Advances in Prosthodontics

CLINICAL EBOOK SERIES POWERED BY
ADVANCES IN
PROSTHODONTICS
DECEMBER 2018
2 C E C R E D I T S
GINGIVAL RECESSION
Prosthetic Management of Gingival

Recession Around Implants
Louis R. Marion, DMD, MS; and Leslie Stone Hirsh, DDS
2 C E C R E D I T S
EDENTULOUS TREATMENTS
Removable and Fixed Fully Edentulous

Treatment Options for the Aging Patient
Stephen Parel, DDS
C A S E R E P O R T
FIXED REMOVABLE PROSTHESIS
Treatment of the Fully Edentulous Patient

With a Fixed Removable Prosthesis
Arnold Rosen, DDS, MBA
SUPPORTED BY AN UNRESTRICTED GRANT FROM DENTSPLY SIRONA IMPLANTS • Published by AEGIS Publications, LLC © 2018
Fixed and of Continuing Education in Dentistry
Removable Options DECEMBER 2018 | www.compendiumlive.com
P
PUBLISHER
AEGIS Publications, LLC
of Continuing Education in Dentistry
rosthetic considerations are in the forefront SPECIAL PROJECTS MANAGER
in this special Compendium eBook. The e- Justin Romano
Book provides two continuing education (CE) SPECIAL PROJECTS EDITOR

Cindy Spielvogel of Continuing Education in Dentistry
articles and a case report involving advances
SPECIAL PROJECTS COORDINATOR
in fixed and removable prosthodontics and June Portnoy
related considerations. BRAND DIRECTOR
The first CE covers prosthetic management of gingi- Matthew T. Ingram
val recession around implants, offering case examples. MANAGING EDITOR

Bill Noone
Complex implant rehabilitations can require staged ap-
CREATIVE
proaches, which often involve serial extraction and can Claire Novo
precipitate gingival recession. This article discusses vary- EBOOK DESIGN
ing approaches for dealing with such gingival changes and Jennifer Barlow
reviews implant treatment-planning protocols. The au-

COVER
thors conclude that, while waiting for the second stage © AEGIS Publications,, LLC
of implants to osseointegrate, it is important to consider
temporary abutments rather than final custom abutments. Copyright © 2018 by AEGIS Publications, LLC. All
rights reserved under United States, International and
As an alternative, the authors suggest that immediate load- Pan-American Copyright Conventions. No part of this
publication may be reproduced, stored in a retrieval
ing be considered to ensure stability of the gingival tissue system or transmitted in any form or by any means
without prior written permission from the publisher.
and minimal future changes. In either case, it is important
PHOTOCOPY PERMISSIONS POLICY:
to employ proper treatment planning and understand the This publication is registered with Copyright
Clearance Center (CCC), Inc., 222 Rosewood
potential causes of gingival recession. Drive, Danvers, MA 01923. Permission is granted
The second CE looks at removable and fixed treatment for photocopying of specified articles provided
the base fee is paid directly to CCC.
options for the fully edentulous aging patient. The au- Printed in the U.S.A.
thor reviews aging as it relates to the use of dentures and
discusses prosthetic restorative alternatives for senior
patients while examining the impact of caries, neurosen-
sory disorders, facial esthetics, and chronological aging on
dental treatments. Although challenges in restoring the
aging patient to a reasonable functional level are always Chief Executive Officer
present, the possibilities that implant therapy offers are Daniel W. Perkins
increasingly encouraging. The author notes that implants President

Anthony A. Angelini
are particularly relevant in addressing the potential for
Chief Operating and Financial Officer
bone loss. He adds that aging patients will benefit from Karen A. Auiler
advances in immediate-load fixed provisionalization and Media Consultant, Midwest and West
same-day final restoration delivery concepts. Jeffrey E. Gordon
Media Consultant, East
In addition to the two CE articles, this eBook provides Scott MacDonald
a case report on treatment of a fully edentulous patient Subscription and CE information
with a fixed removable prosthesis. For more information Hilary Noden
877-423-4471, ext. 207
on prosthodontics topics, please visit https://www.aegis- hnoden@aegiscomm.com
dentalnetwork.com/cced/prosthodontics/.
Sincerely,
Louis F. Rose, DDS, MD

Editor-in-Chief
lrose@aegiscomm.com AEGIS Publications, LLC
104 Pheasant Run, Suite 105
Newtown, PA 18940
CONTINUING EDUCATION 1 GINGIVAL RECESSION
Prosthetic Management of Gingi-

val Recession Around Implants:
Lessons Learned from Staged-
Approach Treatment Planning
ABSTRACT: Complex implant rehabilitations can include procedures requiring mul-

tiple phases of treatment, commonly referred to as staged approaches. The reasons for
staged approaches are varied but usually involve serial extraction of hopeless teeth.
These treatment plans both enable the patient to avoid removable prostheses by keep-
ing natural teeth during healing phases, and circumvent the immediate loading of
some implants placed in grafted bone. One major disadvantage to serial extraction in
a staged approach is the potential for gingival changes. These changes include gingival
recession around abutments that can affect the gingival profile around the finished
case. This article discusses varying approaches for dealing with these gingival changes
and suggests protocol modifications during the implant treatment-planning phase.
LEARNING OBJECTIVES
• Understand the purpose of • Describe different methods of • Discuss protocol

using a staged approach for dealing with gingival changes modifications that can be
multiple implant restorations. that occur due to a staged made to the multiple-implant
T
approach. treatment plan.
reatment plans involving the transi- treatment plan—was formulated primarily to

tion of a patient from a failed denti- provide fixed restorations for patients with
tion to one supported by implants hopeless dentitions without the need for re-
can take time when the goal is to movable provisional phases.1,3,4 While it may
avoid placing that patient in a re- vary for each patient, this type of treatment
movable prosthesis. One option is immediate generally involves multiple stages of implant
loading of implants with a full-arch provi- placement during which residual but hopeless
sional.1,2 However, if the treating surgeon de- teeth are kept as temporary abutments to hold
termines that the implants cannot be loaded fixed provisional restorations. Once the abut-
(which could be for a variety of reasons), meth- ment connection is performed on the first set
odologies to avoid immediate loading need to of implants, the residual teeth are extracted
be employed. Many restorative dentists and and a second stage of implant placement is
surgeons might then opt for serial extractions accomplished. After the second or final set
so that the patient is never totally without of implants has healed, implant prosthodon-
teeth. This protocol—often termed a staged tic procedures can be performed to complete
approach, serial extraction protocol, or phased treatment. Cavallaro and Greenstein divide
DISCLOSURE: The authors had no disclosures to report.
www.compendiumlive.com December 2018 COMPENDIUM EBOOK SERIES 3

this protocol into two classifications: Class I, keratinized peri-implant tissue tend to help
with all the implants placed during the initial minimize recession. However, after a thor-
surgery; and Class II, with two or more stages ough literature review of many soft-tissue
of implant placement to generate sufficient factors, Greenstein and Cavallaro concluded
implant support.4,5 that the literature does not clearly define a
Whether the staged approach treatment patient’s susceptibility to recession related to
plan has one, two, or multiple implant phas- many of these factors.19
es, the main disadvantages often relate to the Saadoun and Touati cite biotype at implant
treatment time and multiple surgical steps sites and position of the implant fixture in
involved. The advantages are numerous, in- relation to the cortical wall as factors in po-
cluding the ability to use a fixed provisional tentially predicting a susceptibility to reces-
restoration throughout treatment and healing sion.12,13 Lee et al found that a thin soft-tissue
phases, simplified guidance for implant place- biotype of <2 mm is associated with thinner
ment, and preserved masticatory function.1,3 underlying bone, angular bone defects, and
Cordaro et al also cite soft-tissue management increased susceptibility to the loss of papilla
as an advantage with this staged approach.1 after immediate implant placement.20 In ad-
Despite such recent advances in implant den- dition, such a biotype is more prone to reces-
tistry as virtual planning, immediate loading, sion in response to trauma and bacteria than
and improved fixture surfaces, soft-tissue a thick biotype. In response to this concern,
healing is still not routinely predictable.6-9 Butler and Kinzer recommend planning
While loss of up to 1 mm of marginal bone in implant placement at a minimum of 2-mm
the first year after abutment connection was palatal to the facial contour of the adjacent
once considered acceptable,10,11 it has become teeth.21 They agree with Bashutski and Wang,
evident that over time, this can also mean loss who observed that facially positioned im-
of soft tissue in that same period or in years to plants are at risk for gingival recession.22 Le
come.12,13 Whether tissue loss is immediate or and Borzabadi-Farahani concluded that both
subsequent, the success of treatment is judged labial soft-tissue thickness and labial bone
not only by function and dental esthetics, but thickness are key factors in predicting reces-
also by soft-tissue esthetics. sion occurrence.23
Recession defects, whether around a natural Tarnow et al have suggested that, if the dis-
tooth or an implant, may be caused by a variety tance between adjacent implants is <3 mm,
of factors. Surgical trauma, aggressive tooth the height of the alveolar bone decreases and
brushing, periodontitis or peri-implantitis, preserving the gingival papilla becomes diffi-
parafunctional habits, and tooth malposition cult.24 In a key study in 2003, Tarnow et al con-
have been cited as some of the causitive fac- cluded that clinicians should use great caution
tors.14 With implants specifically, initial lon- when placing implants adjacent to each oth-
gitudinal studies have always measured the er, so that they are at least 3 mm apart. They
recession at the time of abutment placement further suggest that treatment plans should
or periodically at later periods after final case be modified to either adhere to this rule or
insertion. Adell et al reported 1.7 mm of reces- utilize pontics and/or natural teeth to better
sion in a 3-year study.15 Aspe et al,16 Bengazi preserve esthetic soft-tissue contours.25
et al,17 and Small and Tarnow18 found similar Retained natural-tooth roots were utilized
results in their respective studies that ana- under removable prostheses to preserve al-
lyzed the issue at times from initial placement veolar bone many years before implants.26,27
to 9 years; all concluded that factors such as Extraction of teeth triggers the resorption
4 COMPENDIUM EBOOK SERIES December 2018

of alveolar bone and surrounding tissues. resorption and concomitant recession.30,31

Schropp et al found that such resorption re- Soft-tissue management in the staged-
duces the width of the alveolar ridge by up to approach protocol can be unpredictable and
50% in just 1 year.28 Salama et al demonstrated present esthetic challenges—mainly gingival
that submerged roots can maintain surround- recession.13,22,33 This article will show several
ing alveolar bone and soft tissues adjacent examples of different staged-approach cases
to implants. They also demonstrated that a with soft-tissue recession around abutments.
submerged root will preserve a much great- These cases are organized by treatment plan
er amount of surrounding tissue than com- modifications, which range from leaving the
monly used socket preservation techniques, visible gold collar of the abutments alone to
which often result in crestal bone resorption, remaking the abutments and castings.
thereby reducing the height of the interdental
papilla and edentulous ridge width.29 Case Examples
Abutment connections to implant fixtures Case 1 – Re-preparing Abutments Intraorally
can also be a factor in recession susceptibil- Background: This patient had a failing maxil-
ity. Jansen et al30 and Zipprich et al31 found lary dentition and refused to wear a removable
that abutment connection type can be a fac- prosthesis. A staged approach was employed
tor in bone loss and associated soft-tissue to retain some of his natural tooth abutments,
recession. Jansen et al tested many different and recession was noticed at the time of the
implant abutment systems for microbial leak- impression for the second group of implants.
age and bacterial colonization around the in- Figure 1 shows the patient following insertion
ner surfaces of the implant systems (fixture of the first set of implant custom abutments;
head, abutment screw, and abutment). They the adjacent natural teeth are still present to
concluded that certain types of implants with support the provisional bridge. Seven months
flat-to-flat interfaces allow more bacteria to later, as shown in Figure 2, those first-stage
colonize in and around their components.30 custom abutments exhibited evidence of 1 mm
Zipprich et al found that elastic deformation to 3 mm of recession.
of the connection screw in non–self-locking Results: A decision was made to re-prepare
implants—such as externally hexed implants all of the abutments intraorally (Figure 3) so
with flat-to-flat abutment interfaces—tilt un- that all abutment margins would be at or be-
der extra-axial loading and cause micromove- low the gingival margin. (Of note, tooth Nos.
ment at prosthetic abutment-to-implant inter- 8 and 9, also shown in Figure 3, were later
faces.31 Brunski stated that “micromotion can submerged for the case to be fully implant-
be deleterious at the bone–implant interface, supported.) While re-preparation greatly
especially if the micromotion occurs soon af- improved the esthetics of the final result, it
ter implantation,” and micromotion of more required retraction cord placement, new im-
than 100 µm should be avoided to prevent the pressions, and new castings.
wound from undergoing fibrous repair rather (Note: A separate but similar type of case
than osseous regeneration.32 While techniques shown in Figure 4 and Figure 5 further illus-
like platform switching can reduce such mi- trates intraoral abutment re-preparation.)
cromovement, self-locking implants such as
those that are internally hexed with long in- Case 2 – Re-preparing Abutments
ternal connections are particularly effective Intraorally with Extraoral Impressions
in preventing micromovement that could in- Background: This case had similar recession
flame the soft tissue and cause crestal bone problems as the previously mentioned cases.

impression tray could be used to provide sup-

port for the impression material). Figure 7
shows the custom abutment with cotton and
wax placed to prevent impression material
from entering the screw-access chamber, and
Figure 8 illustrates the impression technique.
This avoids the need to place retraction cord in
the sulcus around the implant. This technique
Fig 1. is also useful for adding to the margins of the
provisional.
Case 3 – Remilling of Custom Abutments

Background: In this case, the patient had a
failing mandibular and maxillary dentition
due to caries secondary to radiation-induced
xerostomia. The patient had had a radical
neck dissection to remove a squamous cell
Fig 2. carcinoma of the throat 9 years prior to his
prosthodontic consultation with the authors.
The patient reported a history of radiation
therapy following surgery, but did not have a
shielding stent. A staged approach was used
so as to avoid removable prosthetics on his
severely dry soft tissues. He chose to treat
his mandibular issues first. Figure 9 shows
healing abutments next to the temporarily
retained natural teeth, and Figure 10 shows
Fig 3. the first-stage custom abutments inserted
Fig 1. Patient following insertion of first set of im-
with relatively good gingival contour and no
plant custom abutments. Fig 2. After 7 months, the recession. Recession was clearly seen around
first-stage custom abutments exhibited evidence all first-stage abutments following adjacent
of 1 mm to 3 mm of recession. Fig 3. Abutments re- extractions and second-stage implant place-
prepared intraorally.
ment (Figure 11).
Although the abutments were re-prepared Results: The decision was made to remove
intraorally to follow the new tissue margins, these abutments and make a fixture-level im-
the decision was made to impress outside the pression of all the implants so that both new
mouth to avoid manipulation of the patient’s and first-stage abutments could be milled
thin biotype tissue. Each custom abutment was together for parallelism and proper gingival
removed and healing abutments were imme- margin location. Because this requires the re-
diately inserted to avoid collapse of the tissues. moval of the first-stage abutments that were
Results: Each custom abutment was placed retaining the provisional prosthesis, tempo-
on an implant fixture analog. Figure 6 shows rary abutments were placed prior to removal
the newly prepared abutment on its analog with of all custom abutments in order to assure
a large-sized copper band to support impres- proper seating and vertical dimension of the
sion material (alternatively, a stock quadrant provisional. These temporary abutments then

retained the provisional while all custom abut-

ments were fabricated and/or milled in the
laboratory. Figure 12 shows the placement of
the remilled (first-stage implants) and new
(second-stage implants) custom abutments.
Case 4 – Temporary Abutments

Background: This patient had a failing man-
Fig 4.
dibular right posterior dentition due to a ver-
tical root fracture and secondary caries. The
authors used screw-retained temporary abut-
ment cylinders as an initial means of retention
for the provisional bridge after the first stage
of treatment, which included extractions and
implant placement.
Results: The temporary cylinders screwed
to the implants following placement are shown
in Figure 13. They were luted to a prefabricat- Fig 5.
ed acrylic shell constructed from the patient’s
Fig 4. Following osseointegration of an implant
diagnostic wax-up (Figure 14). Following at No. 12, recession was observed at the fixture-
removal of excess acrylic, the fixed screw- level impression stage of No. 13; it was decided to
retained provisional prosthesis was inserted re-prepare the margins of the CAD/CAM custom
(Figure 15). abutment of implant No. 12. Retraction cord was
placed prior to preparation to avoid tissue injury
and improve visibility of both tooth No. 11 and the
Case 5 – Conical Abutments Used as implant custom abutment margin. As expected,
Temporary Abutments recession was greater along the distal side of
abutment No. 12, adjacent to the healed extrac-
Background: The patient in this case present- tion/newer implant site. Fig 5. Newly placed
ed with a failing dentition due to generalized custom abutment on No. 13 with the previously
severe periodontal disease with secondary re-prepared abutment at No. 12. No new recession
endodontic lesions. She adamantly refused to has occurred since the case was completed more
than 3 years ago.
wear removable transitional prostheses. Full
maxillary and mandibular extractions were Results: Stock titanium abutments were
performed in the first phase of treatment. Not used until all tissue healing was achieved and
all implants could be placed in this initial phase the secondary implants had healed. Figure 18
due to the need for healing of certain grafted shows the maxillary and mandibular custom
sites. The implants placed in this first phase abutments inserted. Figure 19 shows a close-
were loaded with conical abutments and, in up of the patient’s right side quadrants, depict-
some cases, their angulated counterparts ing the final case 15 months after initial treat-
(Figure 16 and Figure 17). These stock titanium ment began. Recession can be seen around
Fig 11. Fig 12.
abutments were selected to avoid the need, as units corresponding to tooth Nos. 5 and 6. In
in Case 3, to change or remill the more costly this case, the authors attempted to minimize
custom abutments. They also have the advan- recession susceptibility by employing stock
tage of making it unnecessary to use temporary temporary screw-retained abutments during
cement near and around surgical sites, as they healing phases throughout the initial stages
use occlusal screws only for retention. of the treatment plan. Despite these efforts,

recession still occurred in certain areas where Once implant Nos. 6 and 11 integrated, custom
the implants were labially placed. Since the abutments were placed, and the provisional
photographs shown in this case were taken, was relined to add their support. Then im-
an unsuccessful attempt was made by the pa- plants and their respective subsequent abut-
tient’s surgeon to graft soft tissue around these ments could be placed at position Nos. 7 and
sites with recession. 9 (Figure 20). Tooth No. 8 received elective
endodontic treatment in order to be reduced
Case 6 – Root Submergence and eventually submerged following insertion
Background: This patient presented with a of the abutments at Nos. 7 and 9 (Figure 21
failing maxillary bridge spanning tooth Nos. and Figure 22).
6 through 11. In order to keep the patient in Results: In Figure 22, it is apparent that there
a fixed transitional prosthesis, the first phase is no recession around abutment Nos. 7 and
of treatment involved placing a provisional 9 following root submergence. Of additional
restoration on Nos. 6 through 11, with the first note, Figure 23 illustrates excellent bone labial
set of implants placed at site Nos. 6 and 11. to all the implants, with no recession around
Fig 6. Fig 7. Fig 8.
Fig 9. Fig 10.
Fig 11. Fig 12.
Fig 6. Newly prepared abutment on analog. Fig 7. Custom abutment with cotton and wax. Fig 8. Impres-
sion technique. Fig 9. Healing abutments. Fig 10. First-stage custom abutments. Fig 11. Recession evi-
dent around first-stage abutments following adjacent extractions and second-stage implant placement.
Fig 12. Remilled and new custom abutments.

abutment Nos. 6 or 11. These first abutments

were inserted 8 months prior to the ones at
Nos. 7 and 9. The time between Figure 21, when
root submergence took place, and Figure 23,
when the final bridge was to be inserted, was
7 months. Figure 24 shows placement of the
provisional bridge on all abutments.
Fig 13.
Discussion
All of the above clinical cases used staged treat-
ment plans that involved careful surgical and
prosthetic planning. The one common difficulty
throughout each case was managing the soft-
tissue architecture. The gingival recession seen
in most of these complex cases highlights the
importance of careful consideration of vari-
ous factors that can lead to recession, even in
Fig 14.
simpler cases. The potential causes of gingival
recession, and related considerations when
treatment planning implant-supported rehabil-
itations, are discussed in the following sections.
Implant Position
Quantity of buccal bone—Le and Borzabadi-
Farahani concluded that a minimum of 2 mm
of facial bone is necessary to prevent future
recession.23 Bashutski and Wang noted that the Fig 15.
most common esthetic complication is gingival Fig 13. Temporary cylinders screwed to implants.
recession, and cited inadequate buccal bone Fig 14. The cylinders luted to prefabricated acrylic
thickness, implants placed too far buccally, shell. Fig 15. Fixed screw-retained provisional
prosthesis.
and failure to graft “jumping distance” during
immediate placement in the etiology of reces- Buccal-labial position of implants—
sion.22 Case 5’s final result (Figure 19) shows Saadoun and Touati concluded that the buccal
more than 2 mm of labial recession around the orientation of the implant will impinge upon
implant-supported abutments at site Nos. 5 the buccal cortical wall and induce bone re-
and 6 (this was also the case at site Nos. 13 and sorption and apical migration of the tissue.13
14). Referring back to Figure 17, it is apparent Chu et al reported that if the implant is not
that site Nos. 5, 6, 8, and 12 demonstrate very placed more palatally and 3-mm to 4-mm api-
little buccal soft tissue due to the labial place- cal to the free gingival margin to assure the
ment of the implants. Butler and Kinzer sup- proper emergence profile, the esthetic out-
port the premise that there must be adequate come may be compromised.34 Bengazi et al’s
bone volume facially, even when the implant is 2-year longitudinal study demonstrated that
placed ideally, and they found that many com- anteriorly positioned implants demonstrated
plications are related more to the implant posi- slightly more recession than implants in pos-
tion and the associated anatomical findings.21 terior positions.17 Buccal implant placement

can be clearly seen in Case 5 (Figure 17) with notes that patients with periodontal disease
healing abutments in place. requiring tooth replacement often have os-
Proximity to adjacent implants—Tarnow seous defects that, if left untreated, can result
et al24 and Tarnow et al25 recommend that a in esthetic failures. When the gingival margin
minimum of 3 mm of bone exist between two of the tooth to be extracted is apical to the de-
adjacent implants. In site Nos. 13 and 14 (Case sired implant position, it may be beneficial
5) the fixture heads have less than 2 mm be- to employ orthodontic forced eruption prior
tween them, and the abutments have less than to extraction, which allows the tooth or teeth
1 mm (Figure 17). Because interdental tissues surrounding bone and papilla to be moved
do not have the same level of support between coronally.35 Salama and Salama demonstrated
implants as they do with natural teeth, inter- that this will enhance both the alveolar bone
dental distance becomes more critical in pre- and soft-tissue profile prior to extraction and
dicting the final soft-tissue position. implant placement.36 Saadoun and Touati note
Implant tissue depth—While not an issue in that after 8 weeks of extrusion, the gingival
any of the cited cases, proper depth during im- margin and papilla are located at a level that
plant placement is also important. Bashutski is compatible with the future implant crown
and Wang suggest that placing an implant too position, followed by 3 months of splinting to
deep may result in bone loss and gingival reces- gain bone maturation and gingival stability.12
sion, and they recommend implant placement Again, while this is a critical factor, none of
at 1.5 mm to 3 mm below the cementoenamel the patients in the presented cases required
junction for optimal esthetics.22 orthodontic therapy to correct preoperative
Preoperative tooth position—Rasner tooth position.
Fig 16. Fig 17.
Fig 18. Fig 19.
Fig 16 and Fig 17. First-phase implants loaded with conical abutments and, in some cases, their angulat-
Fig
ed 15.
counterparts. Fig 18. Custom abutments inserted. Fig 19. Final result 15 months after initial treatment
began, showing patient’s right side quadrants.

Biotype: Thin vs Thick biotype, which will ultimately enhance gingi-

Cases 3 and 5 presented with a thin-scalloped val stability and improve tissue management
architecture or biotype. Lee et al20 and Le and throughout the restorative phase.13 Minor
Borzabadi-Farahani23 cite this biotype as a ma- grafting to improve the level of attached ke-
jor determining factor for increased suscepti- ratinized tissue was employed in Cases 3 and 6.
bility to recession. Kao and Pasquinelli note
that for thin biotypes, both acute and chronic Surgery
inflammation will result in gingival recession. Number of surgical steps—In many cases,
Because patients with a thin biotype respond the patient’s treatment plan may consist of
to periodontal, surgical, or other soft-tissue both serial extraction and phased implant
traumas with recession, additional care and placement involving as many as four differ-
careful treatment planning must be done to ent surgeries, including extractions, implant
minimize the possibility of soft-tissue loss and placement, and uncovering at different stages.
increase the chance for esthetic success.37 The authors believe that reducing the number
As Saadoun and Touati point out, a thick bio- of surgical interventions may minimize the
type with a greater amount of attached kera- amount of recession as well as the potential
tinized gingiva will have more resistance to for soft-tissue changes. Cordaro et al also con-
traumatic or inflammatory recession, while cluded that one of the main drawbacks of a
a thin biotype is more susceptible to peri-im- serial extraction/staged approach is extended
plant recession induced by the resorption of treatment time and multiple surgical steps.1
the thin labial cortical plate.13 Bashutski and In addition, Saadoun and Touati point out
Wang recommended that for patients with that forced eruption may be the best solution
thin biotypes with less than 1.5-mm facial for patients with a thin biotype to limit the
gingival thickness, implants should be placed number of surgical procedures by improv-
more palatally and apically.22 Saadoun and ing the hard- and soft-tissue profile prior to
Touti suggest that a connective tissue graft extraction.12
will convert a thin biotype into a thick gingival Surgical preservation protocols—One of
Fig 22.
Fig 20. Fig 21.
Fig 20. Implants and their re-
spective subsequent abutments
placed at Nos. 7 and 9. Fig 21.
Endodontically treated tooth No.
8. Fig 22. Tooth No. 8 eventu-
ally submerged following abut-
ment insertion at Nos. 7 and 9.
Fig 23. Excellent bone labial to
all the implants; no recession
around abutment Nos. 6 or 11.
Fig 24. Provisional bridge on all
Fig 23. Fig 24.
abutments.

the most critical surgical strategies, according soft-tissue recession around wide-diameter
to Chu et al, should be atraumatic tooth remov- implants measured, on average, 1.58 mm com-
al without flap elevation. This is particularly pared to 0.57 mm around standard-diameter
critical in the esthetic zone, where the buccal implants.12 Small et al suggest that smaller-di-
bone plate and soft tissues are the thinnest. ameter implants may be more beneficial than
They reason that it is vital to maintain the re- wider ones in the esthetic zone, because wider
maining blood supply from the periosteum and ones may leave thinner labial or buccal bone,
endosteum for maximum healing potential.34 which leads to a potential for increased crestal
Penarrocha-Oltra et al suggest the use of resorption.40 All the cases presented above uti-
particulate autogenous bone to fill implant- lized standard- to small-diameter implants in
bone gaps wider than 2 mm and to cover any esthetic zones; therefore, the occurrence of
dehiscences and fenestrations.38 Chu et al recession was likely due to other factors.
recommend using autogenous allograft, xe-
nografts, and synthetic bone materials in the Types of Abutments: Temporary, Stock
gaps to improve bone contours for better hard- Titanium, Custom
and soft-tissue volume.34 In a recent review of Cases 1 and 3 demonstrate that placing final
surgical techniques, Orgeas et al concluded abutments adjacent to planned extraction
that most socket-preservation techniques are teeth and implant sites during staged ap-
effective in preserving horizontal and vertical proaches often results in gingival recession
ridge height. Their meta-analysis concluded apical to the shoulder of the final abutments.
barrier membranes alone might improve heal- A better protocol would be to place tempo-
ing in extraction sites.39 rary abutments to secure the provisional, and
Despite the use of these intricate surgical only once all the teeth have been extracted,
preservation protocols, soft-tissue preserva- all the implants have integrated, and the tis-
tion did not always occur in the cases above. sue is stable should impressions be taken for
Cases 1 and 3 employed such techniques; the final abutments. The options prior to final
however, recession resulted following post- abutments include temporary abutments, as
surgical healing, which may have been due to utilized in Case 4; stock titanium abutments
other contributing factors. would be another option. This would result
in a greater degree of gingival predictability
Implant Type because the final abutments and final restora-
Internally versus externally connected tion are fabricated from a post-surgical and,
abutments—Recession occurred in Cases 3 more importantly, a post-healing impression.
and 5, both of which utilized externally hexed All six cases reviewed in this paper used cast
implants from two different manufacturers. custom abutments. While the tissue cuff and
One factor could have been what Zipprich et contour can be precisely designed per patient,
al referred to when they discussed both in- it is not this design that determines recession;
ternal and external abutment connections. In rather, the authors believe, it is the timing
their 2007 study, they demonstrated that an that determines the soft-tissue outcomes in
external connection can allow for the poten- these staged treatment plans. Some clinicians
tial for micromovement, which may lead to have converted their techniques to CAD/CAM
crestal bone loss and subsequent soft-tissue custom abutments. Several companies sug-
recession.31 gest that this offers the advantage that two
Implant diameter: standard versus wide custom abutments can be produced for each
or narrow—Saadoun and Touati report that implant—one that can be used as a temporary

abutment for a temporary phase of treatment, The best protocol to avoid recession or to adapt
and the other as a final abutment for the final to the changing gingival contours might be to
restoration.41,42 While this may offer a benefit, proceed with final custom abutments only
if recession occurs, the implants will still have when all surgical healing is completed. The
to be re-impressed or the clinician will have to ideal practice is to use what the authors call
modify the second abutment with one or more a “staged abutment protocol,” utilizing tem-
of the techniques discussed above to accom- porary abutments or stock conical or angled
modate the changes in the gingival margins. abutments with related temporary cylinders.
This staged-abutment protocol would not use
Extraction vs Root Submergence a final abutment until all soft-tissue healing
Case 6 demonstrates the use of root submer- has occurred. Then and only then should new
gence adjacent to implants. Teeth that have fixture-level impressions be done to fabricate
been temporarily retained to secure a provi- these final custom abutments.
sional during osseointegration can be reduced
to a subosseous level and submerged rather Conclusion
than extracted. Salama et al reported that The causes of gingival recession are multifacto-
the use of the root submergence technique rial. In light of studies that illustrate increased
for pontic site development can result in a gingival recession when implants are placed
minimization of crestal bone resorption and buccally or with minimal buccal bone, too
an increased preservation of surrounding soft close to one another, too deep, or are externally
tissue.29 This ultimately results in a greater connected; when wide-bodied implants are
degree of gingival stability and predictability. employed in the esthetic zone; when the pre-
operative tooth position is too apical; or when a
Immediate Loading Option staged approach is required, gingival recession
Tarnow et al reported that implants stabilized should be anticipated as a possible sequela fol-
by splinting at initial placement, using the wid- lowing extractions and second-stage implant
est anterior-posterior distribution, were able placement. This necessitates reevaluation dur-
to resist the critical degree of micromovement ing the treatment-planning phase to minimize
at the bone–implant interface.43 Lemongello44 the possibility of gingival recession. Should re-
and Cooper et al45 suggested that immediate cession occur, various techniques can be used
implant placement is recommended for its to modify the final abutments. Techniques in-
ability to reduce gingival tissue loss following clude re-preparing the abutments intraorally
extraction and maintenance of gingival and al- and impressing them intraorally or extraorally,
veolar structures. In addition, the advantages or remilling the first set of abutments at the
of immediate provisionalization include an time the second set of implant abutments are
elimination of additional surgery, immediate being constructed. Unfortunately, in all of the
nonocclusal loading in some partially edentu- cases presented above, the castings for the final
lous patients, bone preservation, and esthetic crowns, which were constructed by the labora-
benefit. As shown in Case 4, which was an im- tory when the abutments were made, had to
mediately loaded case, no gingival recession be discarded and new castings made. While
was observed. the final result is esthetically acceptable, the
Regardless of the specific etiology of gingival need for new castings can dramatically in-
recession, staged-approach implant treatment crease the laboratory costs to the restorative
plans usually will involve some, if not all, of the dentist as well as the amount of time required
factors of potential recession outlined above. for treatment.

report. Pract Proced Aesthet Dent. 2005;17(4):267-

Therefore, it is important to reconsider 272.
using temporary abutments rather than fi- 4. Cavallaro JS Jr. The classification and clinical ap-
nal custom abutments while waiting for the plication of the serial extraction protocol for full- and
second stage of implants to osseointegrate. partial-arch fixed prostheses.
2008;20(6):377-382.
Temporary abutments would secure the pro- 5. Greenstein G, Cavallaro J Jr. Serial extraction pro-
visional while allowing a fixture-level im- tocol: transitioning a hopeless dentition to a full-
pression of all the integrated implants to be arch reconstruction. Compend Contin Educ Dent.
2008;29(9):526-534.
taken following gingival healing. Thus, when
6. Johansson B, Friberg B, Nilson H. Digitally planned,
utilizing a staged approach, one must employ immediately loaded dental implants with prefabri-
staged abutments rather than proceed to the cated prostheses in the reconstruction of edentulous
final abutment before all the implants have maxillae: a 1-year prospective, multicenter study. Clin
Implant Dent Relat Res. 2009;11(3):194-200.
healed to ensure a greater degree of soft-tissue 7. Katsoulis J, Pazera P, Mericske-Stern R. Prostheti-
predictability. Alternatively, immediate load- cally driven, computer-guided implant planning for
ing should be considered to ensure stability of the edentulous maxilla: a model study. Clin Implant
the gingival tissue and minimal future changes Dent Relat Res. 2009;11(3):238-245.
8. Junker R, Dimakis A, Thoneick M, Jansen JA. Effects
following fixture-level impressions. In either of implant surface coatings and composition on bone
case, proper treatment planning and under- integration: a systematic review. Clin Oral Implants
standing the potential causes of gingival reces- Res. 2009;20(4 suppl):185-206.
9. Piattelli A, Pontes AE, Degidi M, Iezzi G. Histologic
sion are paramount.
studies on osseointegration: soft tissues response to
implant surfaces and components. A review. Dent
ABOUT THE AUTHORS Mater. 2011;27(1):53-60.
Louis R. Marion, DMD, MS 10. Albrektsson T, Zarb G, Worthington P, Eriksson AR.
Clinical Assistant Professor, Department of Periodontics, Long-term efficacy of currently used dental implants:
University of Pennsylvania School of Dental Medicine, a review and proposed criteria of success. Int J Oral
Philadelphia, Pennsylvania; Clinical Assistant Professor, Maxillofac Implants. 1986;1(1):11-25.
Department of Oral and Maxillofacial Surgery and Pediatric 11. Jemt T, Lekholm U, Grondahl K. A 3-year fol-
Dentistry, Children’s Hospital of Philadelphia, Philadelphia, lowup of early single implant restorations: ad mo-
Pennsylvania; Prosthodontist, Private Practice, Philadelphia, dum Brånemark. Int J Periodontics Restorative Dent.
Pennsylvania 1990;10(5):340-349.
12. Saadoun AP, Touati B. Soft tissue recession around
Leslie Stone Hirsh, DDS implants: is it still unavoidable? Part I. Pract Proced
Clinical Assistant Professor, Department of Preventive and Aesthet Dent. 2007;19(1):55-62.
Restorative Sciences, University of Pennsylvania School of 13. Saadoun AP, Touati B. Soft tissue recession around
Dental Medicine, Philadelphia, Pennsylvania; Prosthodontist, implants: is it still unavoidable? Part II. Pract Proced
Private Practice, Philadelphia, Pennsylvania Aesthet Dent. 2007;19(2):81-87.
14. Rose LF, Mealey B, Genco R, Cohen DW. Periodon-
Queries to the authors regarding this course may be submit- tics: Medicine, Surgery and Implants. Philadelphia, PA:
ted to authorqueries@aegiscomm.com. Mosby; 2004:122-128.
15. Adell R, Lekholm U, Rockler B, et al. Marginal tis-
REFERENCES sue reactions at osseointegrated titanium fixtures
1. Cordaro L, Ferrucio T, Ercoli C, Gallucci G. Transition (I). A 3-year longitudinal prospective study. Int J Oral
from failing dentition to a fixed implant-supported Maxillofac Surg. 1986;15(1):39-52.
restoration: a staged approach. Int J Periodontics Re- 16. Aspe P, Zarb GA, Schmitt A, Lewis DW. The longitu-
storative Dent. 2007;27(5):481-487. dinal effectiveness of osseointegrated dental implants.
2. Ercoli C, Geminiani A, Heeje L, et al. Restoration of The Toronto study: peri-implant mucosal response.
immediately loaded implants in a minimal number of Int J Periodontics Restorative Dent. 1991;11(2):94-111.
appointments: a restrospective study of clinical effec- 17. Bengazi F, Wennstrom JL, Lekholm U. Recession
tiveness. Int J Oral Maxillofac Implants. 2012;27(6):1527- of the soft tissue margin at oral implants. A 2-year
1533. longitudinal prospective study. Clin Oral Implants Res.
3. Waliszewski M, Janakievski J. Sequencing patients to 1996;7(4):303-310.
implant-supported, full-mouth reconstructions: a case 18. Small PN, Tarnow DP. Gingival recession around

implants: A 1-year longitudinal prospective study. Int restoration. A report of three cases. Eur J Prothodont
J Oral Maxillofac Implants. 2000;15(4):527-532. Restor Dent. 2010;18(2):55-59.
19. Greenstein G, Cavallaro J. The clinical significance 34. Chu SJ, Salama MA, Salama H, et al. The dual-
of keratinized gingiva around dental implants. Com- zone therapeutic concept of managing immediate
pend Contin Educ Dent. 2011;32(8):24-31. implant placement and provisional restoration in an-
20. Lee A, Fu JH, Wang HL. Soft tissue biotype affects terior extraction sockets. Compend Contin Educ Dent.
implant success. Implant Dent. 2011;20(3):e38-e47. 2012;33(7):2-11.
21. Butler B, Kinzer GA. Managing esthetic im- 35. Rasner, SL. Orthodontic extrusion: an adjunct to
plant complications. Compend Contin Educ Dent. implant treatment. Dent Today. 2011;30(3):104-109.
2012;33(7):514-522. 36. Salama H, Salama MA. The role of orthodontic
22. Bashutski JD, Wang HL. Common implant esthetic extrusive remodeling in the enhancement of soft and
complications. Implant Dent. 2007;16(4):340-348. hard tissue profiles prior to implant placement: a
23. Le BT, Borzabadi-Farahani A. Labial bone thick- systematic approach to the management of extrac-
ness in area of anterior maxillary implants associated tion site defects. Int J Periodontics Restorative Dent.
with crestal labial soft tissue thickness. Implant Dent. 1993;13(4):312-333.
2012;21(5):406-410. 37. Kao RT, Pasquinelli K. Thick vs. thin gingival tis-
24. Tarnow DP, Cho SC, Wallace SS. The effect of inter- sue: a key determinant in tissue response to dis-
implant distance on the height of inter-implant bone ease and restorative treatment. J Calif Dent Assoc.
crest. J Periodontol. 2000;71(4):546-549. 2002;30(7);521-526.
25. Tarnow D, Elian N, Fletcher P, et al. Vertical dis- 38. Penarrocha-Oltra D, Covani U, Aparicio A, et al.
tance from the crest of bone to the height of the Immediate versus conventional loading for the maxilla
interproximal papilla between adjacent implants. J with implants placed in fresh and healed extraction
Periodontol. 2003;74(12):1785-1788. sites to support a full-arch prosthesis: nonrandomized
26. Dachi, SF, Howell FV. A survey of 3,874 routine full- controlled clinical study. Int J Oral Maxillofac Implants.
mouth radiographs. I. A study of retained roots and 2013;28(4):1116-1124.
teeth. Oral Surg Oral Med Oral Pathol. 1961;14:916-924. 39. Vittorini Orgeas G, Clementini M, De Risi V, de Sanc-
27. O’Neal RB, Gound T, Levin MP, del Rio BCE. Sub- tis M. Surgical techniques for alveolar socket preserva-
mergence of roots for alveolar bone preservation. I. tion: a systematic review. Int J Oral Maxillofac Implants.
Endodontically treated roots. Oral Surg Oral Med Oral 2013;28(4):1049-1061.
Pathol. 1978;45(5):803-810. 40. Small PN, Tarnow DP, Cho SC. Gingival recession
28. Schropp L, Wenzel A, Kostopoulos L, Karring T. around wide-diameter versus standard-diameter im-
Bone healing and soft tissue contour changes follow- plants: a 3- to 5-year longitudinal prospective study.
ing single tooth extraction: a clinical and radiographic Pract Proced Aesthet Dent. 2001;13(2):143-146.
twelve-month prospective study. Int J Periodontics 41. Howell KJ, McGlumphy EA, Drago C, Knapik G.
Restorative Dent. 2003;23(4):313-323. Comparison of the accuracy of Biomet 3i Encode
29. Salama M, Ishikawa T, Salama H, et al. Advantages Robocast technology and conventional implant im-
of the root submergence technique for pontic site pression techniques. Int J Oral Maxillofac Implants.
development in esthetic implant therapy. Int J Peri- 2013;28(1):228-240.
odontics Restorative Dent. 2007;27(6):521-527. 42. Priest G. Virtual-designed and computer-milled
30. Jansen VK, Conrads G, Richter EJ. Microbial leak- implant abutments. J Oral Maxillofac Surg. 2005;63(9
age and marginal fit of the implant-abutment inter- suppl 2):22-32.
face. Int J Oral Maxillofac Implants. 1997;12(4):527-540. 43. Tarnow DP, Emtiaz S, Classi A. Immediate loading
31. Zipprich H, Weigl P, Lange B, Lauer HC. Micro- of threaded implants at stage 1 surgery in edentulous
movements at the implant-abutment interface: mea- arches: ten consecutive case reports with 1- to 5-year
surement, causes, and consequences. Implantologie. data. Int J Oral Maxillofac Implants. 1997;12(3):319-324.
2007;15(1):31-46. 44. Lemongello GJ Jr. Immediate custom implant pro-
32. Brunski J. Biomechanics of dental implants. In: visionalization: a prosthetic technique. Pract Proced
Block MS, Kent JN, eds. Endosseous Implants for Max- Aesthet Dent. 2007;19(5):273-279.
illofacial Reconstruction. W.B. Saunders Co.: Philadel- 45. Cooper LF, Rahman A, Moriarity J, et al. Immediate
phia, PA; 1995:22-39. mandibular rehabilitation with endosseous implants:
33. Partalis C, Kampiosiora P, Papavasilou G, Douk- simultaneous extraction, implant placement, and load-
oudakis A. Fabrication of a fixed provisional implant ing. Int J Oral Maxillofac Implants. 2002;17(4):517-525.

CONTINUING EDUCATION QUIZ
1 QUIZ 2 Hours CE Credit
Prosthetic Management of Gingival Recession Around Implants:

Lessons Learned from Staged-Approach Treatment Planning
TAKE THIS FREE CE QUIZ BY CLICKING HERE: compendiumlive.com/go/advanceinprosth1

ENTER PROMO CODE: ADPROSTH1

1. With a staged approach treatment plan, the 6. It has been recommended that implant place-
main disadvantages often relate to the treatment be how many mm below the cemento-
ment time involved and: enamel junction for optimal esthetics?
A. the inability to use a fixed provisional restora- A. 0.5 mm to 1 mm
tion throughout treatment. B. 1.5 mm to 3 mm
B. complex guidance for implant placement. C. 3 mm to 4.5 mm
C. difficult soft-tissue management. D. 4 mm to 5.5 mm
D. multiple surgical steps.
7. C
ompared to a thin biotype, a thick biotype
2. Biotype at implant sites and position of with a greater amount of attached keratinized
the implant ﬁxture in relation to the cortical gingiva will:
wall have been cited as factors in potentially A. have less resistance to inflammatory
predicting: recession.
A. susceptibility to recession. B. have more resistance to inflammatory
B. implant failure. recession.
C. alveolar bone loss. C. have the same amount of resistance to
D. bacterial colonization. inflammatory recession.
D. be more susceptible to peri-implant recession.
3. In the staged-approach protocol, what can be
unpredictable and present esthetic challenges? 8. According to Saadoun and Touati, the best
A. managing the bone-to-implant interface solution for patients with a thin biotype to
B. re-preparing abutments intraorally limit the number of surgical procedures may be:
C. utilizing pontics A. the use of synthetic bone materials.
D. soft-tissue management B. the use of particulate autogenous bone.
C. forced eruption.
4. Le and Borzabadi-Farahani concluded that a D. an elevated flap surgery.
minimum of how many mm of facial bone is
necessary to prevent future recession? 9. I t has been suggested that smaller-diameter
A. 2 mm implants may be more beneﬁcial than wider
B. 4 mm ones in the esthetic zone, because:
C. 6 mm A. wider ones may leave thinner labial or buccal
D. 8 mm bone.
B. small-diameter ones will leave thinner labial or
5. Tarnow et al recommend that a minimum of buccal bone.
how many mm of bone exist between two C. small-diameter ones will lead to increased
adjacent implants? crestal resorption.
A. 0.5 mm D. soft-tissue recession around wide-diameter
B. 1 mm implants is generally less.
C. 2 mm
D. 3 mm 10. The advantages of immediate provisionaliza-
tion include:
A. elimination of additional surgery.
B. immediate nonocclusal loading in some
partially edentulous patients.
C. bone preservation.
D. All of the above
Course is valid from 12/1/2018 to 12/31/2021. Participants

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CONTINUING EDUCATION 2 EDENTULOUS TREATMENTS
Removable and Fixed Fully

Edentulous Treatment Options
for the Aging Patient
Stephen Parel, DDS
ABSTRACT: As the number of seniors in the United States continues to rise, eden-
tulism remains a serious ailment affecting many elderly patients. Though many se-
niors are taking fuller dentitions into their later years due to a greater emphasis on
oral health maintenance than in the past, this growing population still often requires
creative edentulous treatment solutions from skilled clinicians. Fortunately, with the
evolution of implant dentistry various possibilities are available to treat edentulous
aging patients with removable and/or fixed options. This article will review aging as it
relates to the use of dentures and discuss prosthetic restorative alternatives for se-
nior patients. It also will examine the impact of caries, neurosensory disorders, facial
esthetics, and chronologic aging on dental treatments.
learning objectives
• Discuss the impact of long- • Explain why caries etiology, • Describe possible
term denture wear on a prevention, and treatment restorative solutions for
patient’s mandibular and now also focuses on the senior patients with neurosensory
maxillary bone. population. disorders and facial
morphology changes
P
over time.
atients aged 65 years and older are failing dentition is a complete set of dentures.
a growing population in the United Whether this is due to socioeconomic con-
States. Older dental patients com- straints, family history of long-term denture
monly present with a variety of use, or simply fear of an alternative proce-
conditions, including edentulism. dure, the mid- to long-term consequence as
Restoring aging, edentulous patients, particu- these patients age and reach senior status
larly those who have experienced decades of is inevitably bone loss.1-4 Denture bone loss
denture use and subsequent alveolar bone at- patterns can be significantly more rapid in
rophy, can be a challenge to clinicians; how- the mandible than in the maxilla, and this
ever, a number of possibilities are currently treatment may represent the single most de-
available using dental implant therapy. This structive procedure option the dental pro-
article will explore both removable and fixed fession can offer patients when the natural
prosthetic options for this expanding demo- dentition is no longer salvageable. Ironically,
graphic group. the dichotomy between the most esthetic res-
toration in dentistry (ie, the denture) and
Aging and the Denture the most destructive one (ie, the denture)
It is unfortunate that one of the most com- is often lost on the prescribing practitioner
monly accepted forms of therapy for a until the damage may be too significant to
DISCLOSURE: The author had no disclosures to report.
treat effectively in the aging patient. and 5 months, reparative bone had formed to
A classic example of potential damage from the apices of all implants (Figure 3), and all of
long-term denture wear may be the severely them remained in uncompromised function
atrophic mandible, where causative factors until the patient passed away at age 90.
seem to exacerbate with age. For example, Severe maxillary atrophy may have a differ-
there was a time when ceramic denture ent etiology compared to that of the mandible,
teeth were considered a therapeutic means but the resultant resorption is no less debili-
of maintaining the vertical dimension of oc- tating. Grafting in the upper arch is increas-
clusion, but often did so at the expense of the ingly less common with the advent of implant
underlying bone. Fifty years ago half of the types such as zygoma that are anchored in re-
US population lost all of their teeth between mote bone and offer a far less traumatic and
the ages of 65-75, which in terms of denture functionally improved option, especially for
wear longevity also contributed to potentially an aging patient. This is illustrated in Figure
greater bone loss, especially in the mandible.5 4 and Figure 5. The patient had worn both a
The use of dental implants to treat denture removable partial denture and full lower den-
damage has been a focus of the dental profes- ture for more than 40 years with resulting
sion since the 1940s with devices such as blade severe maxillary atrophy opposing a natural
or subperiosteal implants. With the exception dentition. Four zygoma implants were placed
of the transosseous staple implant, none of the using the “quad” approach9,10 in lieu of a bone
early implant scenarios had enough evidence graft procedure (Figure 4). The final restora-
or documentation to be considered realistic tion remains in function in the patient’s sev-
options given today’s criteria of success.6-8 enth decade (Figure 5).
The Toronto Conference in 1982, chaired
by Professor George Zarb and presented by Aging and Caries
Professor Per-Ingvar Brånemark, was a semi- Once thought to be a condition mainly for
nal event that changed edentulous treatment the pediatric and young adult population, the
planning concepts irrevocably. No longer occurrence of dental caries has been elevated
was it necessary to rebuild lost bone through to the level of a medical model for disease
grafting alone in either arch. The severely consideration.11,12 Caries etiology, preven-
atrophic mandible, for example, could be tion, and treatment now also focuses on the
treated with as few as four implants used to senior population, ie, those in the 65 to 75
support a bone-sparing prosthesis through years and older age groups, as these individu-
integrated tooth analogs, as demonstrated in als live longer and retain their dentition in far
Figure 1 through Figure 3. Here, an 81-year- greater numbers than previous generations.
old patient presented with severe mandibular They also are more pharmacologically de-
atrophy (Figure 1) from denture wear since pendent than ever, and more than half of the
a very young age and had a history of being 500 most common medications they may use
unable to manage a mandibular prosthesis list xerostomia as a side effect.13 Changes in
despite numerous attempts at new denture salivary function due to aging can also occur
construction. Four vertical machined-surface as a result of factors such as mouth breath-
osseointegrated implants were placed in 1983 ing or receiving radiation treatment, and
by Professor Brånemark, and all four pene- this can produce a form of caries that may
trated the inferior cortex up to 3 mm to 4 mm be persistent and insidious.14 Recurrent car-
in depth, as shown on the immediate postop- ies under existing restorations may be more
erative panoramic film (Figure 2). At 4 years likely to occur and difficult to detect until its

for younger patients who

present with a high caries
index historically. These
Fig 2. individuals may have a rea-
sonably healthy dentition
periodontally but can be
projected to continue to have
carious breakdown with ag-
Fig 1. Fig 3. ing that will be more difficult
Fig 1. 81-year-old patient had severe mandibular atrophy from many
to treat in a nursing home
years of denture wear and had a history of inability to manage a environment at a later time
mandibular prosthesis. Fig 2. Four vertical machined-surface osseo- in life and lead to a situation
integrated implants placed in 1983 penetrated the inferior cortex where extensive dental re-
up to 3 mm to 4 mm in depth, immediate postoperative. Fig 3. At
4 years and 5 months follow-up, reparative bone had formed to the habilitation becomes either
apices of all implants. Fig 4. Four zygoma implants placed using impractical or unavailable.
“quad” approach. Fig 5. Final restoration remains in function. Interceptive implant ther-
apy may then become a con-
sideration earlier in life to
create restorations that will
not be subject to the latent
effect of dental caries as ag-
ing continues. An example
is shown in Figure 6 and
Figure 7; the panoramic film
of a 56-year-old man shows
several orthognathic and
Fig 4.
extensive dental procedures
historically. All full-coverage
restorations had been re-
placed for a second time, and,
again, all evidenced recur-
rent caries, but the existing
dentition was periodontally
sound and relatively esthetic.
The choice of removing a
caries-challenged but restor-
able dentition at a younger
Fig 5.
age is ethically complex.
Ultimately, the decision is
destructive effects become evident. Cervical the patient’s alone based on informed con-
and root caries also may increase asymptom- sent of all available options. The removal of a
atically, adding another layer of diagnostic potential lifetime of caries activity that is now
concern for the older population.15 more predictable than ever may be a viable
This demographic shift may play a role in option for this high-risk segment of a younger
contemporary treatment planning, especially patient base.

Fig 6. Fig 7.
Fig 8. Fig 9.
Fig 10. Fig 11.
Fig 6. Panoramic radiograph of 56-year-old patient illustrating a number of dental procedures historically.
Fig 7. Existing dentition was sound periodontally and reasonably esthetic. Fig 8. Failing dentition in an
82-year-old patient currently diagnosed with tardive dyskensia. Fig 9. Transition line could not be hidden
due to uncontrolled contortions of the facial musculature. Fig 10 and Fig 11. Recording a repeatable cen-
tric position was virtually impossible for this patient due to spasticity of the masticatory system. Among
the compromises necessary in creating an occlusal scheme was to revert to a monoplane approach.
Aging and Neurosensory Disorders Given the array of neurologic disorders

Aging generally results in a decreased blood that can be related to changes patients may
flow to the brain, sometimes as much as 20%, experience with age, and the related cogni-
and this percentage may increase with smok- tive or coordination issues associated with
ers, diabetics, those with hypertension, and each presentation, there may be no general
those with atherosclerotic disease.16,17 Changes treatment concept that will apply universally.
in myelin degradation and synaptic transmis- Implants may provide significant benefits in
sion can affect neuromotor function, and a de- mastication or digestion but may not be as
crease in peripheral sensory nerve cells can easily managed as those placed in a less-chal-
impair some sensory-based activities.18 lenged individual.

Individuals may have a reasonably healthy

dentition periodontally but can be projected to
continue to have carious breakdown with aging
that will be more difficult to treat in a nursing
home environment at a later time in life.
A patient with tardive dyskensia, for ex- to repeat a centric position.19,20 Figure 8 and
ample, may experience dramatic changes in Figure 9 show an 82-year-old patient who had
expressive facial activity and corresponding previously been treated for depression, had
dysfunction in the muscle memory needed a failing dentition, and was diagnosed with
Fig 12. Fig 13.
Fig 14. Fig 15.
Fig 12. Treatment to restore this patient’s smile and

functionability commenced when she was 102 years
old. Fig 13. An All-on-4 approach was used to treat
both arches with interim immediate and eventual
definitive restorations. Fig 14. Final restorations
used for 6-1/2 additional years. Fig 15 and Fig 16.
This all-resin interim restoration, which served
as a fixed long-term provisional for more than 5
years, is an example of an entry-level option that
offers the physiologic benefits of a long-term fixed
restoration but with an economic equivalence to a
mandibular two-implant overdenture.
Fig 16.

Given the array of neurologic disorders that can

be related to changes patients may experience
with age, and the related cognitive or coordination
issues associated with each presentation, there
may be no general treatment concept that will
apply universally.
tardive dyskensia. Extreme uncontrolled record a high smile line; removal of enough
contortions of the facial musculature were maxillary bone to hide the transition line was
evident in the patient when attempting to impossible. Dramatic compromises in occlu-
sal scheme may be necessary to achieve even a
moderately successful result; yet the implant
approach realistically may be the only way to
offer any functional improvement (Figure 10
and Figure 11).
Aging and Facial Esthetics

Facial morphology changes with time, with
virtually no exception for gender or systemic
health. Among the changes that occur in the
Fig 17.
esthetic zone is a predictable loss in tissue
elasticity that can create an inverse smile dis-
play over time.21 In repose, the display of the
maxillary incisors may, in fact, change from
3 mm on average at age 30 to 1 mm or more
of negative display at age 60.22,23 The empha-
sis on facial display may, therefore, change
from managing the incisal edge esthetics to
minimizing the mandibular component with
dramatic changes sometimes occurring in oc-
clusal plane position.
Fig 18.
Fig 17 and Fig 18. A three-implant fixed bridge may Aging and Chronologic Age
be an immediate-load alternative for a fixed resto- Whether dealing with denture complications
ration as opposed to a two-implant overdenture.
In addition to significant cost reduction due to
or a failing natural dentition, the decision-
pre-manufactured components, the final long-term making process for senior patients in tran-
restoration is delivered on the day of surgery. sitioning to an implant restoration often

rests on the individual’s perception of their cost (Figure 17 and Figure 18).24-26 Both of
remaining life expectancy. Current life table these fixed options—the resin long-term pro-
analytics aside, many feel that they cannot visional and the three-implant bridge—are
justify the effort or expense based on the economically comparable to the most com-
time they may have left to enjoy the benefits monly considered implant prosthesis for el-
of osseointegration. derly patients, the two-implant overdenture.
This is an unfortunate mindset in that cur- In contrast to the latter, however, both fixed
rent advances in protocol and technology can restorations offer significant advantages in
result in significant advantages in addressing bite force, bone preservation, maintenance,
some or most of these concerns. The patient and patient satisfaction that are simply un-
shown in Figure 12 may serve to illustrate this achievable with the removable implant over-
point. She had a destroyed maxillary denti- denture prosthesis.27-31
tion, a less-compromised but highly unes-
thetic mandibular component, and a single Conclusion
goal: to be able to “smile at my grandchildren While challenges in restoring the aging pa-
again.” In consultation with her and her fam- tient to a reasonable functional level are al-
ily, it was decided that a double-arch fixed im- ways present, the possibilities now available
plant approach would most realistically ad- using implant therapy for this segment of
dress her esthetic goals and provide her with the population are increasingly encourag-
the desired prosthetic result. She was 102 ing. This is especially so in combating the
years old at the time of initial consultation. ever-present potential for bone loss with
Using a staged operating-room approach, pro- removable prosthetics, including implant
visional restorations were initially delivered, overdentures. This patient demographic
followed by subsequent definitive hybrid fi- will benefit from advances in immediate-
nal restorations. She was able to use these load fixed provisionalization and same-day
comfortably for the next 6-½ years (Figure final restoration delivery concepts, which
13 and Figure 14). provide an even better functional outcome
As an alternative to the relatively expen- with physiologic protection of remaining os-
sive traditional hybrid restoration that the seous structures.
senior population may perceive as unattain-
able at their age, an immediate-load all-resin ABOUT THE AUTHOR
provisional may often be a reasonable op- Stephen Parel, DDS
tion as an entry-level prosthesis. This can Private Practice, Dallas, Texas
serve for extended periods or indefinitely, Queries to the author regarding this course may be submitted
to authorqueries@aegiscomm.com.
and when made with a sufficient volume of
resin and opposing a light occlusion such as REFERENCES
a maxillary denture, it can offer the benefit 1. Tallgren A. Alveolar bone loss in denture wearers
of fixed retention at a significant reduc- as related to facial morphology. Acta Odontol Scand.
tion in expense (Figure 15 and Figure 16). 1970;28(2):251-270.
2. Tallgren A, Lang BR, Miller RL. Longitudinal study
Technology involving a guided approach for of soft-tissue profile changes in patients receiving
placing three implants universally in the immediate complete dentures. Int J Prosthodont.
same sites with pre-manufactured, one-size- 1991;4(1):9-16.
3. Atwood DA. Reduction of residual ridges in the
fits-all bar components in the mandible can partially edentulous patient. Dent Clin North Am.
now allow placement of a final restoration 1973;17(4):747-754.
in one day, again at a significantly reduced 4. Carlsson GE, Ericson S. Postural face height in full

denture wearers. A longitudinal x-ray cephalometric neuromuscular system. In: Tallis J, ed. The Clinical
study. Acta Odontol Scand. 1967;25(2):145-162. Neurology of Old Age. London: John Wiley and Sons;
5. Douglass CW, Shih A, Ostry L. Will there be a need 1989:137-142.
for complete dentures in the United States in 2020? 18. Faggion CM Jr. Critical appraisal of evidence
J Prosthet Dent. 2002;87(1):5-8. supporting the placement of implants in patients
6. Small IA, Misiek D. A sixteen-year evaluation of the with neurodegenerative diseases. Gerodontology.
mandibular staple bone plate [erratum in J Oral Max- 2016;33(1):2-10.
illofac Surg. 1986;44(10):789]. J Oral Maxillofac Surg. 19. Yassa R, Jones BD. Complications of tardive dys-
1986;44(1):60-68. kinesia: a review. Psychosomatics. 1985;26(4):305-313.
7. Carlsson L, Röstlund T, Albrektsson B, et al. Osseo- 20. Rana AQ, Chaudry ZM, Blanchet PJ. New and
integration of titanium implants. Acta Orthop Scand. emerging treatments for symptomatic tardive dyski-
1986;57(4):285-289. nesia. Drug Des Devel Ther. 2013;7:1329-1340.
8. Albrektsson T, Brånemark PI, Hansson HA, Lindström 21. Vig RG, Brundo GC. The kinetics of anterior tooth
J. Osseointegrated titanium implants. Requirements display. J Prosthet Dent. 1978;39(5):502-504.
for ensuring a long-lasting, direct bone-to-implant an- 22. Sarver DM. Growth maturation aging: how the den-
chorage in man. Acta Orthop Scand. 1981;52(2):155-170. tal team enhances facial and dental esthetics for a life-
9. Aboul-Hosn Centenero S, Lázaro A, Giralt-Her- time. Compend Contin Educ Dent. 2010;31(4):274-283.
nando M, Hernández-Alfaro F. Zygoma quad com- 23. Fradeani M. Evaluation of dentolabial parameters
pared with 2 zygomatic implants: a systematic review as part of a comprehensive esthetic analysis. Eur J
and meta-analysis. Implant Dent. 2018. doi: 10.1097/ Esthet Dent. 2006;1(1):62-69.
ID.0000000000000726. Epub ahead of print. 24. Parel SM. A system for definitive restoration
10. Balshi TJ, Wolfinger GJ, Petropoulos VC. Qua- of single-stage implants in one day. Dent Today.
druple zygomatic implant support for retreatment 2002;21(2):106-111.
of resorbed iliac crest bone graft transplant. Implant 25. Chow J, Hui E, Liu J, et al. The Hong Kong Bridge
Dent. 2003;12(1):47-53. Protocol. Immediate loading of mandibular Brånemark
11. Featherstone JD, Doméjean S. The role of remin- fixtures using a fixed provisional prosthesis: preliminary
eralizing and anticaries agents in caries management. results. Clin Implant Dent Relat Res. 2001;3(3):166-174.
Adv Dent Res. 2012;24(2):28-31. 26. Engstrand P, Gröndahl K, Ohrnell LO, et al. Prospec-
12. Featherstone JD. Remineralization, the natural car- tive follow-up study of 95 patients with edentulous
ies repair process-the need for new approaches. Adv mandibles treated according to the Brånemark Novum
Dent Res. 2009;21(1):4-7. concept. Clin Implant Dent Relat Res. 2003;5(1):3-10.
13. Yanase RT, Le HH. Caries management by risk as- 27. Goodacre CJ, Kan JY, Rungcharassaeng K. Clinical
sessment care paths for prosthodontic patients: oral complications of osseointegrated implants. J Prosthet
microbial control and management. Dent Clin North Dent. 1993;70:135-140.
Am. 2014;58(1):227-245. 28. Vogel R, Smith-Palmer J, Valentine W. Evaluating
14. Pjetursson BE, Brägger U, Lang NP, Zwahlen M. the health economic implications and cost-effective-
Comparison of survival and complication rates of ness of dental implants: a literature review. Int J Oral
tooth-supported fixed dental prostheses (FDPs) and Maxillofac Implants. 2013;28(2):343-356.
implant-supported FDPs and single crowns (SCs) [er- 29. Haraldson T, Carlsson GE. Bite force and oral func-
ratum in Clin Oral Implants Res. 2008;19(3):326-328]. tion in patients with osseointegrated oral implants.
Clin Oral Implants Res. 2007;18(suppl 3):97-113. Scand J Dent Res. 1977;85(3):200-208.
15. Sreebny LM, Schwartz SS. A reference guide to 30. Jacobs R, van Steenberghe D, Nys M, Naert I. Maxil-
drugs and dry mouth—2nd edition. Gerodontology. lary bone resorption in patients with mandibular im-
1997;14(1):33-47. plant-supported overdentures or fixed prostheses. J
16. Müller F, Shimazaki Y, Kahabuka F, Schimmel M. Prosthet Dent. 1993;70(2):135-140.
Oral health for an ageing population: the importance 31. Jacobs R, Schotte A, van Steenberghe D, et al.
of a natural dentition in older adults. Int Dent J. 2017;67 Posterior jaw bone resorption in osseointegrated
(suppl 2):7-13. implant-supported overdentures. Clin Oral Implants
17. Hubbard BM, Squier M. The physical aging of the Res. 1992;3(2):63-70.

CONTINUING EDUCATION QUIZ
1 QUIZ 2 Hours CE Credit
Removable and Fixed Fully Edentulous Treatment Options

for the Aging Patient
Stephen Parel, DDS
TAKE THIS FREE CE QUIZ BY CLICKING HERE: compendiumlive.com/go/advanceinprosth2

ENTER PROMO CODE: ADPROSTH2

1. One of the most commonly accepted forms of 6. The choice of removing a caries-challenged
therapy for a failing dentition is/are: but restorable dentition at a younger age:
A. immediate-load dental implants. A. has no impact on esthetics.
B. mini dental implants. B. is ethically complex.
C. a complete set of dentures. C. is solely the doctor’s decision.
D. porcelain veneers. D. is not considered a viable option.
2. The Toronto Conference in 1982 was a seminal 7. Aging generally results in a decreased blood
event that: flow to the brain; this decreased blood flow
A. changed edentulous treatment planning may be greater with:
concepts. A. smokers.
B. introduced the All-on-4 treatment concept. B. diabetics.
C. highlighted caries management by risk as- C. people with hypertension.
sessment (CAMBRA). D. All of the above
D. presented the use of dental implants to treat
denture damage. 8. A patient with tardive dyskensia may experi-
ence changes in expressive facial activity and
3. Grafting in the upper arch is increasingly less dysfunction in muscle memory needed to:
common with the advent of: A. smile.
A. zygoma implants. B. maintain adequate saliva.
B. subperiosteal implants. C. repeat a centric position.
C. digital dentures. D. All of the above
D. bone morphogenetic proteins.
9. I n repose, the display of which of the follow-
4. According to the article, changes in salivary ing may change from 3 mm on average at
function due to aging can occur as a result of age 30 to 1 mm or more of negative display
factors such as mouth breathing or: at age 60?
A. experiencing a change in socioeconomic A. the mandibular bicuspids
status. B. the maxillary incisors
B. consuming more sugar-based foods. C. the mandibular incisors
C. undergoing caries treatment. D. the gingival margin
D. receiving radiation treatment.
10. According to the article, fixed options such
5. What may become a consideration earlier in as a resin long-term provisional or three-
life to create restorations that will not be sub- implant bridge offer advantages over a two-
ject to the latent effect of dental caries as ag- implant overdenture in:
ing continues? A. bite force.
A. endodontic surgery B. bone preservation.
B. clear aligner therapy C. maintenance.
C. interceptive implant therapy D. All of the above
D. oral cancer examinations
Course is valid from 12/1/2018 to 12/31/2021. Participants

must attain a score of 70% on each quiz to receive credit. Par-
ticipants receiving a failing grade on any exam will be notified AEGIS Publications, LLC, is an ADA CERP Recognized
Provider. ADA CERP is a service of the American Dental Approval does not imply acceptance
and permitted to take one re-examination. Participants will by a state or provisional board of
Association to assist dental professionals in identifying quality
receive an annual report documenting their accumulated providers of continuing dental education. ADA CERP does not dentistry or AGD endorsement. The
approve or endorse individual courses or instructors, nor does current term of approval extends from
credits, and are urged to contact their own state registry it imply acceptance of credit hours by boards of dentistry. 1/1/2017 to 12/31/2022.
boards for special CE requirements. Concerns or complaints about a CE provider may be directed Provider #: 209722.
to the provider or to ADA CERP at www.ada.org/cerp.

CASE REPORT FIXED REMOVABLE PROSTHESIS
Atlantis® Conus
Abutment – Treatment of
the fully edentulous patient with
a fixed removable prosthesis
A
54-year-old female presented with a chief com-
plaint of difficulty eating and chronic sores from
a 22-year-old complete upper denture (CUD).
A thorough examination uncovered an atrophic Arnold Rosen, DDS, MBA
Prosthodontist, private practice,
maxilla, deep vertical anterior overbite, loss of ver- Boston, MA
tical dimension of occlusion (VDO), and a prosthesis that was The technician for the new
worn thin, unstable, and that had fractured at least two times. Her complete denture was Robert
Kreyer, CDT, of Custom Prosthetics
mandible was partially edentulous with multiple restorations, Inc. in Los Gatos, CA.
and she has no dental insurance and limited financial resources.
Clinician case note: For most cas-

es, a framework is fabricated for
the denture. However, due to the
smaller anatomical oral structure
The Atlantis Conus Abutment solution was selected for its and slight physical build of the
surgical and restorative simplicity, and as a cost-effective treat- patient, it was determined that
a framework was not critical for
ment that satisfies the patient’s stability, restored function and the case. In addition, the patient
esthetics, and easy hygiene maintenance. elected to keep the palate.
Fig 1. Fig 2.
Fig 1. After rebase, the complete upper denture was duplicated in a translucent radiopaque resin.
Fig 2. A CBCT was taken and viewed in Simplant software for case planning. The radiopaque duplicate
simplified the process of planning the position of the implants and provided the opportunity to measure
available space for the overdenture abutments and copings.

Fig 3. Fig 4.
Fig 5. Fig 6.
Fig 7. Fig 8.
Fig 3. The masking feature in Simplant software allowed for planning of optimal implant locations in rela-
tion to the denture teeth and the denture base ensuring that the abutment emergence was within the
body of the complete denture. Fig 4. Four OsseoSpeed TX 3.5 S implants (two 8 mm, two 9 mm) were
placed with Healing Abutment Uni. Before relining with a soft material, the denture base was relieved to
prevent any contact with the healing abutments. Fig 5. The duplicate denture was adjusted and used as
a scanning guide for the design of Atlantis Conus Abutments and tooth position reference for the new
denture setup. The duplicate denture was modified and used for an open-tray impression for implant
pick up and an occlusal record base were taken. Fig 6. The implant cast and duplicate denture were
scanned. The denture base served as an aid in establishing the optimal path of insertion for the parallel
abutments and of the new denture. Fig 7. The four Atlantis Conus Abutments are perfectly parallel to
each other and to the plane of occlusion. They were positioned for the body of the denture and finished
on the master cast with soft tissue moulage ready for insertion. Fig 8. The abutments were inserted and
checked for proper placement and torqued to 25 Ncm.

Fig 9. Fig 10.
Fig 11. Fig 12.
Fig 14.
Fig 9. Four Ankylos Taper Cap Degulor for Syn-

Fig 13. Cone 4° were placed with light finger pressure.
Fig 10. Silicone sleeves were placed under the
tapered caps to ensure that no pick up mate-
rial would engage an undercut. Fig 11. The new
complete upper denture was adjusted for access
to the abutments and copings and to ensure that
there was no contact with the abutments and
tapered caps. Fig 12. Denture base autopoly-
merizing resin was used to engage the copings.
During this process, the denture was held in place
with light finger pressure. After curing time, the
denture was removed and cleaned. Fig 13. The
process of engaging the copings was completed
and finished in the laboratory. Fig 14. Small hori-
zontal grooves that could be engaged with verti-
Fig 15. cal pressure for removal were placed on each side
of the denture. Fig 15. Final result.

Dentsply Sirona does not waive any right to its trademarks by not using the symbols ® or ™. 32671214-USX-1611 © 2016 Dentsply Sirona. All rights reserved.
Atlantis®
Why choose between
stability and easy maintenance?
Fully edentulous patients want both the stability of a fixed solution and the
easier hygiene of a removable prosthesis. By providing the friction-retained,
conometric retention of the Atlantis Conus concept, your clinical partners
no longer need to compromise on a secure fit or simplified maintenance for
their patients.
Because a little friction is a good thing. Atlantis® Conus concept
www.dentsplysirona.com

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CLINICAL EBOOK SERIES POWERED BY

Prosthetic Management of Gingival

Removable and Fixed Fully Edentulous

FIXED REMOVABLE PROSTHESIS

Treatment of the Fully Edentulous Patient

Removable Options DECEMBER 2018 | www.compendiumlive.com

Book provides two continuing education (CE) SPECIAL PROJECTS EDITOR

val recession around implants, offering case examples. MANAGING EDITOR

reviews implant treatment-planning protocols. The au-

increasingly encouraging. The author notes that implants President

Louis F. Rose, DDS, MD

Prosthetic Management of Gingi-

ABSTRACT: Complex implant rehabilitations can include procedures requiring mul-

• Understand the purpose of • Describe different methods of • Discuss protocol

reatment plans involving the transi- treatment plan—was formulated primarily to

DISCLOSURE: The authors had no disclosures to report.

www.compendiumlive.com December 2018 COMPENDIUM EBOOK SERIES 3

4 COMPENDIUM EBOOK SERIES December 2018

of alveolar bone and surrounding tissues. resorption and concomitant recession.30,31

www.compendiumlive.com December 2018 COMPENDIUM EBOOK SERIES 5

impression tray could be used to provide sup-

Case 3 – Remilling of Custom Abutments

6 COMPENDIUM EBOOK SERIES December 2018

retained the provisional while all custom abut-

Case 4 – Temporary Abutments

www.compendiumlive.com December 2018 COMPENDIUM EBOOK SERIES 7

Fig 6. Fig 7. Fig 8.

Fig 9. Fig 10.

Fig 11. Fig 12.

8 COMPENDIUM EBOOK SERIES December 2018

abutment Nos. 6 or 11. These first abutments

www.compendiumlive.com December 2018 COMPENDIUM EBOOK SERIES 9

Fig 16. Fig 17.

Fig 18. Fig 19.

10 COMPENDIUM EBOOK SERIES December 2018

Biotype: Thin vs Thick biotype, which will ultimately enhance gingi-

www.compendiumlive.com December 2018 COMPENDIUM EBOOK SERIES 11

12 COMPENDIUM EBOOK SERIES December 2018

www.compendiumlive.com December 2018 COMPENDIUM EBOOK SERIES 13

report. Pract Proced Aesthet Dent. 2005;17(4):267-

14 COMPENDIUM EBOOK SERIES December 2018

www.compendiumlive.com December 2018 COMPENDIUM EBOOK SERIES 15

Prosthetic Management of Gingival Recession Around Implants:

TAKE THIS FREE CE QUIZ BY CLICKING HERE: compendiumlive.com/go/advanceinprosth1

Course is valid from 12/1/2018 to 12/31/2021. Participants

16 COMPENDIUM EBOOK SERIES December 2018

Removable and Fixed Fully

18 COMPENDIUM EBOOK SERIES December 2018

for younger patients who

www.compendiumlive.com December 2018 COMPENDIUM EBOOK SERIES 19

Fig 10. Fig 11.

Aging and Neurosensory Disorders Given the array of neurologic disorders

20 COMPENDIUM EBOOK SERIES December 2018

Individuals may have a reasonably healthy

Fig 12. Fig 13.

Fig 14. Fig 15.

Fig 12. Treatment to restore this patient’s smile and

www.compendiumlive.com December 2018 COMPENDIUM EBOOK SERIES 21

Given the array of neurologic disorders that can

Aging and Facial Esthetics

22 COMPENDIUM EBOOK SERIES December 2018

www.compendiumlive.com December 2018 COMPENDIUM EBOOK SERIES 23

24 COMPENDIUM EBOOK SERIES December 2018

Removable and Fixed Fully Edentulous Treatment Options