This document discusses treatment planning and prosthetic options in implant dentistry. It outlines 5 prosthetic options ranging from fixed to removable restorations: 1. Fixed prostheses (FP) that can replace single teeth (FP-1) or multiple teeth along with some soft tissue (FP-2, FP-3). 2. Removable prostheses that are completely implant supported (RP-4) or combine implant and soft tissue support (RP-5). The goals of treatment planning are to evaluate the patient's anatomy and desires to determine the most cost-effective option that meets their needs. Implant placement and number are then determined based on the chosen prosthetic design.

1. 1

2. Introduction.
Treatment options.
Treatment planning for implant supported
prosthesis.
Completely edentulous prosthesis design.
2

3. Advantages of removable implant
supported prosthesis in completely
edentulous patient.
Partially edentulous design.
Advantages of implant supported FPD.
Guidelines for joining tooth with implant.
Prosthetic options.
Summary.
3

4. 4

5. Implant dentistry is similar to all aspects of
medicine in that treatment begins with a
diagnosis of the patient’s condition.
 Implant dentistry provide a wide range of
treatment to most partially and completely
edentulous patients.
Not all patients should be treated with
same restorative type or design.
5

6. Goals of implant dentistry-
replace patients missing teeth to normal
contour, comfort,function,esthetics,speech
and health.
6

7. 7

8. Removable partial dentures.
Fixed partial dentures.
Complete dentures.
8

9. 9

10. Designing the prosthesis [to satisfy
patients needs and desire].
Individual areas of abutment support are
determined.
Bone in that area is evaluated for type of
implant
10

11. 11

12. Pts desires-fixed or removable.
To assess ideal final prosthetic design-
existing anatomy evaluated.
An axiom of implant treatment is to provide,
most cost effective treatment that will
satisfy pts anatomical needs and personal
desires.
12

13. Some completely edentulous patients require
a fixed restoration because of desire or
because their oral condition makes the
fabrication of teeth difficult if a superstructure
and removable prosthesis are planned.
 For example, when the patient has abundant
bone and implants have already been placed,
the lack of crown height space may not permit
a removable prosthesis.
13

14. Too often, treatment plans for completely
edentulous patients consist of :
Maxillary denture mandibular
overdenture with
2
implants
14

15. In the long term, this treatment option may
prove a disservice to the patient.
The maxillary arch will continue to lose bone,
and the bone loss may even be accelerated in
the premaxilla. When this dimension is lost, the
patient will have much more difficulty with
retention and stability of the restoration.
 Posterior bone loss will continue due to the lack
of posterior implant support in mandible.
 Paresthesia, facial changes, and reduced
posterior occlusion on the maxillary prosthesis
are to be expected. 15

16. Fixed prostheses often last longer than
overdentures, because attachments do not
require replacement and acrylic denture teeth
wear faster than porcelain to metal.
No food entrapment for fixed prosthesis.
16

17. 17

18. Facial esthetics can be enhanced with labial
flanges and denture teeth compared with
customized metal or porcelain teeth. The labial
contours of the removable restoration can
replace lost bone width and height and support
the labial soft tissues without hygienic
compromise.
The prosthesis can be removed at night to
manage nocturnal parafunction.
Fewer implants may be required.
18

19. Shorter treatment if no bone augmentation
is required.
The treatment may be less expensive for
the patient.
Long-term treatment of complications is
facilitated.
Daily home care is easier.
19

20. 20

21. Common axiom in traditional prosthodontics
for partial edentulism is FPD.
Ideally, the FPD is completely implant
supported rather than joining implants to
teeth.
This concept leads to the use of more
implants in the treatment plan.
 The added implants in the edentulous site
result in fewer pontics, more retentive units in
the restoration and less stress to the 21

22. Psychological (feels more like natural teeth)
 Less food entrapment
Less maintenance (no attachments to
change or adjust)
 Longevity (lasts the life of the implants)
Similar overhead cost as completely
implant-supported overdentures
22

23. 23

24. When Compared conventional tooth
supported FPD Implant supported FPD
has –
• No caries.
• No endodontic problems.
• No retention failure.
• No periodontal breakdown.
• Easier to clean.
24

25. 25

26. No clinically observed mobility of the
natural tooth.
Use of rigid connectors.
Less lateral forces to the prosthesis
[occlusion].
Rarely connect to anterior tooth.
26
Contemporary implant dentistry, page
261

27. 27

28. 28

29. 29

30. In 1989, Misch proposed five prosthetic
options for implant dentistry.
 first 3 are fixed prostheses (FPs).
- may replace partial (one tooth or several) or total
dentitions .
- depend on the amount of hard and soft tissue structures
replaced and the aspects of the prosthesis in the esthetic
zone.
 Last 2 are removable prostheses (RPs).
- depend on the amount of implant support, not the
appearance of the prosthesis.
30

31. Fixed prosthesis
Replaces only the crown; looks like a
natural tooth.
To fabricate this restoration type, there must
be minimal loss of hard and soft tissues.
31

32. The volume and position of the residual bone
must permit ideal placement of the implant in a
location similar to the root of a natural tooth.
The final restoration appears very similar in
size and contour to most traditional fixed
prostheses used to restore or replace natural
crowns of teeth
32
Figure 1. A, An implant is positioned
in the maxillary right canine position.
The hard and soft tissue conditions
are ideal for a crown of normal
contour and size.

33. B, The maxillary right canine implant crown in
position. The soft tissue drape is similar to a
natural tooth, and the crown contour is similar
to the clinical crown contour of a natural tooth.
This is the goal of an FP-1 prosthesis.
33

34. The FP-1 prosthesis is most often desired in
the maxillary anterior region, especially in
the esthetic zone during smiling or speaking.
The final FP-1 restoration appears to the
patient to be similar to a crown on a natural
tooth. Because the width or height of the
crestal bone is frequently lacking after the
loss of multiple adjacent natural teeth.
##### bone augmentation is
often required before implant placement to
achieve natural-looking crowns in the
cervical region. 34

35. Figure 2. The bone and soft tissue must be
ideal in volume and position to obtain an FP-
1 appearance for the final restoration. When
multiple teeth are replaced, bone and tissue
augmentation is usually required to obtain an
FP-1 prosthesis.
35

36. FP-1 prostheses difficult to achieve when
more than two adjacent teeth are missing.
Bone loss and lack of interdental soft tissue
complicate the final esthetic result, especially
in the cervical region of the crowns.
The restorative material of choice for an FP-1
prosthesis is porcelain to noble-metal alloy.
A single tooth FP-1 crown may use aluminum
oxide cores and porcelain crowns, or ceramic
abutments and porcelain crowns. 36

37. FP-2 fixed prosthesis appears to restore the
anatomical crown and a portion of the root of
the natural tooth.
volume and topography of the available bone
is more apical compared with the ideal bone
position of a natural root (1 to 2 mm below the
cement-enamel junction)
#### So implant to be placed
is more apical as compared
with FP-1 prosthesis. 37

38. As a result, the incisal edge is in the correct
position, but the gingival third of the crown is
overextended, usually apical and lingual to
the position of the original tooth.
These restorations are similar to teeth
exhibiting periodontal bone loss and gingival
recession
38
Figure 3. A, An FP-2 prosthesis
has longer clinical crowns than
healthy natural teeth. The soft
tissue drape is also reduced
around the prosthesis.

39. B, The high maxillary lip line during smiling is
noted before fabrication of the prosthesis.
When the upper lip during smile does not
expose any of the interdental papillary regions,
an FP-2 prosthesis may be fabricated.
If the high lip line during smiling or the low lip
line during speech does not display the cervical
regions, the longer teeth are usually of no
esthetic consequence, provided that the patient
has been informed before treatment(see Figure
3,B).
39

40. The material of choice for an FP-2 prosthesis
is precious metal to porcelain.
The amount and contour of the metal work is
different than for a FP-1 restoration and is
more relevant in an FP-2 prosthesis,
because the amount of additional volume of
tooth replacement increases the risk of
unsupported porcelain in the final prosthesis,
when the metal work is undercontoured.
40

41. The FP-3 fixed restoration appears to
replace the natural teeth crowns and has
pink-colored restorative materials to
replace a portion of the soft tissue.
 As with the FP- 2 prosthesis, the original
available bone height has decreased by
natural resorption or osteoplasty at the
time of implant placement.
41

42. To place the incisal edge of the teeth in
proper position for esthetics, function, lip
support, and speech, the excessive vertical
dimension to be restored requires teeth that
are unnatural in length.
the patient may have a normal to high
maxillary lip line during smiling or a low
mandibular lip line during speech.
The ideal high smile line displays the
interdental papilla of the maxillary anterior
teeth but not the soft tissue above the 42

43. Complain----- display of longer teeth
Gingival color of FP-3---- esthetic
### gingival tone acrylic or
porcelain for more natural
fixed prosthesis appearance is often
indicated with multiple implant abutments
because bone loss is common with these
conditions.
43

44. Figure 4. A, An intraoral view of this FP-3
restoration shows how it replaces the
interdental papillae with pink porcelain
B, The high lip line during smiling shows
the interdental papillary regions in the
anterior maxilla. The fixed prosthesis
should replace the gingival regions in the
esthetic zone by soft tissue surgery or with
the final restoration (FP-3).
44

45. There are basically two approaches for an
FP-3 prosthesis:
(1) A hybrid restoration of denture teeth and
acrylic and metal substructure or
(2) A porcelain metal restoration
45

46. Figure 5. An FP-3
prosthesis with pink
porcelain on a porcelain to-
metal restoration.
46

47. The primary factor that determines the
restoration material is the amount of crown
height space.
An excessive crown height space means a
traditional porcelain-metal restoration will have
a large amount of metal in the substructure, so
the porcelain thickness will not be greater than
2-mm thick. Otherwise there is an increase in
porcelain fracture.
Precious metals are indicated for implant
restorations to decrease the risk of corrosion
and improve the accuracy of the casting, as 47

48. An alternative to the traditional porcelain-
metal fixed prosthesis is a hybrid
restoration. This restoration design uses a
smaller metal framework, with denture teeth
and acrylic to join these elements together.
This restoration is less expensive to
fabricate and is highly esthetic because of
the premade denture teeth and acrylic pink
soft tissue replacements.
 In addition, the intermediary acrylic
between the denture teeth and framework
may reduce the impact force of dynamic 48

49. Figure 6 A, An FP-3
porcelain-to-metal restoration
in the maxilla and a FP-3
hybrid acrylic-metal denture
tooth in the mandible
A panoramic radiograph of the
same prostheses. Note the
difference in the metal
substructures.
49

50. An FP-2 or FP-3 prosthesis rarely has the
patient’s interdental papillae or ideal soft
tissue contours around the emergence of
the crowns,
because these restorations are used when
there is more crown height space and the lip
does not expose the soft tissue regions of
the patient
50

51. • Retrievability.
• No cement in the
sulcus.
• Low profile retention.
• Possible with limited
inter-arch space .
51
 Cement retained
◦ Passive castings.
◦ Enhanced esthetics.
◦ Improved direction of
loading.
◦ Reduced crestal bone
loss.
◦ Reduced
complications,cost, time.
 Screw retained

52. RP-4 is a removable prosthesis completely
supported by the implants, teeth, or both.
The restoration is rigid when inserted:
overdenture attachments usually connect the
removable prosthesis to a low-profile tissue
bar or superstructure that splints the implant
abutments.
Usually five or six implants in the mandible
and six to eight implants in the maxilla are
52

53. Figure 7A, An RP-4 restoration is a removable
prosthesis (usually an overdenture) that is
completely implant supported. In this patient,
the mandibular restoration has five implants
between the mental foramina and a cantilevered
bar to the posterior regions. The prosthesis is
rigid and therefore requires attention to implant
position and an implant number similar to an
FP-3 restoration.
B, A maxillary denture
opposing an RP-4
overdenture in the
mandible.
53

54. The implant placement criteria for an RP-4
prosthesis is different than that for a fixed
prosthesis.
Denture teeth more acrylic are required for the
removable restoration. In addition, a
superstructure and overdenture attachments
must be added to the implant abutments.
 This requires a more lingual and apical
implant placement in comparison with the
implant position for a fixed prosthesis.
54

55. The overdenture attachments permit
improved oral hygiene or allow the patient to
sleep without the excess forces of nocturnal
bruxism on the prosthesis.
55

56. RP-5 is a removable prosthesis combining
implant and soft tissue support. The amount of
implant support is variable. The completely
edentulous mandibular overdenture may have:
(1) Two anterior implants independent of each
other;
(2) Splinted implants in the canine region to
enhance retention;
56

57. (3) Three splinted implants in the premolar
and central incisor areas to provide lateral
stability; or
(4) Implants splinted with a cantilevered
bar to reduce soft tissue abrasions and to
limit the amount of soft tissue coverage
needed for prosthesis support.
57

58. The primary advantage of an RP-5
restoration is the reduced cost. The
prosthesis is very similar to traditional
overdentures supported by natural teeth
58
Figure. Intraoral view of three mandibular implants inserted
between the foramina. A bar connects the implants and can support
an RP-5 mandibular overdenture

59. A pre-implant treatment denture may be
fabricated to ensure the patient’s satisfaction.
This technique is especially indicated for
patients with demanding needs and desires
regarding the final esthetic result.
The implant dentist can also use the
treatment denture as a guide for implant
placement. The patient can wear the
prosthesis during the healing stage.
59

60. Relines and occlusal adjustments every few
years are common maintenance
requirements of an RP-5 restoration.
Bone resorption with RP-5 restorations may
occur two to three times faster than the
resorption found with full dentures.
This can be a factor when considering this
type of treatment in young patients, despite
the lesser cost and low failure rate.
60

61. 61

62. 62

63. 63

64.  To assess ideal final prosthetic design-existing
anatomy evaluated.
 An axiom of implant Rx is to provide ,most cost
effective Rx that will satisfy pts anatomical needs
and personal desires.
 5-prosthetic options available.
 Amt of support required initially designed.
 Once prosthesis designed-implant Rx established.
64

65. 65

66. Misch CE. Contemporary Implant Dentistry –
3rd Edition,Mosby, South Asia edition,2008.
Jacobs R, Schotte A, van Steenberghe D et al.
Posterior jaw bone resorption in
osseointegrated implant overdentures. Clin
Oral Implants Res 1992;2:63-70.
Misch CE. Bone classification, training keys.
Dent Today 1989;8:39-44.
Misch CE. Prosthetic options in implant
dentistry. Int J Oral Implantol 1991;7:17-21.
Greenstein, et al. Connecting Teeth to
Implants: A Critical Review of the Literature
and Presentation of Practical Guidelines. 66

67. 67