RESEARCH

‘ ABCD’’ Implant Classification: A Comprehensive

Philosophy for Treatment Planning in Completely
Edentulous Arches
Ali Tunkiwala, MDS1
Udatta Kher, MDS1
Nupur H. Vaidya, MDS2*

A thorough and precise treatment plan that considers various factors such as age, availability of bone, interarch space for prosthesis
design, smile line, lip support, patient desires, and economics is a necessity before implant surgery. Many previous classification systems
for treatment planning in edentulous situations tend to focus on only a certain parameter such as esthetics, or available bone volume, or
are specifically designed for the maxilla or mandible. The authors have proposed a simplified and universal ABCD classification that uses
the 4 vital parameters of age, bone volume, cosmetic display, and degree of resorption to create an algorithm that satisfies the treatment
needs of every patient. Various permutations of the 4 parameters can be used to arrive at a solution that streamlines the further phases of
the rehabilitative process. The aim of the present article is to provide a science-driven approach to understand a patient’s individual needs
with careful attention to the interplay of all the aforementioned factors in the decision-making process.

Key Words: completely edentulous, full-mouth implant reconstructions, implant classification, implant treatment planning

INTRODUCTION prosthetic solution for the patient. The final esthetics, bone
volume, space availability, and age are all essential criteria in

T
he World Health Organization categorizes the com-
pletely edentulous patient as being physically impaired,
handicapped, and disabled.1 Contrary to popular belief,
the number of patients suffering from this debilitating
condition is on the increase worldwide, regardless of varying
economic standards and general lifestyle.1–3 Edentulism,
though not life-threatening, severely impacts facial appearance,
nutrition, and the ability to speak and socialize.2 Significant
numbers of complete denture wearers are dissatisfied; with
complaints ranging from loose lower dentures, sore spots, and
inability to eat various kinds of food.4 Ever since the McGill
Consensus Conference5 concluded that the 2-implant-support-
ed overdenture was the minimal standard of care for patients
with edentulous mandibles, dental technology has been in
overdrive to develop a variety of solutions to restore
completely edentulous patients with implants.4 However,
patients come to the dental office for teeth, not implants6;
and a prosthetically driven approach is necessary. Multiple
surgical procedures such as sinus grafting, and horizontal or
vertical augmentations are now available to provide the fixed
restorative care patients desire.7,8 The availability and regener-
ation of bone for idealized implant placement should not be
the lone factor used by the clinician to decide the best
1
Private practice, Khar West, Mumbai, Maharashtra, India.
2 different set of clinical situations that need to be managed
Private practice, Thane West, Maharashtra, India.
* Corresponding author, e-mail: nupur.vaidya@gmail.com
https://doi.org/10.1563/aaid-joi-D-19-00147
the treatment planning process. Several classification systems
for treatment planning in edentulous situations tend to focus
on only a certain parameter such as esthetics or available bone
volume, or are specifically designed for the maxilla or
mandible.7–11 The aim of the present article is to provide a
scientifically driven approach to best suit a patient’s individual
needs while carefully understanding the interplay of all the
aforementioned factors in the decision-making process.
‘‘ABCD’’ IMPLANT CLASSIFICATION
Completely edentulous situations can be restored with
removable overdentures or fixed prostheses, which can be
screw/cement-retained with prefabricated or custom abut-
ments.4 The complete treatment phase from the presurgical
diagnostics to delivery of the final prostheses involves multiple
steps and use of various diagnostic aids, surgical techniques,
prosthetic components, and material. The clinician faces
multiple challenges during the entire rehabilitation process;
errors in any step adversely affect the final treatment outcome.
This whole process is time-consuming and can be stressful,
especially for beginners. The authors have delineated the entire
treatment protocol into 4 phases, each of which present a
accordingly. This delineation will help streamline the flow of
treatment.

Journal of Oral Implantology 93

‘‘ABCD’’ Implant Classification in Completely Edentulous Arches
I. Planning and Diagnostic Evaluation. This involves deci-
sions made about the type of prosthesis based on the
finalized number and location of the implants.
II. Surgical Phase. Decisions regarding need for soft/hard
tissue augmentation and free-handed or guided surgery are
made depending on the evaluation in the planning phase.
III. Provisional Phase. Immediate or delayed loading of the
implants based on implant stability and adjunctive surgical
procedures performed during the surgical phase.
IV. Final Restoration Phase. This is the phase focused on
achieving ideal esthetics, phonetics, and function for the
particular patient. Initiate a maintenance and recall protocol
to ensure long-term function of the prosthesis by early
detection and resolution of any potential complications.
The decision on the type of final prosthesis at the
beginning of the treatment process enables the clinician to
develop a precise understanding of the implant type, number
and location, type of regenerative procedures required to
achieve this ideal implant placement, and use of a particular
material and manufacturing technique for the final prosthesis. It
also allows for better communication with the laboratory and a
realistic accomplishment of the patients’ desires while consid-
ering the anatomic, structural, and esthetic limitations every
case may present.
To simplify this decision-making process and allow
predictability in final treatment outcomes, the authors propose
the ‘‘ABCD’’ classification system for treatment planning in
completely edentulous maxillary and or mandibular arches. This
classification of the patient is based on 4 parameters to help
choose the final prosthesis design at the planning stage.
1. A (age)
We have an aging population due to increased life expectancy
while on the other hand we have a large group of younger
edentulous patients due to a radical shift in lifestyle choices and
resultant periodontal disease or caries.2 Surely, the same
treatment plan cannot be applied to the young and geriatric
patients.
A holistic approach considering the influence of chronic
diseases and degenerative changes in soft and hard tissues is
best suited to deal with the dental needs of an aging
population. Also, the diminished tolerance to extensive surgical
procedures, uncertainty over access to care in the long term,
and the ability to maintain satisfactory hygiene during the
maintenance phase are areas of concern.12 It may be prudent
to design a relatively straightforward implant overdenture or a
fixed-implant prosthesis in geriatric and medically compro-
mised patients by planning placement of implants in available
bone instead of extensive regenerative surgical procedures that
may increase morbidity. On the contrary, in the younger age
group of edentulous patients, who present compromised bone
support; all efforts need to be taken toward regenerative
strategies to enable prosthetically driven implant positions. The
authors have presented 4 classes based on the age of the
patient: A1: young edentulous (,50 years); A2: intermediate
edentulous (50–65 years); A3: old edentulous (65–75 years); and
A4: geriatric edentulous (.75 years).
The issues to be addressed at the two opposite ends of the
94 Vol. XLVI / No. Two / 2020
spectrum are longevity for the younger age group and
simplicity of treatment for the geriatric patient. Without an
individualized approach, young patients may end up being
treated with lesser number of implants and geriatric ones with
more complex regenerative strategies. Understanding the age
factor can guide the clinician in choosing the most appropriate
option.
2. B (bone)
The authors have integrated the Bedrossian8 classification of
bone zones and modified it. Although this parameter is focused
on the more complex maxilla, the concept can be extended to
the mandibular arch as well. The absence of bone in the
posterior mandible will indicate either regenerative procedures
if conventional axial implants are to be placed or whether tilted
implants should be used in the interforaminal region. In
situations with considerable loss of bone in the anterior and
posterior regions of the mandible, a subperiosteal or trans-
osteal approach can be undertaken if the age and systemic
condition of the patient preclude extensive regenerative
surgeries.
The classification of bone zones based on bone availability
in each zone is as follows: B1: all zones; B2: only incisors and
bicuspids; B3: incisors and zygoma; and B4: only zygoma
(quad).
So, when bone is available in all zones (B1), 6 to 8 axial
implants may be placed to minimize cantilevers. In category B2,
2 or 4 axial implants in the incisor region and 2 tilted implants
in the bicuspid zone may be considered. For B3, the incisor
zone management may remain the same with 2 tilted implants
in the zygoma. In category B4, it could be quad zygoma.
3. C (cosmetic display)
The static and dynamic positions of the upper lip and its
tonicity are important determinants in the decision-making
process regarding the type of prosthesis and resulting esthetics.
The authors have adopted the Tjan et al13 smile line analysis to
categorize the cosmetic display parameter in the ABCD
protocol. They stress the fabrication of a provisional complete
denture to preempt the position of the anterior teeth, their
visibility, and inclination with respect to the residual ridge,
esthetics, and phonetics that are to be achieved in the final
prosthesis. Following are the classifications: C1: low lip line (,
75% of anterior teeth); C2: medium lip line (75%–100% of
anterior teeth and interproximal gingiva); and C3: high lip line
(complete anterior teeth and continuous band of gingiva).
The maximum lip mobility that the patient can elicit will
determine if the transition line between the future prosthesis
and the residual ridge will be visible. If yes, a crestotomy must
be performed during surgery to hide the transition line behind
the envelope of the upper lip. When the prosthesis is in full
display during smiling, the junction between the pink and
white of the prosthesis must be managed appropriately to
provide a good esthetic result. In low lip line cases, these
factors will not matter much and hence the overall bone
reduction can be kept to a minimum, sufficient to create a
good soft tissue bed to house the intaglio of the prosthesis.
If the ridge is visible on smiling and the interarch space is

FIGURES 1–4. FIGURE 1. Interarch space. FIGURE 2. Preoperative orthopantomogram, case 1. FIGURE 3. Postextraction profile view. FIGURE 4.
Maxillary arch with well-distributed implant positions to avoid cantilevers.
less, a metal-ceramic profile prosthesis can be used and the
visibility of the gingiva will give it a more natural appearance.
However, if the interarch space is greater due to advanced
atrophy, the lip may require support from the prosthesis. In
such cases an overdenture may be the design of choice over a
fixed prosthesis. This decision will depend on other factors
mentioned in the classification previously such as the age of
the patient and availability of bone, which will determine the
number and position of implants.
Regardless of the degree of ridge resorption, similar to
traditional complete denture fabrication, the position of incisal
edge of upper incisors is determined by esthetics, phonetics,
and lip dynamics.4,13,14 The most predictable way to finalize the
length of upper incisors is to follow the concept of locating the
cuspid zero.15 This method allows a more accurate judgment of
the incisor length compared to the traditional methods that
show a wide gender variation.
4. D (degree of resorption)
The technical success of prosthetic materials depends on
certain minimum space requirements that must be fulfilled. If
materials are used in thinner sections there will be more failures
due to breakage. The available restorative space is measured
from the implant prosthetic platform to the proposed incisal
edge in the anterior region and occlusal plane in the posterior
region and this space will govern the selection of the
prosthesis.4,16
The authors have categorized the interarch space into 4
Tunkiwala et al
classes (Figure 1): D1: minimal (10–12 mm); D2: moderate (12–
15 mm); D3: moderate (15–18 mm); and D4: excessive (.18
mm).
The choice of final restorative material will depend on the
available space (Table). In minimal resorption cases (D1), only
the anatomical crowns of the missing natural teeth will be
replaced. For D2 and D3 classes, it would also appear to replace
a part of the resorbed alveolus. In these cases, as the degree of
resorption has increased, the use of pink ceramic becomes
important if the patient has a high lip line. Fixed restorative
options would be a porcelain-fused-to-metal (PFM) prosthesis/
monolithic zirconia/layered zirconia, which could be screw/
cement retained based on location of screw access openings.4
In D3 cases either a hybrid prosthesis with resin teeth or a
combination bridge (screw-retained framework with cement-
retained crowns) can be used. The overall choice depends on
the economics as well as the position of the implant access
holes.
As the interarch space is restricted, overdentures for D1
class should be avoided. In D2 cases, the Locator attachment is
preferable. In the maxilla the implants must be splinted with a
bar attachment, which is unfeasible with the limited interarch
space.4
As the degree of resorption increases further (D3), use of
traditional designs of PFM make the prosthesis too heavy and
sometimes difficult to produce. Removable prostheses could be
designed with a ball and socket or a locator attachment. A
milled low-profile bar attachment is a possibility; however, the
choice should be made with caution.4
Journal of Oral Implantology 95
‘‘ABCD’’ Implant Classification in Completely Edentulous Arches

Interarch Distance
(implant platform/
ridge crest to incisal edge
of opposing dentition)
1 10–12 mm
2 12–15 mm
3 15–18 mm
4 .18 mm
TABLE
Restorative design options as per available interarch space*
Type of Prostheses
Fixed option
Porcelain fused to metal
Monolithic/layered zirconia
Removable option
Contraindicated
Fixed option
Same as aforementioned with addition of pink ceramic to replace lost alveolus
Removable option
Overdenture with locator or telescopes
Bar-supported overdenture contraindicated
Fixed option
Hybrid prosthesis (metal framework with acrylic resin)
Hybrid prosthesis (bio-HPP framework with composite-resin teeth)
Combination bridge (screw-retained milled framework with small units of cement retained bridges/ crowns)
Removable option
Overdenture with ball abutments or locator or telescopes
Low-profile milled bar-supported overdenture
Fixed option
Contraindicated
Removable option
Overdenture supported/retained by milled or casted bar attachments or telescopes

*Reproduced with permission from Tunkiwala et al.4 HPP indicates high performance polymer.

In D4 cases the degree of resorption has advanced to such
great levels that using any form of fixed prosthesis will make
the design biomechanically unfavorable. The preferred restor-
ative choice is an overdenture with different attachments.4
The four factors (ABCD) need to be carefully analyzed at the
presurgical diagnostic step. Different permutations of these will
help the clinician arrive at a definitive treatment plan for a
patient and also anticipate and resolve any complications that
may arise during the successive stages of the rehabilitation
process.
CLINICAL APPLICATIONS OF THE ABCD CLASSIFICATION
The following clinical cases will demonstrate the application of
this classification. The first case is of a young edentulous patient
(Figures 2 through 8), who had lost all her teeth due to
periodontal disease.
 16), who is 70 years old.
A: A1 (40 years),
 B: B2,
 C: C3, and
 D: D2, leaves us with 14 mm of interarch space.
Considering the patient’s age, long-term function was
desired from the prosthesis. The case was engineered with 7
implants in each arch to support a fixed screw retained PFM
prosthesis. Also, the lip line was high (C3), and the ridge crest
was visible in maximum smiling position. A crestotomy was
planned during surgery to hide the transition line, after
ensuring there was sufficient bone available (B2) for axial
implant placement in the anterior region. The prosthetic pink-
and-white junction was managed and made age appropriate
for the young patient. The posterior maxilla was grafted to
achieve a better bone dimension.
Application of the classification allowed the authors to plan
all parameters of the surgery. The need for additional bone was
addressed with appropriate sinus management techniques to
allow for optimal engineering of the case. In a geriatric patient,
the same case could have been managed with tilted implant
placements without any sinus intervention. The classification
allowed for a time tested, robust approach and not a
preconceived plan of tilted implants. Although tilted implants
show great success rates at 10 years,17 the authors felt that
expecting them to survive for several decades without any
complications would be unreasonable. The classification also
allowed the final prosthesis material choice to be made before
starting treatment.
The second case is of a female patient (Figures 9 through
 A: A3 (70 years),
 B: B2,
 C: C3, and
 D: D3.
All these parameters were weighed against the age of the
patient. Instead of regenerating bone with sinus grafting in the
posterior maxilla, a simpler solution was provided with 2 tilted
and 2 axially placed implants. Since the lip line was high (C3), it
was decided to make the final prosthesis as a screw retained
framework with individual cement retained crowns with a

96 Vol. XLVI / No. Two / 2020


FIGURES 5–8. FIGURE 5. Mandibular arch with optimum implant distribution. FIGURE 6. Final prosthesis in maximum intercuspation. FIGURE 7.
Profile view of final prosthesis. FIGURE 8. orthopantomogram of final prosthesis.
specifically individualized pink zone to make the pink-white
junction esthetically perfect.
DISCUSSION
There is considerable ambiguity in literature regarding data on
preference for a fixed or removable implant prosthesis with
each design having distinct advantages. Removable designs are
economical and suited for cases with severe resorption, high lip
lines, need for hygiene maintenance and a certain degree of
freedom in positioning of implants.18–20 Fixed prostheses allow
increased retention, enhanced masticatory ability, and reduced
maintenance appointments.18 Given the risks and benefits of
these rehabilitation options, comprehensive guidelines for
selecting a particular prosthesis for a patient become manda-
tory. Too often clinicians face scenarios where implants have
been placed only to discover that the type of prosthesis
promised to the patient and the available restorative space do
not match.4 Past classification systems tend to focus on a
certain parameter relating to esthetics, bone volume, virtual
implant planning procedures, or providing guidelines for either
fixed/removable restorations.
Interestingly, all these classifications focus on the maxillary
arch and use a particular parameter: esthetics in the case of the
lip-tooth-ridge classification by Pollini et al,9 fixed maxillary
restorations such as in Bedrossian et al,8 Bidra and Agar,21
virtual planning by Avrampou et al,11 or only removable
Tunkiwala et al
prostheses such as by Ahuja and Cagna.10 Most classifications
tend to undervalue the age factor in the final prosthesis choice.
The mandibular arch is largely neglected and removable
prostheses designs unexplored to a considerable extent. One
of the earliest classifications in implant dentistry given by
Misch7 is based on the amount of hard and soft tissue
structures replaced and the support obtained from the
implants and or soft tissues.
The authors felt a need to develop a holistic classification
that would encompass all the different criteria without diluting
the importance of any parameter and at the same time enable
the clinician to foresee potential complications at the
diagnostic stage. The ABCD classification uses the 4 vital
parameters of age, bone volume, cosmetic display, and degree
of resorption to create an algorithm that satisfies the treatment
needs of every patient. Various permutations of the 4
parameters can be used to arrive at a solution that streamlines
the further phases of the rehabilitative process. An accurate
diagnostic assessment of aesthetics is important to avoid
disappointment in the later stages of treatment, especially after
implants have been placed. The amount of lip support required,
the degree of exposure of the ridge, and trial denture teeth on
smiling along with the interarch space available help the
clinician decide the type of prosthesis. These 2 factors dictate
the number and position of implants and, if adequate bone is
not available, the need for regenerative surgery as well. The age
factor, when weighed against these parameters, helps deter-
Journal of Oral Implantology 97
‘‘ABCD’’ Implant Classification in Completely Edentulous Arches

FIGURES 9–14. FIGURE 9. Preoperative profile view: case 2. FIGURE 10. Preoperative maxillary occlusal view. FIGURE 11. Preoperative
orthopantomogram with radiographic markers. FIGURE 12. Two tilted and two axially placed implants to avoid advanced sinus grafting
procedures. FIGURE 13. Measurement of interarch space. FIGURE 14. Final prosthesis with customized pink zone.

mine the risk-benefit ratio of undertaking complex surgical individualized approach to rehabilitate every patient in a
procedures for achieving ideal, fixed restorations or the need to manner best suited to their needs and expectations.
opt for relatively straightforward removable prosthesis designs.

ABBREVIATIONS
CONCLUSION
ABCD classification: ‘‘age, bone, cosmetic display, degree of resorption’’
The ABCD classification system uses the interplay between the
classification
4 vital parameters of diagnosis to arrive at a precise,
predictable, esthetically, and functionally favorable treatment LTR: lip-tooth-ridge
plan for the edentulous patient. It is a scientifically driven, PFM: porcelain fused to metal

98 Vol. XLVI / No. Two / 2020


FIGURES 15–18. FIGURE 15. Final prosthesis in maximum intercuspation. FIGURE 16. Profile view of final prosthesis. FIGURE 17. Postoperative
radiograph of final prosthesis. FIGURE 18. Bone zones.
NOTE
The authors declare no conflicts of interest.
REFERENCES
1. Felton DA. Complete edentulism and comorbid diseases: an
update. J Prosthodont. 2016;25:5–20.
2. Tyrovolas S, Koyanagi A, Panagiotakos DB, et al. Population
prevalence of edentulism and its association with depression and self-rated
health. Sci Rep. 2016;6:1–9.
3. Emami E, De Souza RF, Kabawat M, Feine JS. The impact of
edentulism on oral and general health. Int J Dent. 2013;2013:1–7.
4. Tunkiwala A, Kher U, Bijlani P. Numerical guidelines for selection of
implant supported prostheses for completely edentulous patients. Quintes-
sence India. 2017;1:46–53.
5. Feine J, Carlsson G, Awad M. McGill consensus statement on
overdentures. Mandibular two-implant overdentures as first choice standard
of care for edentulous patients. Montreal, Quebec, May 24-25, 2002. Int J
Oral Maxillofac Implant. 2002;17:601–602.
6. Misch C. Prosthetic options in implant dentistry. In: Contemporary
Implant Dentistry. 3rd ed. Maryland Heights, Md: Mosby; 2008:43–52.
7. Misch CE. Contemporary Implant Dentistry. 3rd ed. Maryland
Heights, Md: Mosby; 2008.
8. Bedrossian E, Sullivan RM, Fortin Y, Malo P, Indresano T. Fixed-
prosthetic implant restoration of the edentulous maxilla: a systematic
pretreatment evaluation method. J Oral Maxillofac Surg. 2008;66:112–122.
9. Pollini A, Goldberg J, Mitrani R, Morton D. The lip-tooth-ridge
classification: a guidepost for edentulous maxillary arches. Diagnosis, risk
assessment, and implant treatment indications. Int J Periodontics Restorative
Dent. 2017;37:835–841.
Tunkiwala et al
10. Ahuja S, Cagna DR. Classification and management of restorative
space in edentulous implant overdenture patients. J Prosthet Dent. 2011;105:
332–337.
11. Avrampou M, Mericske-Stern R, Blatz MB, Katsoulis J. Virtual implant
planning in the edentulous maxilla: criteria for decision making of prosthesis
design. Clin Oral Implants Res. 2013;24:152–159.
12. Dudley J. Implants for the ageing population. Aust Dent J. 2015;60:
28–43.
13. Tjan AHL, Dent DDS, Miller GD, The JGP. Some esthetic factors in a
smile. J Prosthet Dent. 1984;53:24–28.
14. Watt D. Tooth positions on complete dentures. J Dent. 1978;6:147–
160.
15. Misch CE. Guidelines for maxillary incisal edge position - a pilot
study: the key is the canine. J Prosthodont. 2008;17:130–134.
16. Misch CE, Goodacre CJ, Finley JM, et al. Consensus conference
panel report: crown-height space guidelines for implant dentistry part 1.
Implant Dent. 2005;14:312–320.
17. Malo P, De Araújo Nobre M, Lopes A, Moss SM, Molina GJ. A
longitudinal study of the survival of all-on-4 implants in the mandible with
up to 10 years of follow-up. J Am Dent Assoc. 2011;142:310–320.
18. Sadowsky SJ, Fitzpatrick B, Curtis DA. Evidence-based criteria for
differential treatment planning of implant restorations for the maxillary
edentulous patient. J Prosthodont Dent Implant. 2015;23:87–102.
19. Heydecke G, Boudrias P, Awad MA, de Albuquerque RF, Lund JP,
Feine JS. Within-subject comparisons of maxillary fixed and removable
implant prostheses. Patient satisfaction and choice of prosthesis. Clin Oral
Impl Res. 2003;14:125–130.
20. Zitzmann N, Marinello C. Treatment outcomes of fixed or
removable implant-supported prostheses in the edentulous maxilla. Part I:
patients’ assessments. J Prosthet Dent. 2000;83:424–433.
21. Bidra AS, Agar JR, Parel SM. Management of patients with excessive
gingival display for maxillary complete arch fixed implant-supported
prostheses. J Prosthet Dent. 2012;108:324–331.
Journal of Oral Implantology 99
Copyright of Journal of Oral Implantology is the property of Allen Press Publishing Services
Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv
without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.