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

Age

Key points

In elderly patients consider reduced bone metabolism and extended healing and integration times. Interventions should be minimally invasive
In elderly patients consider prosthetic superstructures in a straight-forward design to allow for easy hygiene measures. Removable prostheses are preferred after years of edentulism
In the rare case of juvenile patient anodontia or juvenile edentulism, an implant-supported fixed tooth replacement may be considered at an early age

Agenesis & edentulism in juveniles

Edentulism as a consequence of (sub)total agenesis of deciduous and/or permanent teeth in children and adolescents is extremely rare. It is commonly a component of a generalized underlying condition such as ectodermal dysplasia. There are different subtypes such as hypohidrotic ectodermal dysplasia, often associated with mental retardation. The external appearance and shape of the juvenile edentulous mandible will depend on the presence of deciduous teeth.

In patients with development of deciduous teeth but missing permanent tooth buds, a high, but extremely narrow alveolar process will be found. After the loss of the deciduous teeth, the alveolar process will show a shape being pointed in occlusal direction (Fig 1).

However, in patients with simultaneous agenesis of deciduous teeth, the outer appearance and shape of the mandible is characterized by a virtually complete lack of the alveolar process associated with a reduction of the local growth potential.

Bild 2.jpeg — Fig 1:a. Total aplasia of the permanent mandibular teeth.b. CT section of the anterior mandible before removal of deciduous teeth.c. CT section of the anterior mandible after removal of deciduous teeth.Courtesy of Dr. Georg Watzek, Vienna

Edentulism in advanced age

Development of edentulim during adulthood will lead to alveolar ridge resorption over time. In elderly patients changes in the external appearance and shape of the jaws will also be accompanied by osseous metabolic changes. Cellular activity of the bone as well as neoangiogenesis is clearly reduced with advanced age. Bone healing is consequently substantially prolonged in elderly patients. As a result, the number of bone-implant surface contacts tends to decrease with increasing age. However, even advanced age has not been shown to be a risk factor for implant failure.

Consequences for the treatment of juvenile patients

Early prosthetic rehabilitation of such patients influences favorably the direction of growth of both the maxilla and the mandible. Such treatments should only be performed in highly qualified centers. In patients with extensive dental aplasia, implants can already be placed at an early adolescent age considering the rather limited growth in some areas (Fig 2). Change of abutment lengths and prosthetic superstructures can cope with some growth.

Bild 4.jpg — Fig 2:a. Patient with subtotal aplasia of both deciduous and permanent teeth and implantation at the age of 10 years.b. Situation at the age of 17 years.Courtesy of Dr. Georg Watzek, Vienna

Consequences for the treatment of patients with advanced age

If possible, all procedures and interventions should be minimally invasive and implant healing and integration times are to be extended. For bone augmentation procedures prolonged healing times should definitely be observed.

Prosthetic superstructure should allow for convenient oral hygiene in order to compensate for any age-related loss of manual dexterity or general frailty. If the patient has been edentulous for some time and is used to removable dentures, he/she will often prefer a removable overdenture over a fixed reconstruction.

Upon appropriate observation of these guidelines the prognosis for the implants will be similar to the prognosis for “standard patients” (Fig 3).

Bild 1.jpeg — Fig 3: Example for a minimally invasive approach in elderly patients.a. Virtual planning.b. Clinical picture immediately after flapless implant insertion.c. Panoramic radiograph with appropriate virtual planning of the implants placed.Courtesy of Dr. Georg Watzek, Vienna

Clinical topics

Fixed prosthetics Removable prosthetics Local factors Systemic factors Patient assessment

Treatment guidelines

Edentulous

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)...

Diagnosis and treatment planning

Patient assessment

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Treatment guidelines

Edentulous

Alveolar atrophy and insufficiency

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....

Radiology

Systemic factors

Patient assessment

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Treatment guidelines

Edentulous

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

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Questions

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Age

Agenesis & edentulism in juveniles

Edentulism in advanced age

Consequences for the treatment of juvenile patients

Consequences for the treatment of patients with advanced age

Clinical topics

Related articles

Treatment guidelines

Vertical dimension

Treatment guidelines

Alveolar atrophy and insufficiency

Treatment guidelines

Skeletal consequences of edentulism

Scientific References

Questions