Dental Implant Therapy for the Completely Edentulous Patient

Aldo Leopardi, BDS, DDS, MS

Practice Limited to Implant, Fixed and Removable Prosthodontics
Greenwood Village, Colorado
www.knowledgefactoryco.com
www.aldoleopardi.com
email: aldo@aldoleopardi.com

Treatment Planning and Clinical Considerations:

Determine the Patient Expectations
Completely Edentulous Key Factors:
$ Functional demands: is minimal movement of their denture Okay (tissue
supported implant retained overdenture therapy), or are they expecting the new
overdenture to be very stable (multiple implants for implant supported and
retained overdenture therapy)?
$ Oral hygiene.
$ Financial commitment.
$ Treatment phases/time frame.
$ Aesthetics.
$ Phonetics.

Health History Contraindications:

$ Immunosuppression (chemotherapy, HIV, etc).
$ Antimetabolic treatment.
$ Poorly controlled diabetes.
$ Poorly controlled cardiovascular problems.
$ Active pharmacodependency.
$ Psychiatric disorders.
$ Bisphosphonates-intravenous: contraindicated.
$ Bisphosphonates-oral: informed consent.
$ Smoking: informed consent.

Implant Placement
Available Bone:
$ Minimum implant length 10 mm.
$ Ideal length: 12/13 mm.
$ Maximum length: 15 mm.

Bone Quality:
$ Type I/II - Mandibular anterior and posterior sites. Require minimum of 1.5-2 mm
of bone surrounding the dental implant.
$ Type III/IV - Maxillary anterior and posterior sites. Require minimum of 2 mm of

Aldo Leopardi, BDS, DDS, MS www.knowledgefactoryco.com Page 1

 surrounding the dental implant.

Prosthetic Design:
Dependent on...
$ Patient expectations.
$ Bone quality/quantity/biomechanical considerations.
$ Number of implants.
$ Position of implants.

Prosthetic Option Breakdown: Two Groups

Group A: Stress-broken
ÿ Fewer implants.
ÿ Biomechanical considerations.
ÿ Bar and/or solitary attachment systems: tissue supported overdentures,
implant retained.

Group B: Rigid
ÿ Multiple implants required.
ÿ Number of implants dependent on bone quality/biomechanical considerations,
including parafunctional activity.
ÿ Position of implants: even/wide spread.
ÿ Milled bar overdentures: implant supported and retained.
ÿ Fixed-detachable: implant supported.

Bar Overdentures:
Advantages:
∑ Requires less specific implant placement compared to fixed prosthetic.
∑ Prosthetic stability and retention (psychologically satisfying for patients).
∑ Maintain facial esthetics and minimize bone loss after extraction of teeth.
∑ Maxillary implant overdentures with or without the palate enable patients to
produce more intelligible speech than fixed protheses.
∑ Improved oral hygiene.
∑ Bars: implants splinted together are capable of withstanding off axis loads better
than free standing (not connected with a bar) solitary anchor systems (e.g.; ball
or stud abutment/attachment designs).

Criteria:
∑ Minimum vertical distance: 13-14 mm from implant platform to incisal edges (4
mm for bar, 1 mm below bar for hygiene, then clip and acrylic tooth housing).
∑ Span/Length:
ÿ No more than 18mm with a 2 mm vertical stiffener.
∑ Bar-clip requires minimum of 10-12 mm between implants, otherwise a milled bar
Aldo Leopardi, BDS, DDS, MS www.knowledgefactoryco.com Page 2
 with friction fit superstructure is required (Group B rigid design, multiple
implants).

Disadvantages:
$ Maintenance: regular attachment mechanism replacements.
$ Maxillary Satisfaction Rating Studies:
ÿ Patients with chronic problems with their maxillary dentures may prefer an
overdenture to the fixed design.
ÿ If the patient had a satisfactory experience with their complete Maxillary
denture, the satisfaction with implant supported prostheses was Not
significantly higher than conventional maxillary prostheses (denture). This
suggests that maxillary implant prostheses should not be considered as a
general treatment of choice in patients with good bony support for
maxillary conventional prostheses.
$ Maxillary Arch Complications:
ÿ Retrospective studies report higher frequency of complications compared
with implant fixed prostheses.
ÿ Hyperplasia adjacent to the bar.
ÿ Higher rate of stomatitis as compared with the mandible.
ÿ Lack of in compliance when removing the overdenture when sleeping.
ÿ Higher mucosal and mechanical complications when compared with
mandibular overdentures.
$ Relining: With Group A stress-broken, implant retained overdentures, functional
loads are distributed to the edentulous areas. Bone resorption w ill continue to
occur and relining of tissue-bearing areas will be required every 2-3 years.

Implant Biomechanics
∑ Implant dentistry requires a “baseline” working knowledge of the key factors of
the biomechanics and how they affect the treatment plan.
∑ Minimize bending moments (lateral forces).
∑ For Group A stress-broken bar-overdentures, the retentive components need to
be designed to allow rotation anteriorly/posteriorly to prevent overloading of the
implants and allow transfer of forces to the edentulous areas.

Bar Types:
$ Dolder bar: egg-shaped cross section. Allows transactional (slight vertical) and
rotational movement. When used in frontal areas (linear) only, the Dolder Bar
Joint with its three different degrees of space freedom, loads the abutments least
of all, regardless of the number of abutments.
$ Round Bar: permits rotational movement only.
$ Dolder bar, “U” shaped cross-section. No rotational freedom. For Group B rigid
implant supported and retained overdentures only.

Aldo Leopardi, BDS, DDS, MS www.knowledgefactoryco.com Page 3

Solitary Anchor Systems: Ball-Socket and Stud Attachment Systems
$ Allow for 360 degrees of freedom and vertical movement.
∑ Designed for Group A stress broken, tissue supported and implant retained
prostheses only.

Cantilever Guidelines:
Mandible:
Cantilever lengths with implants in Type I Bone: equal to the anterior-posterior spread of
implants multiplied by 1.5. Guideline only. Only recommended in low biomechanical
risk patens (e.g., when there is an oppoising denture).
Maxilla:
Poor bone quality, and considering bars with distal cantilevers tend to increase loads on
terminal implants by more than 3 times, cantilevers should be minimized or avoided
(keep them no more than 8 mm in length, irrespective of anterior-posterior spread or
number of implants, with cross-arch stabilization). Guideline only.
Cantilevers are contraindicated in parafunctioning patients, and should be m inimized or
avoided when opposing a natural dentition or rigid implant restoration.
Rigid designs with cantilevers function best long-term when the opposing occlusion is a
complete denture.

Maxillary Arch Multiple Implants (minimum 4 – case selection, 6-8 ideal).

Milled Bar-Overdentures:
Implants can be placed in an axial or inclined direction, with or without sinus
augmentation procedures.
When implants placed are posteriorly in the first molar position (following sinus
augmentation, as required, total of 6 implants), a wide A-P (anterior-posterior) spread
can be achieved.
Advantages:
$ No cantilevers present. Improved biomechanical/stress-transfer.
$ Rigid design. Infrastructure provides the same rigidity as a fixed prosthesis
(precise fit to the superstructrure, which is removable).
$ Offers benefits of both fixed and removable restorations.
$ Access to oral hygiene.
$ Prosthetic - closed adaption to soft tissue. Improved phonetics.

Treatment Planning: Number of Implants

The following breakdown of restorative treatment options have been developed

by Dr. Aldo Leopardi. These options can be effectively communicated to the
patient.

Aldo Leopardi, BDS, DDS, MS www.knowledgefactoryco.com Page 4

Implant Restorative Options:
The type of restoration made to attach and/or be supported by the dental implants will
depend on the number and position of the implants placed.

The restorative options for the Mandibular (lower) jaw are as follows:
1. Two Anterior Implants, Ball abutment (trailer-hitch style abutment) on
implants, and attachment inside the overdenture. Group A: Stress-broken.
This denture is implant retained only. This means that the denture is designed to
move slightly when biting in order to avoid overloading (stressing) the two
implants. All biting forces are transferred directly to the supporting gum-
tissue/bone of the lower jaw (as in a conventional denture). The implants retain
the denture improving its stability and comfort. Mastication and confidence is
therefore enhanced.

Maintenance: The silicone/plastic ring-inserts inside the denture will require

replacement every 6 months to a year. The overdenture will require a laboratory
hard reline every 2-3 years. Metal attachment housings will require intra-oral re-
attachment following the laboratory reline procedure. A new overdenture will be
made every 7 to 10 years.

Advantages: Cost savings - this is the least expensive implant option since there
are only two implants and these are kept separate (not connected w ith a bar).
Disadvantages: Slight vertical movement in the posterior/back zone during heavy
clenching is necessary in order to avoid implant overload. The attachments
inside the denture also need to be replaced on a reg ular (6 month/yearly) basis.
Because the overdenture is supported by the bone/gum tissue, the bone
resorption process continues in the posterior regions.

2. Two Anterior Implants, Gold Bar and Clip Assembly Overdenture. Group A:
Stress-broken. This denture is implant retained only. This means that the
denture is designed to move slightly when biting in order to avoid overloading
(stressing) the two implants. All biting forces are transferred directly to the
supporting bone of the lower jaw (as in a conventional denture). The implants
retain the denture improving its stability and comfort. Mastication and confidence
is therefore enhanced.

Maintenance: The clips inside the lower overdenture will need to be replaced as
needed (varies from every year for plastic and 3-5 years for gold clips). The
overdenture will require a reline in 2-3 years, and a new overdenture in 7-10
years. However, the original gold/metal bar remains as is and is utilized again
(unless damaged/worn-out).

Aldo Leopardi, BDS, DDS, MS www.knowledgefactoryco.com Page 5

 Advantages: Retention and stability is improved.
Disadvantages: The lower denture is still supported primarily by the
underlying bone and gum tissue. The bone behind the
implants (posterior jaw) provide support. Therefore, the
bone will continue to resorb slowly over time.

3. Three Anterior Implants, Ball abutment (trailer-hitch style abutment) on

implants, and attachment inside existing denture. Group A: Stress-broken.
This is the same as 1 above, except the third implant adds additional retention
and helps to preserve additional bone in the anterior/front region. The
advantages and disadvantages are the same as option 1 and 2 above.

Maintenance: The silicone/plastic ring-inserts inside the denture will require

replacement every 6 months/year. The overdenture will require a laboratory hard
reline every 2-3 years. A new overdenture will be made every 7 to 10 years.

4. Four Implants, Gold/Metal Bar and Clip Assembly Overdenture.

Combination Group A/B. This is the same as above, except the four implants
allow for the construction of a more securely retained overdenture. The denture
is still predominantly implant retained with additional implant support. That is, it
is still stress broken and has some built-in vertical give under significant
pressure. If implant spread is ideal, and implant supported/rigid (little to no
movement) overdenture can be constructed, as long as the number of teeth on
the posterior portion of the denture is minimized to prevent implant overload
(Cantilever length in type I bone = A-P spread X 1.5).

5. Four to Five Implants (Anterior/Chin Zone), Fixed-Detachable Hybrid

Bridge. Group B: Rigid. This is a fixed bridge. It is screw-retained. Either
acrylic fused to gold/metal or porcelain fused to gold/metal or Zirconium.

Maintenance: Regular 6 month cleaning with the hygienist. Occasionally, screws

may come loose which will involve replacement and occlusal adjustment. Acrylic
teeth, if utilized, will need to be replaced every 7 or more years, depending on
the rate of wear. The gold substructure, if not damaged, can be re-utilized. Less
episodes of problems/maintenance with porcelain fused to gold.

6. Seven/Eight or More Implants, Fixed Porcelain fused to Gold Bridge (Fixed

Partial Denture) or Zirconium. Group B: Rigid. Implants can be placed in
molar region. For metal-ceramics, the prosthetic can be divided into two or more
sections to accommodate possible jaw flexure. Metal-ceramics require less
maintenance than an acrylic fused to metal hybrid prosthesis. Aesthetics are
also optimized due to the porcelain. Zirconia is another option, althoug h proving

Aldo Leopardi, BDS, DDS, MS www.knowledgefactoryco.com Page 6

 to be a viable option, less long-term data is available.

The restorative options for the Maxillary (upper) jaw are as follows:
1. Four Implants, Stress-broken Bar Overdenture. Group A: Stress-broken.
This denture is palate free (horse-shoe shaped). It is a combination of implant
and tissue supported, stress-broken design. With the same advantages and
disadvantages as described above.

2. Four Implants, Fixed. Group B: Rigid.

Posterior implants are often inclined to improve A-P spread.
Recommend minimizing or avoiding cantilevers in high biomechainical risk
patients. Contraindicated in parafunctioning patients. Otherwise 6-8 implants.
Case selection is key.

3. Six to eight Implants, Milled Gold/Metal Bar (laboratory or CAD-CAM) and

Clip Assembly Overdenture. Group B: Rigid. This denture is palate free
(horse-shoe shaped). It is implant supported and retained. A milled gold/metal
bar is attached to the implants, and a corresponding milled component and/or
clip assembly is placed inside the denture and attaches to th e gold/metal bar.

Maintenance: The clips inside the overdenture will need to be replaced as

needed (varies from every year to three years depending on the design utilized).
The overdenture will require new teeth and/or revised superstructure/overdenture
every seven-ten years. However, if the original gold/metal implant-bar remains in
good condition, it can be utilized again (unless damaged/worn-out).

Advantages:
Retention and stability is improved considerably. Open palate.
Disadvantages:
Removable, not fixed. Clip maintenance.

4. Six to Eight, Fixed-Detachable (Acrylic fused to Metal) Hybrid Bridge

(laboratory or CAD-CAM). Group B: Rigid. This is a fixed prosthesis. It is
screw or cement-retained. Acrylic fused to gold/metal hybrid.

Maintenance: The teeth will need to be replaced every 7-10 or more years,
depending on the rate of wear. The gold/metal substructure, if not damaged, can
be re-utilized.

Advantages:
The restoration is fixed and rigid. Aesthetics and mastication is excellent.
Disadvantages:

Aldo Leopardi, BDS, DDS, MS www.knowledgefactoryco.com Page 7

 Phonetics is more challenging at first and takes time to adjust. The prosthesis
needs to be cleaned at least once per day, and there is a learning/dexterity curve
for cleaning. The plastic teeth lose luster over time and require periodic
polishing.

Please Note: when fixed acrylic restorations are opposing a rigid opposing occlusion,
they are subject to high rates of wear, fatigue fractures and therefore significant
maintenance. With continued wear comes a loss of vertical dimension over time,
locking of opposing teeth and high lateral loads on inherently week acrylic materials.
These problems are exacerbated in parafunctioning patients. Consequently, not
recommended in high risk biomechanical patients. A ceramic solution is recommended.

5. Six to Eight Implants, Fixed All-Ceramic Zirconium Porcelain or Porcelain

fused to Gold Bridge (Fixed Partial Denture). This is the same as 2 above,
except that the materials used to construct the bridge include all-ceramic
porcelain or porcelain over/fused to gold. This bridge requires less maintenance
than the acrylic fused to metal hybrid bridge. Porcelain is less/non-porous and
therefore does not stain, nor does it loose its luster as readily as acrylic.
Therefore, aesthetics is optimized.

Advantages: The restoration is fixed and rigid. Aesthetics and mastication is

excellent. Porcelain is non-porous (does not stain as readily as
plastic) and maintains its luster long-term compared with plastic.
Porcelain is resistant to wear and therefore maintains vertical
dimension. Consequently, less maintenance and an opportunity for
a longer life restoration: 10 to 20 years, depending on individual
wear and tear, parafunctional habits (grinding, etc.,), oral hygiene,
and incidence of trauma.
Disadvantages: Phonetics is more challenging at first and takes time to
adjust. The prosthesis needs to be cleaned at least once
per day, and there is a learning/dexterity curve for cleaning.
Porcelain is brittle and subject to chipping/fracture. When
this occurs, the teeth can be smoothed or individual teeth
replaced (depending on prosthetic design).

Maxillary (upper) Arch Fixed Solutions Summary:

Six to Eight Implants, Fixed (retained by screws) Bridge (Fixed Partial Denture).
Option A: Acrylic fused to metal.
Option B: Zirconium Porcelain.
Option C: Porcelain fused to Gold.

The advantage of Acrylic is lower overall cost. The disadvantages include wear (loss of

Aldo Leopardi, BDS, DDS, MS www.knowledgefactoryco.com Page 8

vertical height over time), stain and greater incidence of tooth fracture. The teeth will
also need to be replaced every 8 years due to wear over time. Consequently, overall
maintenance is greatest with acrylic when compared to the other two restorative
options.

The advantage of Zirconium is resistance to wear. Therefore, vertical dimension

(vertical face height) is maintained. The teeth do not need to be replaced every 8 years
as with the Acrylic option. However, Zirconium is less translucent (less aesthetic) than
either acrylic or the porcelain fused to gold option. The Zirconium teeth, if layered with
veneering porcelain, are also subject to chipping and/or fracture. Overall, less
maintenance that Acrylic. Monolithic Zirconium has the potential for minimal
chipping/fracture. These bridges therefore have the potential of long-term use (10-20
year plus prosthesis).

Porcelain fused to gold has the longest clinical data available. It has the same
advantages as Zirconium, with less disadvantages. However, the cost is greatest when
compared to the other two options.

The bridges (all three options) are cleaned professionally by the hygienist every 6
months. The Acrylic option is removed every 2 to 5 years to check screws (check for
screw loosening) and professional cleaning. The Zirconium and Porcelain option is
removed as needed (average 5 or more years) for professional cleaning and screw
assessment or repair (as needed).

Immediate Implant Placement and Fixed Teeth in a day

(Provisionals/Temporaries)
For group B rigid options. Case selection and patient desire.

Mandibular, Group B Fixed-Detachable Acrylic Fused to Gold/Metal Prosthesis

∑ Require ideally 15-17 mm of vertical restorative room from implant platform to
incisal edges of future prosthetic table/teeth. However, it is possible with less
vertical dimension with screw-retained designs depending on individual patient
presentation.
∑ Recommend abutment level design. Transmucosal abutments therefore
required.
∑ Splinted open-tray impression technique, incorporating retromolar pads and
posterior ridge anatomy.
∑ Laboratory gold or CAD-CAM metal framework fabrication.
∑ Convex surfaces: light or no contact with tissues.
∑ Posterior cantilever lengths: no more than 1.5 X A-P spread for mandibular
prostheses in low biomechanical risk patients.
∑ Delayed/conventional or Immediate Load.
Aldo Leopardi, BDS, DDS, MS www.knowledgefactoryco.com Page 9
∑ Immediate Load Criteria:
ÿ Minimum 4-5 implants in the pre-symphyseal region of the mandible.
ÿ Minimum 10 mm length implants.
ÿ Primary implant stability.
ÿ Abutment level provisional prosthesis.
ÿ Cross-arch stabilization.
ÿ Minimal (less than 1 X A-P spread) or no cantilevers.
ÿ Soft diet for 6 weeks.

Maxillary, Group B Fixed-Detachable Acrylic Fused to Gold/Metal Prosthesis

∑ Number of recommended implants: minimum 4 with wide A-P spread, 6 ideal and
8 maximum.
∑ Splinted open-tray impression technique, transmucosal abutment level.
∑ Convex surfaces.
∑ Anterior modified ridge lap design from region 5/6 to 11/12, with light contact on
tissue to maximize phonetics.
∑ Avoid cantilevers (if needed, no more than 8 mm cantilevers, with cross-arch
stabilization).
∑ Implant placement for 6 implants: spread from molar, premolar and lateral incisor
regions.
∑ Implant placement for 8 implants: either spread or molar to canine bilaterally.
∑ Frameworks: custom gold or CAD-CAM metal.
∑ Immediate Load Criteria:
ÿ Minimum 4-8 implants, with wide anterior-posterior spread (molar to molar).
ÿ Minimum 10 mm length implants.
ÿ Primary implant stability.
ÿ Abutment level provisional prosthesis.
ÿ Cross-arch stabilization.
ÿ No cantilevers.
ÿ Soft diet for 6 weeks.

Group B Fixed Zirconium.

• Zirconium with layered feldspathic porcelain are more aesthetic than monolithic
Zirconium. However, layered designs are subject to high rates of chipping.
• Monolithic designs have strength and are not subject to chipping. However, lack
of translucence can compromise aesthetics, especially in high value ceramics.
• Lack of long-term data available. However, a promising prosthetic solution for
Group B rigid designs.
References:

Heydecke G, McFarland DH, Feine JS, Lund JP. Speech with maxillary implant
prostheses: ratings of articulation. J Dent Res. 2004 Mar;83(3):236-40.
Aldo Leopardi, BDS, DDS, MS www.knowledgefactoryco.com Page 10
Zitzmann NU, Marinello CP. Implant-supported removable overdentures in the
edentulous maxilla: clinical and technical aspects. Int J Prosthodont 1999;12:358-90.

Heydecke G et al. Speech with maxillary implant prostheses: ratings of articulation. J

Dent Res 2004;83:236-40.

Henry PJ. Future therapeutic directions for the management of the edentulous
predicament. J Prosthet Dent 1998;79:100-6.

De Albuquerque Junior RF et al. Within-subject comparison of maxillary long-bar

implant-retained prostheses with and without palatal coverage: patient based outcomes.
Clin Oral Implants Res. 2000 Dec;11(6):555-65.

Jemt T et al. Failures and complications in 92 consecutively inserted overdentures

supported by Branemark implants in severely resorbed edentulous maxillae: a study
from prosthetic treatment to first annual check-up. Int J Oral Maxillofac Implants
1992;7:162-7.

Zarb GA, Schmitt A. The edentulous predicament II: the longnitudinal effectiveness of
implant supported overdentures. J Am Dent Assoc 1996;127:66-72.

Eckfeldt A et al. Implant-suppoted overdenture therapy: a retrospective study. Int J

Prosthodont 1997;10:366-74.

Watson RM et al. Prosthodontic treatment, patient response, and the need f or

maintenance of complete implant-supported overdentures: an appraisal of 5 years of
prospective study. Int J Prosthodont 1997;10:345-54

Naert I et al. Rigidly splinted implants in the resorbed maxilla to retain a hinging
overdenture: a series of clinical reports for up to 4 years. J Prosthet Dent 1998;79:156-
64.

Widbom C et al. A retrospective evaluations of treatments with implant-supported

maxillary overdentures. Clin Implant Dent Relat Res 2005;7:166-72.

Watson RM et al. Prosthodontic treatment, patient response, and the need f or

maintenance of complete implant-supported overdentures: an appraisal of 5 years of
prospective study. Int J Prosthodont 1997;10:345-54.

Visser A et al. Implant-retained mandibular overdentures verses conventional dentures:

10 years of care and aftercare. Int J Prosthodont 2006;19:271-278.

Aldo Leopardi, BDS, DDS, MS www.knowledgefactoryco.com Page 11

Bidez MW, Misch CE. Force transfer in implant dentistry: basic concepts and principles.
J Oral Implantol 1992;18:264-74.

Benzing UR et al. Biomechanical aspects of two different implant-prosthetic concepts

for the edentulous maxillae. Int J Oral Maxillofac Implants 1995; 10:188-98.

Kramer A et al. Implant and prosthetic treatment of the edentulous maxilla using a bar-
supported prosthesis. Int J Oral Maxillofac Implants 1992;7:251-5.

Bidez MW, Misch CE. Force transfer in implant dentistry: basic concepts and principles.
J Oral Implantol 1992;18:264-74.

Ranger B et al. Bending overload and implant fracture: a retrospective clinical analysis.
Int J Oral Maxillofac Implants 1995; 10:326-34

Benzing UR et al. Biomechanical aspects of two different implant-prosthetic concepts

for the edentulous maxillae. Int J Oral Maxillofac Implants 1995; 10:188-98.

Phillips K, Wong KM. Vertical space reqwuirement for the fixed-detachable, implant-
supported prosthesis. Compend Contin Educ Dent 2002;23:750-2, 754, 756

Palmqvist S et al. Implant supported maxillary overdentures: outcome in planned and

emmergency cases. Int J Oral and Maxillary J Prosthet Dent 2007;97:340-348.

Steven J. Sadowsky. Treatment considerations for maxillary implant overdentures: A

systematic review. J Prosthet Dent 2007;97:340-348.

Enuku Chung, W et. al. Outcomes Assessment of Patients Treated with

Osseointegrated Dental Implants at the University of Washington Graduate
Prosthodontic Program, 1988 to 2000. Int J Oral Maxillofac Implants 2009;24:927-935.

Yamamoto E et. al. Accuracy of Four Impression Techniques for Dental Implants: A
scanning Electron Microscopic Analysis. JOMI 2010;25:1115-1124.

Jemt T, Johansson J. Implant treatment in the edentulous maxillae: a 15-year follow-up

study on 76 consecutive patients provided with fixed prostheses. Clin Implant Dent
Relat Res. 2006;8(2):61-69.

Romanos GE, Nentwig GH. Immediate functional loading in the maxilla using implants
with platform switching: five-year results. Int J Oral Maxillofac Implants 2009;24:1106-
1112.

Aldo Leopardi, BDS, DDS, MS www.knowledgefactoryco.com Page 12

Kinsel RP, Liss M. Retrospective analysis of 56 edentulous dental arches restored with
344 single-stage implants using an immediate loading fixed provisional protocol:
statistical predictors of implant failure. Int J Oral Maxillofac Implants. 2007 Sep-
Oct;22(5):823-30.

Leopardi A. Fixed Restorative Options for the Edentulous Maxilla Functional Esthetics
and Restorative Dentistry, 2008 July;2(3):44-56.

Krennmair G, Krainhofner M, Piehslinger. Implant supported maxillary overdentures

retained with milled bars: Maxillary anterior verses Maxillary posterior concept – a
retrospective study. Int J Oral Maxillofac Implants 2008;23:343-35.

Steven J. Sadowsky. Treatment considerations for maxillary implant overdentures: A

systematic review. J Prosthet Dent 2007;97:340-348.

Rasmusson L et al. Clin Implant Dent Relat Res 2005;7:36-42.

Attard N, Zarb G. Int J Prosthodont 2004;17:417-424.
Snauwaert K et al. Clin Oral Implants Res 2000;4:13-20.

Malchiodo L et. al. (Immediate Load, 6-7 years) Int J Oral Maxillofac Implants
2011;26:373-384.

Capelli M et. al. (immediate load, 40 months) Int J Oral maxillofacial Implants. 2007 Jul-
Aug;22(4):639-44.

Benzing UR, Gall H,Weber H. Int J Oral Maxillofac Implants.1995;10(2):188-198.

Krämer A,Weber H, Benzing U. Int Oral Maxillofac Implants. 1992;7(2):251-255.

Nishimura I, Garrett N. Impact of Human Genome Project on treatment of frail and

edentulous patients. Gerodontology 2004;213-9.

Feine JS, Carlsson GE, Awad MA, et al. The McGill Consensus Statement on
Overdentures. Montreal, Quebec, Canada. May 24-25, 2002. Int J Prosthodont
2002;15:413-414.

Atwood DA. Bone loss of edentulous alveolar ridges. J Periodontol 1979;50:11-21.

Aldo Leopardi, BDS, DDS, MS www.knowledgefactoryco.com Page 13

Nishimura I, Garrett N. Impact of Human Genome Project on treatment of frail and
edentulous patients. Gerodontology 2004;213-9.

Huumonen S, Haikola B, Oikarinen K, Söderholm AL, Remes-Lyly T, Sipilä K. Residual

ridge resorption, lower denture stability and subjective complaints among edentulous
individuals. J Oral Rehabil. 2012 May;39(5):384-9.

Roumanas ED. The social solution-denture esthetics, phonetics, and f unction. J

Prosthodont. 2009 Feb;18(2):112-5.

Hantash RO et. al. Relationship between impacts of complete denture treatment on

daily living, satisfaction and personality profiles. J Contemp Dent Pract. 2011 May
1;12(3):200-7.

Lin YC et. al. The association of chewing ability and diet in elderly complete denture
patients. Int J Prosthodont. 2010 Mar-Apr;23(2):127-8.

Luraschi J, Schimmel M, Bernard JP, Gallucci GO, Belser U, Müller F.

Mechanosensation and maximum bite force in edentulous patients rehabilitated with
bimaxillary implant-supported fixed dental prostheses. Clin Oral Implants Res. 2012
May;23(5):577-83.

Brennan M et. al. Patient satisfaction and oral health-related quality of life outcomes of
implant overdentures and fixed complete dentures. Int JOMI. 2010 Jul-Aug;25(4):791-
800.

Müller F, Hernandez M, Grütter L, Aracil-Kessler L, Weingart D, Schimmel M. Masseter

muscle thickness, chewing efficiency and bite force in edentulous patients with fixed
and removable implant-supported prostheses: a cross-sectional multicenter study. Clin
Oral Implants Res. 2012 Feb;23(2):144-50.

Aglietta M et. al. A systematic review of the survival and complication rates of implant
supported fixed dental prostheses with cantilever extensions after an observation period
of at least 5 years. Clin Oral Implants Res. 2009 May;20(5):441-51.

Aldo Leopardi, BDS, DDS, MS www.knowledgefactoryco.com Page 14

Assunção WG, Barão VA, Delben JA, Gomes EA, Tabata LF. A comparison of patient
satisfaction between treatment with conventional complete dentures and overdentures
in the elderly: a literature review. Gerodontology. 2010 Jun;27(2):154-62.

Turkyilmaz I, Company AM, McGlumphy EA. Should edentulous patients be

constrained to removable complete dentures? The use of dental implants to improve the
quality of life for edentulous patients. Gerodontology. 2010 Mar;27(1):3-10.

Geckili O, Bilhan H, Mumcu E, Dayan C, Yabul A, Tuncer N. Comparison of patient

satisfaction, quality of life, and bite force between elderly edentulous patients wearing
mandibular two implant-supported overdentures and conventional complete dentures
after 4 years. Spec Care Dentist. 2012 Jul-Aug;32(4):136-41.

Rismanchian M, Bajoghli F, Mostajeran Z, Fazel A, Eshkevari P. Effect of implants on

maximum bite force in edentulous patients. J Oral Implantol. 2009;35(4):196-200.

Burcin A et al. Five-year treatment outcomes with three brands of implants supporting
mandibular overdentures. JOMI 2011;26:188-194.

Anterior Mandible: Immediate Load:

Strietzel FP et. al. Int J Oral Maxillofac Implants. 2011 Jan-Feb;26(1):139-47
Penarrocha-Diago MA et. al. J Oral Maxillofac Surg. 2011 Jan;69(1):154-9.
Capelli M et. al. Int J Oral Maxillofac Implants. 2007 Jul-Aug;22(4):639-44.

Implant Placement, Graftless, in the Edentulous Arch:

Jensen OT et. al. Oral Craniofac Tissue Eng 2012;2:66-71.
Bedrossian E. Int J Oral Maxillofacial Implants. 2010 Nov-Dec;25(6):1213-21.
Malevez C et al. Int J Oral Maxillofac Implants. 2006;21(6):937-942.
Brånemark PI et al. Scand J Plast Reconstr Surg Hand Surg. 2004;38(2):70-85.
Schmidt BL et al. J Oral Maxillofac Surg. 2004;62(9 Suppl 2):82-89.

Silva GC, Mendonça JA, Lopes LR, Landre J Jr. Stress patterns on im plants in
prostheses supported by four or six implants: a three-dimensional finite element
analysis. Int J Oral Maxillofac Implants. 2010 Mar-Apr;25(2):239-46.
Sinus Graft:
Jensen OT, et al. 1998;13(Suppl):11-45
Aldo Leopardi, BDS, DDS, MS www.knowledgefactoryco.com Page 15
 Keller EE, et. al. Int J Oral Maxillofacial Implants. 1999;14(5):707-721.
Raghoebar GM, et al. Clin Oral Implants Res. 2001;12:279-286.
Wallace SS, Froum SJ. Ann Periodontol. 2003;8(1):328-343.
Del Fabbro M, et al. Int J Periodontics Restorative Dent. 2004;24(6):565-577.

Penarrocha-Oltra D, Candel-Marti E, Ata-Ali J, Peñarrocha M.

Rehabilitation of the Atrophic Maxilla with Tilted Implants: Review of the Literature. J
Oral Implantol. 2011 Nov 28

Brennan M, Houston F, O'Sullivan M, O'Connell B. Patient satisfaction and oral health-

related quality of life outcomes of implant overdentures and fixed complete dentures.
Int J Oral Maxillofac Implants. 2010 Jul-Aug;25(4):791-800.

Müller F, Hernandez M, Grütter L, Aracil-Kessler L, Weingart D, Schimmel M. Masseter

muscle thickness, chewing efficiency and bite force in edentulous patients with fixed
and removable implant-supported prostheses: a cross-sectional multicenter study. Clin
Oral Implants Res. 2012 Feb;23(2):144-50.

Manfredini D, Poggio CE, Lobbezoo F. Is Bruxism a Risk Factor for Dental Implants? A
Systematic Review of the Literature. Clin Implant Dent Relat Res. 2012 Nov 13.

Immediate Load, 4 Implants, Tilted, Fixed:

Crespi R et. al. Int J Oral Maxillofac Implants. 2012 Mar-Apr;27(2):428-34.
Babbush CA et. al. J Oral Implantol. 2011 Aug;37(4):431-45.
Graves S et.al. Oral Maxillofac Surg North Am. 2011 May;23(2):277-87.

Romanos GE, Nentwig GH. Immediate functional loading in the maxilla using implants
with platform switching: five-year results. Int J Oral Maxillofac Implants 2009;24:1106-
1112.

Malchiodi L et. al. Int J Oral Int J Oral Maxillofac Implants 2011;26:373-384.

Kinsel RP, Liss M. Retrospective analysis of 56 edentulous dental arches restored with
344 single-stage implants using an immediate loading fixed provisional protocol:
statistical predictors of implant failure. Int J Oral Maxillofac Implants. 2007 Sep-
Oct;22(5):823-30.
Aldo Leopardi, BDS, DDS, MS www.knowledgefactoryco.com Page 16
Jemt T, Johansson J. Implant treatment in the edentulous maxillae: a 15-year follow-up
study on 76 consecutive patients provided with fixed prostheses. Clin Implant Dent
Relat Res. 2006;8(2):61-69.

Bozini T et.al. A meta-analysis of prosthodontic complication rates of implant-supported

fixed dental prostheses in edentulous patients af ter an observation period of at least 5
years. Int J Oral Maxillofac Implants. 2011 Mar-Apr;26(2):304-18.

Pjetursson BE et. al. A systematic review of the survival and complication rates of
implant-supported fixed dental prostheses (FDPs) after a mean observation period of at
least 5 years. Clin Oral Implants Res. 2012 Oct;23 Suppl 6:22-38.

Papaspyridakos P et. al. A systematic review of biologic and technical complications

with fixed implant rehabilitations for edentulous patients. Int J Oral Maxillofac Implants.
2012 Jan-Feb;27(1):102-10.

Zafiropoulos GG et. al. Zirconia removable telescopic dentures retained on teeth or

implants for maxilla rehabilitation. Three-year observation of three cases. J Oral
Implantol. 2010;36(6):455-65

Larsson C, Vult Von Steyern P. Implant-supported full-arch zirconia-based mandibular

fixed dental prostheses. Eight-year results from a clinical pilot study. Acta Odontol
Scand. 2012 Dec 4

Guess PC, Att W, Strub JR. Zirconia in fixed implant prosthodontics. Clin Implant Dent
Relat Res. 2012 Oct;14(5):633-45

Larsson C et. al. A prospective study of implant-supported full-arch yttria-stabilized

tetragonal zirconia polycrystal mandibular fixed dental prostheses: three-year results.
Int J Prosthodont. 2010 Jul-Aug;23(4):364-9

Michael Moscovitch, DDS, CAGS. Int J Periodontics Restorative Dent

2015;35:315–323. doi: 10.11607/prd.2270

Hosseini M et. al. Fracture mode during cyclic loading of implant-supported single-tooth
restorations. J Prosthet Dent. 2012 Aug;108(2):74-83
Aldo Leopardi, BDS, DDS, MS www.knowledgefactoryco.com Page 17
Millen CS et. al. The effect of coping/veneer thickness on the fracture toughness and
residual stress of implant supported, cement retained zirconia and metal-ceramic
crowns. Dent Mater. 2012 Oct;28(10):e250-8

Zhou Y1, Gao J, Luo L, Wang Y. Does Bruxism Contribute to Dental Implant Failure? A
Systematic Review and Meta-Analysis. Clin Implant Dent Relat Res. 2015 Mar 2.

Manfredini D, Poggio CE, Lobbezoo F. Is Bruxism a Risk Factor for Dental Implants? A
Systematic Review of the Literature. Clin Implant Dent Relat Res. 2012 Nov 13

Aglietta M et. al. A systematic review of the survival and complication rates of implant
supported fixed dental prostheses with cantilever extensions after an observation period
of at least 5 years. Clin Oral Implants Res. 2009 May;20(5):441-51

Müller F, Hernandez M, Grütter L, Aracil-Kessler L, Weingart D, Schimmel M. Masseter

muscle thickness, chewing efficiency and bite force in edentulous patients with fixed
and removable implant-supported prostheses: a cross-sectional multicenter study. Clin
Oral Implants Res. 2012 Feb;23(2):144-50

Aldo Leopardi, BDS, DDS, MS www.knowledgefactoryco.com Page 18