3 RISKS IN IMPLANT DENTISTRY

Class I: Class II: Class III: Class IV:

No defect Vertical defect Horizontal defect Combined defect

Esthetic risk

Structural risk

Fig 16. The LTR classification. Visual representation of the four major indications related to the maxillary complete edentulous situation. Note that the
classification is based on the defect present between the ridge and the lip horizontally and the prosthetic tooth and ridge vertically. The bone availability for
implant placement does not influence the type of indication. (From Pollini et al, 2017, with permission).

The EERA consists of seven clinical risk factors that influence
esthetic outcomes when managing fully edentulous arches
with implant-assisted prostheses. Table 4 highlights these
risk factors. Several factors have been addressed in publica-
tions by Zitzmann and Marinello in 1999 and as mentioned
previously Pollini and coworkers in 2017. An important key
factor when utilizing the EERA is to consider all treatment
approaches and options (ie, fixed vs. removable and varia-
tions). Doing so will ensure that the clinical and diagnostic
findings assist in the identification of information-driven
treatment choices. This approach often identifies the need
for either an analog (wax try-in) and digital tooth arrange-
ment to determine and review potential treatment out-
comes and to effectively utilize the EERA (Figure 17).

Table 4 Edentulous esthetic risk assessment (EERA).

Esthetic risk factors - Edentulous Level of risk

Low Medium High
Arch Mandible Maxilla

Facial support (fixed) Alveolar process provides Minimal changes tolerated Flange required for adequate
adequate facial support by the patient facial support
Facial support (removable) Flange provides adequate Minimal changes tolerated Insufficient space for a flange
facial support by the patient

Labial support Designed tooth position provides Minimal changes tolerated Designed tooth position causes
satisfactory labial support by the patient unsatisfactory labial support

Upper lip length Long upper lip (> 20 mm) Short upper lip (< 20 mm)
Buccal corridor* (atrophic ridge) Removable prosthesis Fixed prosthesis
Smile line No display of the ridge(s) at full Display of the ridge(s) at full
smile (maxilla or mandible) smile (maxilla or mandible)

Maxillomandibular relationship Class I Class II Class III

*Desired narrow corridor in definitive prosthesis.

a b c
Fig 17 a–c. Example of a digital tooth arrangement for a full-mouth rehabilitation.

22 The SAC Classification in Implant Dentistry