0 Patient Assessment
- 0.1 Patient demand
- 0.2 Overarching considerations
- 0.3 Local history
- 0.4 Anatomical location
- 0.5 General patient history
- 0.6 Risk assessment & special high risk categories
  - 5.1 Risk assessment & special high risk categories
  - 5.2 age
  - 5.3 Compliance
  - 5.4 Smoking
  - 5.5 Drug abuse
  - 5.6 Recreational drugs and alcohol abuse
  - 5.7 Parafunctions
  - 5.8 Diabetes
  - 5.9 Osteoporosis
  - 5.10 Coagulation disorders and anticoagulant therapy
  - 5.11 Steroids
  - 5.12 Bisphosphonates
  - 5.13 BRONJ / ARONJ
  - 5.14 Radiotherapy
  - 5.15 Risk factors
1 Diagnostics
- 1.1 Clinical Assessment
  - 0.1 Lip line
  - 0.2 Mouth opening
  - 0.3 Vertical dimension
  - 0.4 Maxillo-mandibular relationship
  - 0.5 TMD
  - 0.6 Existing prosthesis
  - 0.7 Muco-gingival junction
  - 0.8 Hyposalivation and Xerostomia
- 1.2 Clinical findings
  - 1.1 Occlusion
  - 1.2 Alveolar atrophy and insufficiency
  - 1.3 Skeletal consequences of edentulism
  - 1.4 Head-neck cancer
- 1.3 Clinical diagnostic assessments
  - 2.1 Microbiology
  - 2.2 Salivary output
- 1.4 Diagnostic imaging
  - 3.1 Imaging overview
  - 3.2 Intraoral radiographs
  - 3.3 Panoramic
  - 3.4 CBCT
  - 3.5 CT
- 1.5 Diagnostic prosthodontic guides
  - 4.1 Prosthodontic guides overview
  - 4.2 Wax-up, arrangement, mock-up
  - 4.3 Splints and imaging for surgery
  - 4.4 Provisionals
2 Treatment Options
- 2.1 Mucosally-supported
  - 0.1 Mucosally supported - Overview and important considerations
  - 0.2 Complete denture
  - 0.3 Immediate denture
  - 0.4 Occlusal schemes
- 2.2 Implant-retained/supported, general
  - 1.1 Prosthodontic options overview
  - 1.2 Number of implants maxilla and mandible
  - 1.3 Time to function
  - 1.4 Submerged or non-submerged
  - 1.5 Soft tissue management
  - 1.6 Hard tissue management, mandible
  - 1.7 Hard tissue management, maxilla
  - 1.8 Need for grafting
  - 1.9 Healed vs fresh extraction socket
  - 1.10 Digital treatment planning protocols
    
    9.1 Digital treatment planning protocols, introduction
    
    9.2 Digital treatment planning protocols, NobelClinician
- 2.3 Implant prosthetics - removable
  - 2.1 Implant overdenture, overview
    
    0.1 Implant overdenture, introduction
    
    0.2 Overdenture retention devices, overview
  - 2.2 Secondary splinting
  - 2.3 Primary splinting
- 2.4 Implant prosthetics - fixed
  - 3.1 Fixed implant prosthesis, introduction
  - 3.2 Screw-retained restorations
    
    1.1 Screw-retained
    
    1.2 Implant-supported vs abutment-supported
  - 3.3 Cement-retained restorations
    
    2.1 Cement-retained
    
    2.2 Abutment materials
  - 3.4 Framework materials
    
    3.1 Framework materials
    
    3.2 Veneering with ceramic
    
    3.3 Veneering with Acrylic
- 2.5 Comprehensive treatment concepts
3 Treatment Procedures
- 3.1 Surgical
  - 0.1 Surgical considerations
    
    0.1 Anesthesia
    
    0.2 Peri-operative care
    
    0.3 Post-operative care
    
    0.4 Flap-or flapless
    
    0.5 Wound closure
    
    0.6 Intra-operative complications
    
    0.7 Guided vs non-guided
    
    0.8 Semi-guided surgery with prosthetic template
    
    0.9 Guided surgery with drill guides
  - 0.2 Surgical protocols - general
    
    1.1 Crestal incision
    
    1.2 Choice of implant
    
    1.3 Parallel implant placement
    
    1.4 Tapered implant placement
    
    1.5 Insertion torque
    
    1.6 Insertion height
    
    1.7 Implant angulation
  - 0.3 Surgical protocols - mandible
    
    2.1 Implant placement with open flap procedure - mandible
    
    2.2 Grafting, mandible
  - 0.4 Surgical protocols - maxilla
    
    3.1 Implant placement - maxilla
    
    3.2 Grafting, maxilla
    
    3.3 Sinus lifting
    
    3.4 Zygomatic implants
    
    3.5 Pterygoid implants
    
    3.6 Problems and complications in maxillary implant surgery
- 3.2 Removable prosthetics
  - 1.1 Complete dentures
    
    0.1 Complete denture clinical protocol
    
    0.2 Complete denture impressions
    
    0.3 Complete denture - maxillo-mandibular relations
    
    0.4 Complete denture trial placement
    
    0.5 Complete denture placement
    
    0.6 Complete denture post-placement
  - 1.2 Implant overdentures
    
    1.1 Overdenture clinical protocol
    
    1.2 Implant overdenture impressions
    
    1.3 Implant overdenture maxillo-mandibular relations
    
    1.4 Implant overdenture trial placement
    
    1.5 Implant overdenture placement
    
    1.6 Implant overdenture post-placement
- 3.3 Fixed prosthetics
  - 2.1 Fixed implant prosthesis clinical protocol
  - 2.2 Impressions
    
    1.1 Impressions - overview
    
    1.2 Splinted vs unsplinted impression copings
    
    1.3 Open versus closed tray
    
    1.4 Parallel vs non-parallel
  - 2.3 Maxillo-mandibular relations
  - 2.4 Trial placement
  - 2.5 Framework trial placement
  - 2.6 Placement
  - 2.7 Post-placement
4 Aftercare
- 4.1 Surgical aftercare
  - 0.1 Medication
  - 0.2 Post-operative soft tissue management
  - 0.3 Suture removal
  - 0.4 Post-surgical recommendations
- 4.2 Prosthetic aftercare
  - 1.1 Esthetic and function check
  - 1.2 Provisionals / temporary prosthesis
  - 1.3 Oral hygiene instructions
  - 1.4 Occlusal guard
- 4.3 Post-treatment complications and management
  - 2.1 Bleeding
  - 2.2 Soft tissue and hard tissue
  - 2.3 Patient compliance / recall
  - 2.4 Biologic complications
  - 2.5 Esthetic complications
- 4.4 Recall visits and logistics
  - 3.1 Recall visits - overview
  - 3.2 Patient expectations
  - 3.3 General health check
  - 3.4 Professional oral hygiene
  - 3.5 Implant overdenture maintenance
  - 3.6 Occlusion check
  - 3.7 Probing
  - 3.8 Inflammation, infection
    
    7.1 Inflammation and infection - overview
    
    7.2 Infection, microbiological diagnostics
  - 3.9 Radiological control

Treatment guidelines

Alveolar atrophy and insufficiency

Key points

Alveolar ridge reduction/resorption is influenced by local, systemic and genetic factors
Frequent use of 2-D imaging to evaluate residual edentulous bone reveals better height than width assessment
Implant-supported prostheses, unlike complete dentures, appear to retard the ongoing bone resorption

Alveolar ridge resorption / reduction

Teeth extractions are followed by a reduction of the bucco-lingual as well as the vertical dimension of the residual alveolar ridge. The ensuing resorption is progressive and even the basal jaw may become involved. In the lower jaw, the mandibular nerve can become located on top of the crest, causing pain to denture wearers.

Reduction of alveolar ridge height is far more frequently encountered in edentulous mandibles than in edentulous maxillae. Longevity of denture wearing, gender and a diminished Body Mass Index are associated with increased ridge resorption, while age does not appear to be relevant. Osteoporosis has not yet been shown to significantly influence alveolar ridge resorption, while recent research from specialized centers suggests that identified genetic factors can determine such bony changes.

Inserting endosseous implants to retain/support a dental prosthesis retards further jaw bone resorption. When alveolar ridge resorption is advanced, clinical and specific imaging examinations will inform the doctor which remaining jaw bone areas are still available for the optimal placement of short/narrow endosseous implants. This scrupulous evaluation can lead to avoidance of invasive bone augmentation procedures.

Alveolar insufficiency

Patients with ectodermal dysplasia and anodontia, or patients with a cleft palate syndrome can have an alveolar insufficiency. The absence of teeth prevents the development of proper jaw bone dimensions and the associated available bone volume often does not allow placement of endosseous implants without prior bone augmentation procedures. Part of the diagnosis is to determine the skeletal age and growth to determine the timing of implant placement.

Alveolar insufficiency may also refer to the bone quality. The maxillary tuberosity for example, consists mainly of marrow spaces and adipose tissue and female patients demonstrate in general a lower amount of mineralized bone trabeculae. Distal mandibular sites may also reveal extremely poor bone mineralization. Spiral CT scans permit bone density quantification in Hounsfield Units, although bone density measurements on CBCT images are less reliable.

Fig 2: The absence of teeth prevents the development of proper jaw bone dimensions and the associated available bone volume often does not allow placement of endosseous implants without prior bone augmentation procedures. Part of the diagnosis is to determine the skeletal age and growth to determine the timing of implant placement.Courtesy of Dr. Andrew Dawood, London

Clinical topics

Treatment guidelines

Skeletal consequences of edentulism

Teeth loss in the maxilla initiates residual ridge/alveolar resorption, especially in the anterior region, which is flared labially. The consequences of this resorption is a gradual medial or palatal shift of the crest of the maxilla. This...

Patient assessment

Treatment guidelines

Vertical dimension

The recording of patient-specific vertical and horizontal jaw relations is a necessary starting point when planning for the occlusal rehabilitation. They are integral components of the mandible’s centric relation (CR)...

Treatment guidelines

Need for grafting

There are three main indications for grafting from an anatomical perspective...

Additional resources

Videos

Andrew Dawood: Graftless management of the resorbed ridge

The lecture gives insight in the use of short, narrow and zygomatic implants in cases with severe bone resorption and how using these technologies can avoid bone grafting and protracted treatment periods. Supported by impressive patient cases, Dr Dawood reviews a treatment solution...

Videos

David Chvartszaid: Distinction between normality and pathology of marginal bone around oral implants

Distinguishing normal and abnormal marginal bone behaviour around osseointegrated implants is a complex and controversial topic. Dr Chvartszaid reviews why this distinction is difficult, and discusses topics such as the existence of multiple proposed etiologies, deficiencies in...

Videos

Sreenivas Koka: Systemic considerations in the context of osseointegration

The lecture discusses fundamental systemic health challenges and their impact on osseointegration, and reviews the influence of diabetes, osteoporosis, smoking, bisphosphonates and radiation therapy. Dr Koka presents the concepts of osseointegration and osseosufficiency, as well as...

Questions

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Alveolar atrophy and insufficiency

Alveolar ridge resorption / reduction

Alveolar insufficiency

Clinical topics

Related articles

Treatment guidelines

Skeletal consequences of edentulism

Treatment guidelines

Vertical dimension

Treatment guidelines

Need for grafting

Additional resources

Videos

Andrew Dawood: Graftless management of the resorbed ridge

Videos

David Chvartszaid: Distinction between normality and pathology of marginal bone around oral implants

Videos

Sreenivas Koka: Systemic considerations in the context of osseointegration

Scientific References

Questions