**B** **R** **Å** **N** **E** **M** **A** **R** **K** **C** **E** **N** **T** **R** **E** **P** **E** **R** **T** **H** **Associated Brånemark Osseointegration Centre Perth** **The University of Western Australia** Management of Edentulism and the Terminal Dentition —Mandible Fixed Clin A/Prof Glen Liddelow BDSc(WA), MScD(WA), DClinDent(Syd), MRACDS(Pros), FPFA, FICD, FRACDS *Associated Brånemark Osseointegration Centre Perth — The University of Western Australia* Management of Edentulism and the Terminal Dentition — Mandible Fixed Clin A/Prof Glen Liddelow BDSc(WA), MScD(WA), DClinDent(Syd), MRACDS(Pros), FPFA, FICD, FRACDS # Edentulism Usually from caries or periodontal disease Cumulative effect - % increases with age ~25% 65-75yo, 58% over 75yo edentulous in UK, similar US, Germany Declining by 1%/year for industrialised countries but lifespan has risen Over 65yr demographic rising in all countries Will outpace the decline in edentulism Global economy may increase need Mojon P The world without teeth: Demographic trends. In Feine et al Implant overdentures. Quintessence, 2003 Douglass CW, Shih A, Ostry L. Will there be a need for complete dentures in the US in 2020? J Prosthet Dent 2002;87:5-8. Carlsson G, Omar R. The future of complete dentures in oral rehabilitation. J Oral Rehab 2010;37:143-156. Thomason JM, Kelly SA, Bendowski A, Ellis JS. Two implant retained overdentures - A review of the literature supporting the McGill and York consensus statements. J Dent 2012;40:22-34 Usually from caries or periodontal disease. Cumulative effect — percentage increases with age: - ~25% of 65–75 year olds and 58% over 75 years old edentulous in the UK; similar figures in the US and Germany Trends in industrialised countries: - Declining by 1%/year, but lifespan has risen - Over 65-year demographic rising in all countries - Will outpace the decline in edentulism - Global economy may increase need *Mojo P. The world without teeth: Demographic trends. In Feine et al. Implant overdentures. Quintessence, 2003.* *Douglass CW, Shih A, Ostry L. Will there be a need for complete dentures in the US in 2020? J Prosthet Dent 2002;87:5-8.* *Carlsson G, Omar R. The future of complete dentures in oral rehabilitation. J Oral Rehab 2010;37:143-156.* *Thomason JM, Kelly SA, Bendowski A, Ellis JS. Two implant retained overdentures - A review of the literature supporting the McGill and York consensus statements. J Dent 2012;40:22-34* **Edentulism** Maladaptive denture patients – little correlation with quality of dentures, strong psychosocial component Progressive degeneration of supporting tissues and neuromuscular control Progression from adaptive to maladaptive Psychological health Changes in food selection – Lower nutrient content, more processed foods, fats and cholesterol **Table 1. References** Tallgren A. The continuing reduction of the residual alveolar ridges in complete denture wearers: A mixed longitudinal study covering 25 years. J Prosthet Dent 1972;27:120–132. Zarb GA. The edentulous predicament. In: Zarb GA, Bolender CL. *Prosthodontic Treatment for Edentulous Patients*. Mosby, Philadelphia, PA. 2004. Fiske J, Davis DM, Frances C, Gelbier S. The emotional effects of tooth loss in edentulous people. Br Dent J 1998;184:90–1. Hinds K, Gregory JR. National diet and nutrition survey: People aged 65 years or over. Vol 2: Report of the oral health survey. London: Stationary Office, 1998. Joshipura KJ, Willett WC, Douglas CW. The impact of edentulousness on food and nutrient intake. J Am Dent Assoc 1996;127:459–467. Allen PF. Association between diet, social resources and oral health related quality of life in edentulous patients. J Oral Rehabil 2005;32:623–628. Carlsson G. Facts and fallacies: An evidence base for complete dentures. Dental Update 2006;33:134–142. Carlsson G, Omar R. The future of complete dentures in oral rehabilitation. J Oral Rehab 2010;37:143–156. Maladaptive denture patients: - Little correlation with quality of dentures; strong psychosocial component - Progressive degeneration of supporting tissues and neuromuscular control - Progression from adaptive to maladaptive - Psychological health - Changes in food selection — lower nutrient content, more processed foods, fats and cholesterol #### Table 1. References *Tallgren A. The continuing reduction of the residual alveolar ridges in complete denture wearers: A mixed longitudinal study covering 25 years. J Prosthet Dent 1972;27:120–132.* *Zarb GA. The edentulous predicament. In: Zarb GA, Bolender CL. Prosthodontic Treatment for Edentulous Patients. Mosby, Philadelphia, PA. 2004.* *Fiske J, Davis DM, Frances C, Gelbier S. The emotional effects of tooth loss in edentulous people. Br Dent J 1998;184:90–1.* *Hinds K, Gregory JR. National diet and nutrition survey: People aged 65 years or over. Vol 2: Report of the oral health survey. London: Stationary Office, 1998.* *Joshipura KJ, Willett WC, Douglas CW. The impact of edentulousness on food and nutrient intake. J Am Dent Assoc 1996;127:459–467.* *Allen PF. Association between diet, social resources and oral health related quality of life in edentulous patients. J Oral Rehabil 2005;32:623–628.* *Carlsson G. Facts and fallacies: An evidence base for complete dentures. Dental Update 2006;33:134–142.* *Carlsson G, Omar R. The future of complete dentures in oral rehabilitation. J Oral Rehab 2010;37:143–156.* > [!note] Lecturer — Edentulism Trends > Edentulism is declining partly because of fluoridation, improved dental practice, and changing views about dental hygiene. However, population growth means that edentulous patients remain common. > [!note] Lecturer — Maladaptive Dentures > Later maladaptation may make the lower denture, particularly the mandibular denture, increasingly difficult to control. > > - Problems may include pain, discomfort, low self-esteem, and reduced oral-health-related quality of life. > - Difficulty eating a broad range of foods may contribute to poorer nutrition and reduced general health. > - Implant-supported removable or fixed prostheses can improve quality of life compared with conventional dentures. > - Patient education can improve nutrition by enabling patients to eat less processed, fresher, and more fibrous foods. > [!note] Lecturer — Treatment Selection > Treatment selection should be individualized rather than based only on technical possibilities. > > - The lecturer considered patient wishes, functional requirements, stability, longevity, safety, invasiveness, complexity, maintenance burden, and cost. > - Placing many implants may be possible but can create an unnecessarily difficult maintenance situation. > - The lecturer compared treatment planning with choosing a vehicle: a durable, maintainable option may be preferable to an expensive option requiring frequent major repairs. > [!note] Lecturer — Denture Adaptation > Lower dentures are generally more difficult for patients to control than upper dentures. Complete dentures can look good, but teeth positioned beyond anatomical limits or made extremely white may produce an unnatural appearance. Social media has also increased patients’ demand for fixed rather than removable prostheses. # Prosthodontic Treatment *Palliative therapy aimed at improving function and quality of life* Decision making process goes beyond success/survival of implants/prosthesis Patient based measures - psychosocial function and perceived health Locker D. Patient-based assessment of the outcomes of implant therapy: A review of the literature. *Int J Prosthodont* 1988;11:453–461. Zarb GA. The Edentulous Predicament. *In*: Zarb GA, Bolender CL. *Prosthodontic Treatment for Edentulous Patients*. Mosby, Philadelphia, PA. 2004. Carlsson G, Omar R. The future of complete dentures in oral rehabilitation. J Oral Rehab 2010;37:143–156. *Palliative therapy aimed at improving function and quality of life* - Decision making process goes beyond success/survival of implants/prosthesis - Patient-based measures: psychosocial function and perceived health *Locker D. Patient-based assessment of the outcomes of implant therapy: A review of the literature. Int J Prosthodont 1988;11:453–461.* *Zarb GA. The Edentulous Predicament. In: Zarb GA, Bolender CL. Prosthodontic Treatment for Edentulous Patients. Mosby, Philadelphia, PA. 2004.* *Carlsson G, Omar R. The future of complete dentures in oral rehabilitation. J Oral Rehab 2010;37:143–156.* Prosthodontic Treatment Most complete denture wearers adapt and cope Some suffer substantially from chronic dysfunction, pain, low self esteem and reduced OHRQOL - maladaptive Zarb GA. The edentulous predicament. In:Zarb GA, Bolender CL. Prosthodontic Treatment for Edentulous Patients. Mosby, Philadelphia, PA. 2004. - Most complete denture wearers adapt and cope - Some suffer substantially from chronic dysfunction, pain, low self-esteem and reduced OHRQOL — maladaptive *Zarb GA. The edentulous predicament. In: Zarb GA, Bolender CL. Prosthodontic Treatment for Edentulous Patients. Mosby, Philadelphia, PA. 2004.* # Edentulism Fixed or removable implant prostheses compared to conventional dentures - Improved OHRQOL - Higher nutritional state - Improvement in blood parameters - Improved anthropometric measures post treatment Hutton B, Feine J, Morais J. Is there an association between edentulism and nutritional state? J Can Dent Assoc 2002;68:182-187. Carlsson G, Omar R. The future of complete dentures in oral rehabilitation. J Oral Rehab 2010;37:143-156. ! " # $ % & ' ( ) *  Fixed or removable implant prostheses compared to conventional dentures: - Improved OHRQOL - Higher nutritional state - Improvement in blood parameters - Improved anthropometric measures post treatment *Hutton B, Feine J, Morais J. Is there an association between edentulism and nutritional state? J Can Dent Assoc 2002;68:182-187.* *Carlsson G, Omar R. The future of complete dentures in oral rehabilitation. J Oral Rehab 2010;37:143-156.* > [!note] Lecturer — Implant Satisfaction > In the lecturer’s experience, patients who can afford treatment are generally more satisfied with fixed solutions than removable solutions. A mandibular overdenture with a complete maxillary denture can still be satisfactory, although limited studies specifically examine satisfaction in patients with a terminal dentition. A close-up photograph displays a dental prosthesis, specifically a full-arch implant-supported denture set against a black background. The upper arch features a complete row of artificial teeth attached to a pink acrylic base, with five visible metallic abutments or implant connectors protruding from the top surface. The lower arch shows a corresponding set of teeth, positioned below the upper set to simulate a bite or occlusion. # Prosthodontic Treatment Minimum Acceptable Protocol (or Principle) Variety of treatments available complying with the principles Minimizing outlay of resources and maximising treatment outcomes from a patient perspective Treatment options change with time Owen CP. Appropriatech: Prosthodontics for the many, not just for the few. Int J Prosthodont 2004;17:261–262 Minimum Acceptable Protocol (or Principle) - Variety of treatments available complying with the principles - Minimizing outlay of resources and maximising treatment outcomes from a patient perspective - Treatment options change with time *Owen CP. Appropriatech: Prosthodontics for the many, not just for the few. Int J Prosthodont 2004;17:261–262* > [!note] Lecturer — Mandibular Immediate Loading > For mandibular full-arch immediate loading, the lecturer’s routine approach is generally four implants, used in approximately 99 out of 100 such patients in the practice. The implants are placed prosthetically, connected to multi-unit abutments, and used to support an immediately fabricated provisional or definitive-style bridge. A posterior cantilever may provide a six-to-six occlusion when appropriate. # Prosthodontic Treatment ### Principles * Safest * Least invasive * Least costly * Least complex $$\rightarrow$$ **<u>Reasonable needs and expectations</u>** * Mechanical stability * Biologic stability * Longevity * Low maintenance Fitzpatrick B. Standard of care for the edentulous mandible: A systematic review. J Prosthet Dent 2006;95:71-78. #### Guiding Principles - Safest - Least invasive - Least costly - Least complex → **Reasonable needs and expectations** - Mechanical stability - Biologic stability - Longevity - Low maintenance *Fitzpatrick B. Standard of care for the edentulous mandible: A systematic review. J Prosthet Dent 2006;95:71-78.* > [!note] Lecturer — Digital Treatment Planning > Digital planning is now used extensively for diagnosis, implant positioning, surgical guidance, scanning, and bridge production. Treatment should be planned before surgery so the clinician understands the mental nerve position, anatomical concavities, expected jaw anatomy, available bone, and prosthetic requirements. > > - Static guided surgery may achieve approximately 0.2–0.5 mm placement accuracy, compared with approximately 1.5–2 mm for freehand placement. > - A static guide may be unsuitable when the teeth supporting it are mobile; navigated surgery can then be used. > - The lecturer emphasized avoiding lingual concavities because perforation may injure the submental or mylohyoid arteries. > - Lingual arterial injury can cause delayed tongue swelling that obstructs the airway after the patient has left the clinic. > - The inferior alveolar nerve, mental nerve, and anterior loop of the mental nerve also require consideration; the loop may extend several millimetres and occasionally approximately 8 mm. > [!note] Lecturer — Mandibular Atrophy > Tooth loss causes loss of alveolar bone followed by resorption toward basal bone. Progressive mandibular resorption reduces the denture-bearing area and facial support, reduces vertical dimension, and makes the mental foramen more prominent. > > - As the mental foramen approaches the surface, nerve impingement may produce neuropathic pain. > - Severe atrophy may contribute to mandibular fracture risk. > - Implant placement may stimulate bone apposition in distal mandibular regions and potentially strengthen thin areas at risk of fracture. Sequelae of tooth loss Sequelae of tooth loss # Consequences of Jaw Atrophy 40% 60% 50% 50%   - 40% - 60% - 50% - 50% A schematic lateral cross-section of the human head and neck illustrating facial proportions, specifically showing the vertical division of the lower face into two segments labeled 40% (upper portion) and 60% (lower portion). The drawing depicts the skeletal structure of the maxilla and mandible with teeth in occlusion, highlighting the relationship between jaw position and facial height. A schematic lateral profile diagram of a human skull and mandible illustrating the proportions of facial height. The vertical dimension is divided into two equal sections, each labelled '50%', demarcating the upper face (from orbit to nose base) and lower face (from nose base to chin). # Centripetal resorption in the maxilla & centrifugal resorption in the mandible  Centripetal resorption in the maxilla & centrifugal resorption in the mandible > [!note] Lecturer — Bone Quality > The mandible is generally thicker and contains more cortical bone, whereas the posterior maxilla often has thin or absent cortex and lower-density trabecular bone. Initial implant stability is important because integration requires the implant to remain stable; the lecturer compared this with placing a screw in dense versus soft wood. > [!note] Lecturer — Edentulous Treatment Options > The lecture series was divided into mandibular fixed solutions, removable solutions, and maxillary treatment, which was described as more complicated. Options for an edentulous jaw include complete dentures, removable implant overdentures, more sophisticated detachable prostheses, and fixed implant prostheses. > [!note] Lecturer — Maxillary Denture Support > Patients generally adapt better to an upper denture than to a lower denture. A mandibular fixed prosthesis may provide additional support for an opposing maxillary denture, particularly when the mandibular prosthesis extends to the six region. The lecturer estimated that approximately 75% of patients may be happy with an upper denture combined with a lower implant prosthesis, although this may be changing as patients increasingly request fixed treatment. A schematic diagram illustrating the directional patterns of bone resorption in the jaws. Arrows indicate centripetal (inward) resorption in the maxilla and centrifugal (outward) resorption in the mandible. Centripetal resorption in the maxilla & centrifugal resorption in the mandible  Centripetal resorption in the maxilla & centrifugal resorption in the mandible A schematic line drawing illustrates the direction of bone resorption in the maxilla and mandible relative to a vertical dashed reference line. The upper section depicts the maxilla with a horizontal arrow pointing inward (centripetally) towards the midline, while the lower section depicts the mandible with a vertical arrow pointing downward and outward (centrifugally). # Increased inter-arch distance as a result of resorption   Increased inter-arch distance as a result of resorption A lateral schematic line drawing of the human skull and mandible, illustrating the temporomandibular joint region. The diagram shows a separation or gap between the maxilla (upper jaw) and mandible (lower jaw), visually representing an increased inter-arch distance. A lateral schematic line drawing of the human skull and mandible showing an edentulous ridge. Vertical double-headed arrows and a shaded band between the maxilla and mandible illustrate the increased inter-arch distance resulting from resorption. Treatment strategies for the edentulous jaw     Treatment strategies for the edentulous jaw A close-up photograph of a dental model showing the upper and lower arches fitted with artificial teeth and pink gum-colored acrylic bases. The image displays the full set of prosthetic teeth in occlusion, illustrating the components of a complete denture. Clinical photograph showing the tissue-bearing surface of a maxillary denture base. A circular hole is visible in the anterior midline region, likely representing an access opening or space for an implant attachment component. Clinical photo: An occlusal view of an implant-retained removable dental prosthesis, displaying the intaglio surface with a metal framework and multiple circular attachment housings embedded in the denture base. A clinical photograph of a fixed dental prosthesis, specifically a full-arch implant-supported bridge (likely for the lower jaw). The image shows the prosthetic teeth attached to a metal framework with visible cylindrical abutment connections on the interior side. # Lecture 1 Fixed Prosthesis Mandible  - Fixed Prosthesis - Mandible Clinical photograph showing a frontal view of the mandibular (lower) teeth, displaying the anterior and posterior dentition in occlusion. The image illustrates the alignment and condition of the lower arch relevant to fixed prosthodontic treatment planning. Lecture 2      Lecture 2 Radiograph: A panoramic dental X-ray (orthopantomogram) displaying the patient's maxilla and mandible, teeth, and temporomandibular joints. The image reveals multiple hyperdense restorations in the posterior teeth and a distinct, vertically oriented radiopaque implant fixture placed in the anterior region of the lower jaw. A clinical photograph showing the intaglio (tissue-facing) surface of a horseshoe-shaped dental prosthesis. The image highlights the internal structure, featuring a distinct circular metal housing or attachment embedded in the anterior region of the acrylic base. A 3D CT reconstruction of a mandible showing two dental implants placed in the anterior region. The image illustrates a surgical planning or guided placement concept, with angled drill guides and trajectory lines superimposed over the implant sites. Text labels indicating specific dimensions (e.g., "15x11", "4x15") are visible along the trajectories. A clinical photograph showing the intaglio (tissue-facing) surface of a horseshoe-shaped dental prosthesis. The image reveals a rigid metal framework embedded within the structure, featuring distinct circular housings or attachment caps distributed along the arch, which serve as the interface for the detachable mechanism. This is a clinical photograph showing an intraoral view of the upper palate with a metal dental appliance in place. The device features a broad, curved anterior bar that spans across the front of the mouth, resting on the tissue behind the teeth. # Lecture 3 Fixed Prosthesis Maxilla  - Fixed Prosthesis - Maxilla A composite collage of clinical photographs and radiographs illustrating fixed prosthodontic rehabilitation. The images include panoramic X-rays showing dental implants (some tilted) and a 3D CT reconstruction, alongside close-up photos of the prosthetic components such as a screw-retained denture arch with metal abutments. Treatment strategies for the edentulous jaw **Maxillary complete denture prosthetics** –Mandibular prosthodontics –Mn IOD –Mn IFP (Least maintenance) –Review at 12 months (75% satisfied) Treatment strategies for the edentulous jaw #### Maxillary complete denture prosthetics - Mandibular prosthodontics - Mn IOD - Mn IFP (least maintenance) - Review at 12 months (75% satisfied) Large numbers of patients with downhill dentitions, but not yet edentulous       Large numbers of patients with downhill dentitions, but not yet edentulous. A panoramic dental radiograph showing the maxilla and mandible with multiple remaining teeth, several of which exhibit bright radiopaque restorations or crowns. The image illustrates a dentition that is partially edentulous but still retains natural tooth roots. Clinical intraoral photograph showing a frontal view of the anterior dentition in a patient with a 'downhill' occlusal plane. The image illustrates significant wear and flattening of the incisal edges of the upper teeth, along with gum recession and visible root surfaces on the lower anterior teeth. A panoramic dental radiograph showing a patient's dentition with multiple missing teeth (edentulous spaces) and several remaining teeth that appear to have restorations or root canal treatments. The image illustrates the clinical presentation of significant tooth loss while retaining some natural teeth. A clinical intraoral photograph showing severe dental wear, with teeth significantly reduced in height (downhill dentition). The image displays worn incisal edges and visible restorations or carious lesions on the remaining tooth structure. A panoramic dental radiograph showing a partial dentition with multiple missing teeth (edentulous spaces) in both the maxillary and mandibular arches. Several remaining teeth exhibit significant restorations, including bright radiopaque crowns and fillings. Clinical intraoral photograph showing a severely worn and broken-down dentition with multiple remaining teeth exhibiting significant structural loss, dark staining, and shortened clinical crowns. The image illustrates the advanced attrition and erosion characteristic of downhill dentitions. **Terminal dentition - Definition** A residual dentition considered by clinical parameters or economic rationalism, unable to be restored for a reasonable prognosis - Wait until self destructs - Intervene earlier - retain some teeth - maintain facial form, speech - limit bone resorption #### Definition A residual dentition considered by clinical parameters or economic rationalism, unable to be restored for a reasonable prognosis. #### Management Options - Wait until self destructs - Intervene earlier - Retain some teeth - Maintain facial form, speech - Limit bone resorption > [!note] Lecturer — Terminal Dentition Surveys > Some patients retain teeth that are technically present but are unlikely to remain functional. Surveys may underestimate the size of this group because patients may report that they still have teeth even when many of those teeth are unusable and likely to be lost. - ==Remove the remaining teeth and proceed to implant rehabilitation== - ==Excessive attempts to preserve severely compromised teeth may result in substantial further bone loss== - ==The clinician must eventually decide when continued periodontal treatment is no longer appropriate and another treatment strategy is required== **Title:** What are patients satisfied with? **References:** Liddelow GJ, Henry PJ. The immediately loaded single implant retained mandibular overdenture:A 36-month prospective study. Int J Prothodont 2010;23:13-21. Brennan M, Houston F, O'Sullivan M, O'Connell B. Patient satisfaction and oral health-related quality of life outcomes of implant overdentures and fixed complete dentures. Int J Oral Maxillofac Implants. 2010;25:791-800. Turkyilmaz I, Company AM, McGlumphy EA. Should edentulous patients be constrained to removable complete dentures? The use of dental implants to improve the quality of life for edentulous patients. Gerodontology. 2010;27:3-10. Carlsson GE, Omar R. The future of complete dentures in oral rehabilitation. A critical review. J Oral Rehabil. 2010;37:143-56. Clin Oral Implants Res. 2009 Jun;20(6):533-44. Emami E, Heydecke G, Rompré PH, de Grandmont P, Feine JS. Impact of implant support for mandibular dentures on satisfaction, oral and general health-related quality of life: a meta-analysis of randomized-controlled trials. Clin Oral Implants Res. 2009;20:533-44. What are patients satisfied with? *Turkyilmaz I, Company AM, McGlumphy EA. Should edentulous patients be constrained to removable complete dentures? The use of dental implants to improve the quality of life for edentulous patients. Gerodontology. 2010;27:3-10.* *Carlsson GE, Omar R. The future of complete dentures in oral rehabilitation. A critical review. J Oral Rehabil. 2010;37:143-56.* *Emami E, Heydecke G, Rompré PH, de Grandmont P, Feine JS. Impact of implant support for mandibular dentures on satisfaction, oral and general health-related quality of life: a meta-analysis of randomized-controlled trials. Clin Oral Implants Res. 2009;20:533-44.* # What are patients satisfied with? - Currently edentulous patients are satisfied with a one or two implant mandibular overdenture and complete maxillary denture - Comparison with fixed mandibular prosthesis equivocal, younger patients prefer fixed and generally better function - No studies on terminal dentition and satisfaction with various prostheses **If patients are financial, fixed is far more predictable with less maintenance long term and greater patient satisfaction** Liddelow GJ, Henry PJ. The immediately loaded single implant retained mandibular overdenture: A 36-month prospective study. Int J Prothodont 2010;23:13-21. Brennan M, Houston F, O'Sullivan M, O'Connell B. Patient satisfaction and oral health-related quality of life outcomes of implant overdentures and fixed complete dentures. Int J Oral Maxillofac Implants. 2010;25:791-800. Turkyilmaz I, Company AM, McGlumphy EA. Should edentulous patients be constrained to removable complete dentures? The use of dental implants to improve the quality of life for edentulous patients. Gerodontology. 2010;27:3-10. Carlsson GE, Omar R. The future of complete dentures in oral rehabilitation. A critical review. J Oral Rehabil. 2010;37:143-56. Emami E, Heydecke G, Rompré PH, de Grandmont P, Feine JS. Impact of implant support for mandibular dentures on satisfaction, oral and general health-related quality of life: a meta-analysis of randomized-controlled trials. Clin Oral Implants Res. 2009;20:533-44. What are patients satisfied with? - Currently edentulous patients are satisfied with a one or two implant mandibular overdenture and complete maxillary denture - Comparison with fixed mandibular prosthesis equivocal: younger patients prefer fixed and generally better function - No studies on terminal dentition and satisfaction with various prostheses > If patients are financial, fixed is far more predictable with less maintenance long term and greater patient satisfaction *Liddelow GJ, Henry PJ. The immediately loaded single implant retained mandibular overdenture: A 36-month prospective study. Int J Prothodont 2010;23:13-21.* *Brennan M, Houston F, O'Sullivan M, O'Connell B. Patient satisfaction and oral health-related quality of life outcomes of implant overdentures and fixed complete dentures. Int J Oral Maxillofac Implants. 2010;25:791-800.* *Turkyilmaz I, Company AM, McGlumphy EA. Should edentulous patients be constrained to removable complete dentures? The use of dental implants to improve the quality of life for edentulous patients. Gerodontology. 2010;27:3-10.* *Carlsson GE, Omar R. The future of complete dentures in oral rehabilitation. A critical review. J Oral Rehabil. 2010;37:143-56.* *Emami E, Heydecke G, Rompré PH, de Grandmont P, Feine JS. Impact of implant support for mandibular dentures on satisfaction, oral and general health-related quality of life: a meta-analysis of randomized-controlled trials. Clin Oral Implants Res. 2009;20:533-44.* - ==Patients generally seek improved appearance, function, and confidence.== - ==Many patients increasingly want fixed treatment and do not want a removable appliance.== - ==Satisfaction depends not only on the prosthesis itself but also on appearance, function, adaptation, comfort, cleanability, and maintenance requirements.== (img>Dental X-ray labeled "The mandible") *Dental X-ray labeled "The mandible"* Fixed **Brånemark PI**, **Hansson BO**, **Adell R**, et al. Osseointegrated implants in the treatment of the edentulous jaw. Experience from a 10-year period. *Scand J Plast Reconstr Surg Suppl* 1977;16:1–132. **Ekelund JA**, **Lindqvist LW**, **Carlsson GE**, **Jemt T**. Implant treatment in the edentulous mandible: a prospective study on Brånemark system implants over more than 20 years. *Int J Prosthodont* 2003: 16: 602–608. **Brånemark P-I**, **Svensson B**, **van Steenberghe D**. Ten-year survival rates of fixed prosthesis on four or six implants ad modum Brånemark in full edentulism. *Clin Oral Impl Res* 1995;6:227–231. #### Fixed Prosthesis References - *Brånemark PI, Hansson BO, Adell R, et al. Osseointegrated implants in the treatment of the edentulous jaw. Experience from a 10-year period. Scand J Plast Reconstr Surg Suppl 1977;16:1–132.* - *Ekelund JA, Lindqvist LW, Carlsson GE, Jemt T. Implant treatment in the edentulous mandible: a prospective study on Brånemark system implants over more than 20 years. Int J Prosthodont 2003;16:602–608.* - *Brånemark P-I, Svensson B, van Steenberghe D. Ten-year survival rates of fixed prosthesis on four or six implants ad modum Brånemark in full edentulism. Clin Oral Impl Res 1995;6:227–231.* > [!note] Lecturer — Implant Longevity > Long-term implant treatment developed from early implant research and clinical experience. Early implants made from materials other than titanium had reported success rates of approximately 15–20%, whereas titanium implants subsequently demonstrated much higher long-term success. > > - Four-implant mandibular treatments in the lecturer’s studies and other studies showed very high success rates. > - The lecturer reported approximately 99.5% success over 8–10 years in the relevant practice experience. > - Approximately 500 patients had been treated in the lecturer’s practice since the early 2000s. > [!example] Mandibular Reconstructions Over Decades > A patient treated in 1965 retained the implants until the patient died in 2006. The lecturer also described mandibular reconstructions approximately 40–43 years old and a 92-year-old patient whose lower bridge had been present for approximately 43 years, with the reconstruction changed or refurbished several times. > [!note] Lecturer — Implant History > The historical development of implant treatment was associated with Brånemark’s observations of bone attachment to titanium chambers. The first patients were treated in 1965, but the results were reported approximately 15 years later to provide long-term follow-up. > > - The 1982 Toronto conference presented Swedish and European implant experience to North America. > - George Zarb was identified as a significant prosthodontic figure associated with the Toronto conference and with major texts on edentulous jaws. > - The first patient in Australia was treated in 1985 by a team associated with Patrick Henry. > - A Brånemark Centre was established in Perth around 1985 and became involved in research, teaching, continuing education, clinical care, and foundation activities. **Immediate** **Loading** Fixed Henry P, Liddelow G. Immediate loading of dental implants. Aust Dent J 2008;53:S69–S81 Jokstad A, Carr AB. What is the effect on outcomes of time-to-loading of a fixed or removable prosthesis placed on implant(s)? Int J Oral Maxillofac Implants 2007;22(Suppl):19–48. Aparicio C, Rangert B, Sennerby L. Immediate / early loading of dental implants: a report from the Sociedad Espanola de Implantes World Congress consensus meeting in Barcelona, Spain, 2002. Clin Implant Dent Relat Res 2003;5:57–60. 26. Attard NJ, Zarb GA. Immediate and early implant loading protocols: a literature review of clinical studies. J Prosthet Dent 2005;94:242–258. Nkenke E, Fenner M. Indications for immediate loading of implants and implant success. Clin Oral Implants Res 2006; 17 Suppl 2:19–34.30. #### Immediate Loading References (Fixed) - *Henry P, Liddelow G. Immediate loading of dental implants. Aust Dent J 2008;53:S69–S81.* - *Jokstad A, Carr AB. What is the effect on outcomes of time-to-loading of a fixed or removable prosthesis placed on implant(s)? Int J Oral Maxillofac Implants 2007;22(Suppl):19–48.* - *Aparicio C, Rangert B, Sennerby L. Immediate / early loading of dental implants: a report from the Sociedad Espanola de Implantes World Congress consensus meeting in Barcelona, Spain, 2002. Clin Implant Dent Relat Res 2003;5:57–60.* - *Attard NJ, Zarb GA. Immediate and early implant loading protocols: a literature review of clinical studies. J Prosthet Dent 2005;94:242–258.* - *Nkenke E, Fenner M. Indications for immediate loading of implants and implant success. Clin Oral Implants Res 2006;17 Suppl 2:19–34.* > [!note] Lecturer — Immediate Loading > Before immediate loading, implants were generally covered by mucosa and exposed after approximately three to six months. Immediate loading of four implants was initially considered close to heretical. > > - In early studies, six implants were placed but only four were immediately loaded. > - The immediately loaded implants demonstrated better bone levels than the unloaded implants in the reported experience. > - Immediate loading is now routine in the lecturer’s mandibular full-arch practice. > [!example] Original Immediate-Loading Patient > The original immediately loaded patient described in the lecture had implants functioning well after approximately 33 years. > [!note] Lecturer — Immediate Loading Protocol > The early immediate-loading proposal was made around 1991 and presented to treatment centres internationally. Most centres reportedly rejected the proposal, while Australian centres agreed to attempt it. > > - The original experience included a reported 100% success rate. > - Immediate mandibular full-arch treatment is a routine protocol involving four implants. # Lekholm and Zarb Classification of Bone Quality **Quality 1:** Nearly entirely cortical bone. **Quality 2:** Thick cortical bone, dense trabecular bone. **Quality 3:** Thin cortical bone, dense trabecular bone. **Quality 4:** Thin cortical bone, low density trabecular bone. 1 2 3 4 Lekholm U, Zarb GA. Patient selection and preparation. In: Tissue Integrated Prosthesis: Osseointegration in Clinical Dentistry. Bªnemark P-I, Zarb GA, Albrektsson T. (Eds). Chicago: Quintessence; 1985. p. 199-209.     - **Quality 1:** Nearly entirely cortical bone. - **Quality 2:** Thick cortical bone, dense trabecular bone. - **Quality 3:** Thin cortical bone, dense trabecular bone. - **Quality 4:** Thin cortical bone, low density trabecular bone. *Lekholm U, Zarb GA. Patient selection and preparation. In: Tissue Integrated Prosthesis: Osseointegration in Clinical Dentistry. Brånemark P-I, Zarb GA, Albrektsson T. (Eds). Chicago: Quintessence; 1985. p. 199-209.* - ==The mandible generally contains thicker cortical bone and is commonly associated with type I or type II bone.== - ==The posterior maxilla more often contains thin or absent cortex and low-density trabecular bone.== - ==Greater bone density provides better primary implant stability and a better environment for integration.== > [!note] Lecturer — Implant Number > The number of implants used for a mandibular full-arch prosthesis has changed over time. > > - Six implants were initially used, followed by five when placing six implants between the mental foramina became difficult. > - Five implants became more common in the late 1980s and 1990s, although some clinicians later used very large numbers, including one implant per root position. > - Excessive implant numbers can create a prosthesis that is difficult or impossible for the patient to clean. > - In a five-implant arrangement, the middle implant may receive little functional load and develop disuse atrophy; reduced loading may contribute to bone resorption because bone requires stress to be maintained. > - With a posterior load, approximately 80% may be taken by the distal implant, approximately 10% by the next implant, and little or none by the implant farther forward, with the remainder taken by the implant on the opposite side. > - Four implants are generally sufficient for the lecturer’s mandibular full-arch protocol. > [!note] Lecturer — All-on-4 Protocol > Immediate loading of four implants was described as the routine mandibular full-arch protocol. > > - Implants are placed in a prosthetically determined position, commonly anterior to the mental foramina, with the posterior implants angled distally. > - A posterior molar may be cantilevered from the distal implant to provide a six-to-six occlusion. > - Earlier five-to-five occlusion studies were reported to have long follow-up periods without functional problems. > - Extending the prosthesis farther posteriorly may provide additional support but must be balanced against mandibular deformation and maintenance. A close-up photograph of a sectioned mandible showing the internal architecture of the bone, specifically the cancellous (trabecular) structure within the edentulous ridge. This visual evidence illustrates one of the four categories in the Lekholm and Zarb classification system for bone quality. This is a clinical photograph of a cross-sectioned bone specimen, likely from the jaw. It visually illustrates the internal structure of bone, showing the relationship between the outer cortical layer and the inner trabecular (spongy) network, which serves as an example for one of the Lekholm and Zarb bone quality classifications. Photo: A cross-sectional view of a bone specimen showing the internal trabecular structure surrounded by a cortical shell. This image illustrates one of the four categories in the Lekholm and Zarb classification system for bone quality, which categorizes jawbone based on the relative thickness of cortical bone and density of trabecular bone. Clinical photo: A close-up photograph of a dissected section of the human mandible, revealing the internal trabecular bone structure and cortical plates. This specimen illustrates the varying densities of jawbone used in the Lekholm and Zarb classification system. # How many implants? ## All-on-4 ? CRESTAL BONE LOSS HENRY, PJ & ROSENBERG I. Immediately loaded implants in the edentulous mandible. Pract Periodont & Aesthet Dent 1994; 6:15-22. (Nobel Biocare Study T-033C) Maló P, Rangert B, Nobre M."All-on-Four" immediate-function concept with Brånemark System implants for completely edentulous mandibles: a retrospective clinical study. Clin Implant Dent Relat Res. 2003;5 Suppl 1:2-9.  #### All-on-4 Crestal bone loss. *Henry, PJ & Rosenberg I. Immediately loaded implants in the edentulous mandible. Pract Periodont & Aesthet Dent 1994; 6:15-22. (Nobel Biocare Study T-033C)* *Maló P, Rangert B, Nobre M. "All-on-Four" immediate-function concept with Brånemark System implants for completely edentulous mandibles: a retrospective clinical study. Clin Implant Dent Relat Res. 2003;5 Suppl 1:2-9.* Clinical photograph showing multiple metallic implant abutments protruding through the gingival tissue in the mandibular arch. The image illustrates a case with several implants placed, consistent with the 'All-on-4' or similar multi-implant treatment concepts referenced in the slide text. How many implants? Carlsson GE, Lindquist LW, Jemt T. Long-term marginal periimplant bone loss in edentulous patients. Int J Prosthodont. 2000 Jul-Aug;13(4): 295-302. Rangert B, Jemt T, Jörneus L. Forces and Moments on Brånemark Implants. Int J Oral Maxillofac Implants 1989;4:241-247. Henry PJ, Rosenberg I. Single stage surgery for rehabilitation of the edentulous mandible: Preliminary results. Pract Periodont Aesthet Dent 1994;6:15–24. Henry P, Liddelow G. Immediate loading of dental implants. Aust Dent J 2008;53:S69-S81 Brånemark P-I, Svensson B, van Steenberghe D. Ten-year survival rates of fixed prosthesis on four or six implants ad modum Brånemark in full edentulism. Clin Oral Impl Res 1995;6:227-231.   *Carlsson GE, Lindquist LW, Jemt T. Long-term marginal periimplant bone loss in edentulous patients. Int J Prosthodont. 2000 Jul-Aug;13(4): 295-302.* *Rangert B, Jemt T, Jörneus L. Forces and Moments on Brånemark Implants. Int J Oral Maxillofac Implants 1989;4:241-247.* *Henry PJ, Rosenberg I. Single stage surgery for rehabilitation of the edentulous mandible: Preliminary results. Pract Periodont Aesthet Dent 1994;6:15–24.* *Henry P, Liddelow G. Immediate loading of dental implants. Aust Dent J 2008;53:S69-S81* *Brånemark P-I, Svensson B, van Steenberghe D. Ten-year survival rates of fixed prosthesis on four or six implants ad modum Brånemark in full edentulism. Clin Oral Impl Res 1995;6:227-231.* Radiograph: A panoramic dental X-ray showing an edentulous maxilla and a mandible restored with a fixed prosthesis supported by six endosseous implants. The image illustrates the bone levels surrounding the implant fixtures in the lower jaw. A panoramic radiograph (OPG) showing an edentulous maxilla and a mandible restored with a fixed prosthesis supported by six dental implants. The image is labelled '20 years', indicating the long-term status of the restoration, and displays the metallic fixtures and superstructure clearly against the jawbones. **All-on-4** First All-on-4 patient treated 2002 - over 500 pts treated since Cumulative Success Rate of 320 Replace Select TiUnite implants (75 pts) 5 - 11 years : 99.6% Mean age of treatment: 7.2 years One implant failure was observed - Early altered healing No peri-implantitis, 40% peri-implant mucositis Bone remodeling within 1mm of placement level High Satisfaction - 94% would recommend treatment to a friend Liddelow G, Carmichael G. Retrospective evaluation of immediate placement and loading of four implants to support a complete mandibular fixed prosthesis with at least 7 years of follow-up. Int J Pros 2017 (In Press) - First All-on-4 patient treated 2002 — over 500 pts treated since - Cumulative Success Rate of 320 Replace Select TiUnite implants (75 pts), 5–11 years: 99.6% - Mean age of treatment: 7.2 years - One implant failure was observed — early altered healing - No peri-implantitis; 40% peri-implant mucositis - Bone remodeling within 1mm of placement level - High satisfaction — 94% would recommend treatment to a friend *Liddelow G, Carmichael G. Retrospective evaluation of immediate placement and loading of four implants to support a complete mandibular fixed prosthesis with at least 7 years of follow-up. Int J Pros 2017 (In Press)* - ==An original immediately loaded patient was still functioning well after approximately 33 years.== > [!note] Lecturer — Treatment Requirements > The high reported survival and success of four-implant mandibular treatment depends on several clinical and maintenance factors. > > - Appropriate planning, sufficient primary stability, accurate implant positioning, and a well-designed prosthesis > - Good occlusion and cleanability > - Ongoing professional follow-up and patient home care # How many implants? Diagram showing implant distribution and force percentages Diagram illustrating occlusal forces, compression, and tension on a mandibular implant prosthesis Rangert B, Jemt T, Jörneus L. Forces and Moments on Brånemark Implants. Int J Oral Maxillofac Implants 1989;4:241-247. Henry PJ, Rosenberg I. Single stage surgery for rehabilitation of the edentulous mandible: Preliminary results. Pract Periodont Aesthet Dent 1994;6:15–24. Duyck J et al. Magnitude and distribution of occlusal forces on oral implants supporting fixed prostheses: An in vivo study. Clin Implant Dent Relat Res 2000;11:465-475.   *Diagram showing implant distribution and force percentages.* *Diagram illustrating occlusal forces, compression, and tension on a mandibular implant prosthesis.* *Rangert B, Jemt T, Jörneus L. Forces and Moments on Brånemark Implants. Int J Oral Maxillofac Implants 1989;4:241-247.* *Henry PJ, Rosenberg I. Single stage surgery for rehabilitation of the edentulous mandible: Preliminary results. Pract Periodont Aesthet Dent 1994;6:15–24.* *Duyck J et al. Magnitude and distribution of occlusal forces on oral implants supporting fixed prostheses: An in vivo study. Clin Implant Dent Relat Res 2000;11:465-475.* A schematic cross-section diagram illustrating a fixed dental prosthesis supported by four threaded implants. The arrangement includes one vertical implant (rendered in dark grey/black) and three angled or tilted implants (rendered in light grey), all connecting to a horizontal superstructure bar at the top. A schematic line drawing of a mandibular arch with dental implants, illustrating the biomechanical effects of occlusal loading. The diagram shows how an 'Occlusal force' applied at a distance (labeled 'a') from the most posterior implant creates a lever arm that generates opposing forces of 'Compression' and 'Tension' on the distal aspect of the bone. # How many implants? - 5th implant - Carlsson et al - > bone loss on midline implants with poor plaque control and bruxism - Less space between implants - desirable to have 3mm between implants **Carlsson GE, Lindquist LW, Jemt T. Long-term marginal periimplant bone loss in edentulous patients. Int J Prosthodont. 2000 Jul-Aug;13(4):295-302.** **Rangert B, Jemt T, Jörneus L. Forces and Moments on Brånemark Implants. Int J Oral Maxillofac Implants 1989;4:241-247.** **Henry PJ, Rosenberg I. Single stage surgery for rehabilitation of the edentulous mandible: Preliminary results. Pract Periodont Aesthet Dent 1994;6:15–24.** **Henry P, Liddelow G. Immediate loading of dental implants. Aust Dent J 2008;53:S69-S81** **Brånemark P-I, Svensson B, van Steenberghe D. Ten-year survival rates of fixed prosthesis on four or six implants ad modum Brånemark in full edentulism. Clin Oral Impl Res 1995;6:227-231.**  - 5th implant — Carlsson et al: greater bone loss on midline implants with poor plaque control and bruxism - Less space between implants — desirable to have 3mm between implants *Carlsson GE, Lindquist LW, Jemt T. Long-term marginal periimplant bone loss in edentulous patients. Int J Prosthodont. 2000 Jul-Aug;13(4):295-302.* *Rangert B, Jemt T, Jörneus L. Forces and Moments on Brånemark Implants. Int J Oral Maxillofac Implants 1989;4:241-247.* *Henry PJ, Rosenberg I. Single stage surgery for rehabilitation of the edentulous mandible: Preliminary results. Pract Periodont Aesthet Dent 1994;6:15–24.* *Henry P, Liddelow G. Immediate loading of dental implants. Aust Dent J 2008;53:S69-S81* *Brånemark P-I, Svensson B, van Steenberghe D. Ten-year survival rates of fixed prosthesis on four or six implants ad modum Brånemark in full edentulism. Clin Oral Impl Res 1995;6:227-231.* A line drawing schematic of a dental arch (likely the mandible) viewed from above, showing the placement of five circular implant abutments distributed along the curve. The illustration visualizes the concept of using a fifth implant to provide additional support and spacing within a fixed prosthesis framework. **Mandibular deformation** Corporal approximation 11-53μm (up to 780μm) No relation with height but significant in cross section Pain, screw fracture, loosening, fracture of metal substructure Al-Sukhun J, Helenius M, Lindqvist C, Kelleway J. Biomechanics of the Mandible Part I: Measurement of Mandibular Functional Deformation Using Custom-Fabricated Displacement Transducers. J Oral Maxillofac Surg 2006;64:1015-1022. De Marco P, Paine S. Mandibular dimensional change J Prosthet Dent 1974;31:482. - Corporal approximation 11–53 μm (up to 780 μm) - No relation with height but significant in cross section - Pain, screw fracture, loosening, fracture of metal substructure *Al-Sukhun J, Helenius M, Lindqvist C, Kelleway J. Biomechanics of the Mandible Part I: Measurement of Mandibular Functional Deformation Using Custom-Fabricated Displacement Transducers. J Oral Maxillofac Surg 2006;64:1015-1022.* *De Marco P, Paine S. Mandibular dimensional change J Prosthet Dent 1974;31:482.* - ==As the mouth opens and closes, the posterior portions of the mandible contract.== - ==Deformation may range from approximately 10–60 microns and may reach as much as 800 microns.== - ==The fit of an implant bridge is approximately 20–30 microns.== - ==When deformation exceeds bridge-fit accuracy, stress may transfer to prosthetic screws, frameworks, and other mechanical components.== - ==An extremely rigid bridge may transfer stress to the bone and jaws.== - ==Patients with a small mandible and significant parafunction may develop pain when implants are linked too far posteriorly.== - ==For full-arch prostheses, the bridge is generally not extended too far posteriorly.== - ==The posterior implant is usually placed anterior to the mental foramen, angled distally, and used with a limited posterior cantilever.== Implant tilting Krekmanov L, Kahn M, Rangert B, Lindström H. Tilting of posterior mandibular and maxillary implants for improved prosthesis support. Int J Oral Maxillofac Implants 2000;15:405-414. Maló P, Rangert B, Nobre M. “All-on-4” immediate function concept with Brånemark System® implants for completely edentulous mandibles: A retrospective clinical study. Clin Implant Dent Relat Res 2003;5(suppl 1):2-9.   *Krekmanov L, Kahn M, Rangert B, Lindström H. Tilting of posterior mandibular and maxillary implants for improved prosthesis support. Int J Oral Maxillofac Implants 2000;15:405-414.* *Maló P, Rangert B, Nobre M. "All-on-4" immediate function concept with Brånemark System® implants for completely edentulous mandibles: A retrospective clinical study. Clin Implant Dent Relat Res 2003;5(suppl 1):2-9.* > [!note] Lecturer — Implant Tilting > Implant tilting has been used for many years and remains part of the mandibular full-arch approach. > > - Four implants are commonly placed where the available bone and prosthetic design permit. > - Tilting the distal implants can keep them anterior to the mental foramina while providing a more favorable prosthetic extension. > - Tilting is not inherently problematic when planned appropriately and used with suitable multi-unit abutments. > [!note] Lecturer — Bone Requirements > The described approach required approximately 8 mm of mandibular bone and approximately 10 mm of maxillary bone. > > - A patient with approximately 8 mm of interforaminal mandibular bone and approximately 5 mm near the mental foramen may still be treated with appropriate planning > - Implant placement may stimulate distal bone apposition and strengthen thin mandibular regions Radiograph: A panoramic dental X-ray showing multiple endosseous implants placed in the maxilla and mandible. The image illustrates the concept of implant tilting, with the posterior implants angled obliquely relative to the vertical anterior implants. A panoramic radiograph (orthopantomogram) showing the maxilla and mandible with multiple dental implants supporting fixed prostheses. The image illustrates the concept of implant tilting, particularly in the posterior regions where angled implants are used to support the prosthetic arches. I M M E D I A T E L O A D I N G **Edentulous Jaws** 1991 – Single stage surgery and immediate loading – T-033C 1994 – Routine lower jaw on 4 implants, immediate loading 1998 – Branemark Novum – T-086 2000 – Immediate loading maxilla 2003 – Teeth in an hour ( NobelGuide ) 2008 – Immediate loading of Zygoma implants  #### Edentulous Jaws: Milestones in Immediate Loading - 1991 – Single stage surgery and immediate loading (T-033C) - 1994 – Routine lower jaw on 4 implants, immediate loading - 1998 – Brånemark Novum (T-086) - 2000 – Immediate loading maxilla - 2003 – Teeth in an hour (NobelGuide) - 2008 – Immediate loading of Zygoma implants > [!note] Lecturer — Immediate Workflow > Immediate mandibular full-arch treatment can proceed from tooth removal to a bridge in approximately 24 hours. > > - Tooth removal, bone reduction, prosthetically determined implant placement, multi-unit abutment connection, suturing, and placement of a denture or provisional arrangement > - Jaw-relation recording followed by impression, scanning, or photogrammetry > - Laboratory production of a cast or digital model, articulator or digital mounting, framework design, titanium-alloy milling, and processing of denture teeth onto the framework > - The bridge is usually produced by injection molding, and the clinical impression procedure may take approximately one minute A circular logo featuring a central stylized icon resembling an osseointegrated implant or tooth root, surrounded by the text 'ASSOCIATED BRÅNEMARK OSSEOINTEGRATION CENTER'. <caption>Definitive phase – 1yr after implant placement</caption> ![Procera Titanium/acrylic denture attached to dental implant model] ![Dental prosthesis attached to titanium frame with acrylic teeth] Riedy SJ, Lang BR, Lang BE. Fit of implant frameworks fabricated by different techniques. J Prosthet Dent 1997;78:596-604. Ortorp A, Jemt T. Clinical experiences of computer numeric control-milled titanium frameworks supported by implants in the edentulous jaw: A 5-year prospective study. Clin Impl Dent Relat Res 2004;6:199-209.   *Definitive phase – 1yr after implant placement* *Procera Titanium/acrylic denture attached to dental implant model.* *Dental prosthesis attached to titanium frame with acrylic teeth.* *Riedy SJ, Lang BR, Lang BE. Fit of implant frameworks fabricated by different techniques. J Prosthet Dent 1997;78:596-604.* *Ortorp A, Jemt T. Clinical experiences of computer numeric control-milled titanium frameworks supported by implants in the edentulous jaw: A 5-year prospective study. Clin Impl Dent Relat Res 2004;6:199-209.* > [!note] Lecturer — Loading Evolution > Initial implant treatment involved delayed loading after approximately three to six months. > > - Immediate loading of four implants was introduced experimentally in the early 1990s and subsequently became routine in mandibular full-arch treatment > - Current workflows can involve digitally planned surgery, guided implant placement, immediate provisionalization, and digitally fabricated definitive frameworks A close-up clinical photograph of a dental cast model showing a mandibular prosthesis (with acrylic teeth and a metal framework) being positioned over three cylindrical implant abutments. The image illustrates the seating of a definitive titanium/acrylic fixed denture onto the implant supports. Clinical photograph showing the underside view of a complete dental prosthesis, featuring white acrylic teeth attached to a polished, contoured metallic framework. The image highlights the structural design and screw access holes of the titanium base. # Home Care ## *Patient Aids*   *Home Care — Patient Aids* > [!note] Lecturer — Cleaning Access > Prostheses must be designed so patients can clean beneath and around them. > > - A thin tissue-connecting area, similar to an ovate pontic, can provide access for cleaning. > - Suggested aids included Pixters and water flossers. > - Some periodontists are less enthusiastic about conventional floss because floss fibres may become caught around implants. A product photo of a Waterpik oral irrigator (water flosser) featuring a white base unit with a water reservoir, control dials, and a handheld wand. The top lid is open to reveal a storage compartment containing multiple interchangeable tips. A product photograph of an Oral-B Braun home care system featuring two handheld devices docked on a central base unit. The left handle is a power toothbrush, while the right handle is an OxyJet water flosser; between them sits a translucent graduated water reservoir marked with volume levels (100–600) and an 'air filter' button. # Maintenance * Complete denture opposing FDP less potential for wear/breakages * Minimised cantilevers and occlusal table * Retrievability with screw retained prosthesis * Complete denture superior aesthetics and lip support * 4 implants well spaced easier plaque control - interproximal brushes * Passive fit of CAD/CAM framework – ↓ component stress Recall visits tailored to need – at least 6 monthly - Complete denture opposing FDP — less potential for wear/breakages - Minimised cantilevers and occlusal table - Retrievability with screw-retained prosthesis - Complete denture superior aesthetics and lip support - 4 implants well spaced — easier plaque control (interproximal brushes) - Passive fit of CAD/CAM framework → ↓ component stress Recall visits tailored to need — at least 6 monthly > [!note] Lecturer — Maintenance and Smoking > Follow-up is essential because many implant rehabilitation patients have previously experienced severe destruction of their dentitions, and they may require more frequent review than routine dental patients. > > - Reviews assess hygiene, prosthesis fit, occlusion, cleanability, tissue health, radiographic bone levels, and mechanical complications. > - Risk factors commonly include poor plaque control, smoking, diabetes or other systemic factors, periodontal disease, and poor dental attendance or hygiene. > - Some patients improve their habits after investing financially in treatment, but this cannot be assumed; persistent poor hygiene may require repeated instruction and firm reinforcement. > - Heavy smoking was described in some studies as more than ten cigarettes per day. The lecturer reported that approximately 90% of problematic implant patients in the lecturer’s experience are smokers with peri-implant or healing problems. > - A small, statistically weak study reported approximately 95% implant success in non-smokers, failure rates as high as 40% in active smokers of more than ten years, and approximately 11% failure after patients stopped smoking two weeks before implant placement. > - Smoking cessation must be genuine and supported by a plan; patients requiring extensive grafting, particularly in the maxilla, may be refused treatment until they stop smoking. ASSOCIATED BRÅNEMARK OSSEOINTEGRATION CENTER PERTH THE UNIVERSITY OF WESTERN AUSTRALIA # Thank you! glenliddelow@gmail.com www.branemarkcentre.com.au B R Å N E M A R K C E N T R E P E R T H Thank you! - glenliddelow@gmail.com - www.branemarkcentre.com.au *Associated Brånemark Osseointegration Centre, Perth — The University of Western Australia — Brånemark Centre Perth.* > [!note] Lecturer — Patient Adaptation > Patients are biological rather than mechanical systems, so occlusion cannot be treated as a static relationship reproduced perfectly by an articulator. > > - Muscles, temporomandibular joints, facial muscles, nervous systems, and behavioral patterns all influence function. > - Implant patients may initially have reduced sensory feedback because implants lack the periodontal ligament. > - Over time, osseoperception develops: mechanosensibility associated with osseointegrated implants. Adaptation may involve central and peripheral neuroplastic changes and may take approximately three months to two years. > - Retaining a small number of posterior teeth when clinically reasonable may help patients adapt more quickly to a reconstruction. > - The final outcome depends on both the technical quality of treatment and the patient’s ability to maintain the prosthesis. ## Case: Long-term outcome of a 43-year-old mandibular implant bridge ### Question **Scenario:** A 92-year-old patient who received a lower implant bridge in 1985. **What's shown:** Radiographs/images of the patient's 43-year-old implant reconstruction. **Consider:** What can be observed regarding the long-term survival and maintenance of this early implant rehabilitation? ### Answer **Observations:** - The implants have been in place and functioning for 43 years. - The prosthetic reconstruction has been changed or retreaded a couple of times over the decades. **Reasoning:** The case demonstrates that while the implant fixtures themselves can survive for over four decades, the prosthetic components may require periodic replacement or maintenance due to wear and material degradation over time. **Takeaway:** Well-maintained implant fixtures can achieve exceptional long-term survival (over 40 years), though the suprastructure may require periodic replacement. ## Case: Prosthetic maintenance in a severe bruxer with a two-jaw implant case ### Question **Scenario:** A patient described as a "world champion bruxer" who received a two-jaw implant case 43 years ago. **What's shown:** Images of the patient's two-jaw implant rehabilitation. **Consider:** How does extreme parafunction affect the long-term maintenance of the implant prosthesis? ### Answer **Observations:** - The patient requires the prosthetic teeth to be changed approximately once a year. - The underlying implants have survived for 43 years despite the severe bruxing. **Reasoning:** Extreme parafunctional forces cause rapid wear of the prosthetic materials. While the osseointegrated implants can withstand the forces, the prosthetic teeth cannot and must be frequently replaced to restore function and aesthetics. **Takeaway:** In patients with severe bruxism, the implant fixtures can remain stable long-term, but the prosthetic teeth will require frequent annual replacement due to excessive wear. ## Case: 33-year follow-up of an immediately loaded four-implant mandible ### Question **Scenario:** A patient from an early 1990s study who received four mandibular implants that were immediately loaded. **What's shown:** Images of the patient's four-implant immediate-load restoration, evaluated 33 years later. **Consider:** What does this long-term follow-up demonstrate about the immediate loading protocol in the mandible? ### Answer **Observations:** - The four implants placed and immediately loaded in the early 1990s are still functioning very well after 33 years. **Reasoning:** At the time, immediate loading was considered highly controversial. However, because the anterior mandible typically consists of dense cortical bone (Type 1 or 2), it provides excellent primary stability, allowing for successful immediate loading and long-term osseointegration. **Takeaway:** Immediate loading of four implants in the dense bone of the anterior mandible is a highly predictable and successful long-term treatment modality. ## Case: Long-term outcome and radiographic findings of a five-implant mandibular restoration ### Question **Scenario:** A patient with a mandibular implant restoration supported by five implants, which has been in function for 40 years. **What's shown:** Images/radiographs of the five-implant mandible, with a specific focus on the middle implant. **Consider:** What does this long-term follow-up reveal about the biomechanical load distribution and bone levels around the middle implant? ### Answer **Observations:** - The five-implant restoration has been in function for 40 years. - The middle implant exhibits more bone loss compared to the adjacent implants. **Reasoning:** When five implants are placed close together, the middle implant may not receive adequate functional load. According to Wolff's law, a lack of mechanical stress on the bone leads to disuse atrophy and subsequent bone resorption. Additionally, placing implants too close together makes the area more difficult to clean. **Takeaway:** Placing implants too close together can result in disuse atrophy and bone loss around the unloaded middle implant; therefore, four well-distributed implants are often biomechanically preferable to five closely spaced ones. ## Case: Long-term outcome of a 43-year-old mandibular implant bridge ### Question **Scenario:** A 92-year-old patient who received a lower implant bridge in 1985. **What's shown:** Radiographs/images of the patient's 43-year-old implant reconstruction. **Consider:** What can be observed regarding the long-term survival and maintenance of this early implant rehabilitation? ### Answer **Observations:** - The implants have been in place and functioning for 43 years. - The prosthetic reconstruction has been changed or retreaded a couple of times over the decades. **Reasoning:** The case demonstrates that while the implant fixtures themselves can survive for over four decades, the prosthetic components may require periodic replacement or maintenance due to wear and material degradation over time. **Takeaway:** Well-maintained implant fixtures can achieve exceptional long-term survival (over 40 years), though the suprastructure may require periodic replacement. ## Case: Prosthetic maintenance in a severe bruxer with a two-jaw implant case ### Question **Scenario:** A patient described as a "world champion bruxer" who received a two-jaw implant case 43 years ago. **What's shown:** Images of the patient's two-jaw implant rehabilitation. **Consider:** How does extreme parafunction affect the long-term maintenance of the implant prosthesis? ### Answer **Observations:** - The patient requires the prosthetic teeth to be changed approximately once a year. - The underlying implants have survived for 43 years despite the severe bruxing. **Reasoning:** Extreme parafunctional forces cause rapid wear of the prosthetic materials. While the osseointegrated implants can withstand the forces, the prosthetic teeth cannot and must be frequently replaced to restore function and aesthetics. **Takeaway:** In patients with severe bruxism, the implant fixtures can remain stable long-term, but the prosthetic teeth will require frequent annual replacement due to excessive wear. ## Case: 33-year follow-up of an immediately loaded four-implant mandible ### Question **Scenario:** A patient from an early 1990s study who received four mandibular implants that were immediately loaded. **What's shown:** Images of the patient's four-implant immediate-load restoration, evaluated 33 years later. **Consider:** What does this long-term follow-up demonstrate about the immediate loading protocol in the mandible? ### Answer **Observations:** - The four implants placed and immediately loaded in the early 1990s are still functioning very well after 33 years. **Reasoning:** At the time, immediate loading was considered highly controversial. However, because the anterior mandible typically consists of dense cortical bone (Type 1 or 2), it provides excellent primary stability, allowing for successful immediate loading and long-term osseointegration. **Takeaway:** Immediate loading of four implants in the dense bone of the anterior mandible is a highly predictable and successful long-term treatment modality. ## Case: Long-term outcome and radiographic findings of a five-implant mandibular restoration ### Question **Scenario:** A patient with a mandibular implant restoration supported by five implants, which has been in function for 40 years. **What's shown:** Images/radiographs of the five-implant mandible, with a specific focus on the middle implant. **Consider:** What does this long-term follow-up reveal about the biomechanical load distribution and bone levels around the middle implant? ### Answer **Observations:** - The five-implant restoration has been in function for 40 years. - The middle implant exhibits more bone loss compared to the adjacent implants. **Reasoning:** When five implants are placed close together, the middle implant may not receive adequate functional load. According to Wolff's law, a lack of mechanical stress on the bone leads to disuse atrophy and subsequent bone resorption. Additionally, placing implants too close together makes the area more difficult to clean. **Takeaway:** Placing implants too close together can result in disuse atrophy and bone loss around the unloaded middle implant; therefore, four well-distributed implants are often biomechanically preferable to five closely spaced ones. Case: Long-term outcome of a 43-year-old mandibular implant bridge ## Case: Bone apposition in a severely resorbed mandible following implant placement ### Question **Scenario:** A patient with 8 mm of bone interforaminally, which reduces to about 5 mm in the mental foramen region. **What's shown:** Images/radiographs of the patient's mandible showing the bone levels before and after implant placement. **Consider:** What happens to the distal bone in the thinner regions following the placement of implants? ### Answer **Observations:** - There is bone apposition in the distal regions (the thinner 5 mm areas) following implant placement. **Reasoning:** Placing implants stimulates the surrounding and distal bone. This functional stimulation promotes bone apposition, effectively strengthening the jaw in areas that were previously at risk of fracture due to severe resorption. **Takeaway:** Implant placement can stimulate bone apposition in severely resorbed distal mandibular regions, thereby strengthening the jaw and reducing the risk of fracture. ## Case: Pain management in a long-span bridge with mandibular flexure ### Question **Scenario:** A patient who received a fixed bridge from a lower seven to a four. The patient has a thin mandible and high parafunction. **What's shown:** Clinical scenario of a patient experiencing significant pain with the prosthesis. **Consider:** What was the cause of the patient's pain, and how was it resolved? ### Answer **Observations:** - The patient experienced significant pain due to the rigid bridge spanning across a thin mandible subjected to high parafunctional forces. - The pain was resolved by cutting the connectors of the bridge. **Reasoning:** Mandibular deformation during opening and closing places stress on rigid, long-span prostheses. In a thin mandible with parafunction, this stress causes pain. Sectioning the bridge (creating a stress breaker) relieves the mechanical stress on the bone and prosthesis. **Takeaway:** Long-span rigid bridges in thin mandibles with parafunction can cause pain due to mandibular flexure; incorporating stress breakers or sectioning the prosthesis can resolve the issue. ## Case: Bone apposition in a severely resorbed mandible following implant placement ### Question **Scenario:** A patient with 8 mm of bone interforaminally, which reduces to about 5 mm in the mental foramen region. **What's shown:** Images/radiographs of the patient's mandible showing the bone levels before and after implant placement. **Consider:** What happens to the distal bone in the thinner regions following the placement of implants? ### Answer **Observations:** - There is bone apposition in the distal regions (the thinner 5 mm areas) following implant placement. **Reasoning:** Placing implants stimulates the surrounding and distal bone. This functional stimulation promotes bone apposition, effectively strengthening the jaw in areas that were previously at risk of fracture due to severe resorption. **Takeaway:** Implant placement can stimulate bone apposition in severely resorbed distal mandibular regions, thereby strengthening the jaw and reducing the risk of fracture. ## Case: Pain management in a long-span bridge with mandibular flexure ### Question **Scenario:** A patient who received a fixed bridge from a lower seven to a four. The patient has a thin mandible and high parafunction. **What's shown:** Clinical scenario of a patient experiencing significant pain with the prosthesis. **Consider:** What was the cause of the patient's pain, and how was it resolved? ### Answer **Observations:** - The patient experienced significant pain due to the rigid bridge spanning across a thin mandible subjected to high parafunctional forces. - The pain was resolved by cutting the connectors of the bridge. **Reasoning:** Mandibular deformation during opening and closing places stress on rigid, long-span prostheses. In a thin mandible with parafunction, this stress causes pain. Sectioning the bridge (creating a stress breaker) relieves the mechanical stress on the bone and prosthesis. **Takeaway:** Long-span rigid bridges in thin mandibles with parafunction can cause pain due to mandibular flexure; incorporating stress breakers or sectioning the prosthesis can resolve the issue. Case: Bone apposition in a severely resorbed mandible following implant placement [^1]: Original PDF page 1: [[L1 Mx of terminal dentition Mn Fixed notes.pdf#page=1|L1 Mx of terminal dentition Mn Fixed notes, p.1]] [^2]: Original PDF page 2: [[L1 Mx of terminal dentition Mn Fixed notes.pdf#page=2|L1 Mx of terminal dentition Mn Fixed notes, p.2]] [^3]: Original PDF page 3: [[L1 Mx of terminal dentition Mn Fixed notes.pdf#page=3|L1 Mx of terminal dentition Mn Fixed notes, p.3]] [^4]: Original PDF page 4: [[L1 Mx of terminal dentition Mn Fixed notes.pdf#page=4|L1 Mx of terminal dentition Mn Fixed notes, p.4]] [^5]: Original PDF page 5: [[L1 Mx of terminal dentition Mn Fixed notes.pdf#page=5|L1 Mx of terminal dentition Mn Fixed notes, p.5]] [^6]: Original PDF page 6: [[L1 Mx of terminal dentition Mn Fixed notes.pdf#page=6|L1 Mx of terminal dentition Mn Fixed notes, p.6]] [^7]: Original PDF page 7: [[L1 Mx of terminal dentition Mn Fixed notes.pdf#page=7|L1 Mx of terminal dentition Mn Fixed 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