The Edentulous Maxilla: Fixed versus Removable Treatment Planning










589
25
The Edentulous Maxilla:
Fixed versus Removable
Treatment Planning
RANDOLPH R. RESNIK AND CARL E. MISCH
I
n all phases of implant dentistry the treatment planning of
the edentulous maxilla is the most complicated for the long-
term success of implants and the prosthesis. e maxillary
arch is predisposed to inherent anatomic disadvantages, which has
led to many studies verifying a much lower success rate in com-
parison with the mandible. Historically, most research studies on
edentulous arches were completed on the mandible because most
patients often described the instability of the mandibular denture
in comparison with the maxillary. In general, patients are more
likely to wear a maxillary denture in comparison with the man-
dibular edentulous prosthesis. Many patients often waited longer
periods before seeking treatment in the edentulous maxilla, which
resulted in extensive resorption.
e maxillary arch has a lower success rate mainly because in
the past the maxillary arch principles followed the same principles
that are used in the mandibular arch. e long-term prognosis for
implants in the maxilla has been shown to be less predictable in
comparison with the mandible. Because of the resorption pattern
of the maxilla (i.e., horizontal bone loss twice as much as vertical
resorption soon after extraction), anatomic structures such as the
nasal cavity and the maxillary sinus play an important role in treat-
ment planning. Because of the high prevalence of reduced quan-
tity and quality of bone, along with increased esthetic demand, the
maxillary arch requires more detailed approaches to treatment plan-
ning with respect to a xed or removable prosthesis (Fig. 25.1).
Treatment Planning Factors
When evaluating a patient for maxillary implants, one of the most
important diagnostic tools is the patient’s existing denture. From
the patient’s denture, the smile line, amount of lip support, size
and shape of the teeth, interocclusal space (crown height space),
and the relative retention of the prosthesis can be determined.
Smile Line
e smile line is an important variable when evaluating the amount of
teeth the patient should show with movement of the upper lip during
A B
Fig. . The maxilla varies greatly, from abundant bone with attached tissue (A) to a severely resorbed
maxilla with compromised hard and soft tissue (B).
Deceased

590
PART V Edentulous Site Treatment Planning
speech and smiling. Tjan etal.
1
reported that the average smile allows
approximately 75% to 100% of the maxillary incisors and interproxi-
mal gingiva to be visible. With an edentulous arch the clinician should
evaluate the amount of ridge showing when smiling without the den-
ture. If the residual ridge does show during smiling, the treatment
planning for an implant prosthesis may be very challenging (Fig. 25.2).
Lip Support
e lip and soft tissue support is derived from the maxillary ante-
rior teeth contours and also the position of the residual ridge. e
lip and soft tissue support should be evaluated with the existing
denture in place and not in place. is will give crucial information
on whether a xed or removable prosthesis would be more ideal. If
the existing denture greatly supports the lip, then a xed prosthesis
may not be the most ideal because it is often dicult to obtain lip
support from a xed maxillary prosthesis. e soft tissue support is
mainly from the buccal ange of the maxillary prosthesis as resorp-
tion in the maxilla proceeds in a cranially and medially direction.
In addition, a patient with a short upper lip will most likely
show the maxillary teeth on repose. erefore short upper lips are
far more challenging than long upper lips. With a long upper lip,
very little to none of the maxillary teeth will be visible (Fig. 25.3).
Ridge Position
Depending on the amount of bone resorption, the residual ridge
is usually signicantly lingual to the ideal position of the teeth
in the maxillary anterior and posterior. is discrepancy must be
taken into consideration when evaluating the ideal position of
the implants so that a prosthesis may be fabricated that fullls
adequate lip support, phonetics, and patient approval, and allows
for sucient tongue space. When the dierence between the ridge
and the tooth position (i.e., square arch form and tapered tooth
position) is present, signicant prosthetic diculties such as ante-
rior force factors (i.e. from the cantilevered discrepancy between
the ridge and tooth position) may predispose to complications.
Soft Tissue
e thickness and quality of the soft tissue should be evaluated
both clinically and via a cone beam computed tomography exami-
nation. As the maxillary ridge resorbs, the tissue thins and is less
dense with loss of keratinized tissue. In severely resorbed premaxil-
lary regions, the tissue will become hypermobile, which leads to
very little support for the prosthesis. Often maxillary edentulous
patients seek an esthetic xed prosthesis similar to natural teeth.
erefore it is imperative the patient understand the diculty in
achieving a papillary architecture similar to preextraction condi-
tion. Regenerating papilla, which would result in a FP-1 (xed
prosthesis with normal size clinical crown) prosthesis, is usually
dicult and in some cases impossible to achieve.
2
Crown Height Space (Interocclusal Space)
e amount of space between the residual ridge and the incisal
edge is an important factor in the treatment planning of a maxil-
lary prosthesis. For a xed versus a removable implant prosthesis,
there exist dierent dimensional tolerances to accommodate the
prosthesis. erefore a preoperative evaluation and determination
of the amount of crown height space needs to be completed before
any surgical placement of dental implants. In general this may
be accomplished with an articulated setup of maxillary and man-
dibular arches. However, a study cast will not relate an accurate
assessment of the thickness of the soft tissue. erefore newer soft-
ware programs that allow for the three-dimensional evaluation of
the teeth in maximum intercuspation can easily be accomplished
with a cone beam computed tomography survey.
Fig. . Smile Line. When patients exhibit a high smile line, caution
should be exercised in the treatment planning of the edentulous arch
because the final esthetics may be problematic.
AB
Fig. . Lip Support. (A) The lip support should be evaluated with the denture in and the denture out
to determine the future prosthetic demands (B).

591
CHAPTER 25 The Edentulous Maxilla: Fixed versus Removable Treatment Planning
Conventional screw-retained implant prostheses (i.e., zirconia
or porcelain-fused prostheses) can be fabricated with 8-10 mm
(zirconia) between the edentulous ridges and the opposing occlu-
sal plane. For a hybrid prosthesis, approximately 15 mm of inter-
occlusal room is required, as increased space is required to prevent
acrylic material fracture.
3
Sucient crown height space will allow
for adequate bulk of material and permits for more ideal esthetics
and hygiene ability. If space is compromised, an increase in pros-
thetic complications may occur.
4,5
For a removable prosthesis in the maxillary arch, compromised
space can be more problematic in comparison with the mandibular
arch. When inadequate space is available for a removable prosthe-
sis, fracture of the prosthesis or compromised esthetics may result.
A signicant variable is whether the implants would be independent
or bar retained. For an independent attachment implant-supported
overdenture (IOD), a minimum of 9 mm of space is required (i.e.,
Locator Attachment). If a bar-retained prosthesis is to be fabricated,
a minimum of 12 to 14 mm of space is needed, depending on the
attachment system.
6
To prevent fracture of the denture base or attach-
ments, 2 to 3 mm is needed to provide adequate strength as a denture
base material (Fig. 25.4) and prevent denture teeth dislodgement.
7
Literature Review
In general, studies have shown the maxillary overdenture and
maxillary xed prosthesis to be less predictable and associated with
a higher morbidity and failure rate in comparison with the man-
dibular arch prostheses. Jemt
8
evaluated maxillary xed prostheses
with 449 implants for a 5-year period and found a cumulative
implant and prosthesis survival rate to be 92.1% and 95.9% for
5 years, respectively. e mean marginal bone loss was approxi-
mately 1.2 mm at the 5-year evaluation. In this study, speech prob-
lems were the most common patient complaints, followed by resin
prosthesis fractures as the most common prosthetic complication.
Maxillary overdentures have been reported to have the highest fail-
ure rate in comparison with any other type of prosthesis. When evalu-
ating maxillary overdenture success, Hutton etal.
9
showed a nine-times
greater failure in the maxilla compared with the mandible. Numerous
studies have shown implant failure rates of 2% to 5% before loading,
and up to 30% after loading.
10-13
For late failure, maxillary overden-
ture studies have shown failure rates up to 5% to 15%.
14-17
Wilbom et al. evaluated maxillary xed versus overdenture
prostheses for a 5-year period. Interestingly, the survival rate was
77% in the overdenture group and 46% in the group originally
treatment planned for a xed prosthesis; however, it was then
changed to an overdenture. With this study a very high failure
rate was seen, especially with patients in whom the prosthesis was
changed from a xed to a removable prosthesis.
18
Maxillary dentures have also been associated with various
inherent disadvantages in comparison with a xed prosthesis.
Most of the issues stem from the increased palatal coverage that
a conventional denture or RP-5 overdenture in comparison to a
RP-4 overdenture. Shannon etal.
19
showed compromised parotid
ow when palatal coverage was present, thereby decreasing salivary
ow when wearing an RP-5 overdenture. Patients often report a
lack of taste sensation when wearing a maxillary overdenture with
palatal coverage. is has been shown with multiple studies.
20,21
In addition, longitudinal studies on implant-supported max-
illary overdentures have shown an increased frequency rate of
maxillary hyperplasia of up to 30%.
22
In retrospective follow-up
studies, hyperplasia was observed in more than 64% of the sub-
jects originally planned for a xed maxillary prosthesis but who
had an overdenture treatment because of implant failure.
23
Most
commonly, hyperplastic tissue is seen around the retaining bars.
Fixed Maxillary Treatment Plans
A review of the literature found many articles that indicate that
full maxillary xed implant–supported prostheses are fabricated
on an average of six standard-diameter implants with posterior
molar cantilevers. More recently, numerous articles have shown
the success of a xed prosthesis on four implants. However, the
edentulous maxilla has been shown to have the lowest implant sur-
vival for either xed or removable implant restorations, compared
with mandibular prostheses.
24-27
All reports concur with the nd-
ing that maxillary bone tends to be of poorer quality and volume,
and presents several biomechanical disadvantages. To compensate
for the poor local conditions, a greater number of implants should
be planned, along with a greater anteroposterior (A-P) distance.
erefore a number of core principles are used when treatment
planning an edentulous maxillary arch for a xed prosthesis; fol-
lowing these principles increases the success rate.
1. e number of implants is related to the dental arch form.
2. e arch form is dictated by the nal dentition or prosthesis,
not the edentulous ridge arch form.
3. Key implant positions exist: anterior, canine, premolar, and molar.
4. An RP-4 (totally implant supported removable prosthesis)
prosthesis is treatment planned the same as a xed prosthesis.
ree common dental arch forms for the maxilla exist: square,
ovoid, and tapering. As a consequence of bone resorption the
edentulous ridge arch form usually will dier from the dentate
arch form. e dental arch form of the patient is determined by
the nal teeth position in the premaxilla and not the arch shape of
the residual ridge. A residual ridge may appear square because of
resorption or trauma. However, the nal teeth position may need
to be cantilevered facially with the nal prosthesis. In other words,
a dental ovoid arch form may be needed to restore a residual eden-
tulous square arch form. e number and position of implants are
related to the arch form of the nal dentition (prosthesis), not the
existing edentulous arch form (Table 25.1).
Fig. . Maxillary Crown Height Space. Measured from the residual
ridge to the incisal edge, the minimum space requirement is 8 to 10 mm
for a fixed prosthesis, 9 mm for an independent attachment overdenture,
and 12-14 mm for a bar-retained prosthesis.

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58925The Edentulous Maxilla: Fixed versus Removable Treatment PlanningRANDOLPH R. RESNIK AND CARL E. MISCH†In all phases of implant dentistry the treatment planning of the edentulous maxilla is the most complicated for the long-term success of implants and the prosthesis. e maxillary arch is predisposed to inherent anatomic disadvantages, which has led to many studies verifying a much lower success rate in com-parison with the mandible. Historically, most research studies on edentulous arches were completed on the mandible because most patients often described the instability of the mandibular denture in comparison with the maxillary. In general, patients are more likely to wear a maxillary denture in comparison with the man-dibular edentulous prosthesis. Many patients often waited longer periods before seeking treatment in the edentulous maxilla, which resulted in extensive resorption.e maxillary arch has a lower success rate mainly because in the past the maxillary arch principles followed the same principles that are used in the mandibular arch. e long-term prognosis for implants in the maxilla has been shown to be less predictable in comparison with the mandible. Because of the resorption pattern of the maxilla (i.e., horizontal bone loss twice as much as vertical resorption soon after extraction), anatomic structures such as the nasal cavity and the maxillary sinus play an important role in treat-ment planning. Because of the high prevalence of reduced quan-tity and quality of bone, along with increased esthetic demand, the maxillary arch requires more detailed approaches to treatment plan-ning with respect to a xed or removable prosthesis (Fig. 25.1).Treatment Planning FactorsWhen evaluating a patient for maxillary implants, one of the most important diagnostic tools is the patient’s existing denture. From the patient’s denture, the smile line, amount of lip support, size and shape of the teeth, interocclusal space (crown height space), and the relative retention of the prosthesis can be determined.Smile Linee smile line is an important variable when evaluating the amount of teeth the patient should show with movement of the upper lip during A B• Fig. . The maxilla varies greatly, from abundant bone with attached tissue (A) to a severely resorbed maxilla with compromised hard and soft tissue (B).† Deceased 590PART V Edentulous Site Treatment Planningspeech and smiling. Tjan etal.1 reported that the average smile allows approximately 75% to 100% of the maxillary incisors and interproxi-mal gingiva to be visible. With an edentulous arch the clinician should evaluate the amount of ridge showing when smiling without the den-ture. If the residual ridge does show during smiling, the treatment planning for an implant prosthesis may be very challenging (Fig. 25.2). Lip Supporte lip and soft tissue support is derived from the maxillary ante-rior teeth contours and also the position of the residual ridge. e lip and soft tissue support should be evaluated with the existing denture in place and not in place. is will give crucial information on whether a xed or removable prosthesis would be more ideal. If the existing denture greatly supports the lip, then a xed prosthesis may not be the most ideal because it is often dicult to obtain lip support from a xed maxillary prosthesis. e soft tissue support is mainly from the buccal ange of the maxillary prosthesis as resorp-tion in the maxilla proceeds in a cranially and medially direction.In addition, a patient with a short upper lip will most likely show the maxillary teeth on repose. erefore short upper lips are far more challenging than long upper lips. With a long upper lip, very little to none of the maxillary teeth will be visible (Fig. 25.3). Ridge PositionDepending on the amount of bone resorption, the residual ridge is usually signicantly lingual to the ideal position of the teeth in the maxillary anterior and posterior. is discrepancy must be taken into consideration when evaluating the ideal position of the implants so that a prosthesis may be fabricated that fullls adequate lip support, phonetics, and patient approval, and allows for sucient tongue space. When the dierence between the ridge and the tooth position (i.e., square arch form and tapered tooth position) is present, signicant prosthetic diculties such as ante-rior force factors (i.e. from the cantilevered discrepancy between the ridge and tooth position) may predispose to complications. Soft Tissuee thickness and quality of the soft tissue should be evaluated both clinically and via a cone beam computed tomography exami-nation. As the maxillary ridge resorbs, the tissue thins and is less dense with loss of keratinized tissue. In severely resorbed premaxil-lary regions, the tissue will become hypermobile, which leads to very little support for the prosthesis. Often maxillary edentulous patients seek an esthetic xed prosthesis similar to natural teeth. erefore it is imperative the patient understand the diculty in achieving a papillary architecture similar to preextraction condi-tion. Regenerating papilla, which would result in a FP-1 (xed prosthesis with normal size clinical crown) prosthesis, is usually dicult and in some cases impossible to achieve.2 Crown Height Space (Interocclusal Space)e amount of space between the residual ridge and the incisal edge is an important factor in the treatment planning of a maxil-lary prosthesis. For a xed versus a removable implant prosthesis, there exist dierent dimensional tolerances to accommodate the prosthesis. erefore a preoperative evaluation and determination of the amount of crown height space needs to be completed before any surgical placement of dental implants. In general this may be accomplished with an articulated setup of maxillary and man-dibular arches. However, a study cast will not relate an accurate assessment of the thickness of the soft tissue. erefore newer soft-ware programs that allow for the three-dimensional evaluation of the teeth in maximum intercuspation can easily be accomplished with a cone beam computed tomography survey.• Fig. . Smile Line. When patients exhibit a high smile line, caution should be exercised in the treatment planning of the edentulous arch because the final esthetics may be problematic.AB• Fig. . Lip Support. (A) The lip support should be evaluated with the denture in and the denture out to determine the future prosthetic demands (B). 591CHAPTER 25 The Edentulous Maxilla: Fixed versus Removable Treatment PlanningConventional screw-retained implant prostheses (i.e., zirconia or porcelain-fused prostheses) can be fabricated with 8-10 mm (zirconia) between the edentulous ridges and the opposing occlu-sal plane. For a hybrid prosthesis, approximately 15 mm of inter-occlusal room is required, as increased space is required to prevent acrylic material fracture.3 Sucient crown height space will allow for adequate bulk of material and permits for more ideal esthetics and hygiene ability. If space is compromised, an increase in pros-thetic complications may occur.4,5For a removable prosthesis in the maxillary arch, compromised space can be more problematic in comparison with the mandibular arch. When inadequate space is available for a removable prosthe-sis, fracture of the prosthesis or compromised esthetics may result. A signicant variable is whether the implants would be independent or bar retained. For an independent attachment implant-supported overdenture (IOD), a minimum of 9 mm of space is required (i.e., Locator Attachment). If a bar-retained prosthesis is to be fabricated, a minimum of 12 to 14 mm of space is needed, depending on the attachment system.6 To prevent fracture of the denture base or attach-ments, 2 to 3 mm is needed to provide adequate strength as a denture base material (Fig. 25.4) and prevent denture teeth dislodgement.7 Literature ReviewIn general, studies have shown the maxillary overdenture and maxillary xed prosthesis to be less predictable and associated with a higher morbidity and failure rate in comparison with the man-dibular arch prostheses. Jemt8 evaluated maxillary xed prostheses with 449 implants for a 5-year period and found a cumulative implant and prosthesis survival rate to be 92.1% and 95.9% for 5 years, respectively. e mean marginal bone loss was approxi-mately 1.2 mm at the 5-year evaluation. In this study, speech prob-lems were the most common patient complaints, followed by resin prosthesis fractures as the most common prosthetic complication.Maxillary overdentures have been reported to have the highest fail-ure rate in comparison with any other type of prosthesis. When evalu-ating maxillary overdenture success, Hutton etal.9 showed a nine-times greater failure in the maxilla compared with the mandible. Numerous studies have shown implant failure rates of 2% to 5% before loading, and up to 30% after loading.10-13 For late failure, maxillary overden-ture studies have shown failure rates up to 5% to 15%.14-17Wilbom et al. evaluated maxillary xed versus overdenture prostheses for a 5-year period. Interestingly, the survival rate was 77% in the overdenture group and 46% in the group originally treatment planned for a xed prosthesis; however, it was then changed to an overdenture. With this study a very high failure rate was seen, especially with patients in whom the prosthesis was changed from a xed to a removable prosthesis.18Maxillary dentures have also been associated with various inherent disadvantages in comparison with a xed prosthesis. Most of the issues stem from the increased palatal coverage that a conventional denture or RP-5 overdenture in comparison to a RP-4 overdenture. Shannon etal.19 showed compromised parotid ow when palatal coverage was present, thereby decreasing salivary ow when wearing an RP-5 overdenture. Patients often report a lack of taste sensation when wearing a maxillary overdenture with palatal coverage. is has been shown with multiple studies.20,21In addition, longitudinal studies on implant-supported max-illary overdentures have shown an increased frequency rate of maxillary hyperplasia of up to 30%.22 In retrospective follow-up studies, hyperplasia was observed in more than 64% of the sub-jects originally planned for a xed maxillary prosthesis but who had an overdenture treatment because of implant failure.23 Most commonly, hyperplastic tissue is seen around the retaining bars. Fixed Maxillary Treatment PlansA review of the literature found many articles that indicate that full maxillary xed implant–supported prostheses are fabricated on an average of six standard-diameter implants with posterior molar cantilevers. More recently, numerous articles have shown the success of a xed prosthesis on four implants. However, the edentulous maxilla has been shown to have the lowest implant sur-vival for either xed or removable implant restorations, compared with mandibular prostheses.24-27 All reports concur with the nd-ing that maxillary bone tends to be of poorer quality and volume, and presents several biomechanical disadvantages. To compensate for the poor local conditions, a greater number of implants should be planned, along with a greater anteroposterior (A-P) distance. erefore a number of core principles are used when treatment planning an edentulous maxillary arch for a xed prosthesis; fol-lowing these principles increases the success rate. 1. e number of implants is related to the dental arch form. 2. e arch form is dictated by the nal dentition or prosthesis, not the edentulous ridge arch form. 3. Key implant positions exist: anterior, canine, premolar, and molar. 4. An RP-4 (totally implant supported removable prosthesis) prosthesis is treatment planned the same as a xed prosthesis.ree common dental arch forms for the maxilla exist: square, ovoid, and tapering. As a consequence of bone resorption the edentulous ridge arch form usually will dier from the dentate arch form. e dental arch form of the patient is determined by the nal teeth position in the premaxilla and not the arch shape of the residual ridge. A residual ridge may appear square because of resorption or trauma. However, the nal teeth position may need to be cantilevered facially with the nal prosthesis. In other words, a dental ovoid arch form may be needed to restore a residual eden-tulous square arch form. e number and position of implants are related to the arch form of the nal dentition (prosthesis), not the existing edentulous arch form (Table 25.1).• Fig. . Maxillary Crown Height Space. Measured from the residual ridge to the incisal edge, the minimum space requirement is 8 to 10 mm for a fixed prosthesis, 9 mm for an independent attachment overdenture, and 12-14 mm for a bar-retained prosthesis. 592PART V Edentulous Site Treatment Planninge dental arch form in the anterior maxilla is determined by the distance from two horizontal lines. e rst line is drawn from one canine (i.e., in a diagnostic wax-up or existing prosthesis if no teeth are present) incisal edge tip to the other. is line most often bisects the incisive papilla. e second line is drawn parallel to the rst line, along the facial position of the anterior teeth (Fig. 25.5). When the distance between these two lines is less than 8 mm, a square dental arch form is present. When the distance between these two lines is 8 to 12 mm, an ovoid dentate arch form is present—the most com-monly observed. When the distance between the two lines is greater than 12 mm, the dentate arch form is tapering.erefore with respect to dental arch form, the authors have postulated four dierent options for the maxillary xed prosthesis.Maxillary Fixed Prosthesis Treatment Option 1 (Box 25.1)In a dental square arch form, lateral and central incisors are mini-mally cantilevered facially from the canine position, resulting in a lesser requirement of an implant in the central or lateral position. When maxillary xed prosthesis treatment option 1 is used, man-dibular excursions and occlusal forces exert less stress on the canine implants. As a result, implants in the canine position to replace the six anterior teeth may suce when the force factors are low and if they are splinted to additional posterior implants (Figs. 25.6 and 25.7). Maxillary Fixed Prosthesis Treatment Option 2If the nal teeth position is an ovoid arch form, at least three implants should be inserted into the premaxilla: one in each canine and preferably one in a central incisor position (Fig. 25.8). e central incisor position increases the A-P distance from the canine to central and provides improved biomechani-cal support to the prosthesis. In long-term edentulous maxil-lae with signicant atrophy, treatment option 2 will most likely require bone augmentation before implant insertion (Box 25.2). When patient force factors are low to moderate, the anterior implant may be positioned in a lateral incisor site if the cen-tral site in nonideal. e three implant positions in the premax-illa will resist the additional forces created in this arch form, enhance prosthesis retention, and reduce the risk for abutment screw loosening.e suggested locations for this treatment option are at least one central (or lateral) incisor position, bilateral canine positions, Treatment Plan for Edentulous PremaxillaArch FormAnterior Cantilever (mm)Number of Anterior Implants Implant PositionSquare < 8 2 CaninesOvoid 8–12 3 Two canines and one incisorTaper-ing>12 4 Two canines and two incisors TABLE 25.1Cantilever• Fig. . Dental Arch Form Determination: Two horizontal lines are drawn. The first line bisects the incisal papilla and connects the tips of the canines. The second line is parallel and along the facial position of the central incisor. The distance between these lines determines whether the dentate arch form is square, ovoid, or tapering.Indications: Square arch formImplants: 6Positions (bilateral):CanineSecond bicuspidFirst molar • BOX 25.1 Maxillary Fixed Prosthesis (FP-1,2,or 3)Treatment Plan 1CantileverA-P• Fig. . Fixed Treatment Plan 1: When force factors are low, a square dentate arch form may use six implants for a fixed or RP-4 (totally implant supported removable prosthesis) prosthesis. A-P, Anteroposterior distance.• Fig. . Maxillary FP-3 (type 3 xed prosthesis) Prosthesis. This prosthesis follows a square dentate arch form, and therefore is supported by six implants (canines, second premolars, and first molars). Because of the square arch form a minimal cantilever results. 593CHAPTER 25 The Edentulous Maxilla: Fixed versus Removable Treatment Planningbilateral second premolar sites, and the bilateral distal half of the maxillary rst molar sites. e seven implants should be splinted together to function as an arch. ese implant positions create sucient space between each implant to allow for greater implant diameters (i.e., when required for force or bone density factors). Implants should ideally be at least 3 mm apart after placement. Maxillary Fixed Prosthesis Treatment Option 3e prosthesis treatment planned in a tapered dental arch form places the greatest forces on the anterior implants, especially dur-ing mandibular excursions when the residual bone is an ovoid or square ridge form. e anterior teeth create a signicant facial can-tilever from the canine position, and anterior biting forces often lead to a shear type of forces. As such, four implants should be considered to replace the six anterior teeth (Figs. 25.9 and 25.10).e bilateral canine and central incisor positions represent the best option. ese positions are preferred when other force factors are greater, such as crown height, parafunction, and masticatory muscular dynamics. e worst-case scenario is a patient who requires restoration of a dental tapered arch form with a square residual ridge form. Not only are four implants then ideally required to compen-sate for the cantilevered tooth position, but these implants should be connected to additional posterior implants, which can extend to the second molar sites. erefore in treatment plan 3, when force factors are moderate or the dental arch form is tapered, the minimum implant number should increase to eight implants (Box 25.3). When force factors are greater than usual or bone density is poorer, additional implants may be used in any of the arch forms. In the square and ovoid arch form, at least one additional implant is positioned in the premaxilla. For patients with higher force factors or poor bone density, two additional implants are planned in the distal half of the second molar position to improve the arch form. is will result in an increased A-P distance compared with the rst molar site, which will compensate for the increased force factors or poor bone density (Fig. 25.11). e implant number and position guidelines also may counter the eect of an incisal cantilever o the residual anterior bone for an esthetic tooth position and is indicated for patients with chronic parafunction (such as bruxism).e disadvantage of second-molar implants for an ideal treat-ment plan is the additional cost of the second molar implant, pos-sible bone grafting, and the prosthesis. In addition, many patients do not have an existing second molar in the mandibular arch. However, the reason for this implant position is for force transfer, not necessarily esthetics or functional purposes. CantileverA-P• Fig. . Fixed Treatment Plan 2: In an ovoid dentate arch form, three implants should be planned in the premaxilla: one in each canine position and one additional implant. In addition, at least four posterior implants should be splinted to form an arch. A-P, Anteroposterior distance.Indications: Ovoid arch formImplants: 7Positions (bilateral):Central incisor (unilateral)CanineSecond bicuspidFirst molar • BOX 25.2 Maxillary Fixed Prosthesis (FP-1,2,or 3)Treatment Plan 2A-PCantilever• Fig. . Fixed Treatment Plan 3: In a tapered arch form the anterior can-tilever is greater and should be supported by implants in the premaxilla. At least four posterior implants should be added to restore the completely edentulous arch. A-P, Anteroposterior distance.• Fig. . Tapered arch form treated with eight implants in the maxilla and splinted prosthesis.Indications: Tapered arch formImplants: 8Positions (bilateral):Central incisorCanineSecond bicuspidFirst molar • BOX 25.3 Maxillary Fixed Prosthesis (FP-1,2,or 3)Treatment Plan 3 594PART V Edentulous Site Treatment PlanningMaxillary Fixed Treatment Option 4: All-on-FourIn implant dentistry today a shift in treatment options has become popular to minimize treatment time, treatment costs, and decrease patient morbidity. e all-on-four treatment concept has been reported by Maló etal.28 in many reports in an attempt to address these objectives in implant dentistry today. In general the all-on-four technique includes placing four implants in the maxillary arch, with two axially placed implants in the anterior and two pos-terior implants positioned angulated at 30 to 45 degrees.28 Even though the placement of four implants is far less than what has been accepted for years (i.e., usually six to eight implants required for a xed prosthesis in the maxilla) in implant dentistry, high suc-cess rates of 93% to 98% have been shown29-32 (Box 25.4).Maló etal.28 state that the all-on-four technique in the maxilla uses a more favorable bone density in the anterior, along with lon-ger implants in the posterior that are angulated, which increases the A-P spread. Zampelis etal.33 concluded in a nite element analysis model that the tilted posterior implants have a biome-chanical advantage in comparison with cantilevering axial placed implants. e all-on-four technique is most commonly used for immediate load situations (see Chapter 33).In conclusion, the all-on-four technique has shown very promising results in the literature. However, careful patient selection, along with an experienced surgical and prosthetic clinician with an increased skill set, is essential for successful treatment results. Because of the pneumatization of the maxil-lary sinuses and the requirement of bone grafting in many cases, the all-on-four technique allows for the avoidance of the sinus anatomy by tilting the implants, which ultimately increases the A-P spread (Fig. 25.12). Removable Maxillary Treatment Planse primary advantage of a maxillary Implant Overdenture (IOD) compared with a xed prosthesis is the ability to provide a ange for maxillary lip support and the reduced fee compared with a xed restoration. As a consequence, before the selection of a spe-cic prosthesis type and to facilitate the diagnosis, the labial ange above the maxillary teeth of the existing denture (or wax try-in of a new prosthesis) may be removed and the facial appearance of the maxillary lip without labial support assessed.Maxillary IOD complications, such as attachment wear and prosthesis or component fracture, are more frequent than with a xed restoration and primarily occur as a result of inadequate bulk of acrylic and minimal strength of the framework, compared with a xed restoration (Table 25.2).Fewer reports have been published for maxillary IOD compared with the mandible. Most of these reports discuss RP-5 restorations with posterior soft tissue support and anterior implant retention. According to Goodacre et al.,34 the restoration with the highest implant failure rate is a maxillary overdenture (19% failure rate). In 1994 Palmqvist etal.35 reported similar poor results in a 5-year prospective, multicenter study on 30 maxillae and 103 mandibles. Jemt and Lekholm36 reported that the survival rate of mandibular implants was 94.5% versus 100% for mandibular prostheses. In the maxillae the implant survival rate was 72.4%, and the prosthesis survival rate was 77.9%. e authors suggested that the treatment outcome may be predicted by bone volume and quantity. A pro-spective study by Johns etal.11 reported on maxillary IODs at 1, 3, and 5 years.9,37 Sixteen patients were followed throughout the whole study with a cumulative success rate of 78% for prostheses and 72% for implants. A pooled implant survival rate of maxillary removable designs was reported at 76.6% at 5 years.11,37-39Alternatively, Misch followed 75 maxillary IODs (RP-4) and 615 implants for 10 years with 97% implant survival rate and 100% prosthesis survival rate.40 e primary dierences in these treatment modalities have been a completely implant-supported, retained, and stabilized maxillary IOD (RP-4); a greater implant number; and key implant positions following the guidelines of treatment planning based on basic biomechanical concepts to reduce failure and decrease risks.Maxillary Removable Implant Overdenture Treatment OptionsOnly two treatment options are available for maxillary IODs, whereas ve treatment options are available for the mandibular IOD. e dierence is due primarily to the biomechanical dis-advantages of the maxilla compared with the mandible. As such, the two treatment options are limited to an RP-5 with four to six implants with soft tissue support, or an RP-4 restoration with six to eight implants (which is completely supported, retained, and stabilized by implants). e crown height space is critical for maxillary overdentures, and more often a lack of space may com-promise tooth position compared with the mandibular situation. e maxillary anterior crown height space requirement is greater than the posterior dimension. A minimum of 14 mm of anterior crown height space and 12-14 mm of posterior space is required for IOD (i.e., bar-retained) because of the greater anterior teeth coronal dimensions and specic locations (Fig. 25.13).Primary siteSecondary site• Fig. . The ideal seven-implant positioning for a maxillary edentulous arch includes at least one central incisor position, bilateral canine positions, bilateral second premolar sites, and bilateral sites in the distal half of the first molars. In case of heavy stress factors, an additional anterior implant and bilateral second molar positions (to increase the anteroposterior distance) may be of benefit.Indications:Shorter treatment time requiredContraindication to bone graftingLow force factorsImplants: 4Positions (bilateral):AnteriorPosterior (angled at 30–45 degrees), anterior to sinus • BOX 25.4 Maxillary Fixed Prosthesis (FP-1,2,or 3)Treatment Plan 4 595CHAPTER 25 The Edentulous Maxilla: Fixed versus Removable Treatment PlanningOption 1: Removable Maxillary RP-4 Implant Overdenturee rst option for a maxillary IOD is an RP-4 prosthesis with six to eight implants, which is rigid during function (i.e., primary support is by implants, no soft tissue support) (Box 25.5). is option is the preferred IOD design because it maintains greater bone volume and provides improved retention and condence to the patient compared with a denture or RP-5 prosthesis. Because the palate is removed from this prosthesis (i.e., horseshoe-shaped), soft tissue support is lost, thereby requiring increased number of implants. e cost of treatment is similar to a xed prosthesis because of the increased number of implants required.Unfortunately, many clinicians believe that the RP-4 overdenture requires fewer implants and less attention to the biomechanics of occlusal load, just because the prosthesis is removable. In the author’s opinion, this is a primary reason for such a high implant failure rate in maxillary IODs. Combined factors such as reduced cost, patient fear of bone grafting, and lack of advanced training of the doctor are often the determining factors motivating the choice for a maxillary IOD.Treatment planning for RP-4 maxillary overdentures is simi-lar to a xed prosthesis, because the IOD is xed during func-tion. Two of the key implant positions for the RP-4 maxillary IOD are in the bilateral canines and distal half of the rst molar positions. ese implant positions usually require sinus aug-mentation in the molar position. Additional posterior implants are located bilaterally in the premolar position, preferably the second premolar site. In addition, at least one anterior implant between the canines often is required. Six implants is the mini-mum number for an RP-4 treatment option. When force factors are greater, the next most important sites are the second molar positions (bilaterally) to increase the A-P spread and improve the biomechanics of the system. e occlusal scheme for the RP-4 prosthesis is similar to a xed prosthesis: mutually protected occlusion (unless opposing a mandibular complete denture) (Fig. 25.14). Option 2: Removable Maxillary RP-5 Implant Overdenturee second treatment option for the maxillary arch is the RP-5 prosthesis (Box 25.6). A maxillary conventional complete den-ture usually has good retention, support, and stability. Although an RP-5 maxillary IOD is superior to a complete denture, many patients do not see much of a dierence. e major advantages of an RP-5 maxillary IOD are the maintenance of the anterior bone and it being a less expensive treatment option in com-parison with an RP-4 or xed prosthesis. e treatment is far less expensive because bilateral sinus grafts are not required and molar implants are not indicated. erefore this treatment plan is often used as a transition to an RP-4 or FP-3 prosthesis when nancial considerations of the patient require a staged treatment over several years.A B• Fig. . All-on-Four Protocol. (A and B) Two implants placed axially in the anterior and two implants placed posterior, which are angulated less than 45 degrees to avoid the maxillary sinus. Comparison of Maxillary ProsthesesFactorFixed Prosthesis (FP-1,2, or 3)Removable Prosthesis (RP-4)Removable Prosthesis (RP-5)Psycho-logical+++ ++ +Material Zirconia,Porcelain Fused MetalAcrylic HybridTitanium or Gold BarAcrylic Prosthesis Titanium / Gold Bar or Independent AttachmentsAcrylic ProsthesisLip Support + +++ +++Esthetics Zirconia or Porcelain ++Acrylic++Acrylic++Phonetics +++ ++ +Function +++ ++ +Long Term Success+++ ++ +Biting Force+++ ++ +Hygiene + ++ +++++, Best; ++, Better; +, Good. TABLE 25.2 596PART V Edentulous Site Treatment Planninge rst treatment option for a completely edentulous max-illa uses four to six implants supporting an RP-5 prosthesis, of which at least three are positioned in the premaxilla. Based on the poor success rates reported in the literature, specic biomechani-cal requirements, and poor bone quality, the fewest number of implants for an RP-5 maxillary overdenture should be four, with a wide A-P spread. e key implants are positioned in the bilateral canine regions and at least one central or lateral incisor position. In some cases, implant placement in the central incisor region may reduce the amount of available space for the prosthesis. Additional secondary implants may be placed in the rst or second premolar region. In such cases, because of the reduced A-P spread and the lateral incisor in the anterior-most implant site, the second pre-molar position also should be used on the contralateral side (along with the canine) to improve the A-P spread. Six implants are often indicated for an RP-5 prosthesis when force factors are greater.e maxillary RP-5 IOD is designed exactly as a complete denture with fully extended palate and anges. When Locators or O-rings attachments are used to retain the prosthesis, they may be positioned more distal than a Hader clip, often immediately distal to the canine position. e prosthesis should be allowed to move slightly in the incisal region during function so that the restoration may rotate toward the posterior soft tissue around a fulcrum located in the canine or premolar position. e benets of an RP-5 maxillary overdenture primary support from the soft tissue and secondary support from the implants. In addition, the benet of premaxillary bone maintenance is seen because prosthe-sis of the implant stimulation (Figs. 25.15 and 25.16). SummaryMaxillary IODs may be as predictable as mandibular overdentures when biomechanical considerations specic to the maxilla are incor-porated in the treatment plan. In general this requires implants in greater numbers and a greater awareness of prosthetic principles.Only two maxillary IOD treatment options are available. e few-est number of implants for this restoration is four to six implants to support an RP-5 prosthesis. A rigid IOD (RP-4) most often requires the placement of seven or more implants. In other words, maxillary IODs are completely dierent from their mandibular counterpart. In the completely edentulous maxilla, an IOD is often the treatment of choice. Unlike in the mandible, the maxillary lip often requires additional support as a consequence of bone loss. An ideal high lip line exposes the interdental papillae between the anterior teeth. Using overdentures to replace the hard and soft tissue is easier than attempt-ing to do this with bone and soft tissue or zirconia prostheses.A completely implant supported IOD (RP-4) requires the same number and position of implants as a xed restoration. us sinus grafts and anterior implants usually are indicated, regardless of whether the prosthesis is xed or removable. A common com-plication arises when four to six implants are placed, and an RP-4 palateless IOD is fabricated. Without the primary stress bearing area palatal support, the implants are often subjected to increased force factors, thus increasing complications and morbidity.AB• Fig. . Maxillary Overdentures. (A) RP-5: full palatal coverage for which the soft tissue provides primary support and the implants are for secondary support. (B) RP-4: horseshoe-shaped prosthesis that receives its primary support from the implants and no support from the soft tissue. Note the lack of palatal support (primary stress bearing area).Indications: • Patientswhocannottoleratefullpalatalcoverage• Gagreex• PatientswhorequireprosthesiswithnomovementProsthesis design: bar-supported horseshoe shape prosthesisAdvantages• Lesspalatalcoverage(horseshoeshape)• Increasedspeech,taste• Nosofttissuesupport,completelyimplantsupported• Hygieneeasierthanxed Disadvantages• Palateremoved:lackofacrylicbulk>fracture• Cost:moreimplants• Posteriorboneneeded:sinusgrafts Positions (Based on Dental Arch Form)•  Square:6implants:bilateralcanine,bicuspids,andrstmolar•  Ovoid:7implants:bilateralcanines,bicuspids,andrstmolars•  Tapering:8implants:bilateralcanines,bicuspids,rstmolars,andincisor • BOX 25.5 Removable Maxillary Prosthesis Treatment Plan 1 (RP-4) 597CHAPTER 25 The Edentulous Maxilla: Fixed versus Removable Treatment PlanningABC• Fig. . RP-4 Overdenture Treatment Options. (A) Square arch—six implants. (B) Ovoid—seven implants. (C) Tapered—eight implants. An RP-4 is treatment planned similar to a maxillary fixed prosthesis. 598PART V Edentulous Site Treatment PlanningIndications:• Shortertreatmenttimerequired• ContraindicationtobonegraftingProsthesis design: attachments only—complete palatal coverage (primary support from the soft tissue)Advantages• Increasedretentionandstabilityincomparisontoadenture• Maintainpremaxillabone• Reducedfee(∼RP-4) Disadvantages• Requiresfullpalate(∼soft tissue primary support)• Musthaveadequateboneinanteriorandbicuspidarea• Needadequatecrownheightspace Positions (Based on Dental Arch Form)•  Square: 4 implants: bilateral canine, bicuspids and/or incisor•  Ovoid: 5 implants: bilateral canine, bilateral bicuspid, and incisor•  Tapering: 6 implants: bilateral canines, incisors, and bicuspids • BOX 25.6 Removable Maxillary Prosthesis Treatment Plan 1 (RP-5)ABC• Fig. . RP-5 Treatment Options. (A) Four implants in canine and first premolar positions. (B) Five implants in canine, first premolars, and in the central/lateral incisor position. (C) Five implants in canines, one in premolar, and central/lateral incisors positions. Caution should be exercised to not remove palatal coverage from an RP-5 prosthesis. 599CHAPTER 25 The Edentulous Maxilla: Fixed versus Removable Treatment PlanningA B• Fig. . Central Incisor Implant Placement. (A) In tapered arch forms, placement of an implant in the central incisor region may impinge on the prosthesis. (B) Implant positioning that results in inadequate space for a prosthesis. Therefore, implants may be required to be positioned in the central-lateral or lateral position to allow for increased prosthetic room.References 1. Tjan AH, Miller GD, e JG. Some aesthetic factors in a smile. J Prosthet Dent. 1984;51:24–28. 2. Misch CE. Premaxilla Implant Considerations: Surgery and Fixed Prosthodontics. Contemporary Implant Dentistry. 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Immediate loading in the max-illa using apless surgery, implants placed in predetermined posi-tions, and prefabricated provisional restorations. A restrospective 3-year clinical study. Clin Implant Dent Relat Res. 2003;5:S29–S36. 31. Olsson M, Urde G, Andersen E, Sennerby L. Early loading of maxil-lary xed cross-arch dental prostheses supported by six or eight oxi-dized titanium implants: results after 1 year of loading, case series. Clin Implant Dent Relat Res. 2003;5:S81–S87. 32. Fischer K, Stenberg T. ree-year data from a randomized, controlled study of early loading of single-stage dental implants supporting maxillary full-arch prostheses. Int J Oral Maxillofac Implants. 2006;21:245–252. 33. Zampelis A, Rangert B, Heijl L. Tilting of splinted implants for improved prosthodontic support: a two-dimensional nite element analysis. J Prosthet Dent. 2007;97:S35–S43. 34. Goodacre CJ, Bernal G, Rungcharassaeng K, etal. Clinical com-plications with implants and implant prostheses. 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Else-vier. 2004. 601PART VIImplant Surgery26. Basic Surgical Techniques and Armamentarium, 60227. Implant Placement Surgical Protocol, 64428. Ideal Implant Positioning, 67029. Maxillary Anterior Implant Placement, 70630. Mandibular Anatomic Implications for Dental Implant Surgery, 73731. Dental Implant Complications, 77132. Immediate Implant Placement Surgical Protocol, 83033. Immediate Load/Restoration in Implant Dentistry, 860

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