fabricated.
(G) The maxillary and mandibular FP-3 prosthesis in place. (H) The high smile line of the patient.
(I) A panoramic radiograph of the iliac crest, implants, and prostheses. (From Misch CE: Dental
FIG 3.83 When the crown height space is greater than FIG 3.84 A RP-5 overdenture is usually less stable when the
12 mm, pink porcelain (or acrylic) is often used to replace the crown height space (CHS) is large. The CHS of the prosthesis
soft tissue drape in the prosthesis. (From Misch CE: Dental is measured from the occlusal plane to the height of the
implant prosthetics, ed 2, St Louis, 2015, Mosby.) overdenture attachments. (From Misch CE: Dental implant
it should be the last choice. Using gingival-colored prosthetic 3. Increase the number of implants.
materials (pink porcelain, acrylic resin, or stained zirconia) 4. Increase the diameters of implants.
on ixed restorations or changing the prosthetic design to a 5. Utilize implants with maximum surface area.
removable restoration should often be considered when the 6. Fabricate removable restorations that are less retentive and
prosthesis is used to restore excessive CHS (Fig. 3.83). incorporate soft tissue support (e.g., buccal shelf).
In the maxilla, a vertical loss of bone results in a more 7. Remove the removable restoration during sleeping hours
palatal ridge position. As a consequence, implants are often to reduce the noxious effects of nocturnal parafunction.
inserted more palatal than the natural tooth position. Remov- 8. Splint implants together, whether they support a ixed or
able restorations have several advantages under these clinical removable prosthesis.
circumstances. The removable prosthesis does not require Crown height space is a considerable force magniier; the
embrasures for hygiene. The removable restoration may be greater the crown height, the shorter the prosthetic cantilever
removed during sleep to decrease the effects of an increase in that should extend from the implant support system. When
CHS on nocturnal parafunction. The removable restoration the CHS is greater than 15 mm, no cantilever should be con-
may improve the lip and facial support, which is usually dei- sidered unless all other force factors are minimal. The occlu-
cient because of the advanced bone loss. The overdenture may sal contact intensity should be reduced on any offset load
have suficient bulk of acrylic resin to decrease the risk of from the implant support system. Occlusal contacts in centric
prosthesis fracture and allow for ease of repair. The increase in relation occlusion may even be eliminated on the most pos-
CHS permits ideal denture tooth placement without infringe- terior aspect (or offset region) of a cantilever. In this way a
ment of the implant-prosthetic substructure. parafunction load may be reduced because the most cantile-
The excessive CHS on a RP-5 prosthesis often makes the vered portion of the prosthesis is only loaded during func-
restoration more unstable and often requires more soft tissue tional activity (e.g., chewing).52
support. In RP-5 overdentures, there are two different com-
ponents of the CHS: (1) the distance from the crest of the
ridge to the height of the overdenture attachment and (2) the
ARCH POSITION
distance from the overdenture attachment to the occlusal
plane. The greater the distance from the attachment to the
POSTERIOR HAS HIGHER FORCES
occlusal plane, the more force on the prosthesis to move or The arch position is an important part of the treatment plan-
rotate on the attachment and the greater the prosthesis ning process and has a signiicant impact on the amount of
mobility (and less the stability). Therefore, more tissue force generated to an implant prosthesis. In general, the
support, (i.e., buccal shelf) is required during function. If the maximum biting force is greater in the molar region and
prosthesis loads the soft tissue incorrectly, sore spots may decreases as measurements progress anteriorly. Maximum
occur and may accelerate the posterior bone loss (Fig. 3.84). bite forces in the anterior incisor region correspond to
An increase in the biomechanical forces is in direct relation- approximately 35 to 50 psi, those in the canine region range
ship to the increase in CHS. The treatment plan of the implant from 47 to 100 psi, and those in the molar area vary from 127
restoration should consider stress-reducing options whenever to 250 psi (Fig. 3.85).53 Mansour et al evaluated occlusal
the CHS is increased. Methods to decrease stress include: forces and moments mathematically using a class III lever
1. Shorten cantilever length. arm, the condyles being the fulcrum and the masseter and
2. Minimize offset loads to the buccal or lingual. temporalis muscles supplying the force.54 The forces at the
BOX 3.13 Arch Position: Posterior

Regions
1. Signiicantly higher biting force in the molar regions.
a. Mechanical component: class III lever
b. Biologic component: amount of muscle mass contraction
2. Posterior region is associated with long-term crestal bone
loss of integrated implants
3. Bone density poorer than in anterior regions of mouth (e.g.,
D3/D4 - maxilla vs. D2 - mandible)
4. Posterior maxilla more at risk than posterior mandible
because of poorer bone quality
5. Posterior maxilla has least bone volume
a. Crestal bone loss
b. Sinus expansion
c. Close approximation and root apexes extending into
maxillary sinus (e.g., palatal and MB root of irst molar)
FIG 3.85 The maximum bite forces are greater in the poste- 6. Posterior mandible less bone height than anterior regions
rior regions of the jaws compared with the anterior regions. a. Position of mandibular canal and foramen
(From Misch CE: Dental implant prosthetics, ed 2, St Louis, b. Angulation issues because of the buccal bone resorption
2015, Mosby.) c. Sublingual undercuts
second molar were 10% higher than at the irst molar, indica- force in the anterior regions. When the posterior teeth are in
tive of a range from 140 to 275 psi. contact, the large masticatory muscles contract. When the
Arch position should also consider the anterior maxilla posterior teeth are not in contact, two thirds of the temporalis
versus the anterior mandible. Not only is the bone generally and masseter muscles do not contract their ibers, which
denser in the anterior mandible, but the direction of force result in the biting force being reduced.
is also more in the long axis for the lower anterior teeth.
The angled load of 12 to 15 degrees in maxillary anterior Decreased Surface Area. In the anterior regions with less
implants increases the force by approximately 25%. Note that force, the anterior natural tooth roots are smaller in diameter
the maxillary anterior teeth are wider in diameter and have and root surface area compared with posterior teeth. The
greater surface area compared with the smallest teeth in the greatest increase in natural tooth surface area occurs in the
mouth, the mandibular incisors. The amount of force is molar region, with a 200% increase compared with the premo-
similar, but the direction of force places the maxillary teeth lars. Yet in implant dentistry, we primarily determine the
more at risk. implant length by existing bone volume and place longer
Arch position includes the maxillary arch vs. the mandibu- implants in the anterior region and shorter implants in the
lar arch. As previously mentioned the bone in the mandible posterior regions (or cantilever off the anterior implants,
is more often more dense than that of the maxilla, especially which results in posterior bite forces magniied by the cantile-
in the posterior regions. The edentulous maxilla with a poorer ver length). This approach should be corrected to conform to
bone density requires more implants or larger widths the biomechanical load similar to that observed with natural
compared with the edentulous mandible. It is interesting to teeth. However, the length of an implant is less effective to dis-
note that the maxillary dentition has more roots and sipate force. Instead, implant width and design are more effec-
greater surface area roots than the mandibular counterparts tive. The best option to decrease stress is to increase implant
(Box 3.13). Yet, in the edentulous maxilla, there is less avail- number. Implants in the posterior regions should often be of
able bone height than any region because the maxillary sinus greater diameter or greater number (because molars have more
quickly expands to decrease bone height. roots), especially in the presence of additional force factors.
Complications Poorer Bone Density Resulting in Less Support. The natural

Greater Bone Loss. In a study by Chung et al with 339 teeth are surrounded by a thin cortical plate of bone and
implants in 69 patients in function for an average of 8.1 years periodontal complex, which is similar for all teeth and arch
(range, 3–24 years), the posterior implants (even with kera- positions. However, after the teeth are lost, the bone density
tinized mucosa) showed a 3.5-fold greater average bone loss in the edentulous site is reduced and is often different for each
per year than anterior implants.55 In the region of higher bite region of the mouth. The posterior regions, in general, form
forces, greater bone loss may be evident. The anterior biting less bone density after tooth loss than the anterior regions,
force is decreased in the absence of posterior tooth contact with the anterior maxilla less dense than the mandible. The
and greater in the presence of posterior occlusion or eccentric mandibular anterior implant sites beneit from denser bone
contacts. Besides the mechanical properties of a class III lever than the maxillary anterior implant sites. The denser the
function, there also is a biologic component to decrease bite bone, the greater its resistance to stress applied at the
implant-bone interface. In other words, the edentulous bone A complete implant ixed prosthesis does not beneit from
density is inversely related to the amount of force and surface proprioception as do natural teeth, and patients chew food
area of the natural tooth roots generally applied in that arch with a force four times greater than with natural teeth. The
position. As a result, the posterior maxilla is the most at-risk highest forces are created with implant prostheses in the
arch position followed by the posterior mandible and then opposing arch. An RP-4 overdenture may have some move-
the anterior maxilla. The most ideal region for implant stress ment compared with a ixed prosthesis and is more likely to
transfer within the physiologic loading zone for bone is the have acrylic or resin teeth. Hence, the bite force is slightly less
mandibular anterior region.56 than for a full arch ixed implant prosthesis. In addition,
premature contacts in occlusal patterns or during parafunc-
tion on the implant prostheses do not alter the pathway of
OPPOSING ARCH closure because occlusal awareness is decreased with implant
An often overlooked factor in the treatment planning process is prostheses compared with natural teeth. Continued stress
the opposing arch. In general, natural teeth transmit greater increases can be expected to occur with the implant restora-
impact forces through occlusal contacts than soft tissue–borne tion (Box 3.14).
complete dentures. In addition, the maximum occlusal force of The opposing arch is not as major a factor to alter an
patients with complete dentures is limited and may range from implant treatment plan as parafunction, masticatory dynam-
5 to 26 psi.57 The force is usually greater in recent denture wearers ics, or excessive CHS, but is a major factor for the risk of
and decreases with time. Muscle atrophy, thinning of the oral porcelain or prosthesis fracture. In a report by Kinsel and Lin,
tissues with age or disease, and bone atrophy often occur in the opposing dentition varies the incidence of porcelain frac-
edentulous patients as a function of time.58 Some denture ture to an implant crown.59 When the opposing arch was a
wearers may clench on their prosthesis constantly, which may denture, 0% fracture of the implant crowns in the opposing
maintain muscle mass, but will usually result in bone loss. arch was found. The opposing dentition of a natural tooth
The maximum force generated against an implant pros- found 3.2% fracture of implant crowns. The opposing
thesis is related to the number of teeth or implants support-
ing the prosthesis in the opposing arch. Partially edentulous
dentate patients have less force than dentate patients with all
BOX 3.14 Opposing Arch: Force
of their teeth. Patients with partial dentures may have forces
Generated (Lowest to Highest)
intermediate between those of natural teeth and complete
dentures, depending on the location and condition of the 1. Soft tissue–borne denture (conventional complete denture)
remaining teeth, muscles, and joints. In partially edentulous 2. RP-5 overdenture (primary support - soft tissue)
patients with implant-supported ixed prostheses, force 3. Partially edentulous arch
4. Dentate arch
ranges are more similar to those of natural dentition, but lack
5. RP-4 overdenture (primary support - implants)
of proprioception may magnify the load amount during 6. Fixed implant prosthesis (full-arch implant-supported)
parafunctional and functional activity (Fig. 3.86).
A B
C D
FIG 3.86 Opposing arch. Greatest forces from high to low. (A) Implant-supported ixed prosthe-
sis. (B) Conventional ixed porcelain fused to metal. (C) Natural Dentition. (D) Overdenture/
conventional denture.
BOX 3.15 Implant Crown Porcelain

Fracture Related to Opposing Arch: Least
to Highest Risk
1. Complete denture (0%)
2. Natural teeth (3.2%) (19.4% of patients)
3. Crown on a natural tooth (5.7%)
4. Implant crown (16.2%) (69.5% of patients)

2015, Mosby.)
A-P
dentition of a crown on a natural tooth found a 5.7% fracture FIG 3.87 The anteroposterior (A-P) distance is determined by
of the opposing implant crown. A 16.2% fracture was a line drawn from the distal portion of the distalmost implant
observed when an implant crown opposed an implant crown. on each side of the arch and another parallel line drawn
through the center of the anteriormost implant from the
When the percentage of patients with major fractures of por-
cantilever. (From Misch CE: Dental implant prosthetics,
celain were compared to the percentage with no fractures, the
incidence of patients with porcelain fractures of implant
crowns was 19.4% for natural teeth and 69.5% of patients
with implant crowns in the opposing arch. Therefore, the BOX 3.16 Bone Quality Relects
opposing dentition may increase the impact force, and the
• Strength of cortical/cancellous bone
greater the force, the higher the risk of porcelain fracture
• Modulus of elasticity
(Box 3.15). • Bone-implant contact percent (interface)
As a consequence of the opposing arch affecting the inten- • Stress contours around a loaded endosteal implant
sity of forces applied to an implant prosthesis, the treatment • Surgical protocol
plan may be modiied to reduce the risk of fatigue fracture • Healing time
and overload. Rarely should the opposing arch be maintained • Need for progressive bone loading
in a traditional denture as a method to decrease the stress to
the implant arch. Unfortunately, many edentulous patients
opt to remain in a denture for the maxillary arch as a conse- (Fig. 3.89). A tapering arch form has an A-P distance greater
quence of the increased costs associated with implant pros- than 9 mm (Fig. 3.90). Whereas a tapering arch form may
theses. However, the patient should be aware of the continued support a 20-mm cantilever, a square arch form requires the
bone loss in the maxillary edentulous arch, and a preferred cantilever to be reduced to 12 mm or less. A tapering arch
treatment is an implant-supported prosthesis in both arches form is most ideal, and a square arch form is susceptible to
in order to maintain the existing bone volume. force-related complications.
The A-P spread is only one of the force factors to be con-
sidered for the extent of the distal cantilever. If the stress
ARCH FORM factors are high (e.g., parafunction, crown height, mastica-
The patient’s arch form should always be evaluated in the tory musculature dynamics, opposing arch), the cantilever
treatment planning process, especially in the mandibular length of a prosthesis should be reduced and may even be
arch. There exist many variations on the size and shape of contraindicated.
patients’ arch forms. The distance from the center of the most
anterior implant to a line joining the distal aspect of the two
most distal implants on each side is called the anteroposterior BONE DENSITY
(A-P) distance or the A-P spread (Fig. 3.87).60 The greater the
A-P spread (Fig. 3.87),60 theorectically the farther the distal
TREATMENT PLANNING
cantilever may be extended to replace the missing posterior The external (cortical) and internal (trabecular) structure of
teeth, which minimizes force-related issues. As a general rule, bone may be described in terms of quality or density, which
when ive to six anterior implants are placed in the anterior relects a number of biomechanical properties, such as
mandible between the foramina to support a ixed prosthesis, strength, modulus of elasticity, bone-implant contact (BIC)
the cantilever should not exceed two times the A-P spread, percent, and stress distribution around a loaded endosteal
with all other stress factors being low. implant (Box 3.16). The external and internal architecture of
The A-P distance is directly affected by the arch form. The bone controls and dictates virtually the surgical and pros-
types of arch forms may be separated into square, ovoid, and thetic protocol for the patient. The density of available bone
tapering. A square arch form in the anterior mandible has a in an edentulous site is a determining factor in treatment
0- to 6-mm A-P spread between the most distal and most planning, surgical approach, implant design, healing time,
anterior implants (Fig. 3.88). An ovoid arch form has an and the need for initial progressive bone loading during pros-
A-P distance of 7 to 9 mm and is the most common type thetic reconstruction.56
Cantilever
A-P
A E
B D
C
FIG 3.88 A mandibular square arch form has an anteroposterior (A-P) distance of 0 to 6 mm.
As a result, a cantilever is limited. (From Misch CE: Dental implant prosthetics, ed 2, St Louis,
2015, Mosby.)
Cantilever
A-P
A E
B D
C
FIG 3.89 A mandibular ovoid arch form has an anteroposterior (A-P) distance of 7 to 9 mm and
is the most common type. A cantilever may extend to 18 mm with the ovoid-type arch. (From
Misch CE: Dental implant prosthetics, ed 2, St Louis, 2015, Mosby.)
Cantilever
A-P
A E
B D
C
FIG 3.90 A mandibular tapered arch form has an anteroposterior (A-P) distance of greater than
9 mm, and is the type least observed. A cantilever is least at risk for this arch form. (From Misch
CE: Dental implant prosthetics, ed 2, St Louis, 2015, Mosby.)
The bone density has a signiicant impact on the treatment example, both MacMillan and Paritt have reported on the
planning of an implant patient. The initial treatment plan is structural characteristics and variation of trabeculae in the
presented to the patient using the anatomic location as an alveolar regions of the jaws.64 The maxilla and mandible have
index of the bone density: anterior mandible and single tooth different biomechanical functions (Fig. 3.92). The mandible,
replacement is D2, anterior maxilla and posterior mandible as an independent structure, is designed as a force-absorption
is D3, and posterior maxilla is D4. After the initial treatment unit. When teeth are present, the outer cortical bone is much
evaluation of the osseous structures are taken into consider- denser and thicker, and the trabecular bone is more coarse and
ation (e.g., prosthesis type and design, implant key position, dense (Fig. 3.93). This bony architectural make-up is in direct
and patient force factors), a more complete treatment plan relation to the force applied. On the other hand, the maxilla is
relative to bone density is obtained by a CBCT scan or modi-
ied during the surgical procedure using the tactile method
to determine bone density.
Understanding the Basics of Bone

Bone is an organ that is able to change in relation to a number
of factors, including hormones, vitamins, and mechanical
inluences. However, biomechanical parameters, such as the
amount of strain transmitted to bone, are predominant.
Awareness of this adaptability in the skeletal system has been
reported for more than a century. In 1887, Meier qualitatively
described the architecture of trabecular bone in the femur.61
In 1888 Kulmann noticed the similarity between the pattern
of trabecular bone in the femur and tension trajectories in
construction beam concepts used by Eiffel (Fig. 3.91).62 Wolff,
in 1892, further elaborated on these concepts and published:
“Every change in the form and function of bone or of its
function alone is followed by certain deinite changes in the
internal architecture, and equally deinite alteration in its
external conformation, in accordance with mathematical
laws.”63 It has been widely reported that, in the structural
skeleton, the external architecture of bone (cortical bone) FIG 3.92 The maxilla and mandible vary in their bony make-
changes in relation to function, and the internal bony struc- up. The maxilla is a force distribution unit, and the mandible
ture (trabecular bone) is also modiied (Wolff ’s Law). is a force absorption unit. As a consequence, the cortical and
The structural changes in bone as a consequence of trabecular bone are different. (From Misch CE: Dental implant
mechanical inluences have also been noted in the jaws. As an prosthetics, ed 2, St Louis, 2015, Mosby.)
FIG 3.93 The trabecular bone in a dentate mandible is coarser

FIG 3.91 The proximal head of the femur has trabecular bone than that in the maxilla. The cortical bone is thick and dense.
aligned along stress pathways, similar to beams for a bridge The mandible, as an independent structure, is a force-
or tower. (From Misch CE: Dental implant prosthetics, ed 2, absorbing element. (From Misch CE: Dental implant prosthet-
St Louis, 2015, Mosby.) ics, ed 2, St Louis, 2015, Mosby.)
FIG 3.94 The dentate maxilla has a iner trabecular pattern

compared with the mandible. The cortical bone is more thin FIG 3.96 On the left, the opposing mandibular tooth was
and porous. The maxilla is a force distribution unit and is removed. A lack of occlusal contact resulted in loss of trabecu-
designed to protect the orbit and brain. (From Misch CE: lar bone around the maxillary tooth. The tooth on the right is
Dental implant prosthetics, ed 2, St Louis, 2015, Mosby.) from the same monkey, with the opposing mandibular tooth
in place. The trabecular bone is much denser around the tooth.
The disuse atrophy observed on the left is from inadequate
microstrain conditions to maintain the bone. (From Orban B:
Oral histology and embryology, ed 3, St Louis, 1953, Mosby.)
In general, the density change after tooth loss is greatest in

the posterior maxilla and least in the anterior mandible.
Cortical and trabecular bone throughout the body is con-
stantly modiied by either modeling or remodeling. Modeling
has independent sites of formation and resorption and results
in the change of the shape or size of bone. Remodeling is a
process of resorption and formation at the same site that
replaces previously existing bone and primarily affects the
FIG 3.95 The trabecular bone of each jaw has structural varia-
internal turnover of bone, including that region where
tions. The trabecular bone is densest next to the teeth, where
teeth are lost or the bone next to an endosteal implant. These
it forms the cribriform plate. Between the teeth, the bone is
usually densest near the crest and least dense at the apex. adaptive phenomena have been associated with the alteration
(From Misch CE: Dental implant prosthetics, ed 2, St Louis, of the mechanical stress and strain environment within the
2015, Mosby.) host bone.67
Stress is determined by the magnitude of force divided by
the functional area over which it is applied. Strain is deined
as the change in length of a material divided by the original
a force-distribution unit. Stresses to the maxilla are transferred length. The greater the magnitude of stress applied to the
by the zygomatic arch and palate away from the brain and bone, the greater the strain observed in the bone.18 Bone
orbit. As a consequence, the maxilla has a thin cortical plate modeling and remodeling are primarily controlled, in part or
and ine trabecular bone surrounding the teeth (Fig. 3.94). whole, by the mechanical environment of strain. Overall, the
When evaluating bone quality around natural teeth, Neufeld density of alveolar bone evolves as a result of mechanical
noted that the bone is most dense around the teeth (cribri- deformation from microstrain.
form plate) and more dense around the teeth at the crest Frost proposed a model of modeling/remodeling patterns
compared with the regions around the apices (Fig. 3.95).65 for compact bone as it relates to mechanical adaptation to
Orban demonstrated a decrease in the trabecular bone strain.68 Spontaneous fracture, the pathologic overload zone,
pattern around a maxillary molar with no opposing occlusion mild overload zone, adapted window, and acute disuse
compared with a tooth with occlusal contacts on the contra- window were described for bone in relation to the amount of
lateral side (Fig. 3.96).66 Bone density in the jaws also decreases the microstrain experienced (Box 3.17). These categories also
after tooth loss. This loss is primarily related to the length of may be used to describe the trabecular bone response next to
time the region has been edentulous and not loaded appro- a dental implant in the jaws.
priately, the initial density of the bone, lexure and torsion in With disuse atrophy, bone loses mineral density, and disuse
the mandible, and parafunction before and after tooth loss. atrophy occurs because modeling for new bone is inhibited
and remodeling is stimulated, with a gradual net loss of bone. cortical bone is remodeled each year in the physiologic
The microstrain of bone for trivial loading is reported to be loading zone, which corresponds to the adapted window.71
0 to 50 microstrain.68 This phenomenon may occur through- This is the range of strain ideally desired around an endosteal
out the skeletal system, as evidenced by a 15% decrease in the implant after a stress equilibrium has been established. Bone
cortical plate and extensive trabecular bone loss consequent turnover is required in the adapted window; Mori and Burr
to immobilized limbs for 3 months.69 A cortical bone density provide evidence of remodeling in regions of bone microfrac-
decrease of 40% and a trabecular bone density decrease of ture from fatigue damage within the physiologic range.72
12% also have been reported with disuse of bone (Fig. 3.97).70 The mild overload zone (1500–3000 microstrain) causes a
The adapted window (50–500 microstrain) represents an greater rate of fatigue microfracture and increase in the cel-
equilibrium of modeling and remodeling, and bone condi- lular turnover rate of bone. As a result, the bone strength and
tions are maintained at this level. Bone in this strain environ- density decrease. The histologic description of bone in this
ment remains in a steady state, and this may be considered range is usually woven or repair bone. Woven bone is able to
the homeostatic window of health. The histologic description form faster but is less mineralized and less organized than
of this bone is primarily lamellar or load-bearing bone. lamellar bone. This may be the state for bone when an end-
Approximately 18% of trabecular bone and 2% to 5% of osteal implant is overloaded and the bone interface attempts
to adapt to the greater strain environment. During the repair
process, the woven bone is weaker than the more mature,
mineralized lamellar bone.73 Although bone is loaded in the
BOX 3.17 Mechanical Adaptation mild overload zone, care must be taken because the “safety
of Bone Categories68 range” for bone strength is reduced during the repair.
Pathologic overload zones are reached when microstrains
1. Spontaneous fracture are greater than 3000 units. Cortical bone fractures occur
2. Pathologic overload zone at approximately 10,000 to 20,000 microstrain (1%–2%
3. Mild overload zone
deformation). However, pathologic overload may begin at
4. Adapted window
microstrain levels of only 20% to 40% of the ultimate strength
5. Acute disuse window
or physical fracture of cortical bone. The bone may resorb
Strain O
Stress F/A
Strain
50 1500 3000 10,000+
Acute Adapted Mild Pathologic Spontaneous

disuse window overload overload fracture
window window window
FIG 3.97 Four zones for bone related to mechanical adaption to strain before spontaneous frac-
ture. The acute disuse window is the lowest microstrain amount. The adapted window is an
ideal physiologic loading zone. The mild overload zone causes microfracture and triggers an
increase in bone remodeling, which produces more woven bone. The pathologic overload zone
causes increase in fatigue fractures, remodeling, and bone resorption. (From Misch CE: Dental
and form ibrous tissue or, when present, repair woven bone trabecular bone (Fig. 3.100). D3 bone types have a thinner
is observed in this zone because a sustained turnover rate is porous cortical crest and facial/lingual regions, with ine tra-
necessary. The marginal bone loss evidenced during implant becular bone in the region next to the implant (Fig. 3.101).
overloading may be a result of the bone in the pathologic D4 bone has almost no crestal cortical bone and porous corti-
overload zone. Implant failure from overload may also be a cal lateral plates. The ine trabecular bone comprises
result of bone in the pathologic overload zone. almost all of the total volume of bone next to the implant
(Fig. 3.102). A very soft bone, with incomplete mineralization
Understanding Different Bone Densities and large intratrabecular spaces, may be addressed as D5
In 1988, Misch proposed four bone density groups indepen- bone (Fig. 3.103). This bone type is found often in the imma-
dent of the regions of the jaws based on macroscopic cortical ture bone of a developing bone graft site. The bone density
and trabecular bone characteristics.74 This bone density clas- may be determined by the general location, tactile sense
siication allows for different treatment protocols according during surgery, or computerized radiographic evaluation.
to the type of bony anatomy. Suggested treatment plans,
implant design, surgical protocol, healing time, and progres- Complications Related to Bone Density
sive loading time spans have been described for each bone D1. Dense cortical bone also presents several disadvantages.
density type.17 Following this regimen, similar implant sur- The implant height is often limited to less than 12 mm in the
vival rates have been observed for all bone densities.75 atrophic mandible, and the crown height space is often
Dense or porous cortical bone is found on the outer sur- greater than 15 mm. As a result, additional force-multiplying
faces of bone and includes the crest of an edentulous ridge.
Coarse and ine trabecular bone types are found within the
outer shell of cortical bone and occasionally on the crestal
TABLE 3.5 Misch Bone Density
surface of an edentulous residual ridge. These four macro-
Classiication Scheme
scopic structures of bone may be arranged from the most
dense to the least dense, as irst described by Frost and by Bone Tactile Typical Anatomic
Roberts: dense cortical bone, porous cortical bone, coarse Density Description Analog Location
trabecular bone, and ine trabecular bone (Fig. 3.98). D1 Dense cortical Oak or Anterior mandible
In combination, these four macroscopic densities consti- maple
wood
tute the four bone categories described by Misch (D1, D2, D3,
and D4) located in the edentulous areas of the maxilla and D2 Porous cortical White pine Anterior mandible
and coarse or spruce Posterior mandible
mandible (Table 3.5; Fig. 3.99). The regional locations of the
trabecular wood Anterior maxilla
different densities of cortical bone are more consistent than
D3 Porous cortical Balsa Anterior maxilla
the highly variable trabecular bone.
(thin) and ine wood Posterior maxilla
D1 bone is primarily dense cortical bone. D2 bone has
trabecular Posterior mandible
dense to porous cortical bone on the crest and lateral to the
D4 Fine trabecular Styrofoam Posterior maxilla
implant site. The bone within this cortical housing has coarse
D5 Immature, — Early healed
non- grafted bone
mineralized
bone
D1 D2 D3 D4
FIG 3.99 Misch described four bone densities found in the
anterior and posterior edentulous regions of the maxilla and
mandible. D1 bone is primarily dense cortical bone, D2 bone
has dense to thick porous cortical bone on the crest and
coarse trabecular bone underneath, D3 bone has a thinner
FIG 3.98 The macroscopic structure of bone may be porous cortical crest and ine trabecular bone within, and D4
described, from the least dense to the most dense, as (1) bone has almost no crestal cortical bone. The ine trabecular
ine trabecular, (2) coarse trabecular, (3) porous cortical, and bone composes almost all of the total volume of bone.
(4) dense cortical. (Courtesy E. Roberts; from Misch CE: (From Misch CE: Dental implant prosthetics, ed 2, St Louis,
Dental implant prosthetics, 2e, St Louis, 2015, Mosby.) 2015, Mosby.)
FIG 3.100 A cross section of a D2 mandible in the region of FIG 3.102 An anterior maxilla demonstrating D3 bone with a
the midline. A dense to porous cortical plate exists on the thin porous cortical plate on the crest with ine trabecular
crest and lateral borders, and a coarse trabecular bone pattern bone underneath. (From Misch CE: Dental implant prosthet-
exists within. (From Misch CE: Dental implant prosthetics, ics, ed 2, St Louis, 2015, Mosby.)
FIG 3.103 In a D4 posterior maxilla, the posterior crestal

region has little to no cortical bone on the crest and is com-
posed primarily of ine trabecular bone. (From Misch CE:
FIG 3.101 A posterior mandible with D3 bone. A thin porous D1 bone has a more compromised vasculature with fewer
cortical bone is at the crest and ine trabecular bone is in the blood vessels than the other three types, and it is more depen-
body of the mandible. (From Misch CE: Dental implant pros- dent on the periosteum for its nutrition. The cortical bone
thetics, ed 2, St Louis, 2015, Mosby.) receives the outer one third of all its arterial and venous
supply from the periosteum.76 This bone density is almost all
factors (such as cantilevers or lateral forces) are further mag- cortical, and the capacity of regeneration is impaired because
niied on the implant-prosthetic system. Stress-reducing of the poor blood circulation. Delicate and minimal perios-
factors may be incorporated in the prosthesis design to reduce teal relection is indicated. When D1 density is present, the
these effects, not only on the bone, but also on the prosthetic bone width is usually abundant (i.e., as bone is lost in height,
components (Fig. 3.104). the mandible exhibits greater width). Fortunately, there are
BOX 3.18 D1 Bone: Surgical

Modiications
1. Overheating During Osteotomy
• Abundant external or internal irrigation
• Cooled saline irrigation
• Intermittent pressure on drill (e.g., bone dancing)
• Maintain irrigation while pausing every 3-5 seconds
• Utilize new, sharp drills
• Incremental drill sequence (use more drills; pass same drill
more than once to widen osteotomy)
2. Blood Supply
FIG 3.104 D1 bone, when present, is almost always in the • Primarily from periosteum, results in longer healing times
anterior mandibular area in the severely atrophic mandible. • Minimal relection to decrease blood compromise
This type of bone has a high BIC (~80%) and is susceptible
3. Final Osteotomy Drill
to surgical complications (i.e., overheating the bone during
• Greater width to minimize pressure necrosis
osteotomy preparation).
• Greater depth
• Slower drill speed
• Verify no bone debris remaining
4. Bone Tap
few occurrences when facial or lingual undercuts are observed
• Short of full osteotomy depth
with D1 bone densities, and lap relection can be safely kept
• Allows passive implant it to minimize pressure necrosis
to a minimum. The precise closure of the periosteum and the • Prevents internal implant-body–implant-bone interface micro-
overlaying tissue has been shown to help recover the blood fracture
supply and is encouraged (Box 3.18). • Removes drill remnants
5. Final Implant Placement at or Above Bone Level
D2. D2 bone provides excellent implant interface healing,
• After inal insertion, unthread 12 turn to relieve internal
and osteointegration is very predictable. There exist basically stresses
no disadvantages to this type of bone. Most implant systems
refer to this density of bone for their ideal surgical protocol. 6. Slower Healing Rate
• Lamellar bone – fewer blood vessels
The dense to porous cortical bone on the crest or lateral por-
• Five months to achieve mature interface – anterior mandible
tions of the implant site provides a secure initial rigid inter-
face. Osteoplasty to gain additional width of bone before 7. Stage II Uncovery
implant placement or countersinking below the crestal bone • May initiate stage II surgery after 3 to 4 months
does not compromise support because the lateral cortices and • May often use immediate loading (when prosthesis is bio-
mechanically stable)
coarse internal trabecular bone provide rigid ixation. The
implant may even be placed slightly above the crest of the
ridge with decreased compromise or risk of movement at
the interface during healing, compared with softer bone
types. The intrabony blood supply allows bleeding during the
osteotomy, which helps control overheating during prepara-
tion and is most beneicial for bone-implant interface healing
(Figs. 3.105 and 3.106).
D3. D3 bone also presents several disadvantages (Box 3.19).

It is more dificult to manage than the previous two bone
density types (D1 and D2) because its preparation is com-
pleted easily. Bone preparation in D3 bone completed with
constant care of direction to avoid enlargement or elliptical
preparation of the site.
A common mistake that causes an elliptical site to form is
the use of a inger rest during the osteotomy. Because the drill
is often longer than 20 mm, a inger rest results in an arched
pathway of the drill into the bone. In dense bone, the side of
the drill encroaches upon the dense cortical crest, which FIG 3.105 D2 bone has a dense to porous cortical crest, and
opposes the movement and stops the rotation before the inner trabecular bone is coarse. It is found most often in the
crestal osteotomy is enlarged. In D3 bone the arc pathway is mandible. (From Misch CE: Contemporary implant dentistry,
not stopped and the osteotomy at the level of the crestal ed 3, St Louis, 2008, Mosby.)
A B
FIG 3.106 D2 bone. (A) D2 bone is the ideal bone for implant placement and healing with a high
success rate. (B) This type of bone also allows for the accumulation of bone from the osteotomy
that can be used to augment defects.
BOX 3.19 D3 Bone: Surgical and bone is of greater diameter than the drill. If the implant
Prosthetic Modiications design does not increase at the crestal region, the surgical
defect created around the top of the implant may heal with
1. Bone Anatomy
• Most common in anterior maxilla; usually deicient in width
ibrous tissue rather than bone and cause an initial bony
pocket. Additionally, the direction for the osteotomy may be
2. Osteotomy changed (see Box 3.19).
• Lateral perforation may occur because of width deiciency To improve rigid ixation of traditional root form designs
• Osteotomy is commonly overprepared during healing, the opposing thin cortical bone of the nasal
• Ideal angulation to prevent apical perforation or antral loor is often engaged in the maxilla or the apico-
lingual plate in the mandible, when immediate loading is
3. Bone-Implant Contact
• Approximately 50%, which compromises initial stability
considered. If the original implant height determined before
and increases bone healing surgery does not engage the opposing cortical bone, the
• Additional implant may need to be placed for biomechani- osteotomy is increased in depth until it is engaged and
cal advantage even perforated. Slightly longer implants are placed in this
approach to further increase surface area of support with
4. Implant Placement rigid ixation being of utmost importance. However, it should
• One time, no removal and reinsertion be noted this technique improves stability during healing but
• Level with thin crestal cortical bone or slightly below does not decrease the crestal loads to bone after healing.
• Greater risk of load during healing, verify no interim pros-
Instead, implant crest module design and the crestal one-
thesis pressure
• Use high-torque handpiece to insert self-tapping threaded
third of the implant body design are necessary to decrease
implant – avoid using insertion ratchet as this tends to stress when the implant prosthesis is loaded (Fig. 3.107).
widen osteotomy or redirect implant
D4. Fine trabecular bone presents the clinician with the
5. Implant Design most dificult and greatest possibilty for rigid ixation prob-
• Titanium plasma spray (TPS) or hydroxyapatite (HA) coated lems. Bone trabeculae are sparse and, as a result, initial ixa-
• Larger-thread design tion of any implant design presents a surgical challenge (Box
• Only threaded implants should be placed 3.20). The implant surgeon should not prepare D4 bone
• Increased diameter implants, results in greater surface area
with rotating drills, which use an extraction technique to
6. Healing Period remove bone preparation of the osteotomy. The initial drill
• Six months to increase lamellar bone and mineralization to determine site depth and angulation is the only drill to be
• Prosthetic progressive loading more important than for D1 used in this bone type, after which osteotomes may be used
or D2 with a surgical mallet or hand piece to compress the bone
site, rather than remove bone, as the osteotomy increases in
7. Prosthetic Rehabilitation size. The compaction technique of the site is prepared with
• Splint implants for biomechnical stress distribution
great care. The bone site is easily distorted, resulting in
• Narrow occlusal table
reduced initial stability of the implant. The inal osteotomy
• Progressive bone loading
diameter is similar to the D3 preparation. The residual ridge
FIG 3.108 The posterior maxilla is the most common location

for D4 bone. Because of the poor bone implant contact
(∼25%), modiications of the surgical and prosthetic proce-
dures need to be implemented to decrease complications.
A
BOX 3.20 D4 Bone: Surgical and
Prosthetic Modiications
1. Bone Anatomy
• Location is usually posterior maxilla, which results in surgi-
cal dificulty
• No cortical crest results in compromised initial ixation
• Decreased height because of maxillary sinus pneumatization
• Bone augmentation is usually indicated
2. Osteotomy
• Easily overprepared, surgical site should be underprepared
• Use of osteotomes is highly recommended
• Angulation should be strictly monitored and misdirection
often occurs
3. Bone-Implant Contact
• Approximately 25% resulting in poor initial ixation
• Additional implant indicated for biomechanical stress
distribution
4. Implant Placement
B • No removal and reinsertion
• Placement below the crestal bone to minimize loading
FIG 3.107 (A) and (B), D3 bone has a thin, porous cortical during the healing phase
crest and ine trabecular bone within the alveolus. It is fre- • Implant design with greater surface area
quently found in a posterior mandible. (From Misch CE: Con- • Placement with handpiece is recommended to maintain
temporary implant dentistry, ed 3, St Louis, 2008, Mosby.) path of insertion
• Insertion ratchet should not be used
5. Prosthesis Fabrication
is easily expanded in this bone type. The osteotomy may • Progressive loading highly recommended
both compress the bone trabeculae and expand the osteot- • Narrow occlusal table decreases force-related issues
omy site resulting in an improved bone density (Fig. 3.108 • Splinting of implants for force distribution
and Box 3.20). (From Misch CE: Contemporary Implant Dentistry, ed 3, St Louis,
2008, Mosby.)
PREVENTION OF BONE DENSITY
COMPLICATIONS
density is directly related to the strength of bone before
Understanding Bone Strength and Density microfracture. Misch et al. reported on the mechanical prop-
To understand how the direct effect bone density has on erties of trabecular bone in the mandible using the Misch
dental implant success and morbidity, the clinician must have bone density classiication.77 A 10-fold difference in bone
knowledge of the make-up and biomechanics of bone. Bone strength may be observed from D1 to D4 bone (Fig. 3.109).
Ultimate compressive strength (MPa)
107
5.38
Elastic modulus (MPa)

81
2.57
35
1.70
D2 D3 D4
D2 D3 D4
FIG 3.111 The elastic modulus for D2 trabecular bone is
FIG 3.109 The strength of bone is related directly to the greater than that for D3 trabecular bone, and D4 trabecular
density of bone. (From Misch CE: Dental implant prosthetics, bone has the lowest elastic modulus. (From Misch CE: Dental
ed 2, St Louis, 2015, Mosby.) implant prosthetics, ed 2, St Louis, 2015, Mosby.)
of a particular amount of stress. This has been shown to be

Strength/Density directly related to the apparent density of bone.78 The elastic
D1 modulus of a material is a value that relates to the stiffness of
the material. The elastic modulus of bone is more lexible
than titanium. When higher stresses are applied to an implant
Strength
D2
prosthesis, the titanium has lower strain (change in shape)
compared with the bone. The difference between the two
D3
materials may create microstrain conditions of pathologic
D4 overload and cause implant failure. When the stresses applied
to the implant are low, the microstrain difference between
titanium and bone is minimized and remains in the adapted
Density
window zone, maintaining load-bearing lamellar bone at the
FIG 3.110 The ultimate compressive strength of D2 trabecu-
interface.79
lar bone is greater than D3 trabecular bone, and D4 trabecular Misch et al. found the elastic modulus of the trabecular
bone is the weakest. (From Misch CE: Dental implant pros- bone in the human jaw to be different for each bone density
thetics, ed 2, St Louis, 2015, Mosby.) (Fig. 3.111). As a result, when a stress is applied to an implant
prosthesis in D1 bone, the titanium-D1 bone interface exhib-
its very little microstrain difference. In comparison, when
D2 bone exhibited a 47% to 68% greater ultimate compres- the same amount of stress is applied to an implant in D4
sive strength compared with D3 bone (Fig. 3.110). On a scale bone, the microstrain difference between titanium and D4
of 1 to 10, D1 bone is a 9 to 10 relative to strength, D2 bone bone is greater and may be in the pathologic overload zone
is a 7 to 8 on this scale, D3 bone is 50% weaker than D2 bone (Fig. 3.112). As a result, D4 bone is more likely to cause
and is a 3 or 4 on the strength scale, and D4 bone is a 1 to 2 implant mobility and failure. Clinicians must take into con-
and up to 10 times weaker than D1 bone. It should be noted sideration that poorer quality of bone is inherently more
that the studies of bone strength were performed on mature susceptible to implant complications.
bone types. Bone is 60% mineralized at 4 months after
implant surgery, and the strength of bone is related to the Bone-Implant Contact Percentage
amount of mineralization. It is prudent to increase healing The initial bone density not only provides mechanical immo-
time prior to loading in D3 and D4 bone densities. A period bilization of the implant during healing but after healing also
of 3 to 4 months is adequate for D1 and D2 bone. A healing permits distribution and transmission of stresses from the
period of 5 to 6 months is beneicial in D3 to D4 bone. The prosthesis to the implant-bone interface. The mechanical dis-
bone densities that originally relied on clinical impression are tribution of stress occurs primarily where bone is in contact
now fully correlated to quantitative objective values obtained with the implant. Open marrow spaces or zones of unorga-
from CBCT scans and bone strength measurements. These nized ibrous tissue do not permit controlled force dissipa-
values can help prevent failure in speciic situations of weak tion or microstrain conditions to the local bone cells. Because
densities. stress equals force divided by the area over which the force is
applied, the less the area of bone contacting the implant
Elastic Modulus and Density body, the greater the overall stress, other factors being equal.
By deinition, elastic modulus describes the amount of strain Therefore, the BIC percent has a signiicant inluence on the
(changes in length divided by the original length) as a result amount of stress and strain at the interface.
Force: Area- Elastic Modulus

Stress
Ti D1
D2,D3
D4
Strain
FIG 3.112 The microstrain difference between titanium and D4 bone is great and may be in the
pathologic overload zone, whereas at the same stress level, the microstrain difference between
titanium and D2 bone may be within the ideal adapted window zone. (From Misch CE: Dental
A B C D
FIG 3.113 Bone-Implant Contact (BIC): (A) D1 Bone - ~85%, (B) D2 Bone - 65–75%, (C) D3 Bone
- 40–50%, (D) D4 Bone - ~30%.
In 1990, Misch noted that the bone density inluences the BOX 3.21 Initial Bone-Implant Contact
amount of bone in contact with the implant surface, not Percent (BIC %)
only at irst-stage surgery but also at the second-stage uncov-
D1: 85%
ery and early prosthetic loading.80 The BIC percentage is sig-
D2: 65%–75%
niicantly greater in cortical bone than in trabecular bone. D3: 40%–50%
The very dense D1 bone of a C−h resorbed anterior mandi- D4: <30% (% = bone-implant contact)
ble or of the lingual cortical plate of a Division A anterior or
posterior mandible provides the highest percentage of bone
in contact with an endosteal implant and may approximate
more than 85% BIC (Fig. 3.113). D2 bone, after initial body of the implant. With a machined-surface implant, this
healing, usually has 65% to 75% BIC (Fig. 3.114). D3 bone may approximate less than 30% BIC and is most related to
typically has 40% to 50% BIC after initial healing (Box 3.21). the implant design and surface condition. Consequently,
The sparse trabeculae of the bone often found in the poste- greater implant surface area is required to obtain a similar
rior maxilla (D4) offer fewer areas of contact with the amount of BIC in soft bone compared with a denser bone
Stress Transfer
Crestal bone loss and early implant failure after loading
results may occur from excess stress at the implant-bone
interface. A range of bone loss has been observed in implants
in different bone densities with similar load condition.81
Bidez and Misch noted in 1990 that part of this phenomenon
may be explained by the evaluation of inite element analysis
(FEA) stress contours in the different volumes of bone for
each bone density.82 Each model reproduced the cortical and
trabecular bone material properties of the four densities
described. Clinical failure was mathematically predicted
in D4 bone and some D3 densities under occlusal loads
(Fig. 3.116). Other studies using FEA models with various
FIG 3.114 Bone density. An alternative material to evaluate implant designs and bone quality have also evaluated the
bone density is: D1 bone = maple wood; D2 bone = white stress-strain distribution in the bone around the implants.83
pine wood; D3 bone = balsa wood; D4 bone = Styrofoam. For example, Tada et al. evaluated the three-dimensional
changes around different length implants in different bone
qualities (Fig. 3.117).84 The type 3 and 4 bone categories had
four to six times more strain around all implants, with the
3 months 6 months
highest strains around the shortest implants. As a result of
70 the correlation of bone density to the elastic modulus, bone
strength, and BIC percent, when a load is placed on an
60
implant, the stress contours in the bone are different for each
50 bone density.85 In D1 bone, the highest strains are concen-
trated around the implant near the crest, and the stress in the
% Integration
40 region is of lesser magnitude. D2 bone, with the same load,

sustains a slightly greater crestal strain, and the intensity of
30 60.8 60.6
the stress extends farther apically along the implant body. D4
51.5 49 49.8 48.3
bone exhibits the greatest crestal strains, and the magnitude
20
33.2 33.8 of the stress on the implant proceeds farthest apically along
10 the implant body.
As a consequence of different strain regions present around
0 implants with different bone densities, the magnitude of a
cpTi-Mx cpTi-Mn Ti-Mx Ti-Mn
prosthetic load may remain similar, and yet give one of the
FIG 3.115 The percentage of bone contact after initial healing following three different clinical situations at the bone-implant
and before any occlusal load may be related to bone density interface based on the bone density around the implant: (1)
(e.g., mandible vs. maxilla) and healing time. Longer healing
physiologic bone loads in the adapted window zone and no
periods may increase bone-implant contact. (From Misch CE:
marginal bone loss; (2) mild overload to pathologic overload
bone loads and crestal bone loss; or (3) generalized pathologic
overload and implant failure. To obtain a similar clinical result
in each implant prosthesis, the variables in each patient must
quality. As a result, many anterior mandibles with denser be either eliminated or accounted for in the treatment plan.
bone have less importance with respect to the implant Because the myriad of variables cannot be eliminated relative
number, size, or design compared with posterior maxillae to bone density, the treatment plans (including implant
with less dense bone. number, size, and design) should be modiied.
Studies have shown the BIC is directly related to the bone
density and the healing time. For example, in a study by Carr Bone Density Treatment Planning
et al.,80a the BIC was greater in the mandible than the maxilla The irst component of the treatment planning process
(i.e., because of the greater bone density in the mandible in should include the use of a radiographic evaluation, prefer-
comparison to the maxilla). In addition, the BIC was greater ably a CBCT x-ray. Initially, an idea of the potential bone
at 6 months compared with 3 months in both jaws density can be determined by the anatomic position; anterior
(Fig. 3.115). Thus, the healing time before implant loading is mandible and single tooth replacement is D2, anterior maxilla
related to the density of bone because the strength of bone and posterior mandible is D3, and posterior maxilla is D4.
increases and the BIC increases with a longer time period. Secondly, a more accurate representation of the bone density
Three to 4 months of healing for D1 to D2 bone and 5 to 6 may be determined by evaluation of the hounsield units
months for D3 to D4 bone has less risk than a shorter time (Hu) on a medical CT scan or a CBCT scan (i.e., linear cor-
period for all bone types. relation with the corresponding hounsield units). A third
−0.0000011 Implant length

7
9.2 mm
Max EQV Strain (× 10−3)

−0.0000027
6 10.8 mm
−0.0000644 12.4 mm
5 14.0 mm
−0.0000096
−0.0000128 4
−0.0000159 3
−0.0000191
2
−0.0000223
1
−0.0000254
−0.0000286 0
Cy Sc Cy Sc Cy Sc Cy Sc
−0.0000317 Type 1 Type 2 Type 3 Type 4
−0.0000349 bone bone bone bone
−0.0000381 FIG 3.117 The softer bone types (types 3 and 4) have higher
strain values around implants regardless of their length com-
−0.0000412
pared with harder bone types (types 1 and 2). (From Misch
−0.0000444
CE: Dental implant prosthetics, 2e, St Louis, 2015, Mosby;
−0.0000478 Data from Tada S, Stegaroiu R, Kitamura E, et al.: Inluence
A −0.0000507 of implant design and bone quality on stress/strain distribu-
tion in bone around implants: a 3-dimensional inite element
analysis, Int J Oral Maxillofac Implants 18:357–368, 2003.)
−0.0000704
−0.0123
−0.0246
BOX 3.22 Treatment Plan Modiiers
−0.0369 ↓Bone density = ↑ Implant area
↑Implant number
−0.0491
↑Implant width
−0.0614 ↓Cantilevers
−0.0737 ↑Implant body surface area
−0.0859
↑Implant length (D4 bone)
↑Implant surface condition
−0.0982
−0.11
2015, Mosby.)
−0.123
−0.135
−0.147
take into consideration these four facets of bone quality:
(1) each bone density has a different strength; (2) bone
−0.16
density affects the elastic modulus; (3) bone density differ-
−0.172
ences result in different amounts of BIC percent; and (4)
−0.184 bone density differences result with a different stress-strain
B −0.196 distribution at the implant-bone interface. Bone density is an
implant treatment plan modiier in several ways—prosthetic
FIG 3.116 (A) Stress transfer around the implant interface is
factors, implant number, implant size, implant design,
different for each bone density. In this two-dimensional inite
element analysis, D2 bone has an intermediate stress intensity
implant surface condition, and the need or method of pro-
around the implant. (B) A two-dimensional inite element analy- gressive loading (Box 3.22).
sis demonstrates that D4 bone has a higher stress intensity
around the implant, and the higher intensity even extends to Increase Surface Area. As the bone density decreases, the
the zone around the apical threads. (From Misch CE: Dental strength of the bone also decreases. In order to decrease the
implant prosthetics, ed 2, St Louis, 2015, Mosby.) incidence of microfracture of bone, the strain to the bone
should be reduced. Because strain is directly related to stress,
the stress to the implant system should be reduced as the bone
technique would be to use prior experience (i.e., if surgery density decreases. Stress may be reduced by increasing the
has been completed prior in the area) as a guideline for the functional surface area over which the force is applied.
determination of bone density. Increasing implant number is an ideal way to reduce stress by
increasing functional loading area. For example, three
Treatment Planning Modiication. When utilizing bone implants rather than two may decrease applied implant
density in the treatment planning process, the clinician must moments in half and bone reaction forces by two thirds,
depending on implant position and size. An implant prosthe- A load directed along the long axis of the implant body
sis with normal patient forces in D4 bone should have at least decreases the amount of stress in the crestal bone region
one implant per tooth. In the molar region, two implants for compared with an angled load (i.e., nonaxial load). As the
each missing molar may even be appropriate. In D3 bone, one bone density decreases, axial loads on the implant body
implant per tooth is often appropriate in the posterior region, become more critical as crestal bone loss may occur. Bone
where fewer implants are required in the anterior location. In grafting or bone spreading to increase the width of bone and
D2 bone with normal patient forces, one or more pontic may to better position the implant relative to the intended load is
replace a tooth between two implants in both posterior and considered for soft bone types. Additionally, adhering to pro-
anterior regions. gressive bone loading in poorer bone qualities will decrease
the possibility of force-related bone loss.
Implant Design. The surface area of the implant macroge-
ometry may be increased to decrease stress to the implant- Progressive Bone Loading. Progressive bone loading pro-
bone interface. The easiest technique is to increase the implant vides for a gradual increase in occlusal loads, separated by a
diameter, which will decrease stress by increasing the surface time interval to allow the bone to mature and accommodate
area. This may also reduce the length requirement. For to the local strain environment. If proper techniques are uti-
example, when a 0.5-mm increase in width occurs, there is lized, progressive bone loading changes the amount and
an increased surface area between 10% and 15% for a cylin- density of the implant-bone contact (i.e., a D4 bone may be
der implant (i.e., even more difference is found with threaded changed to a D3 bone density). The increased density of bone
implant body designs). Because the greatest stresses are con- at the implant interface improves the overall support system
centrated at the crestal region of the implant in favorable mechanism. The poorer quality of the bone, the more impor-
bone types, width is more signiicant than length for an tant the need for progressive loading.
implant design after adequate length has been established. D4
bone should often require wider implants compared with D1 Bone Density Summary
or D2 bone. This may require onlay grafts or bone spreading A key determinant for clinical success is the diagnosis of the
to increase the width of bone when other stress factors are bone density in a potential implant site. The strength of bone
high. Based on long-term clinical experience of V-shaped has been shown to be directly related to bone density. The
threaded implant bodies, the minimum bone height for modulus of elasticity and the percentage of BIC is related to
initial ixation and early loading for D1 bone is 7 mm; for D2 bone density. The occlusal force and direction of force with
bone, 9 mm; and for D3 bone, 12 mm using the classic the consequences are affected by the density of bone. As a
V-thread screw implant design and titanium surface condi- consequence, the clinician must take into consideration alter-
tion. Because the crestal region is the location of pathologic ing the protocol of treatment related to bone density to
overload of bone most often occurs after prosthetic loading, decrease morbidity and increase survival rates. Studies and
after initial healing is complete, the length of the implant is clinical experience has shown that altering the treatment plan
not as signiicant to solve crestal bone loss (i.e., and the to compensate for soft bone types has provided similar sur-
quality of implant health) as other factors (e.g., implant vival rates in all bone densities. After the prosthetic option,
design, implant width). In contrast, D4 bone beneits from key implant position, and patient force factors have been
relatively longer implants for initial ixation and early loading determined, the bone density in the implant sites should be
compared with other bone densities. This is not only for evaluated to modify the treatment plan. The treatment plan
initial ixation but also because the stress-strain transfer of may be modiied by reducing the force on the prosthesis or
occlusal forces extends farther down the implant body. increasing the area of load by increasing implant number,
implant size, implant design, or implant body surface condi-
Implant Coatings. Coatings or the surface condition on an tion. Of these possibilities, the number of implants (i.e.,
implant body can increase the BIC percentage and the func- adding additional implants) is often the most effective
tional surface area. A rougher surface is strongly suggested in method to decrease the stress to the implant system.
soft bone (e.g., D3, D4) and has resulted in improved survival
rates compared with machined titanium. However, after 1 to 2
years, the mechanical load on the overall implant design is more SIZE OF IMPLANTS
critical to the amount and type of bone contact compared with
the surface condition on the implant body. Rough surface con-
NARROW-DIAMETER (MINI) IMPLANTS
ditions also may have some disadvantages. Plaque retention In the 1970s, narrow-diameter implants smaller than 2 mm
when exposed above the bone, contamination, and increased in diameter were very popular in Europe and South America.
cost are a few of the concerns with roughened surfaces. The These “pin” implants were often used in two or three sets for
beneit and risk of surface conditions suggests that the roughest each tooth (Fig. 3.118). They did not maintain crestal bone,
surfaces are most often used in only softer bone types. often would fail or fracture, and became unpopular after the
3.75-mm-diameter root form implants were developed. More
Direction of Force. The consequences of the direction and recently, these implants have reemerged in the marketplace
amount of occlusal force is directly related to the bone density. (Fig. 3.119).
A D
FIG 3.118 Placement of mini-implants for interim prosthesis. (A) O-ring one piece mini-implant.
(B) 3–implants overdenture. (C) 4–implants overdenture. (D) 5–implants ixed prosthesis.
The initial reentry of the mini-implant was for a transi- most often is immediately placed into more function com-
tional prosthesis; the diameter of these implants ranged from pared with the one- or two-stage approach. This increases
1.8 to 2.4 mm. After the inal implant positions and numbers the risk of failure during the healing period of bone because
were inserted in a two-stage healing process, additional mini- the surgical healing and the early loading period occur at the
implants were used to immediately restore and support a same time.
transitional prosthesis. This approach still has validity when An implant has an increased risk of healing and early
patients do not want to wear a removable restoration during loading failure of 5% to 30% when used for an immediate
the initial healing process or to protect a bone graft site during restoration, in part related to a number of factors, including
augmentation. Although the transitional mini-implants may the implant diameter and design. The mini-implant is usually
fail in some clinical situations, the regular-size implants are less than 2 mm in width. In a study by Misch, the small-
not affected, and the inal restoration is not at risk. diameter implant (2.2–2.4 mm) had a 75.7% survival rate
After a few years, the mini-implants were suggested for after 6 weeks when used immediately for retention of a man-
implant overdenture support. The concept (as presented) dibular denture using four to ive implants per patient.86
places multiple mini-implants with O-ring or other overden- To decrease the risk of healing and early loading failure, a
ture attachment systems and immediately is used to retain wider-diameter implant with an implant body with more
and support the prosthesis (Fig. 3.120). It is also presented as surface area is of beneit. Because the mini-implants are too
a “simple solution for denture comfort because of lapless narrow to increase the depths of each thread, they act more
implant installation.” This concept also encourages a reduced as a “nail” than a screw. The surface area for initial ixation,
fee to have greater patient acceptance. early loading, and mature loading is reduced.
The mini-implant designs are usually deicient in seven
Disadvantages of “Mini” Implants ways: (1) decreased diameter and less surface area for loading;
Compared with implants 3.75 mm or larger, with thousands (2) a decreased thread depth; (3) less initial ixation; (4)
of clinical reports, the small-diameter implant has almost no greater risk of fracture; (5) narrow range of prosthetic abut-
long-term studies. Even studies longer than 3 years are limited ment options; (6) dificult to splint implants together; and
in numbers. Because implants smaller than 3 mm in diameter (7) immediate restoration often required (Box 3.23).
are usually too narrow for a two- or three-piece implant body The “lapless” surgical approach is often suggested with
abutment design, a one-piece implant is most often designed the mini-implant and has a perceived beneit of surgical
(Fig. 3.121). This requires the implant abutment portion to ease and less patient discomfort. However, there is an
extend into the mouth upon insertion. Hence, the implant increased risk of bone perforations in the areas of concavities
B
FIG 3.120 (A–B) Mini-implants being used for retention of an
overdenture.
82 mm2 92 mm2 206 mm2

B
FIG 3.119 Mini-implants. (A–B) The use of mini-implants for
ixed prostheses is associated with a high surgical and pros-
thetic morbidity.
BOX 3.23 Narrow “Mini” Diameter

13 mm length
Implants: Disadvantages
1. Few long-term studies
2. Immediate restoration often required
3. Less surface area for loading
4. Decreased initial ixation
5. Higher associated failure rates
6. Poor emergence proile for ixed prosthesis
7. Greater risk of fracture
8. Higher risk procedure × 1.1× 2.5×
9. Often associated with lapless surgery resulting in increased Standard MAX Standard
morbidity
10. Removal process of fractured implants more dificult FIG 3.121 Most mini-implants are too narrow for a separate
abutment-to-implant connection. As a result, they are one-
piece implants with the abutment connected to the implant
or minimal thickness regions of the crestal bone. If a CBCT body and often placed in function after insertion. (From Misch
scan is not performed before surgery, it is almost impossible CE: Dental implant prosthetics, ed 2, St Louis, 2015, Mosby.)
to evaluate most edentulous maxillae and many edentulous
mandibles without relecting the tissue. Additionally, this with the regular relection surgical technique. It is suggested
places the patient at risk in the posterior mandible for pos- to directly observe the bone region before and during implant
sible neurosensory impairment issues. In a study by Misch, insertion unless abundant bone and CT scans are available.
there was no difference in the postoperative pain medication Less risk of early implant failure is present when the implants
requirements of patients with a “lapless” surgery compared can be splinted together. The mini-implant is most often used
432 431
450 (2.8) (2.4)
400
350
268
300 (1.7)
207
250 180 (1.3)
154 168
200 (1.0) (1.2)
(1.0)
150
100
50
A 0
433 431
(2.4) (2.4)
450
400
FIG 3.122 Fractured mini-implants. Biomechanical failure of 350 273
mini-implants resulting fractured implant bodies. 300 (1.5) 234
220
205 (1.3)
250 179 (1.2)
(1.1)
(1.0)
200
as an independent unit because angled abutments are not
150
available (because the implant-abutment is all one piece).
100
Therefore, the stresses are generally greater and the failure rate
50
risk is greater because the implants are independent units.
B 0
In addition to a higher risk of failure, the bending fracture
FIG 3.123 (A) The root surface area of the mandibular teeth
resistance and fatigue fracture of the mini-implant is 16 times
is greater in the posterior regions, where the bite forces are
less than that of a regular 4-mm-diameter implant. Cycles to
greater. (B) The root surface area of the maxillary teeth is
fracture may be as few as 11,000 to 20,000 cycles at 200 N greater than that of the mandibular teeth because the sur-
(1350 lb). The teeth often have 440 cycles/day of function and rounding bone is less dense. (From Misch CE: Dental implant
parafunction with 314 cycles/day of maximum bite force.87 prosthetics, ed 2, St Louis, 2015, Mosby.)
Thus, the mini-implant is at risk of fracture even within the
irst year of loading (Fig. 3.122).
A mini-implant is often promoted as a less expensive the forces are less and the direction of force is along the long
option for the patient. The product cost to the clinician of a axis of the root. The maxillary anterior teeth have larger roots
“mini” implant is approximately half that of a regular-size and a different cross-section shape to compensate for the off-
implant. It is safer to reduce the fee in half and then add the axis loading that increases lateral forces on the structure. The
extra cost of a regular implant than to reduce the fee; use a canines have a greater root surface area (i.e., maxilla com-
mini-implant; and have a greater risk of early failure, greater pared to mandibular) in response to the higher bite forces
risk of fracture, greater risk with independent units, and (90 lb/in2 compared with 35 lb/in2) and the direction of force
limited prosthetic options. A two-stage implant system may during mandibular excursions.
have conirmation of successful integration healing without The premolars have less surface area than the canines
a prosthetic load. A range of abutments permits individual because they do not receive a lateral load in excursions. The
loading or splinting the implants together after integration is molars have multiple roots splinted together in one crown-
conirmed. However, the mini-implants do have a beneit for mainly due to the amount of force received. The maxillary
transitional prostheses and transitional solutions to protect a posterior region has the least bone density; the mandibular
bone graft, especially when the patient does not accept a counterpart has coarser trabecular bone. The maxillary
transitional removable restoration. The clinician must be molars have more roots than the mandibular components
conscious of the type of removable prosthesis used with mini and have more surface area to dissipate loads in the ine tra-
implants either on a intreim basis or for the inal prosthesis. becular bone located in this region of the mouth. The molar
An RP-5 prosthesis should always be used (i.e., completely crowns are almost twice as large in diameter, and the root
soft tissue–supported) to minimize stress on the implants. surfaces are twice those of the premolars. This compensates
for the amount of load increase by two to three times and
Ideal Implant Width decreases the risk of damaging stresses (Fig. 3.123).
The natural teeth may be used as a guideline to determine the In this light, the mandibular incisors region and the maxil-
ideal implant width for function loads and esthetics. The lary lateral incisor may be replaced with 3- to 3.5-mm-
roots of the natural dentition optimize the amount and direc- diameter implants; the maxillary centrals, canines, and
tion of forces found with the mouth. The smallest-diameter premolars in both arches may use 4-mm-diameter implants.
roots are located in the mandibular anterior region, where The molars may be restored with 5- or 6-mm-diameter
BOX 3.24 Ideal Implant Diameters: in the diameter of the tooth, not in the overall length dimen-
Function and Esthetics (Diameter) sion. These guidelines are consistent for both teeth and
implants when engineering principles determine tooth and
Maxillary centrals: 4.0 mm implant size.
Maxillary laterals: 3.0–3.5 mm
Maxillary cuspids and premolars: 4.0 mm
Maxillary molars: 5.0–7.0 mm SPLINTING IMPLANTS TO TEETH
Mandibular incisors: 3.0 mm
Mandibular cuspids and premolars: 4.0 mm TREATMENT PLANNING
Mandibular molars: 5.0–7.0 mm
Treatment planning a splinted implant-tooth prosthesis is
very controversial in implant dentistry today. The connection
of a natural tooth (i.e., with a periodontal ligament) with a
dental implant (i.e., direct bone interface) poses a biome-
implants in both arches. When larger-diameter implants chanical challenge. To date, studies have been equivocal on
cannot be used in the molar region, two 4-mm-diameter the success of this treatment mainly due to the differential
implants for each molar should be considered, especially in support mechanisms.
the maxilla (Box 3.24). Although rare, the most common scenario for which a
The ideal size of the implant body should be incorporated root form implant may be joined to a natural tooth as a ter-
into a treatment plan rather than the surgeon determining minal abutment is in the posterior regions of the mouth. For
this dimension at the time of surgery. The initial size of an example, if a patient is missing the irst and second molars in
implant is determined in both length and diameter. In a two- a quadrant (with no third molar present), the segment
stage healing protocol the ideal implant length should be at requires at least two implants of proper size and design to
least 12 mm. The poorer quality of the bone, the longer the independently restore these two teeth. If adequate bone exists
implant requirements. The greater the bite force, the longer in the second molar and distal half of the irst molar but
the implant dimension. Therefore, the shortest implant inadequate bone exists in the mesial half of the irst molar, a
length may be treatment planned in the anterior mandible, premolar-size pontic is required. The pontic may be cantile-
the anterior maxilla may have a slightly longer implant, the vered from the anterior natural teeth or the posterior implants.
posterior mandible may have a longer implant, and the Either of these options may result in complications because
longest implant requirement for an ideal treatment plan is of tensile forces on the cement seal of the abutment farthest
usually found in the posterior maxilla. from the pontic.
The diameter of an implant has surgical, loading, and An alternative may be to join the implant to a natural
prosthetic considerations. In the initial treatment plan, the tooth, if all other factors are favorable. This plan is more likely
loading and prosthetic components are most important. The in the presence of a Division C−h ridge in the pontic region,
width of the implant is directly related to the overall func- when inadequate bone height adjacent to the natural tooth
tional surface area. Where the forces are greater or the bone decreases the prognosis of a vertical bone graft. Another sce-
is less dense, the implant is wider, ranging from 3 to 6 mm. nario in favor of this treatment plan is when the posterior
As a general rule, the narrowest implant is found in the ante- implants are of a narrower diameter than usual. When two
rior mandible followed by the anterior maxilla and the pos- Division B root forms are used in the posterior mandible to
terior mandible; the widest-diameter requirements are found replace molars, there should be no cantilever to magnify the
in the molar region of the posterior maxilla. force on the implants. Posterior pontics should not be canti-
The prosthetic aspects of the implant width are primar- levered from even two splinted Division B root form implants.
ily related to the esthetics of the emergence proile, the An additional root form implant or natural tooth is required
force on an abutment screw, and the strength of the as an abutment for the ixed prosthesis. When an additional
implant components. As a result, wider-diameter implants implant insertion is not an option, the posterior implants
are selected in the molar regions; standard diameters in the may be joined by a rigid connector (i.e., a solder joint) to
canines, premolars, and maxillary central incisors; and the natural teeth within the prosthesis, provided all dental factors
smallest-size implants in the maxillary lateral and mandib- are favorable (Fig. 3.124).
ular incisors. The connection of natural teeth and osteointegrated
The natural dentition follows the guidelines established in implants within a single rigid prosthesis has generated
the implant-size treatment plan considerations. The correla- concern and publications, with studies and guidelines for
tion is most likely found because of the biomechanical rela- both extremes (Fig. 3.125). In other words, some articles
tionship of the amount and type of the forces in the location report problems, whereas others state that no problem exists.
of the jaws and the type of the bone in the region. In the To be more speciic to a particular situation, more informa-
maxilla, ine trabecular bone is used to dissipate forces, and tion is required to design a successful treatment plan. Two
the amount of force is the greatest in the molar region. The designs are available for the connection of implants and teeth
mandible is a force-absorbing unit and has coarse trabeculae within the same prosthesis: a conventional ixed partial
and dense cortical bone. The tooth size difference is relected denture or a ixed partial denture with a nonrigid connector.
A B
C D
FIG 3.124 (A) When the inadequate bone adjacent to a tooth can be grafted for implant place-
ment and an independent prosthesis, this is the treatment of choice. (B) When the inadequate
bone adjacent to a tooth cannot be grafted, one option is to cantilever the missing tooth from
the anterior teeth or from posterior implants. The posterior implants permit the replacement of
more than one tooth but require at least two implants. (C) When the inadequate bone adjacent
to a tooth cannot be grafted, another option is to insert an implant more distal and make a three-
unit ixed partial denture by connecting the implant to the nonmobile tooth. (D) When the inad-
equate bone adjacent to a tooth cannot be grafted and the tooth is slightly mobile, one option
is to insert an implant more distal and make a four-unit ixed partial denture by connecting the
implant to two anterior teeth (when the most anterior tooth is nonmobile). (From Misch CE:
Contemporary implant dentistry, ed 3, St Louis, 2008, Mosby.)
To address this issue, the mobility of the natural abutment exhibits no clinical mobility in a vertical direction. Actual
must be assessed. initial vertical tooth movement is about 28 mm and is the
same for anterior and posterior teeth. The immediate rebound
Mobility of the tooth is about 7 mm and requires almost 4 hours for
The mobility of potential natural abutments inluences the full recovery, so additional forces applied within this time
decision to join implants and teeth more than any other period depress the tooth less than the original force. The
factor. In the implant-tooth rigid ixed prosthesis, ive com- vertical movement of a rigid implant has been measured as
ponents may contribute movement to the system: the implant, 2 to 3 mm under a 10-lb force, and is due mostly to the vis-
the bone, the tooth, the prosthesis, and implant/prosthetic coelastic properties of the underlying bone (Fig. 3.126).
components.
Prosthesis Movement. The ixed prosthesis that connects a
Vertical Movement. A natural tooth exhibits normal physi- tooth and implant also illustrates movement. Under a 25-lb
ologic movements in vertical, horizontal, and rotational vertical force, a prosthesis with a 2-mm connector fabricated
directions. The amount of movement of a natural tooth is in noble metal results in a 12-mm movement for one pontic
related to its surface area, root design, and bone support. and 97-mm movement for a two-pontic span. The ixed
Therefore, the number and length of the roots; their diameter, partial denture movement helps compensate for the differ-
shape, and position; and the health of the periodontal liga- ence in vertical mobility of a healthy tooth and implant. A
ment primarily inluence tooth mobility. A healthy tooth ixed prosthesis supported by one implant and one natural
108 mm
Force
97 mm
64 mm
68 mm
69 mm
56 mm
FIG 3.125 Splinting a rigid implant to a natural tooth has

caused concerns relative to the biomechanical differential in 73 mm
movement between the implant and tooth. Because the
tooth moves more than the implant, the implant may receive
a moment force created by the “cantilever” of the prosthe- FIG 3.127 A healthy natural tooth may move laterally from
sis. (From Misch CE: Contemporary implant dentistry, ed 3, 56 to 108 µm, with anterior teeth moving more than posterior
St Louis, 2008, Mosby.) teeth. (From Misch CE: Contemporary implant dentistry,
tooth will have the abutment/gold cylinder screw joint of the

Force
system act as a lexible element. The inherent lexibility will
match the vertical mobility of the natural tooth. The minimal
movement of the tooth and the fact that implant, prosthesis,
and abutment components have some mobility indicate the
risk is small in the vertical direction with the biomechanical
difference of implant and tooth in the same prosthesis when
one or two pontics separate these units.
12-97 mm
Horizontal Movement. With natural teeth, horizontal tooth
mobility is greater than vertical movement. A very light force
10-60 mm (500 g) moves the tooth horizontally 56 to 108 mm (Fig.
3.127). The initial horizontal mobility of a healthy, nonmo-
bile posterior tooth is less than that of an anterior tooth and
ranges from 56 to 75 mm, which is two to nine times the
vertical movement of the tooth. Initial horizontal mobility is
even greater in anterior teeth and ranges from 90 to 108 mm
4 mm 8-28 mm in healthy teeth.
FIG 3.126 A three- or four-unit precious metal prosthesis Muhlemann found that tooth movement may be divided
with an implant and a posterior tooth rigidly splinted has into initial mobility and secondary movement.88 The initial
some inherent movement. The implant moves apically 0 to mobility is observed with a light force, occurs immediately, and
5 µm, and the tooth moves apically 8 to 28 µm but can rotate is a consequence of the periodontal ligament. If an additional
up to 75 µm toward the implant because of a moment force. force is applied to the tooth, a secondary movement is observed,
The metal in the prosthesis can lex from 12 to 97 µm,
which is related directly to the amount of force. The secondary
depending on the length of the span and the width of the
connecting joints. The abutment-to-implant component
tooth movement is related to the viscoelasticity of the bone
movement may be up to 60 µm because of abutment pros- and measures up to 40 mm under considerably greater force.
thetic screw lexure. As a result, a vertical load on the pros-
thesis creates little biomechanical risk when joined to a Implant Movement. The implant-bone interface also exhibits
nonmobile tooth because of the design. (From Misch CE: lateral movement. Sekine et al. evaluated the movement of
Contemporary implant dentistry, ed 3, St Louis, 2008, Mosby.) endosteal implants with rigid ixation and found a range of 12
to 66 mm of movement in the labiolingual direction.89 Komi-

yama measured 40 to 115 mm of implant movement in the
mesiodistal direction under a force of 2000 g (about 4.5 psi)
and a labiolingual range of 11 to 66 mm.90 The greater implant
movement in the mesiodistal dimension corresponds to the
lack of cortical bone between the implants in this direction
compared with the thicker lateral cortical plates present in the
labiolingual dimension. The mobility of implants varies in
direct proportion to the load applied and the bone density
and relects the elastic deformation of bone tissue.
An interesting note in implant mobility is that no signii-
cant difference was related to implant length. This inding
further conirms that implant length is not the primary factor
for implant support, even in the presence of lateral loads.
Bone density affects this condition more than implant length.
These mobility characteristics corroborate the indings of
Fenton et al., who applied a 500-g load for 4 seconds to
FIG 3.128 Clinical image of tooth-implant showing failure
maxillary anterior teeth and osseointegrated implants. The because of recurrent decay.
implants were displaced a mean 10 mm with a rapid elastic
return (less than 1 millisecond), whereas the teeth showed a
mean displacement of 57 mm with a prolonged viscoelastic amount of tooth movement and decrease the amount of
return.91 When all factors are considered, an implant moves implant movement (faciolingual vs. mesiodistal). Horizontal
vertically and horizontally, the abutments and prosthesis lex, forces placed on an implant also magnify the amount of stress
and the tooth has apical and lateral movements. at the crestal bone region. Implants should rarely be con-
nected to anterior teeth because (1) anterior teeth often
Guidelines for Joining Implants to Teeth exhibit greater clinical mobility than the implant can tolerate
A vertical movement/force placed on a posterior implant joined and (2) the lateral forces applied to the restoration during
to a healthy posterior tooth causes mesial tension on the mandibular excursions are transmitted to the natural tooth
implant. The implant can move vertically 3 mm and mesially and implant abutments (Fig. 3.128).
40 to 115 mm, and a noble metal-ixed prosthesis with one
pontic allows mesiodistal movement of 6 mm. A natural tooth Additional Treatment Options. When the natural abutment
with no clinical mobility could be connected rigidly to an osseo- exhibits clinical horizontal movement or conditions promote
integrated implant because the implant, bone, and prosthesis horizontal forces against the abutment tooth, two options can
compensate for the slight tooth movement. There is extensive be selected for the inal prosthesis. The irst, and the option
documentation that implants can be connected rigidly to stable of choice, is to place additional implants and to avoid the
teeth. However, the occlusion should be modiied to allow the inclusion of natural abutments in the inal prosthesis. The
initial occlusal contacts on the natural tooth so that the implant other option is to improve stress distribution by splinting
does not bear the major portion of the initial load. additional natural abutments until no clinical mobility is
observed.
No Mobility of Natural Tooth Abutment. The mobility of
healthy anterior incisor teeth often is recorded as 1 with a Guidelines for Splinting Dental Units
range of movement from 90 to 108 mm. Visual clinical evalu- Splinting natural teeth does not decrease the mobility of a
ation by the human eye can detect movement greater than tooth signiicantly after the prosthesis is removed; however,
90 mm. When the mobility of a natural tooth can be observed, the overall prosthesis movement is decreased, especially when
mobility is greater than 90 mm and too great to be compen- the splinted units form an arch. If posterior contacts cannot
sated by the implant, bone, and prosthesis movement. When be eliminated in lateral excursions as a result of skeletal rela-
the vertical posterior tooth movement, vertical implant tionships or when opposing a removable prosthesis, splinting
movement, mesiodistal implant movement, and prosthesis often is safer to reduce the risk of long-term complications.
movement are compared with the same conditions of an In addition, splinting natural abutments also decreases the
anterior tooth with lateral loads, the biomechanical risk amount of load to each abutment (when a 150-psi load is
factors do not correlate. One primary condition for joining distributed to all splinted abutments, the resultant force on
an implant to natural teeth is the lack of observable clinical each abutment is decreased) (Fig. 3.129).
movement of the natural abutment. The number of teeth to splint together is the number
required to eliminate prosthesis movement. The initial dental
No Lateral Forces on Prosthesis. Another requisite to join evaluation may include acid etching and bonding potential
an implant to a natural tooth is that no lateral force should mobile natural abutments to each other to determine how
be designed on the prosthesis. Lateral forces increase the many teeth must be joined to reduce the prosthesis clinical
end a ixed prosthesis on the weakest splinted abutment. The

weak tooth does not offer additional support and further
burdens the healthier abutments. In addition, if cement
failure occurs or the restoration needs retrieval, the partially
12.2 24 12.1 9.1 7.5 retained prosthesis is more dificult to retrieve from the
18.6 16.4 137 6.8
mobile abutment, resulting in more frequent coronal fracture
6.9 and other complications.
The natural teeth exhibit some faciolingual movement,
5.9 which varies from 56 to 108 µm in health. The discussion
7.1 6.6
9.1 11.8 3.6
here is to reduce tooth movement when it is visible so that
2.5 12.2 the mobile teeth may be connected to the implants. Although
5.2 7.1 5.3 4.2
6.7 the teeth move in a faciolingual direction, different regions
5.4 of the arch have different directions of movement relative to
A each other. In other words, the faciolingual direction of the
anterior teeth corresponds to the mesiodistal direction of the
posterior teeth, and if these dental units are splinted to each
other, the splint may become nonmobile.
A dental arch may be described as a ive-sided structure.
The posterior teeth on one side move in a similar direction
to each other, the canine moves in a different direction, the
anterior teeth move in a third direction, the contralateral
canine moves in yet another direction in comparison, and the
other posterior component of the arch moves in a similar
direction as the irst. The more dental sections are connected,
the more rigid the structure. As a general rule, three or more
sections rigidly connected create an overall nonmobile dental
B structure. Even mild to moderate individual mobile dental
FIG 3.129 (A) Splinting natural teeth together decreases their units may become a nonmobile single unit.
mobility and reduces the amount of stress transferred to the The approach of joining implants to mobile teeth in
support system. (B) When the terminal natural tooth is slightly several different arch positions is usually limited to condi-
mobile, splinting an adjacent tooth is indicated. ([A] Courtesy tions when the multiple sections of the dental arch already
Y. Ismail, Pittsburgh, PA. [B] From Misch CE: Dental implant require restoration. Rarely would one consider crowning
prosthetics, ed 2, St Louis, 2015, Mosby.) eight or more teeth solely to splint to the implant component.
Instead, the use of a natural tooth pier abutment may be
indicated.
mobility to zero. The dentist applies the following prosthetic The last tooth in a splinted prosthesis should not have
guidelines: poor retentive form. When a force is applied to the terminal
1. The last tooth connected in the splint should not be region of a multiple-splinted restoration, the pier abutments
mobile. In other words, to decrease mobility, at least may act as a fulcrum. As a consequence, tensile and shear
the last tooth in the splint (and sometimes more) should forces may be applied to the cement seal. Because the cements
be rigid. are 20 times weaker in shear compared with compressive
2. The terminal abutments in the splint should not have poor forces, the cement seal may break. As a consequence, the
retention form. natural abutment often decays and may be lost. The most
3. Adjacent teeth splinted together should be parallel enough distal tooth in a splinted restoration should have adequate
to have the same path of insertion for the prosthesis. height and retentive form.
4. Adjacent teeth should not be crowded or overlapped and The adjacent teeth should be able to have the path of inser-
should have enough room for splinted crowns to have tion as all the dental units in the prosthesis. It may be neces-
adequate interproximal hygiene. sary to perform endodontics or even extract an offending
A classic axiom for splinting teeth in prosthodontics reads, tooth to accomplish the goal of splinting across an arch.
“It is unadvisable to employ the last tooth as a splinted abut- The adjacent teeth that are splinted together should not
ment if it lacks a degree of irmness comparable to its healthy be overlapped or crowded. It may be necessary to have ortho-
neighbor because the strain on the irm abutment could be dontics or selective extractions to prepare the teeth for a
destructive.”92 Implant prostheses may use additional second- similar path of insertion as the implant prosthesis. When the
ary natural abutments to decrease the movement of the pros- adjacent teeth are splinted, enough interproximal tooth
thesis so that rigid ixation of the implant will not be tissues must be removed to permit adjacent metal crowns,
compromised. However, if the last abutment is mobile, it does connectors, and porcelain to be applied and maintain inter-
not serve the intended purpose. A general guideline is to not proximal hygiene.
In conclusion, the natural abutment connected to a rigidly

ixated implant should not exhibit clinical mobility or poor
retentive form. These same two criteria should be considered
for the natural tooth used as a secondary abutment when
splinting teeth in a FPD.
Nonrigid Connectors. Although nonrigid connectors have

been advocated in the literature,93 a nonrigid connector in a
unilateral prosthesis rarely is indicated for implant-ixed
prostheses and may be detrimental. Nonrigid connection
does not improve the stress distribution between the different
abutments94 and has been reported to have caused migration
of the natural teeth.95 If the nonrigid connector exhibits any
clinically observed mobility, it moves more than the implant.
As such, the implant-supported part of the restoration is A
cantilevered to the attachment. In addition, the nonrigid (or
mobile) attachment adds cost, creates overcontoured abut-
ments, impairs daily hygiene, and does not decrease the clini-
cal tooth movement.
Intrusion. Reports of intrusion of the natural tooth con-

nected to an implant usually include the use of temporary
cement to lute a coping to the natural abutment, leaving the
inal restoration uncemented on the coping, or the use of a
nonrigid connector.96 When implants are joined to teeth that
act as a terminal abutment, a deinitive cement should be
used for the natural tooth. The tooth cannot intrude unless
B
it becomes unretained from the abutment (or has a nonrigid
connector between the units). FIG 3.130 Splinting implants via intracoronal attachment
A possible explanation for tooth intrusion may be that the (A, B). Clinical image of nonrigid attachment, which is contra-
tooth is pushed vertically 28 µm but wants to rebound only indicated. Ideally, the implants should be splinted together,
8 µm. The ixed prosthesis rebounds immediately and pulls independent of the natural teeth.
on the tooth. The cement seal eventually breaks, causing a
space to develop, which is irst occupied by air. The prosthesis
then acts as an orthodontic appliance and continually pushes retentive crown) is a common consequence, with decay being
the tooth in a vertical direction. Eventually, the space is occu- the next most common occurrence.
pied by saliva, and hydraulics continue the downward force This problem is magniied by a longer lever arm such as a
during mastication. The tooth eventually submerges or pontic between the implant and tooth. When the natural
intrudes from the prosthesis (Fig. 3.130). tooth or teeth have clinical mobility, the force is lateral on the
prosthesis, or the forces are greater than usual. A pier implant
Implant Pier (Intermediary) Abutments abutment may cause complications even when joined to non-
A pier abutment is one between two other abutments, some- mobile teeth as terminal abutments (Fig. 3.132).
times referred to as an intermediate abutment. The interme- Uncemented restorations are a common complication in
diate abutment may be an implant or a natural tooth, and FPDs even when all aspects of treatment are within accept-
each type plays a different role in the overall treatment. able limits. Any condition that may increase this problem,
When an implant serves as a pier abutment between two such as the one presently addressed, should be carefully
natural teeth, the difference in movement between implant avoided.
and tooth may increase the complication rate compared with
one intermediate tooth joined to two terminal implants PATIENT TREATMENT PLANNING
(Fig. 3.131). The pier implant abutment exhibits less move-
ment than the natural teeth terminal abutments and acts as FAILURE TO PROVIDE TO THE PATIENT
the fulcrum of a class I lever. As a consequence, a compressive
force on one end of the prosthesis is converted to a tensile or
COMPREHENSIVE TREATMENT OPTIONS
shear force on the other terminal abutment. The cement When discussing a treatment plan with a patient, it is quite
tensile strength is often 20 or more times less than the com- easy to get mentally focused on a certain treatment option
pressive strength. When the implant acts as a fulcrum, an based on the actual needs and perceived values of the patient.
uncemented abutment (usually the least mobile tooth or least Implant clinicians sometimes favor certain treatments (e.g.,
Force
FIG 3.132 When grafting and additional implants are not an
A option, a mobile attachment may be used to prevent the pier
implant from acting as a fulcrum. (From Misch CE: Dental
explanation of the possible ramiications that may occur if

no treatment is rendered. Proposing this treatment option
may seem counterintuitive to clinicians because the goal of
dentistry is to restore a patient to optimal function. However,
the presentation of this option does allow the clinician to
enter into a discussion as to the various consequences of
tooth loss, bone loss, and lack of masticatory eficiency.
Advantages. The only advantages of no treatment are the
patient will not have to undergo further procedures to address
the situation, and secondly, there will be no inancial demands
B for the patient.
Disadvantages
FIG 3.131 A pier implant abutment between two natural
Movement of adjacent teeth. When a patient loses a
teeth may cause a cement seal to break on the teeth, espe-
cially if one is more mobile than the other. (From Misch CE: single tooth, there are numerous consequences that may
Dental implant prosthetics, ed 2, St Louis, 2015, Mosby.) result to create an occlusal disharmony and the potential for
further dental complications. If a tooth is extracted in any
position anterior to the second molars, the patient can expect
overdenture vs. ixed prosthesis) according to their learning for the tooth distal to it to begin tilting mesially into the
curve, training, or their personal preferences. It is imperative vacant space. This will most likely result in a change of the
from an ethical and legal perspective that the clinician discuss occlusal plane on that side. As the teeth experience this mesial
all treatment options, including a conversation concerning tilt, the direction of load changes, which may cause excessive
each option’s advantages and disadvantages. Most state dental stress to the periodontal ligament. The contacting teeth in the
boards in the United States require as part of their dental law opposing arch will begin to supraerupt in relation to the
code that all patients be given all possible and viable options, changes in the occlusal plane. The correction of future supra-
including advantages and disadvantages. erupted teeth may require orthodontic or endodontic/crown
To prevent complications and treatment misunderstand- therapy. In some situations, extraction may be necessary.
ings, a comprehensive treatment planning protocol should be Occlusal force issues. Another consequence of the single
developed with every patient. The next section of this chapter missing tooth is the patient will typically favor the fully
will discuss various edentulous site treatment situations dentate side to chew with, due to a decreased masticatory
along with the associated advantages and disadvantages of eficiency on the partially edentulous side. This situation
each treatment. results in the overuse of the fully dentate side, leading to
fatigue-related issues with the teeth. Examples of these issues
Single Missing Tooth would be porcelain fracture of crowns, fractures of enamel/
No Treatment. Even though in most cases the option of “no illings, signiicant occlusal wear, or myofascial pain compli-
treatment” is not ideal, the patient should always be given an cations (Box 3.25).
BOX 3.25 Missing Single Tooth: BOX 3.26 Missing Single Tooth:
No Treatment Option Removable Partial Denture
Advantages
Treatment Option
• No treatment time for the patient Advantages
• No inancial outlay for the patient • Minimal treatment minimal cost compared to other options
Disadvantages Disadvantages
• Supraeruption of the opposing teeth • Poorly tolerated
• Drifting/tilting movement of the adjacent teeth • Decreased survival rate
• Decrease masticatory function • Increased mobility
• Food impaction • Plaque accumulation
• Adjacent teeth will receive a higher occlusal load • Bleeding on probing caries on abutment teeth
• Occlusal overuse of contralateral side • Increased need for abutment teeth loss or repair
• Food impaction
• Accelerated bone loss in edentulous area
Removable Partial Denture
Advantages. The main advantages of the removable partial
denture (RPD) in restoring a single missing tooth are based
on convenience. The patient can receive a tooth-borne RPD Fixed Partial Denture
after a few appointments, and there is a lack of invasive treat- Advantages
ment in this modality. There is also a lower associated cost in Common type of treatment. A ixed prosthesis is a conven-
comparison to most other treatment options. tional and common type of procedure that most clinicians
are comfortable performing. The prosthesis can be fabricated
Disadvantages rather quickly because a laboratory can generate a complete
Decreased acceptance. Removable partial dentures, restoration in 1 to 2 weeks that satisies the criteria of normal
even those that are primarily tooth borne, have a low patient contour, comfort, function, esthetics, speech, and health.
acceptance rate compared to other treatment options. Patients Most patients have an increased compliance with this type
experience dificulty in eating, as food debris may become of treatment, especially because no surgical intervention
trapped under the prosthesis. Speech patterns are often dis- is needed.
rupted, as the patient must acclimate to the partial framework Minimal need for soft and hard tissue augmentation. With
in the mouth. The prosthesis is often bulky, covering part of a ixed partial denture, augmentation of the edentulous area
the palatal tissue on the maxilla or the lingual tissue on the is very uncommon. Because the pontic may be modiied to
mandible. encompass most defects, surgical augmentation procedures
Increased morbidity to abutment teeth. Reports of remov- are usually not indicated. In some instances, lack of attached
able partial dentures indicate the health of the remaining tissue will be present on abutment teeth; however, this is
dentition and surrounding oral tissues often deteriorates. In rather rare.
a study that evaluated the need for repair of an abutment
tooth as the indicator of failure, the “success” rates of conven- Disadvantages
tional removable partial dentures were 40% at 5 years and Increased caries rate. Despite the many advantages that
20% at 10 years.97 Patients wearing the partial dentures often an FPD has over its removable counterpart, the treatment
exhibit greater mobility of the abutment teeth, greater plaque modality does have inherent disadvantages. Caries and end-
retention, increased bleeding upon probing, higher incidence odontic failure of the abutment teeth are the most common
of caries, speech inhibition, taste inhibition, and noncompli- causes of ixed partial denture prosthesis failure.100 Caries
ance of use. A report by Shugars et al. found abutment tooth occur more than 20% of the time and endodontic complica-
loss for a removable partial denture may be as high as 23% tions to the abutments of a FPD 15% of the time. Recurrent
within 5 years and 38% within 8 years.98 decay on the abutment crown primarily occurs on the margin
Increased bone loss. The natural abutment teeth, on next to the pontic. Fewer than 10% of patients loss on a
which direct and indirect retainers are designed, must submit regular basis, and those using a loss threader are even fewer.101
to additional lateral forces. Because these teeth are often com- As a result, the pontic acts as a large overhang next to the
promised by deicient periodontal support, many partial den- crown and a reservoir for plaque and bacteria. The long-
tures are designed to minimize the forces applied to them. The term periodontal health of the abutment teeth may also
result is an increase in mobility of the removable prosthesis be at greater risk as a result of the plaque increase, including
and greater soft tissue support. These conditions protect the bone loss.
remaining teeth but accelerate the bone loss in the edentulous Increased endodontic treatment. When a vital tooth is
regions.99 It should be noted that bone loss is accelerated in the prepared for a crown, a 3% to 6% risk of irreversible pulpal
soft tissue support regions in patients wearing the removable injury and subsequent need for endodontic treatment
prosthesis compared with no prosthesis (Box 3.26). exists.102 Not only does tooth preparation present a risk for
endodontics on each of the vital abutment teeth, the crown

margin next to the pontic is also more at risk of decay and Single Tooth Implant (Box 3.28)
the need for endodontics as a result. Studies have shown up Advantages
to 15% of abutment teeth for a ixed restoration require end- Higher success rate. The single tooth implant provides
odontic therapy compared with 3% to 6% of nonabutment numerous advantages when compared to the other treatment
teeth with crown preparations.103 options. Most studies to date have shown a single tooth implant
Unfavorable outcomes of FPD failure. There exist many to be the most predictable method of single tooth replacement.
issues that may result when a ixed partial denture fails. These Most long-term studies report success rates exceeding 90%.
may include not only the need to replace the failed prosthesis Hygiene. The dental implant treatment plan will usually
but also the loss of an abutment tooth and the need for addi- allow for easier hygiene access because the proximal surfaces
tional pontics and abutment teeth in the replacement bridge. can be reached for lossing. This acts as a preventive measure
Because 15% of FPD abutment teeth require endodontics, against peri-implatntitis issues.
many abutment teeth may be lost. In addition, an endodontic No alteration of adjacent teeth. Adjacent teeth do not
posterior tooth abutment is at a greater risk of fracture. have to be altered with the implant option, which decreases
Reports indicate that abutment teeth for a FPD fail from the risk of recurrent caries or endodontic possibilities with
endodontic complications (e.g., fracture) four times more these teeth. Because of these advantages the patient is at a
often than those with vital pulps.104 The fracture of the tooth much lower risk of losing further teeth in the future.
may result in failure of the prosthesis and abutment tooth. Better cost comparison. Cost comparison studies con-
The abutment teeth of an FPD may be lost from caries, clude that the implant restoration demonstrates a more
endodontic complications, or root fracture at rates up to 30% favorable cost-effectiveness ratio.30 Even when the adjacent
for 8 to 14 years.105 Recent reports indicate 8% to 18% of the teeth are not lost, the conventional FPD often needs to be
abutment teeth supporting a FPD are lost within 10 years. replaced more frequently because of decay, endodontic com-
This is most disturbing because 80% of abutments have no plications, porcelain fracture, or unretained restoration (i.e.,
previous decay or are minimally restored before the fabrica-
tion of the FPD (Box 3.27).106
BOX 3.28 Missing Single Tooth: Dental

Implant Treatment Option
BOX 3.27 Missing Single Tooth: Fixed Advantages
• Adjacent teeth do not require splinted restorations
Partial Denture Treatment Option
• Less risk of caries
Advantages • Less risk of endodontics
• Most common treatment (doctor friendly) • Less risk of porcelain fracture
• Reduced time (two appointments, 1 to 2 weeks apart) • Less risk of uncemented restoration
• Restores function, esthetics, and intraarch health • Less fracture of tooth
• Few bone and soft tissue considerations • Psychologic need of patient addressed: patient does not
• Proven long-term survival desire two adjacent teeth (often virgin) prepared and
• Reduced cost—dental insurance covers procedure (reduced splinted to restore missing tooth
patient cost) • Improved hygiene conditions
• Indicated when minimal mesiodistal space (<6 mm space) • Less decay risk
• Potential abutments have clinical mobility; will beneit from • Floss vs. loss threader
being splinted • Less pontic “plaque trap overhang”
• Increases patient compliance and reduces fear • Decreased cold or contact sensitivity
• Prepared teeth more temperature sensitive
Disadvantages • Cementum of tooth removed by tooth preparation; tooth-
• Mean life span approximates 10 to 15 years brush or scaler sensitive
• Caries and endodontic failure of abutment teeth most • Maintains bone in site: 30% decreasing bone width within
common complication 3 years after extraction
• Increased plaque retention of pontic increases caries and • Decreases adjacent tooth loss: 30% vs. 0.05% risk at
periodontal disease risk 10 years
• Hygiene dificulty
• Damage to healthy teeth (removing undamaged tooth Disadvantages
structure) • Increased treatment time
• Failure of prosthesis related to loss of abutment teeth (8% • Need for surgical treatment
to 18% within 10 years) • May need hard and soft tissue augmentation
• Fracture complications (porcelain, tooth) • Possibly less esthetic
• Esthetic complications (crowns less esthetic than natural • Retained cement
teeth) • Peri-implantitis
• Uncemented restoration • Increased laboratory fees
which most likely results in decay and the need for endodon- bone loss will occur. This may lead to the future need for hard
tic treatment). and soft tissue augmentation procedures to increase hard and
Improved maintenance of bone. With a ixed partial denture soft tissue volume for implant placement.
replacing a single missing tooth, continued bone resorption Tooth movement. The remaining teeth may continue to
will occur. Therefore, placing an implant into the edentulous shift in relation to the stresses of mastication, causing move-
site will help maintain the existing host bone. Additionally, this ment and tilting. Teeth in the opposing arch will supraerupt
will decrease the possibility of soft tissue recession. due to the lack of stimulation by an opposing tooth, causing
root exposure and occlusal disharmony. These phenomena
Disadvantages combine to potentially complicate or contraindicate future
Increased treatment time. The single tooth implant pro- implant placement.
cedure will take a considerably longer time for treatment in Esthetics. If no treatment is rendered for the edentulous
comparison to a RPD or FPD. From the initial surgical place- area, obvious esthetic issues will result. In most cases, patient
ment, the average implant will require an average of 4 to 6 acceptance of the edentulous areas is low, and esthetics is
months for osseointegration to occur. This time frame is usually a motivating factor in seeking rehabilitation.
dependent on the patient’s bone density in that area as well
as the volume of bone that was present at placement. In an Removable Partial Denture
effort to address this issue, techniques have been proposed to See the advantages and disadvantages for RPD in Box 3.26.
immediately place and at times immediately provisionalize
implants. However, in certain circumstances, these techniques Implanted-Supported Crowns
present disadvantages, especially when the patient criteria for See the advantages and disadvantages for RPD in Box 3.28.
these procedures is not met.
Need for additional treatment. In esthetic areas, modii- Completely Edentulous
cations to the soft tissue may be necessary as well in an effort No Treatment. The patient should always be given an expla-
to change the soft tissue drape or to enhance the patient’s nation of the possible ramiications that may occur if no
tissue biotype. This usually will lead to more complex proce- treatment is rendered.
dures that are needed for tissue augmentation. In addition, Advantages. There exist few advantages other than no
bone augmentation procedures may be indicated to increase treatment time or inancial outlay for the patient.
bone volume for implant placement. In some cases, this may Disadvantages
increase the cost signiicantly as well as the treatment time. Continued bone loss. Most clinicians overlook the insidi-
Esthetics. Based on available bone and crown height space, ous bone loss that will occur after tooth extraction. The patient
the inal prosthesis may feature a traditional tooth contour is often not educated about the anatomic changes and the
(FP1), a longer crown form (FP2), or may require the addition potential consequences of continued bone loss. The bone loss
of pink porcelain to mimic normal soft tissue contours (FP3). accelerates when the patient wears a poorly itting soft tissue–
The patient must be aware of these possibilities as their esthetic borne prosthesis. Most patients do not understand that bone
demands may contraindicate implant placement or will dictate resorption occurs over time and at a greater rate beneath
dictate the need for adjunctive bone grafting procedures. poorly itting dentures. Patients do not return for regular visits
for evaluation of their condition; instead, they return after
Multiple Missing Teeth several years when denture teeth are worn down or can no
No Treatment. The patient should always be given an explana- longer be tolerated. In fact, studies have shown that the average
tion of the possible ramiications that may occur if no treat- denture wearer sees a dentist every 14.8 years after having a
ment is rendered. No treatment is more of a concern in complete denture. The traditional method of tooth replace-
comparison to a single edentulous site as esthetic issues, decrease ment (dentures) often affects bone loss in a manner not suf-
in masticatory eficiency, and food impaction issues may arise. iciently considered by the clinician and the patient. The
Advantages. When a patient is missing multiple teeth, the clinician should inform the patient that a denture replaces
education and communication to the patient is even more more bone and soft tissue than teeth, and every 3 to 5 years a
important. Although there is no inancial or time commit- reline, or new denture is suggested to replace the additional
ment for the patient, the disadvantages are more signiicant bone loss by atrophy that will occur (Fig. 3.133 and Box 3.29).
in comparison to a single missing tooth. Soft tissue consequences. As bone loses width, then
Disadvantages height, then width and height again, the attached gingiva
Decreased masticatory function. The main disadvantage gradually decreases. A very thin attached tissue usually lies
of not replacing multiple missing teeth is the decreased mas- over the advanced atrophic mandible or is entirely absent.
ticatory function. Patients will place more force and stress on The increasing zones of mobile, unkeratinized gingiva are
their remaining teeth, which leads to increased morbidity. prone to abrasions caused by the overlying prosthesis, which
The forces of mastication are transmitted to the remaining will lead to bone loss. In addition, unfavorable high muscle
teeth, which results in a greater possibility of decay, mobility, attachments and hypermobile tissue often complicate the
periodontal issues, and loss of teeth. The longer the edentu- situation. The continued atrophy of the posterior mandible
lous ridge remains without stimulation, the greater chance eventually causes prominent mylohyoid and internal oblique
BOX 3.30 Soft Tissue Consequences of

Edentulism
• Attached, keratinized gingiva is lost as bone is lost
• Unattached mucosa for denture support causes increased
soft spots
• Thickness of tissue decreases with age and systemic
disease that causes more sore spots for dentures
• Tongue increases in size, which decreases denture stability
• Tongue has more active role in mastication, which
decreases denture stability
• Decreased neuromuscular control of jaw in elderly adults

2015, Mosby.)
FIG 3.133 A dentate mandible on the left and a long-term
edentulous mandible on the right. Note the amount of bone
loss in height. Loss of bone height in the mandible may be condition is further compromised by the vertical movement
measured by the centimeter and often is ignored. Such bone of the distal aspect of the prosthesis during contraction of the
loss is often more signiicant than the bone loss (in millime- mylohyoid and buccinator muscles and the anterior incline
ters) from periodontal disease. The patient should understand of the atrophic mandible compared with that of the maxilla.107
that a denture often replaces more bone than teeth to restore The thickness of the mucosa on the atrophic ridge is also
the proper dimensions of the face. (From Misch CE: Dental
related to the presence of systemic disease and the physiologic
changes that accompany aging. Conditions such as the
patient’s age, hypertension, diabetes, anemia, and nutritional
BOX 3.29 Consequences of Bone Loss in disorders have deleterious effects on the vascular supply and
Fully Edentulous Patients soft tissue quality under removable prostheses. These disor-
• Decreased width of supporting bone
ders result in a decreased oxygen tension to the basal cells of
• Decreased height of supporting bone the epithelium. Surface cell loss occurs at the same rate, but
• Prominent mylohyoid and internal oblique ridges with the cell formation at the basal layer is slowed. As a result,
increased sore spots thickness of the surface tissues gradually decreases, and sore
• Progressive decrease in keratinized mucosa surface spots and uncomfortable removable prostheses result. The
• Prominent superior genial tubercles with sore spots and tongue of a patient with edentulous ridges often enlarges to
increased denture movement accommodate the increase in space formerly occupied by
• Muscle attachment near the crest of the ridge teeth. At the same time, it is used to limit the movements of
• Elevation of prosthesis with contraction of mylohyoid and the removable prostheses and takes a more active role in the
buccinators muscles serving as posterior support
mastication process. As a result, the removable prosthesis
• Forward movement of prosthesis from anatomic inclina-
decreases in stability. The decrease in neuromuscular control,
tion (angulation of mandible with moderate to advanced
bone loss)
often associated with aging, further compounds the problems
• Thinning of mucosa with sensitivity to abrasion of traditional removable prosthodontics. The ability to wear
• Loss of basal bone a denture successfully may be largely a learned, skilled per-
• Paresthesia from dehiscent mandibular neurovascular canal formance. An aged patient who recently became edentulous
• More active role of tongue in mastication may lack the motor skills needed to adjust to the new condi-
• Effect of bone loss on esthetic appearance of lower third tions (Box 3.30).
of face Esthetic consequences. The facial changes that naturally
• Increased risk of mandibular body fracture from advanced occur in relation to the aging process can be accelerated and
bone loss potentiated by the loss of teeth (Fig. 3.134). There exist many
• Loss of anterior ridge and nasal spine, causing increased
esthetic consequences that result from the loss of alveolar
denture movement and sore spots during function
bone. A decrease in facial height from a collapsed vertical
(From Misch CE: Dental implant prosthetics, ed 2, St Louis, dimension will causes several facial changes (Fig. 3.135). The
2015, Mosby.) loss of the labiomental angle and deepening of vertical lines
in the area create a harsh appearance. As the vertical dimen-
ridges covered by thin, movable, unattached mucosa. The sion progressively decreases, the occlusion evolves toward a
anterior residual alveolar process also continues to resorb, pseudo class III malocclusion. As a result, the chin
and the superior genial tubercles (which are 20 mm below rotates forward and creates a prognathic facial appearance
the crest of bone when teeth are present) eventually become (Fig. 3.136). These conditions result in a decrease in the hori-
the most superior aspect of the anterior mandibular ridge. zontal labial angle at the corner of the lips; the patient appears
There is little to prevent the prosthesis from moving forward unhappy when the mouth is at rest (Fig. 3.137). People with
against the lower lip during function or speech. This short facial types have higher bite forces, greater bone loss,
Collapse
of
edentulous
bite
FIG 3.135 A patient often wears a denture for more than 15

years. The loss of bone height during this time is associated
with many extraoral facial changes as a closed bite, a man-
dible that rotates forward, a receding maxilla, a reverse smile
line, increased number and depth of lines in the face, more
acute angle between the nose and the face, loss of vermilion
border in the lips and jowls, and witch’s chin from loss of
FIG 3.134 Esthetic aspects of the inferior third of the face muscle attachment. (From Misch CE: Dental implant pros-
are not only related to the position of the teeth but even more thetics, ed 2, St Louis, 2015, Mosby.)
important is the position and amount of bone in the jaws and
include the muscles that attach to the bone. (From Misch CE:
FIG 3.137 This patient has severe bone loss in the maxilla
and mandible. Although she is wearing her 15-year-old den-
tures, the facial changes are signiicant. The loss of muscle
attachments leads to ptosis of the chin (witch’s chin), loss of
vermilion border (lipstick is applied to the skin), reverse lip
FIG 3.136 Loss of bone height can lead to a closed bite with line (decrease in horizontal angles), increased vertical lines in
rotation of the chin anterior to the tip of the nose. This picture the face and lips, increased lip angle under the nose, and a
represents the face of someone without teeth and advanced lack of muscle tonicity in the masseter and buccinator
bone loss. (From Misch CE: Dental implant prosthetics, ed 2, muscles. (From Misch CE: Dental implant prosthetics, ed 2,
St Louis, 2015, Mosby.) St Louis, 2015, Mosby.)
BOX 3.31 Esthetic Consequences of

Bone Loss
• Decreased facial height
• Loss of labiomental angle
• Deepening of vertical lines in lip and face
• Chin rotates forward—gives a prognathic appearance
• Decreased horizontal labial angle of lip—makes patient
look unhappy
• Loss of tone in muscles of facial expression
• Thinning of vermilion border of the lips from loss of muscle
tone
• Deepening of nasolabial groove
• Increase in columella-philtrum angle
• Increased length of maxillary lip, so less teeth show at rest
and smiling—ages the smile
• Ptosis of buccinators muscle attachment—leads to jowls
at side of face
• Ptosis of mentalis muscle attachment—leads to “witch’s
chin”
FIG 3.138 Proile view. Note the maxillary bone loss effect on
the lack of vermilion border of the lip, deep labial folds, and (From Misch CE: Dental implant prosthetics, ed 2, St Louis,
the columella–philtrum angle. Yet the lower lip has a normal 2015, Mosby.)
vermillion border and the muscles to the anterior lower jaw are
still attached, providing a normal contour. (From Misch CE:
“jowls” or a “witch’s chin.” This effect is cumulative because
of the loss in muscle tone with the loss of teeth, the associated
decrease in bite force, and the loss of bone in the regions
and more dramatic facial changes with edentulism compared where the muscles used to attach (Box 3.31). Patients are
with others. A thinning of the vermilion border of the lips usually unaware the hard and soft tissue changes are from the
results from the poor lip support provided by the prosthesis loss of teeth. Among denture wearers, studies have shown that
and the loss of muscle tone. The maxillary retruded position 39% have been wearing the same prosthesis for more than 10
is related to the loss of the premaxillary ridge and the loss of years.87 The profession is unable to evaluate patients unless
tonicity of the muscles involved in facial expression. The con- they return yearly. It is important that the consequences of
traction of the orbicularis oris and buccinator muscles in a tooth loss be explained to partially or completely edentulous
patient with moderate to advanced bone atrophy displaces patients during the early phases of treatment.
the modiolus and muscles of facial expression medially and
posteriorly. As a result, a narrowing of the commissure, inver- Complete Upper Denture
sion of the lips, and hollowing of the cheeks are characteristic Advantages. Compared to no treatment, the complete
indings. upper denture will usually satisfy esthetic and some func-
A deepening of the nasolabial groove and an increase in tional requirements. The patient will have landmarks to use
the depth of other vertical lines in the upper lip are related for pronunciation of words, and they will retain the appear-
to normal aging but are accelerated with bone loss. This ance of facial height, although supericially.
usually is accompanied by an increase in the columella-
philtrum angle. This can make the nose appear larger than if Disadvantages
the lip had more support (Fig. 3.138). Men often grow a Masticatory function. The difference in maximum occlu-
moustache to minimize this effect. The maxillary lip naturally sal forces recorded in a person with natural teeth and one
becomes longer with age as a result of gravity and loss of who is completely edentulous is dramatic. In the irst molar
muscle tone, resulting in less of the anterior teeth shown when region of a dentate person, the average force has been mea-
the lip is at rest. This has a tendency to “age” the smile because sured at 150 to 250 psi.108 A patient who grinds or clenches
the younger the patient, the more the teeth show in relation their teeth may exert a force that approaches 1000 psi. The
to the upper lip at rest or when smiling. Loss of muscle tone maximum occlusal force in an edentulous patient is reduced
is accelerated in edentulous patients, and the lengthening of to less than 50 psi. The longer patients are edentulous, the
the lip occurs at a younger age and is longer (showing less less force they are able to generate. Patients wearing complete
teeth) than dentate patients of a similar age. The upper lip dentures for more than 15 years may have a maximum occlu-
often rolls over the incisal edge of the maxillary dentures, sal force of less than 6 psi.57
which further decreases the size of the vermilion border. As a result of decreased occlusal force and the instability of
The attachments of the mentalis and buccinator muscles the denture, masticatory eficiency also decreases with tooth
to the body and symphysis of the mandible also are affected loss. Ninety percent of the food chewed with natural teeth its
by bone atrophy. This will result in sagging of the tissue or through a no. 12 sieve; this is reduced to 58% in the patient
wearing complete dentures.109 A study of 367 denture wearers when the patient talks, not from vertical dimension issues, but
(158 men and 209 women) found that 47% exhibited a low from the lack of stability and retention of the prosthesis.
masticatory performance. The 10-fold decrease in force and the Speech problems may be associated with a concern for social
40% decrease in eficiency affect the patient’s ability to chew. In activities. Awareness of movement of the mandibular denture
patients with dentures, 29% are able to eat only soft or mashed was cited by 62.5% of these patients, although the maxillary
foods, 50% avoid many foods, and 17% claim they eat more prosthesis stayed in place most of the time at almost the same
eficiently without the prosthesis.110 Lower intakes of fruits, veg- percentage.
etables, and vitamin A by females were noted in this group. Psychologic aspects of tooth loss. The psychologic
Denture patients also take signiicantly more drugs (37%) com- effects of total edentulism are complex and varied and range
pared with those with superior masticatory ability (20%), and from very minimal to a state of neuroticism. Although com-
28% take medications for gastrointestinal disorders. The plete dentures are able to satisfy the esthetic needs of many
reduced consumption of high-iber foods could induce gastro- patients, some believe their social lives are signiicantly
intestinal problems in edentulous patients with deicient mas- affected. They are concerned with kissing and romantic situ-
ticatory performance. In addition, the coarser bolus may impair ations, especially if a new partner in a relationship is unaware
proper digestive and nutrient extraction functions.111 of their oral handicap. Fiske et al., in a study of interviews
Systemic consequences. The literature includes several with edentulous subjects, found tooth loss was comparable
reports suggesting that compromised dental function causes to the death of a friend or loss of other important parts of a
poor masticatory performance and swallowing poorly chewed body in causing a reduction of self-conidence ending in a
food, which in turn may inluence systemic changes favoring feeling of shame or bereavement (Box 3.32).119
illness, debilitation, and shortened life expectancy.112 In
another study, the masticatory performance and eficiency in
Implant-Supported Overdenture
denture wearers were compared with those of dentate indi-
viduals. This report noted that when appropriate corrections (Removable-RP4/RP5)
were made for different performance norms and levels, the Advantages
chewing eficiency of a denture wearer was less than one sixth Reduction in soft tissue coverage. The overdenture
of a person with teeth.113 (RP4) may reduce the amount of soft tissue coverage and
Several reports in the literature correlate a patient’s health extension of the prosthesis. This is especially important for
and life span to dental health. Poor chewing ability may be a new denture wearers, patients with tori or exostoses, and
cause of involuntary weight loss in old age, with an increase patients with low gagging thresholds. Also, the existence of a
in mortality rate.114 In contrast, patients with a substantial labial lange in a conventional denture may result in exagger-
number of missing teeth were more likely to be obese. After ated facial contours for a patient with recent extractions,
conventional risk factors for strokes and heart attacks were which can result in chronic soreness. Implant-supported
accounted for, there was a signiicant relationship between prostheses (RP4) do not require labial extensions or extended
dental disease and cardiovascular disease, the latter still soft tissue coverage. Note: An RP-5 prosthesis would have full
remaining as the major cause of death.115 peripheral acrylic extensions in the maxilla and mandible
Satisfaction of prosthesis. A dental survey of edentulous (i.e., mandible, buccal shelf support; maxilla, full palatal
patients found that 66% were dissatisied with their coverage).
mandibular complete dentures. Primary reasons were discom- Increased retention. In general, an implant overdenture
fort and lack of retention causing pain and discomfort.116 Past prosthesis will have signiicant retention in comparison to a
dental health surveys indicate that only 80% of the edentulous conventional complete removable prosthesis. For example, a
population are able to wear both removable prostheses all the complete mandibular denture moves during most mandibular
time.117 Some patients wear only one prosthesis, usually the max-
illary; others are only able to wear their dentures for short BOX 3.32 Negative Effects of
periods. In addition, approximately 7% of patients are not able Complete Dentures
to wear their dentures at all and become “dental cripples” or “oral
• Bite force is decreased from 200 psi for dentate patients
invalids.” They rarely leave their home environment, and when
to 50 psi for edentulous patients
they feel forced to venture out, the thought of meeting and • 15-year denture wearers have reduced bite force to 6 psi
talking to people when not wearing their teeth is unsettling. • Masticatory eficiency is decreased
Speech effects. A report of 104 completely edentulous • More drugs are necessary to treat gastrointestinal disorders
patients seeking treatment was performed by Misch and • Food selection is limited
Misch.118 Of the patients studied, 88% claimed dificulty with • Healthy food intake is decreased
speech, with one fourth having great dificulty. This most likely • The life span may be decreased
occurs with the mandible, which rests upon the buccinator • Reduced prosthesis satisfaction
muscle and mylohyoid muscle when the posterior mandible • Speech dificulty
resorbs. When the patient opens his or her mouth, the contrac- • Psychologic effects
tion of these muscles acts like a trampoline and propels the (From Misch CE: Dental implant prosthetics, ed 2, St Louis,
lower denture off the ridge. As a result, the teeth often click 2015, Mosby.)
jaw movements in function and speech. Studies have shown a prosthesis. Periimplant probing is easier around a bar than a
mandibular denture may move approximately 10 mm during ixed prosthesis because the crown contour often prevents
function. Under these conditions, speciic occlusal contacts straight-line access along the abutment to the crest of the
and the control of masticatory forces are nearly impossible. An bone. The overdenture may be extended over the abutments
IOD provides improved retention and stability of the prosthe- to prevent food entrapment during function in the maxilla.
sis, and the patient is able consistently to reproduce a deter- With a ixed implant prosthesis, hygiene is usually compli-
mined centric occlusion.120 cated because of the contours of the prosthesis in comparison
Increased biting forces. Higher bite forces have been to the implant position.
documented for mandibular overdentures on implants. The Less trauma from parafunction. An overdenture may be
maximum occlusal force of a patient with dentures may removed at bedtime to reduce the noxious effect of nocturnal
improve 300% with an implant-supported prosthesis.121 A parafunction, which increases stresses on the implant support
study of chewing eficiency compared wearers of complete system. In addition, a ixed prosthesis is not desired as often
dentures with wearers of implant-supported overdentures for a long-term denture wearer. Long-term denture patients
(IODs). The complete denture group needed 1.5 to 3.6 times do not appear to have a psychologic problem associated with
the number of chewing strokes compared with the overden- a removable implant prosthesis vs. a ixed prosthesis.
ture group.122 The chewing eficiency with an IOD is improved Ease of repair. The overdenture prosthesis is usually
by 20% compared with a traditional complete denture.123 easier to repair than a ixed restoration. Reduced laboratory
Better speech. The contraction of the mentalis, buccina- fees and fewer implants allow the restoration of patients at
tor, or mylohyoid muscles may lift a traditional denture off reduced costs compared with a ixed prosthesis. If a ixed
the soft tissue. As a consequence, the teeth may touch during prosthesis fractures (i.e., porcelain), remediation usually will
speech and elicit clicking noises. The retentive IOD remains include refabrication of the prosthesis.
in place during most mandibular movements. The tongue Decreased bone loss. In the areas of implant placement,
and perioral musculature may resume a more normal posi- bone atrophy will be reduced greatly in comparison to areas
tion because they are not required to limit mandibular of edentulism. It has been shown in numerous studies that
denture movement. However, most patients will obtain better the stimulation from the implants and/or prosthesis main-
speech with a RP-4 prosthesis, as a RP-5 overdenture tends to tains posterior bone volume.
have longer langes, which impinge on the musculature. Prosthesis may be upgraded. In most cases, an overden-
Decreased number of implants. An overdenture also pro- ture may be upgraded to a ixed prosthesis (i.e., as long
vides some practical advantages over an implant-supported as there exist no positioning or bone deiciency issues)
complete ixed partial denture. Fewer implants may be (Box 3.33; Box 3.34). For example, a two-implant RP-5 man-
required when a RP-5 restoration is fabricated because soft dibular overdenture may be changed to a RP-4 by adding
tissue areas may provide additional support. The overdenture 2 to 3 additional implants or an FP-3 ixed prosthesis by
may provide stress relief between the superstructure and adding 3 to 4 additional implants in the mandible.
prosthesis, and the soft tissue may share a portion of the
occlusal load. Regions of inadequate bone for implant place- Disadvantages
ment may be eliminated from the treatment plan rather than Patient expectations. The primary disadvantage of a
necessitating bone grafts or placing implants with poorer mandibular overdenture is related to the patient’s desire, pri-
prognosis. As a result of less bone grafting and fewer implants, marily when he or she does not want to be able to remove
the cost to treat the patients is dramatically reduced. An RP-4
prosthesis requires more implants than an RP-5; however, less
than a ixed prosthesis. BOX 3.33 Mandibular Implant
Esthetics. The esthetics for many edentulous patients Overdenture Advantages
with moderate to advanced bone loss are improved with an
overdenture compared with a ixed restoration. Soft tissue • Prevents anterior bone loss
support for facial appearance often is required for an implant • Improved esthetics
• Improved stability (reduces or eliminates prosthesis
patient because of advanced bone loss, especially in the
movement)
maxilla. Interdental papilla and tooth size are easier to repro- • Improved occlusion (reproducible centric relation occlusion)
duce or control with an overdenture. Denture teeth easily • Decrease in soft tissue abrasions
reproduce contours and esthetics compared with time- • Improved chewing eficiency and force
consuming and technician-sensitive porcelain metal ixed • Increased occlusal eficiency
restorations. The labial lange may be designed for optimal • Improved prosthesis retention
appearance, not daily hygiene. In addition, abutments do • Improved prosthesis support
not require a speciic mesiodistal placement position for an • Improved speech
esthetic result because the prosthesis completely encompasses • Reduced prosthesis size (reduces langes)
the implant abutments. • Improved maxillofacial prostheses
Hygiene. Hygiene conditions and home and professional (From Misch CE: Dental implant prosthetics, ed 2, St Louis,
care are improved with an overdenture compared with a ixed 2015, Mosby.)
BOX 3.34 Implant Overdenture BOX 3.35 Overdenture Disadvantages

Advantages vs. Fixed Prosthesis • Psychologic (need for nonremovable teeth)
• Fewer implants (RP-5) • Greater abutment crown height space required
• Less bone grafting required before treatment • More long-term maintenance required
• Less speciic implant placement • Attachments (change)
• Improved esthetics • Relines (RP-5)
• Denture teeth • New prosthesis every 7 years
• Labial lange • Continued posterior bone loss
• Soft tissue drape replaced by acrylic • Food impaction
• Soft tissue considerations • Movement (RP-5)
• Improved periimplant probing (follow-up)
• Hygiene 2015, Mosby.)
• Reduced stress
• Nocturnal parafunction (remove prosthesis at night)
• Stress relief attachment Although porcelain fractures with a ixed restoration may
• Lower cost and laboratory cost (RP-5)
occur and be costly to repair, over a lifetime the implant-
• Fewer implants (RP-5)
supported removable prosthesis is often more expensive.
• Less bone grafting (RP-5)
• Easy repair
Denture teeth attrition. Denture teeth wear faster on an
• Laboratory cost decrease (RP-5) IOD (i.e., hybrid) than with a traditional denture because bite
• Transitional device is less demanding than a ixed force and masticatory dynamics are improved. A new over-
restoration denture often is required at 5- to 7-year increments because
of denture tooth wear and changes in the soft tissue support.
2015, Mosby.)
Patient education regarding the long-term maintenance
requirement and the associated costs should be outlined at
the onset of implant therapy (Box 3.35).
the prosthesis. A ixed prosthesis often is perceived as an
actual body part of the patient, and if a patient’s primary Implant-Supported Fixed Prosthesis (Fixed)
request is not to remove the prosthesis, an implant-supported Advantages
overdenture would not satisfy the psychologic need of Ideal prosthesis. The implant-supported ixed prosthesis
the patient. is the closest available treatment option for an edentulous
Food impaction. Unlike the labial lange of a maxillary patient to return to optimal form, function, and esthetics.
denture, the labial lange of a mandibular overdenture rarely is Most patients receiving a ixed prosthesis will state that it
required for esthetics. A mandibular overdenture often traps “feels like normal teeth,” which carries a profound psycho-
food below its langes, similar to a denture. Dentures and RP-5 logic impact. The prosthesis does not require removal and is
IODs are border molded to the muscle attachment level to less likely to impact food in comparison to a removable
allow the loor of the mouth to raise during swallowing. As a prosthesis.
consequence, food accumulates below the denture lange while Less bone loss in cantilevered areas. Wright et al. have
the muscles are at rest and then is compressed under the res- evaluated posterior mandibular bone loss in IODs (type 5
toration during deglutition. The contour of a ixed restoration removable prosthesis [RP-5]) compared with cantilevered
is less prone to food entrapment. The daily care for a bar IOD ixed prostheses from anterior implants.121 The annual bone
(RP-4) may be similar to that for a ixed mandibular restora- loss index observed in the RP-5 overdentures ranged from
tion because ridge lap pontics are not required for esthetics or +0.02 to −0.05 with 14 of 20 patients losing bone in the poste-
speech, as with some maxillary ixed prostheses. rior regions. The ixed prostheses group had a range from
More maintenance. Removable overdentures require +0.07 to −0.015 with 18 of 22 patients gaining posterior bone
greater maintenance and exhibit more frequent prosthetic- area. Reddy et al. also found a similar clinical observation in
related complications than ixed restorations. For example, 60 consecutively treated cantilevered ixed prostheses sup-
Walton and McEntee noted that there were three times more ported by ive to six implants placed between the foarmina.126
maintenance and adjustments for removable prostheses com- The mandibular body height was measured 5, 10, 15, and
pared with ixed restorations.124 IODs often require attach- 20 mm distal to the last implant. The baseline measurements
ments to be changed or modiied every 6 months to 2 years, up to 4 years after function increased from 7.25 ± 0.25 mm to
and denture teeth often wear, requiring a new prosthesis to 8.18 ± 0.18 mm. Nearly all of the bone growth occurred during
be fabricated every 5 to 7 years.125 In a review of literature by the irst year of function. An important role for the complete
Goodacre et al., IODs have retention and adjustment prob- implant-supported restoration is the maintenance and even
lems 30% of the time, relines 19% of the time, clip or attach- regeneration of posterior bone in the mandible.
ment fracture 17% of the time, and fracture of the prosthesis Decreased maintenance. Because there are no attach-
12% of the time.30 Fixed prostheses need less repair and less ments utilized with a ixed implant prosthesis, there is far less
maintenance and often last the life of the implant support. maintenance required. Less maintenance is associated with
0.08 ixated, removing the prosthesis, whether cement or screw, is

0.06 time-consuming and increases potential complications.
Posterior Area Index
0.04
0.02 SUMMARY
0 The foundation of a successful treatment outcome is to fully
−0.02
inform the patient as to the advantages and disadvantages of
every possible treatment option for their respective condi-
−0.04
tion. Even with superior clinical skill and perfect execution,
−0.06 a clinician may encounter patient dissatisfaction with the
Overdentures Fixed Prostheses inished treatment due to unmet expectations. With a irm
FIG 3.139 Implant overdentures with posterior soft tissue understanding of every possible treatment option, the prac-
support lose bone in the posterior regions almost 75% of the titioner can effectively educate the patient, agree on a treat-
time (purple bars). Fixed prostheses cantilevered from anterior ment plan based on the patient’s values, and manage
implants gain bone in the posterior regions more than 80% of expectations throughout the process. By doing this, both the
the time (blue bars). (From Misch CE: Dental implant prosthet- clinician and patient will enjoy the beneits of their
ics, ed 2, St Louis, 2015, Mosby; Data from Wright PS, Glastz relationship.
PO, Randow K, et al: The effects of ixed and removable
implant-stabilized prostheses on posterior mandibular residual
ridge resorption, Clin Oral Implants Res 13:169–174, 2002.)
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Treatment Planning Complications

TABLE 3.1 Prosthodontic Classiication

ixed vs. removable should be explained. It is imperative that

FP-1 FP-2 FP-3

FP-1 FP-2 FP-3

because of the lack of bone width, the inal implant position

Consent for Implant Surgery

FIG 3.7 A splinted image of #8-#9 implants with pink porce-

Appearance of mandibular teeth in

apicocoronal dimension, adequate interocclusal space is

Implant Criteria. Implants in the mandible are inserted

FIG 3.16 The height of available bone is measured from the

than height, so even when the width is inadequate for implant

Available Bone Width. The width of available bone is mea-

After adequate height is available, the next most signiicant

BOX 3.2 Division A Root Form

A B B–w C–w C–h D

FIG 3.28 Options to treat a Division B ridge in the anterior

FIG 3.31 Bone rapidly resorbs from Division A to Division B

BOX 3.5 Division C Bone

(From Misch CE: Dental implant prosthetics, ed 2, St Louis,

FIG 3.35 Division C−a.

Additionally, muscle pull from the buccinator muscles along

Complications C−a Not Understanding the Divisions of Bone:

BOX 3.6 Division D Bone

(From Misch CE: Dental implant prosthetics, ed 2, St Louis,

1.5 mm 3 mm 3 mm 1.5 mm One Missing Tooth

with a cantilever or extension of 20 mm, the mechanical

FIG 3.46 A cantilever on two implants may be considered a

No Three Adjacent Pontics

the prosthesis has three pontics (because they are supporting

BOX 3.7 Arch Position: Canine

(From Misch CE: Dental implant prosthetics, ed 2, St Louis,

FIG 3.60 (A) Four implants in an edentulous maxilla

Key implant positions - 2 first molars, 2 canines, and a central incisor

Inluence of Bone Density on Implant Number

unfavorable biomechanics of the premaxilla and range from General Complications

Implant positions: key locations

Key implant positions - 2 first molars, 2 canines, a central incisor

BOX 3.8 Bruxism

BOX 3.9 Bruxism: Clinical Signs

muscles and the external pterygoid may also be tender during

FIG 3.72 This patient exhibits an engram pattern of bruxism

number of implants (i.e., greater surface area) should be

Occlusion. With parafunctional habits, the occlusion must

Prosthesis Design. The prosthesis may be designed to

BOX 3.11 Parafunction: Tongue Thrust

(From Misch CE: Dental implant prosthetics, ed 2, St Louis,

BOX 3.12 Crown Height Space

CHS, crown height space.

FIG 3.77 The crown height space is a vertical cantilever to

Mesiodistal Faciolingual axis

FIG 3.81 Crown height is a force magniier to any lateral load

BOX 3.13 Arch Position: Posterior

Complications Poorer Bone Density Resulting in Less Support. The natural

BOX 3.15 Implant Crown Porcelain

(From Misch CE: Dental implant prosthetics, ed 2, St Louis,

Understanding the Basics of Bone