1. Prosthetic Options in Implant Dentistry
Rola Shadid, BDS, MSc, AFAAID

2. Seminar Outline Description of implant prosthesis designs
Selection criteria

3. Ideal goal of implant dentistry to
replace patient’s missing teeth to normal contour, comfort, function, esthetics, speech and health, regardless of previous atrophy, disease or injury of the stomatognathic system
Final restoration – not implants

4. The end result should be clearly identified before the project begins

5. Ideal Treatment Plan Sequence
The prothesis first is planned
The key implant positions and implant number are selected
The patient force factors
The bone density
Implant size
Implant design
Available bone in the edentulous site

6. Biologically-driven implant placement
Prosthetically-driven implant placement

7. Completely edentulous prosthesis design
Partially edentulous prosthesis design

9. Advantages of Fixed IMPLANT Restorations
2. Removable implant overdentures require greater maintenance and exhibit more complications than fixed restorations
Problem of IODs in review of litrature by Goodacare:
Retention and adjestement problem(30%)
Clip or attachment fracture(17%)
Fracture of prosthesis (12%)
Reline(19%)
1. Feeling and acting simillar to natural teeth
3. Mandibular overdenture often traps food below its flanges
4.Important role for the presence of complete implant supported restoration is the maintenance and regeneration of posterior bone in mandible

10. Prosthesis Designs

11. ln 1989, Misch proposed five prosthetic options for implant dentistry:

13. FP-1 Replace only the anatomical crowns
Minimal loss of hard and soft tissues
The bone and soft tissue must be ideal in volume and position to obtain an FP-1 for the final restoration
Very similar in size and contour to most traditional fixed prostheses
Most often desired in the maxillary anterior region

14. FP-1

15. FP-1 is difficult to achieve when more than two adjacent teeth are missing
36% of patients presented bone deficiencies that hindered prosthetically ideal placement of Implants Bone & soft tissue augmentation is often required Andersson et al. 1995

16. FP-1 Material
Porcelain to noble-metal alloy
Zirconia-based restoraion

17. FP-2 Restore the anatomical crown & a portion of the root
The volume and topography of the available bone is more apical
Incisal edge in correct position, but gingival third of crown is overextended.
3. Are similar to teeth exhibiting periodontal bone loss and gingival recession

19. The patient and the clinician should be aware from the onset of treatment that the final prosthetic teeth will appear longer than healthy natural teeth without bone loss

20. Esthetic zone vs FP-2 The smile/lip line should be evaluated
The selection of FP2 or FP3 is often based on the evaluation of the lip line.
An FP2 (in low lip line patients) is easier to fabricate because of fewer porcelain bake cycles.

21. Smile Line Classification
High: display all of the interdental papilla and more than 2 mm of tissue above the cervices of the teeth. Prevalence is 11%
Average: 75% to 100% cervicoincisal length of maxillary anterior teeth and interdental papilla exposed. (69%)
Low < 75% cervicoincisal length of maxillary anterior teeth exposed. (20%)

22. Smile Line Classification
High
Average
Low

23. FP-2
If lip line during smiling does not display cervical regions, longer teeth are usually of no esthetic consequences, provided pt is informed

24. FP-2 Material Porcelain to noble-metal alloy
Easily be separated and soldered in case of a nonpassive fit at the metal try-in
Noble metals in contact with implants corrode less than nonprecious alloys
Zirconia based restoraion

25. FP-3
Replace the natural teeth crowns and has pink-colored restorative materials to replace a portion of the soft tissue

27. FP-3
Normal to high maxillary lip line during smiling, or pt with high esthetic demands

28. Materials for Full Arch FP-3
Porcelain-metal with pink porcelain
Hybrid restoration of denture teeth and acrylic and metal substructure
Zirconia based restoration
The primary factor that determines the restoration material is the amount of crown height space
<15mm ≥15mm
PORCElAIN–METAL HYBRID

29. CHS

30. Excessive CH & traditional porcelain-metal restoration ???
Porcelain thickness should not be greater than 2-mm thick
More shrinkage
Base metals
porosities in the structure
large amount of metal
increases the risk of porcelain fracture
Noble metals
weight and cost

31. Fixed detachable hybrid prosthesis (fixed complete denture) ( CHS ≥15mm)
A smaller metal framework and the acrylic resin polymerized with the denture teeth on the framework.
Titanium bar with retention pins for the acrylic resin

32. Fixed detachable hybrid prosthesis
The denture teeth in these prostheses should not be acrylic or composite, owing to a high fracture rate. Instead, porcelain denture teeth are suggested.

33. Fixed detachable hybrid prosthesis
Smaller metal framework
Denture teeth and acrylic
Less expensive to fabricate
Highly esthetic
Acrylic pink soft tissue replacements
The impact force of dynamic occlusal loads is reduced
Lightweight
Easier to repair
15 to 20 mm

34. Fixed detachable hybrid prosthesis
The fatigue of acrylic is greater than the traditional prosthesis
REPAIR of the restoration is more commonly needed

35. CAD-CAM zirconia-based, screw-retained, cross-arch restorations
Zirconia framework veneered with porcelain
Full-contour (monolithic) Zirconia restorations

36. CAD-CAM zirconia-based, screw-retained, cross-arch restorations
lack of casting distortion due to the CAD/CAM process;
highly reduced chance of chipping compared to acrylic or porcelain
stronger and improved aesthetics of screw access hole areas.
monolithic zirconia bridge requires only 12 to 15 mm of prosthetic space, not 15mm-20mm

37. The success rate of implant supported screw-retained zirconia prostheses have been shown to be as high as 100% for a period of 5 years
Vizcaya, 2011; Oliva, 2012

38. High level of accuracy and rigidity of the framework was obtained by CAD-CAM method, and satisfactory esthetics was featured by layering the porcelain on the Zirconia framework.
Hong et al. 2014

39. Removable Prostheses

40. Removable Prostheses 1. RP-4 2. RP-5
Complete removable overdentures have often been reported with predictability
Two kinds of removable prostheses, based upon support of the restoration:
1. RP-4
2. RP-5

41. RP-4 Completely supported by the implants
The restoration is rigid when inserted
A low-profile tissue bar or superstructure that splints the implant abutments
5 or 6 implants in the mandible
6 to 8 implants in the maxilla

42. RP-5
Implant and soft tissue support

43. RP-5 The primary advantage of an RP-5 restoration is the reduced cost
Bone will continue to resorb in the soft tissue-borne regions
Bone resorption with RP-5 restorations may occur two to three times faster than the resorption found with full dentures
Relines and occlusal adjustments every few years

45. Selection Factors for Completely Edentulous
Patient’s desire
Financial capabilities
Number of implants placed
The amount of vertical resorption (Crown height space)
Labial support requirements. (The amount of Maxillary anterior/posterior resorption)

46. The amount of vertical resorption (Crown height space)
CHS <15mm (Fixed)
CHS ≥15mm (Fixed hybrid or Removable)
If CHS < 12 mm, overdenture is contraindicated without osteoplasty

47. CHS for Removable

48. CHS for Fixed

49. Maxillary Anterior/Posterior Resorption
If the anterior/posterior (A/P) resorption is 7 mm or less, fixed prostheses are probably indicated
If the A/P resorption is in the range of 8 to 10 mm, fixed or removable prostheses may be indicated
If the A/P resorption > 10 mm, removable or fixed prostheses with removable labial veneers
Carl Drago, 2011

50. Maxillary Anterior/Posterior Resorption

53. References
Prosthetic options in implant dentistry (chapter 5), Contemporary Implant Dentistry, 3rd Edition, Carl Misch
Drago C, Carpentieri J. Treatment of maxillary jaws with dental implants: guidelines for treatment. J Prosthodont Jul;20(5):