Treatment Plans for Partially and Completely Edentulous

Arches in Implant Dentistry (Chapter 20)

Implant Dentistry Classification

 Developed by Misch and Judy in 1985.
 Builds on the Kennedy-Applegate system to:
o Communicate bone availability.

o Facilitate common treatment approaches.

Classification of Partially Edentulous Arches

Treatment Planning: Class I
 Bilateral distal edentulous segments.
 Anterior teeth (incisors and canines) retained.
Challenges and Considerations:
1. Removable Partial Denture (RPD):
 Class I patients are more likely to use RPDs.
 Posterior soft tissue-supported RPDs load either the edentulous regions or anterior
teeth.
 Poor RPD designs accelerate bone loss and affect periodontal health, leading to
poorer abutment conditions.
2. Mobile Anterior Teeth:
 Long-term lack of posterior support from poorly fitting or absent RPDs often
causes anterior teeth mobility.
 Implant-supported prostheses in posterior regions are crucial to relieve stress on
mobile anterior teeth.
Considerations:
 Increased posterior implant support compared to Class II/III.
 Specific occlusal schemes accommodating mobile anterior teeth.
 Augmentation to improve bone volume in posterior regions.
 Less aggressive osteoplasty compared to Class IV or fully edentulous patients.
 Prioritize regions with optimal bone for phased treatment if finances are limited.
 Simultaneous bilateral augmentation reduces surgical episodes and optimizes grafting.
 Importance of consistent occlusal adjustments to prevent overload.

Class I, Division A Category:

Treatment: Independent implant-supported fixed prosthesis.
Implant Requirements:
 Two or more endosteal root form implants for molar replacement.
 The number and size of implants depend on the number of missing teeth.
 Avoid critical structures like the mandibular canal or maxillary sinus.
Division B Treatment Plans:
Patient Characteristics:
 Narrow or reduced-height posterior ridges.
 Fixed prostheses require more implants compared to Division A.
 Use one implant per missing tooth root with no cantilever.
Treatment: Fixed prostheses with small-diameter implants.
Specific Cases:
 Patients missing molars and both premolars need additional implant support.
 Four Division B root forms may support an independent fixed partial denture
(FPD) in the mandible.
 Stress factors (e.g., parafunction) and poor bone density (common in the maxilla)
necessitate bone augmentation to Division A before placing larger-diameter
implants.
Functional Considerations:
 Anterior teeth in Class I patients should provide disclusion of posterior implants
during excursions.
 Molar endosteal implants should not be rigidly cross splinted in Class I patients to
avoid lateral forces due to mandibular flexure during opening.
 Independent restorations are recommended to prevent stress from rigid splinting.
Division C Treatment Plans:
When inadequate bone exists in height, width, length, or angulation, or if crown/implant
ratios are equal to or greater than 1, the practitioner must consider several options.
Treatment Options:
1. Conventional Prosthesis:
 Simpler but risks continuous bone loss.

2. Bone Augmentation:
 Converts Division C ridge to Division A/B using grafts. Use autogenous bone
(essential in augmentation).
 Common in maxilla for sinus grafts.

3. Nerve Repositioning (Mandible):

 Suitable for Class I patients who are poor candidates for bone augmentation.
 Risks include paresthesia and fractures.
 Even with nerve repositioning, implant height may only reach 10 mm, leading to
unfavorable crown/implant ratios.

4. Anterior Extraction and Implant Placement

 Implants positioned between mental foramens.
Division D Treatment Plans:
 Most common in: Long-term edentulous maxilla.
Treatment Plan:
1. Sinus Graft:
 Performed before implant placement in the maxilla.
2. Bone Grafts (Mandible):
 Autogenous bone onlay grafts are often required in mandibular cases.

3. Post-graft, patients are treated like Division A/B cases.

Treatment Planning: Class II

Patient Characteristics:
 Partially edentulous, missing teeth in one posterior segment.
 Often manage without RPDs and less tolerant of prosthesis complications.
Bone and Implant Considerations:
 Available bone is often adequate for endosteal implants despite long-term edentulism.
 Local bone density may be decreased in these patients.
 Endosteal implants with minimal osteoplasty are commonly used.
 Minimal osteoplasty required; typically classified as Class II, Division A or B
Occlusion and Opposing Teeth:
 Opposing teeth may extrude into edentulous areas; occlusal plane adjustments and
restorative work (e.g., extractions, endodontics, crown lengthening) are often needed.
Division A Treatment Plans:
Treatment: Independent Implant-Supported Prostheses.
 Requires two or more implants for molar replacement.
 Placement must avoid critical structures (e.g., mandibular canal, maxillary sinus).
 The number and size of implants depend on the number of missing teeth.
Division B Treatment Plans:
 Narrow bone in posterior edentulous spaces.
Treatment: Fixed prosthesis is indicated for these patients.
Placement Considerations:
 Implants must avoid anatomical constraints (e.g., mandibular canal, maxillary sinus).
 Anterior teeth should provide disclusion during excursions to reduce stress.
 Osteoplasty has limited applications for increasing bone width.
Implant Options:
 Mandibular Posterior Division B Ridge:
o Endosteal small-diameter root-form implants are viable.
o Use more implants compared to Division A ridge.
o One implant per missing tooth root with no cantilevers.

Specific cases:
 Patients missing molars and both premolars need additional implant support.
 Four Division B root forms may support an independent fixed partial denture (FPD)
in the mandible.
 Stress factors (e.g., parafunction) and poor bone density (common in the maxilla)
necessitate bone augmentation to Division A before placing larger-diameter implants.
Division C Treatment Plans:
 Occur when there is insufficient height, width, length, or angulation of bone.
 Crown/implant ratios equal to or greater than 1 require careful consideration.
Treatment Options for the Mandible:
Option 1:
 Avoid implant support; use a posterior cantilevered fixed partial denture (FPD)
replacing one premolar-sized crown with two or three anterior teeth as abutments.
This is the easiest option and is strongly recommended when only molars are missing.
Option 2: Bone augmentation procedures.
o Division C to Division A or B conversion requires autogenous bone.
o Most used in Class II maxilla with sinus grafts combining allografts and
autogenous bone for predictable outcomes.
Option 3:
 Use Class II unilateral subperiosteal or disc implants placed above the canal in
Division C cases.
Option 4:
 Nerve repositioning and endosteal implants for Class II patients unsuitable for bone
augmentation.

Division D Treatment Plans:

 Common in long-term edentulous maxilla, rare in the mandible.
Treatment Approach:
 Sinus graft is typically performed before implant placement in the maxilla.
 Autogenous bone onlay grafts are often required in the mandible.
Evaluation and Treatment Post-Graft:
 Once the graft has matured and bone volume is improved:
o Patients are evaluated for implant placement. They are treated similarly to
patients with favorable bone volume.

Treatment Planning: Class III

 Patients are either missing a single tooth or have a long posterior edentulous span.
Treatment:
 Independent prostheses or single-tooth implants when bone/soft tissue is adequate.
Division A Treatment Plans:
 Patients are ideal candidates for endosteal root form implants in edentulous spaces.
Placement Considerations:
 Maximum bone height for implant placement is typically obtained anterior to the
mandibular foramen or maxillary sinus.
Prosthesis Guidelines:
 Final prosthesis should be entirely implant-supported.
 Recommended: Two implants for every three missing tooth roots (not crowns).
 If adjacent teeth are mobile, each missing root may require its own implant to support
both the missing and mobile teeth during occlusion.

Division B Treatment Plans:

 Narrow-diameter endosteal implants are recommended for long-span mandibular
edentulous spaces.
Treatment Plan:
 Primarily used for fixed prosthesis when:
o The span is too long.
o Occlusal forces are too great for natural abutments to provide sole support.
o The final implant prosthesis should function independently of natural teeth.
Division C or Division D Treatment Plans:
Maxilla (Upper Jaw):
 The most common treatment plan is bone augmentation before implant insertion.
 An independent implant prosthesis is typically used.
 Sinus grafting in the posterior Division C ridge is predictable.
Mandible (Lower Jaw):
 A traditional fixed prosthesis is often recommended.
 Bone grafting for height is less predictable and more complex than in the maxilla.
Treatment Planning: Class IV
Maxilla (Upper Jaw):
1. Traditional Approach:
 Fixed partial dentures (FPDs) were used if canines were present.
2. Current Approach:
 An independent implant prosthesis is now often warranted.
3. Challenges and Solutions:
 Lack of anterior bone volume in the maxilla is common.
 Bone grafts are typically required before implant placement to prevent implants from
being positioned palatally relative to the natural roots.
4. Cantilever Design:
 Used for correct positioning of maxillary incisor edge (aesthetics and speech).
 Increases moment force compared to the mandible.
5. Implant Rule:
 One implant per tooth is generally required unless facial bone loss significantly
reduces available length.
Mandible (Lower Jaw):
1. Implant Rule:
 Typically, one implant can replace two teeth.
 Implants are placed in the embrasure areas.
2. Prosthesis Type:
 A screw-retained prosthesis is used.
Division A Treatment Plans:
 Suitable for endosteal root form implant placement in edentulous spaces.
Prosthesis Guidelines:
 Should be restored independently of natural teeth.
 Should be completely implant-supported.
Implant Rule:
 Two implants can support three missing tooth roots (favorable forces).
 If adjacent natural teeth are mobile, greater loads on the implants occur, and one
implant per missing root may be required.
Division B Treatment Plans:
 They are commonly treated with bone augmentation before implant placement.
Challenges:
 Narrow bone ridges affect esthetics and hygiene.
 Requires augmentation in anterior edentulous regions.
Goals:
 Use Division A implants for better crown contour, esthetics, and maintenance.
 Maintain independence of implants and natural tooth replacements.
Principles:
 Canine is critical as a natural abutment.
 Fixed prosthesis contraindicated if the canine and adjacent teeth are missing.
 Canine replacement with an implant is necessary for multiple missing teeth.
Division C and D Treatment Plans:
Bone Augmentation:
 Used to convert Division C or D ridges into Division A or B.
 Autogenous bone is preferred for grafts.
Implant Placement:
 Implants can be placed after the graft has created a Division A ridge.
Treatment Plan:
 Follows the previously addressed options, referenced with Figs. 20.21 to 20.23.
Classification of Completely Edentulous Arches
Misch and Judy Classification:
 Forms the basis for classifying completely edentulous patients.
 Communicates both the volume and location of bone.
 Organizes common implant options for prosthodontic support.
Division of the Edentulous Jaw:
 Jaw divided into three regions:
o Mandible:

 Right and left posterior sections: From mental foramen to retromolar

pad.
 Anterior section: Between the mental foramina (typically spans first
premolar to first premolar).
o Maxilla:

 Right and left posterior regions: From first premolar mesial sites, with
bone height influenced by the maxillary sinus.
 Anterior section: Between the first premolars, anterior to the maxillary
sinus.
Classification System:
 Evaluates the three bone areas independently, meaning one, two, or three different
divisions of bone can exist in a single patient.
 Uses the term "type" (instead of "class") for the completely edentulous classification.
Type 1:
In the Type 1 edentulous arch the division of bone is similar in all three anatomic segments.
Therefore, four different categories of Type 1 edentulous arches are present.
Division A:
 Bone Availability: Abundant bone in all three sections.
 Implants Required:
o Mandible: 5–9 implants for a fixed prosthesis.
o Maxilla: 6–10 implants for a fixed prosthesis.

Division B:
 Bone Availability: Adequate bone for narrow-diameter root form implants.
 Common Practices:
o Mandible: Anterior section often modified to Division A using osteoplasty.
o Posterior Maxilla/Mandible: Often lacks height; narrower implants are used
without grafting.
o One implant is used for every tooth root to compensate for the decrease in
surface area of implant support.
o Maxilla: Bone spreading or lateral augmentation may be needed for fixed
prostheses opposing natural teeth.
 Stress Factors: Lateral augmentation might be required in posterior regions to increase
implant diameter.
Division C:
C−w (Inadequate width):
 Fixed Prosthesis: Requires autogenous onlay graft to convert to Division A.
 Removable Prosthesis: Osteoplasty converts to C−h formula.
C−h (Inadequate height):
 RP-4 or RP-5 removable prostheses reduce occlusal loads.
 The prosthesis should be fully implant-supported (RP-4) to prevent posterior bone
loss.
 If only Division C anterior root-form implants are placed, posterior soft-tissue support
(RP-5) may be necessary.
 Maxilla often treated with removable prosthesis initially until the mandible is
completely restored; additional retention techniques (e.g., HA augmentation,
intramucosal inserts) may be needed.
 Subnasal augmentation and root form implants may be considered for canine
eminence and posterior maxilla.
 Fixed prostheses require autogenous iliac crest grafts and sinus grafts.
Division D:
 Challenges:
o Most difficult for traditional and implant dentistry.
o High risks: Crown heights >20 mm and mandibular fractures during/after
implant placement.
 Solutions:
o Autogenous iliac crest grafts to improve conditions.
o After 6 months, 5–9 implants placed in anterior and posterior regions.

Type 2:
 Posterior sections of bone are similar but differ from the anterior segment.
 Classification: Two division letters describe the arch; anterior segment being listed
first because it often determines the overall treatment plan.
Common Scenarios & Treatments:

Type 2, Division A, C:

1. Condition: Adequate anterior bone, posterior bone resorbed. This condition is

common in the mandible, because the posterior regions resorb four times faster than
the anterior regions.
2. Treatment:
 Mandible: Implants in the anterior section; posterior often treated with cantilevered
prostheses.
 Maxilla: Sinus grafts and endosteal implants for additional posterior support.
Type 2, Division A, B:
1. Condition: Adequate anterior bone, narrow posterior bone.
2. Treatment:
 Mandible:
o Anterior: Large-diameter implants.
o Posterior: Narrow-diameter implants or grafts to convert Division B to A.
(Autogenous grafts are indicated when stress factors and patient desires are
high). Smaller segments can be augmented with intraorally harvested block
grafts.
 Maxilla: Bone spreading or sinus grafts for Division A root forms.

Type 2, Division A, D:
1. Condition: Severe posterior bone loss, abundant anterior bone.
2. Treatment: Treated similarly to Type 2, Division A, C.
 Maxilla:
o Sinus grafts and endosteal implants.
 Mandible.
o Anterior implants with/without grafts.

Type 2, Division B, C:
1. Condition: Anterior may be upgraded to Division A; insufficient posterior height.
2. Treatment:
o Anterior: May be converted to Division A with osteoplasty.
o Posterior: Sinus grafts for height, treated like Type 1 or Type 2, Division.
o Onlay grafts are less predictable than sinus grafts; therefore, the anterior
mandible may be changed to a Division C by osteoplasty, with options
including a mandibular subperiosteal implant and RP-4 restoration or anterior
root forms with an RP-5 prosthesis for Type 1, Division C patients.
Type 2, Division B, D:
1. Condition: Advanced atrophy in posterior, adequate anterior bone.
2. Treatment:
 These patients are treated in a manner like patients with Type 2, Division B, C. The
primary difference is that the posterior graft is more extensive and requires additional
months.
 Mandible treated with grafts as in Type 1, Division D.

Type 3:
 Posterior bone differs between right and left sides, less common than Types 1 and 2.
 Classification: Anterior bone listed first, followed by right and left posterior sections.
 Typical Presentation: Found more frequently in maxilla than mandible.

Common Scenarios & Treatments:

Type 3, Division A, B, D:
1. Condition: Abundant anterior bone, adequate right posterior, no left posterior bone.
2. Treatment: Anterior implants, narrow implants in the right posterior, cantilevered
prosthesis for left posterior.

Type 3, Division A, B, C:
1. Condition: Adequate anterior bone, right posterior adequate, left posterior narrow.
2. Treatment: Anterior root form implants, narrow implants in right posterior, cantilever for
left posterior.
Type 3, Division A, D, C (or A, C, D):
[Link]: Severe posterior bone loss, adequate anterior.
2. Treatment: Anterior implants, grafts for posterior (especially in maxilla).

Type 3, Division C, D, E:
1. Condition: Severe atrophy in anterior and both posterior regions.
2. Treatment: Bilateral sinus grafts and nasal elevation for fixed prostheses.

Type 3, Division C, D, C:
1. Condition: Moderate atrophy in anterior and left posterior, severe atrophy in right
posterior. 2. Treatment:
 Mandible: Anterior implants or subperiosteal implants may suffice.
 Maxilla: Requires sinus grafts and subnasal elevation.
General Treatment Principles:
 Anterior Region Importance:
o Anterior bone typically determines the treatment plan.

o Posterior implants rarely placed without anterior implant support due to poor
biomechanics.
 Biomechanics:
o Lack of anterior support increases risk of prosthetic rotation and and
accelerate posterior implant loss.
o Straight-line posterior implants reduce biomechanical advantage.

 Preferred Prostheses:
o It is usually far more prudent to convince the patient to be treated with an
anterior onlay graft and anterior implants so that a full-arch restoration (RP-4
or fixed) may be fabricated.