Trt plan in implant/prosthodontic courses

Seminar on
TREATMENT PLANS FOR
PARTIALLY AND
COMPLETELY
EDENTULOUS ARCHES IN
IMPLANT DENTISTRY
INDIAN DENTAL ACADEMY
LEADER IN CONTINUING Education
www.indiandentalacademy.com

CLASSIFICATION OF PARTIALLY
EDENTULOUS ARCHES:
♦Classification of edentulous arches
allows the profession to visualize and
communicate the relationship of hard and
soft structures.
♦Though there are 65,000 possible
combination of teeth and edentulous
spaces in a single arch, there are only few
systems of classification which are
familiar and accepted by the professional
like Kennedy's, Cummer’s and Bailyn’s.

♦ Kennedy’s classification of partially
edentulous arches with Applegate's
modifications is universally accepted.
♦ Implantologists usually follow a
classification [for diagnosis and treatment
planning for partially or completely
edentulous patients requiring implant
prosthesis] by which the doctor is able to
convey the dimensions of the bone
available in the edentulous area and also
indicate the strategic position of the
segment to be restored.

♦ The implant dentistry bone volume
classification developed by Misch and Judy
builds on the four classes of partial
edentulism described in the Kennedy-
Applegate system.
♦ This facilitates communication among the
large segment of practitioners already
familiar with this classification and enables
the use of common treatment methods &
principles established for each class.

♦ The implant dentistry classification for
partially edentulous patients also includes
the same four available bone volume
divisions.
TREATMENT PLANNING
CLASS I:
♦ Bilateral distal posterior edentulism with
natural anterior teeth.
♦ Majority of this class have only missing
molars and almost all have retained six or
more anterior teeth.

♦ These anterior teeth once restored to proper
occlusal VD, contribute to the distribution
of forces throughout the mouth in centric
relation occlusion.
♦ These anterior teeth also permit excursions
during mandibular movement to disclude
the posterior implant supported prostheses
and protect them from lateral forces.

♦ On observation it is seen that most often
class I patients have Division C bone- with
either decreased width or height or length.
The cause for reduction of the various
dimensions is due to the fact that most often
Class I patients are treated with removable
partial dentures which when not properly
designed cause rapid resorption of the bone
in the edentulous areas as well as abutment
area.

Class I Division A
a. Edentulous areas have abundant bone
height(>10mm) & Length(>7mm) for
endosteal implant
b. Direction of load is within 30º of
implant body axis
c. Crown implant ratio is <1
d. Root form implants and independent
prostheses often are indicated

Division B
a. Edentulous areas have moderate
available bone width(2.5 to 5mm)
and atleast adequate bone
height(>10mm) & length(15mm).
b. Direction of load is within 20º of
implant body axis.
c. Crown implant ratio is <1
d. Surgical options include osteoplasty,
small-diameter implant and /or
augmentation.

Division C
a. Edentulous areas have inadequate
available bone for endosteal
implements with a predictable
result because of too little bone
width,length,height or angulation
of load.
b. Crown implant is>1.

c. Surgical options incase of inadequate
width include Osteoplasty or
augmentation;for inadequate height
Subperiosteal implants or
augmentation.
d. Root forms may be considered with
augmentation and for nerve
repositioning

Division D
1. Edentulous areas have severely resorted
ridges, involving a position of the basal
or cortical supporting bone.
2. Crown implant ratio is >5
3. Surgical options usually in
augmentation before implant are
involved.

♦ Also due to improper designing the
remaining natural anterior teeth exhibit
mobility due to overload. Therefore these
patients often require the posterior implant
prostheses to be independent from the
mobile anterior teeth and in addition the
occlusal scheme must accommodate the
specific conditions of the mobile anterior
teeth.
♦ This requires greater attention and
frequency for occlusal adjustments and
more implant support in each posterior
section than Class II or III.

The treatment plan must consider the
factors of force previously identified and
relate them to the existing condition.
Osteoplasty cannot be as aggressive in
class I compared with completely
edentulous patient because of the
opposing anatomic landmarks.

Augmentation procedures may be
required to improve posterior bone
volume, increase the implant surface
area, and permit the fabrication of an
independent implant restoration.
If the treatment is to be carried in stages,
the posterior region with the greatest
volume of bone is restored first.

CLASS II:
Partial edentulism with missing teeth in
one posterior segment.
These patients are not likely to wear a
removable denture as they may be able to
function without a denture and as a result
are less likely to tolerate or overcome the
minor complications of wearing the
prostheses.

The available bone is therefore often
adequate for endosteal implant even
when long term edentulism has been
observed.
Still the local density of bone may be
decreased.
Endosteal implants with minimal
osteoplasty are a common modality in
these patients, who are more often class ll
Division A or B types.

Because the patients is less likely to wear
a removable denture, the opposing
natural teeth have often extruded into the
posterior edentulous area. the occlusal
plane and tipped or extruded teeth should
be closely evaluated and restored as
indicated to provide a favorable
environment in terms of occlusion and
forces distribution.

CLASS III:
Bounded unilateral posterior edentulous
space– either a single tooth or a long
edentulous span.
A posterior edentulous region most often
can be restored as an independent
restoration but can also be joined to a
posterior natural abutment.

But a single tooth implant is indicated
primarily in the posterior regions of
the mouth or when the patient does
not agree to crown the adjacent teeth
in the anterior region

CLASS IV :
Patients with anterior edentulous space
that crosses the midline.
Lack of anterior bone is a common scene
and therefore bone graft before implant
placement becomes necessary to prevent
the implants from being placed palatally
in relation to the natural roots.

DIVISION A Treatment plans :
In class l or ll types, when an implant is
considered an independent implant
supported fixed prosthesis is usually
indicated.
Two or more endosteal root form
implants are required to replace
independent molar prostheses.
The greater the no., of teeth missing, the
larger the size and/or no., of implants
required.

Posterior height is limited by the
maxillary sinus or the mandibular canal
and hence care should be taken during
placement.
Partial dentures should be generously
relieved or not worn at all during the
healing process, esp., if parafunction is
present.

In class lll type, patients often have
endosteal root implant placed in the
edentulous space.
This situation is also indicated when
occlusal forces are too great for the
natural abutments to act as support for a
fixed prostheses but are not mobile.
If the adjacent teeth are mobile, the
implant must support both the missing
teeth and mobile teeth during occlusion.

As a general rule, the final prostheses
should be completely implant supported,
and 2 implants should support each
section of 3missing tooth roots [not 3
missing crowns].
Mobile natural teeth adjacent to the
edentulous span cause greater loads on
the implants, therefore 1 implant for each
missing root may be indicated and the
occlusion is adjusted to allow initial tooth
movement before implant crowns contact
in occlusion.

DIVISION B Treatment plans :
Class l or ll patients have narrow bone in
posterior edentulous spaces and anterior
natural teeth.
Osteoplasty is of limited application here.
Endosteal small diameter root form may
be placed in the posterior Division B
edentulous region but greater no., are
used than for Division A ridge. The
smaller the diameter suggests the use of
one implant for every missing tooth root,
and no cantilever should be used.

 The patient missing molars and both
premolars require additional implant
support.
 Four division B root forms may be
the foundation of an independent
fixed partial denture, depending on
the other stress factor.

Molar endosteal implants should not be
rigidly cross splinted to each other in the
class I patient. Flexure of the Mandible
during opening may cause a rigid splint
to exert lateral forces on the posterior
implants.Hence, independent
restorations are indicated.
Class III Division B patients have
narrow –diameter endosteal implants
placed in the middle of a long-span
edentulous space.

 This treatment plan is primarily used
for fixed prosthodontic treatment
when the span is too long or occlusal
forces are for great for the natural
abutments to act sole support for the
final prosthesis. The final implant
prosthesis should be independent of
these teeth.
 Class IV patient most often treated
with augmentation before implant
placement.

 If the ridge is division B and
inadequate in width for Division A
root form implants, the narrow-
diameter root forms compromise
esthetics and oral hygiene
procedures.
 Bone augmentation is more often
used in anterior edentulous areas with
narrow bone, so Division A root from
implants may be used with improved
crown contour,esthetics and hygiene.
Implant and tooth replacement should
remain independent.www.indiandentalacademy.com

 Canine is an important natural
abundant.When missing, the final
prosthesis includes both anterior and
posterior natural abutments,which
compromises the occlusal scheme.
 Likewise,single implants to replace
canine one indicated but the
occlusion should decrease the lateral
loads by distributing some of the
forces to the adjacent teeth.

A hydroxyapatite graft is often placed
on the labial aspect of the Division B
edentulous ridge for enhanced soft
tissue contour, proper emergence
profile and improved lip support for
esthetics when pontics are used in the
region.

Division C Treatment Plans
 In this case, several options must be
considered.
 The first option, [unfortunate from
an implantologists view] is to go for
conventional removal partial
prosthesis though a traditional soft-
tissue borne restoration is possible
but it worsens the bone loss.

Second option is to use bone
augmentation procedures :
a. If the intention is to change it to
Division B & A , autogenous graft
is preferred.
 Most often used in Class I or II
maxilla where sinus graft with a
combination of allografts and
autogenous bone are a predictable
modality.

b. If bone augmentation is performed for
improved ridge contour and soft tissue
support only, non-resorbable HA is
recommended. A convention soft tissue-
borne prosthesis is then indicated and if
there is adequate natural abutment support,
fixed prostheses can be used.

 Third option is to place a
subperiosteal implant-more often is
mandible. Mandibular
circumferential(around the teeth)
subperiosteal implants may be
considered for class I patients.These
implants can be treated with
independent fixed prostheses with no
attachment to natural teeth.

 Class III or IV patients rarely have
subperiosteal implants. Augmentation is
performed before endosteal implant
placement in these patients.
 Fourth option in the mandible is nerve
repositioning and endosteal implants in
class I &II patients who are poor
candidates for bone augmentation or
subperiosteal implants.

However, certain disadvantages do exist
like
a. Paresthesia- Hyperesthesia and pain
b. Grains of height only permit the
placement of 10mm high implants-
insufficient to compensate for the
increased crown height resulting
in unfavorable crown:root.

.
 Class III & IV patient may have root
forms placed without augmentation
since the masticatory dynamics and
bone density are not as unfavorable
as the posterior regions.
 Maxilla usually require
augmentation before implant
placement.

Division D Treatment Plans
 Class I or II and Division D - seen
commonly in the long term edentulous
maxilla.
 Sinus graft performed before implant
placement .
 Mandible- rare finding. If found
(due to trauma or surgical excision of
neoplasm) need autogenous bone onlay
grafts to improve implant success and
prevent pathologic fracture before
prosthodontic reconstruction.

TREATMENT PLANS
FOR COMPLETELY
EDENTULOUS ARCHES

Classification of completely
edentulous arches is also based on
bone volume present.
 Edentulous jaw is divided into 3
regions:

1. Anterior –> Maxilla– between right&
left I Premolars/ anterior to maxillary
sinus.
Mandible– between
right& left I Premolars/anterior to
mental foramina.
2. Right posterior
3. Left posterior
Maxilla- from right &
left II Premolars
respectively
Mandible- Mental
foramen
to the Retro molar pad

♦ The classification of the edentulous
jaw is then determined by the division of
bone in each section of the edentulous
arch.
♦ The three areas are evaluated
independently from each other. Hence,
there may be one, two or three different
divisions of bone.

TYPE 1
♦ Type 1 edentulous arch the division of
bone is similar in all three anatomic
segments. Therefore 4 different categories
of Type 1 arches are present.
♦ Type 1 Division A ridge- abundant
bone in all three sections, therefore as
many root forms as needed may be used
wherever desired to support the final
prostheses.

 Type 1 Division B ridge- adequate
bone in all 3 sections to place
narrow- diameter root form implants.
The anterior section can be changed
to Division A by osteoplasty to place
full- size root form implants in this
region.
 a. Type 1 Division C-w edentulous
arches have inadequate bone width &
therefore requires an autogenous
onlay graft for implant restoration.

 Type 1 Division C-h edentulous
arches have inadequate bone height.
In this case, an implant supported or
implant- tissue supported removable
partial prostheses, is indicated to
reduce occlusal loads.
Mandibular arch may be treated with
a complete subperiosteal implant or
root form implants in the anterior
section.

 Maxilla is treated with conventional
removable prostheses. For additional
retention or stability HA can be used to
augment premaxilla. Fixed prostheses
may need autogenous graft to change
the division and improve long term
success and esthetics.
 Type 1 Division D- most challenging to
traditional and implant dentistry
because if an implant fails in this case,
pathologic fractures or almost
unrestorable conditions may result.

♦ Endosteal implants may be placed in the
anterior mandible. However, the
unfavorable crown-implant ratio is
often greater than 5 to 1 and mandibular
fracture during implant placement or
after implant failure may result in
significant complications.
♦ The best solution is to change the
division with autogenous grafts, then
reevaluate the improved conditions and
appropriately alter the treatment plan.
Autogenous grafts include iliac crest&
particulate grafts. After 6 months a total
of 6 to 10 implants may be placed.www.indiandentalacademy.com

Type 2
 The posterior sections of bone are
similar but differ from the anterior
segment .the most common arches in
this category present less bone in the
posterior regions, under the Maxillary
sinus or over the mandibular canal Type
2 A,C (Designated as Type2 followed
by bone Division in the anterior
segment and then bone Division in the
posterior segment

 Type2 Division A,B arch has posterior
sections that maybe treated with
narrow-diameter implants, whereas the
anterior section is adequate for larger
diameter root form implants to support
the prostheses
 The posterior Division B may be
changed into Division A. Autogenous
grafts are more debilitating and require
extended healing periods, but indicated
when stress factors and patient desires
are high

 Type 2 Division A,C presents two
primary modes of implant treatment
 The most common mandibular situation
is to use only the anterior section for
implant supported root form
implants.The maxillary arch may be
treated with the combination of sinus
grafts and endosteal implants if
additional posterior support is required
for the prostheses.
 Type 2 Division A,D though
uncommon,is treated in a similar
manner as Type2 Division A,C

 Type 2 Division B,C can be treated with
two main treatment options
The anterior section may be changed to
Division A by Osteoplasty and then
treated as Type2 Division A,C
The posterior Division may be changed
by Sinus grafts to convert it into
Division B
 Type 2 Division B,A – Anterior
mandible maybe changed to Division C
by Osteoplasty and a mandibular
complete Subperiosteal implant may be
selected as onlay are less predictable.www.indiandentalacademy.com

 Type 2 Division B,D almost never
occurs in the mandible, but it can be
found on occasion in the maxilla.These
patients are treated in a manner similar
to patients with Type2 Division B,C
Type 3
 Posterior sections of the maxilla or the
mandible differ from each other.
 Less common than other two types and
more frequent in the maxilla
 Anterior bone volume is listed first then
the right posterior followed by the left
posterior www.indiandentalacademy.com

 Type 3 division A,B,C requires a
narrow-diameter implant in the right
posterior, root form in the anterior
sections.
 Type3 Division A,C,B is treated as a
mirror image of Type3 Division A,B,C
 Type3 Division A,D,C are A,C,D
receives a treatment plan similar to
Type2 Division A,C
 Even when the anterior region is similar
to one of the posterior sections, the arch
is Type 3.Anterior section usually
determines the treatment plan.www.indiandentalacademy.com

Trt plan in implant/prosthodontic courses

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