Original Contributions

Clinical Dentistry
Hierarchy of restorative space required for
different types of dental implant prostheses
Joseph Carpentieri, DDS; Gary Greenstein, DDS, MS; John Cavallaro, DDS

ABSTRACT

Background. Management of the full and partially edentulous arch requires an understanding regarding
the amount of vertical and horizontal restorative space that is needed for different types of dental implant
prostheses. Failure to design a prosthetic construct without considering space issues can result in a
rehabilitation with diminished stability, poor esthetics, and inadequate contours. Therefore, available
restorative volume must be computed before initiating therapy to ensure proper prosthesis design.
Types of Studies Reviewed. The authors searched the dental literature for articles that addressed
space requirements for different types of dental implant prostheses and found a few on this subject.
Results. The dental literature indicates there is a 3-dimensional hierarchy of restorative space
necessary for different types of implant constructs. The minimum amount of vertical space required
for implant prostheses is as follows: fixed screw-retained (implant level): 4 through 5 millimeters;
fixed screw-retained (abutment level): 7.5 mm; fixed cement-retained: 7 through 8 mm; unsplinted
overdenture: 7mm; bar overdenture: 11 mm; and fixed screw-retained hybrid: 15mm. These di-
mensions represent the minimal amount of vertical rehabilitative space that can accommodate the
above implant prostheses. With respect to horizontal space, computations are needed to account for
the discrepancy between an implant and tooth position.
Conclusions and Practical Implications. Restorative spaces for each type of prostheses are
restoration specific and should be considered during treatment planning to facilitate proper case
selection and enhance patient satisfaction.
Key Words. Implantology; dental prostheses; restorative space.
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I
mplant dentistry is a prosthetic endeavor with a surgical protocol. To attain an optimal pros-
thetic construct, it should be planned before initiating therapy. The number and position of
implants needed to support a prosthesis are affected by its size (volume) and the quality and
quantity of bone present at different locations. Another factor that needs to be integrated into
treatment deliberations is the evaluation of available vertical and horizontal space to accommodate
a prosthesis. Restorative room for an implant prosthesis may be defined as the total 3-dimensional
(3D) volume necessary to accommodate a particular construct that provides ideal tooth position
while maintaining optimal material properties.
The amount of rehabilitative space must be computed before implant placement; otherwise,
therapeutic options may be compromised. The design of a prosthetic construct with inadequate
restorative volume can result in a structurally weak rehabilitation, poor physiological contours,
inadequate esthetics, reduced interocclusal rest space, and decreased stability.1 This article addresses
the hierarchy of 3D space requirements for different types of dental implant prostheses. This dis-
cussion includes our suggestions based on the literature and our clinical experience.

TREATMENT PLANNING
Copyright ª 2019
After a review of a patient’s medical and dental histories and a clinical examination, appro-
American Dental
priate diagnostic records (such as cone-beam computed tomographic imaging) should be ob- Association. All rights
tained before planning a prosthetic rehabilitation. In many cases, the next step is to clinically reserved.

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 determine either the existing or potential restorative space with respect to the vertical
dimension of occlusion (VDO).
Traditional prosthodontic techniques to establish the VDO include subjective methods that
evaluate esthetics and objective techniques that assess interocclusal rest space, phonetics, and facial
and lip contours.2-5 The existing VDO may be used as a starting point, but it may need to be altered
to accommodate a future prosthesis.6,7 In general, an appraisal of existing rehabilitative volume
cannot be determined until the VDO is established.8 Evaluations to determine the required
restorative space must include establishing the final position of prosthetic teeth and then “working
backward” to ascertain needed restorative volume.9-12 In this regard, it is prudent to plan the final
prosthesis “down from the occlusal plane and not up from the osseous crest.”13
Rehabilitative space determinations for a single tooth can usually be measured intraorally for
anterior and posterior teeth. Clinically, a periodontal probe is used to quantify the vertical distance
from the soft tissue of an edentate ridge to the opposing dentition. If there is a dearth of restorative
space, the soft tissue needs to be sounded to the bone to determine the precise amount of space that
is available, because sink depth (the distance from the implant platform to the height of the gingival
margin) of an implant should be considered when gauging available rehabilitative space. Ideally,
measurements with respect to vertical restorative space should be taken from the implant platform
to the opposing dentition. However, in the treatment planning process this is not possible; mea-
surements are made from the soft tissue or the osseous crest.
With respect to anterior teeth, overbite, which affects vertical space, needs to be considered. For
mandibular anterior teeth, the potential restorative space is measured from the edentulous ridge to
the cingulum area or lingual to the maxillary teeth. For maxillary anterior teeth, space is measured
in the cingulum area (position of implant components) of the proposed tooth from either the soft
tissue or bone to the mandibular incisal edge position. This latter dimension may be less than the
length of the prosthetic tooth when there is a horizontally resorbed edentulous ridge, because the
cervical aspect of the tooth usually does not abut the edentulous ridge; it commonly extends buccal
and coronal to the ridge.
Several other situations warrant special attention regarding where to measure restorative space: a
Class III jaw relationship or a large maxillary anterior overjet. In these circumstances, sites to be
measured differ if anterior maxillary or mandibular teeth are missing (Table 1). For all the previous
scenarios, the mesiodistal and buccolingual dimensions to be occupied by an implant restoration are
also recorded.
To fabricate a large prosthesis, impressions should be obtained and working casts mounted. They
provide information concerning ridge relationships, occlusal scheme, soft-tissue topography, and
interarch space. Casts also can be used to fabricate pretreatment diagnostic setups that facilitate
determining final tooth position, provisional prostheses, and radiographic and surgical guides for
implant placement. For large prostheses, restorative space needs to be calculated extraorally (with
study casts) by measuring the distance from the soft tissue at the ridge crest (as stated earlier, if
necessary, sound the bone for a precise amount of available restorative space) to the opposing arch and
the mesiodistal and buccolingual dimensions of the edentate area to be rehabilitated.
When measurements indicate that additional vertical restorative space is needed to accommodate
a prosthesis, there are 2 methods to achieve this objective. If adequate bone is available for implants,
an alveolectomy can be performed to reduce ridge height at the time of implant placement,14-17 or if
possible, the VDO can be prosthetically increased.18 However, if there is excessive soft- and hard-
tissue loss resulting in too much interarch space (such as  15 millimeters), then use of a con-
ventional fixed porcelain-fused-to-metal implant-supported prosthesis is problematic, because large
prostheses are at risk of causing metal distortion when subjected to multiple heat and cooling cycles
ABBREVIATION KEY and this may hinder proper construct seating.19 Accordingly, when the interarch space is large,
either an implant overdenture or fixed implant rehabilitation designed by different methods (such as
3D: Three-
a hybrid appliance with a titanium computer-aided design and computer-aided manufacturing
dimensional.
CAD-CAM: Computer-aided [CAD-CAM]efabricated substructure and acrylic prosthetic teeth) should be fabricated.
design and
computer-aided REMOVABLE VERSUS FIXED IMPLANT RESTORATIONS
manufacturing.
Several factors need to be considered when choosing between a removable and a fixed dental
VDO: Vertical
dimension of implant rehabilitation. Collected diagnostic information should include both intraoral and
occlusion. extraoral data. Tables 2 and 3 list guidelines to determine whether a fixed or removable prosthesis

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Table 1. Where to measure anterior restorative space with Class III relationship or large maxillary anterior overbite.

MISSING TEETH CLASS III JAW RELATIONSHIP LARGE MAXILLARY OVERJET

Maxillary Anterior Measure from the edentulous ridge where implant Same as for Class III
Dentition components will be located to the level of the relationship
opposing dentition

Mandibular Anterior Measure from the mandibular ridge to a height that Measure from the mandibular ridge to a height
Dentition corresponds to the incisal edge of maxillary teeth that corresponds to the cingulum of the
maxillary anterior teeth

Table 2. Comparison of intraoral factors favoring fixed* versus removable prosthesis.†

FACTOR FIXED PROSTHESIS REMOVABLE PROSTHESIS

Ridge Shape Vertical/convex Buccal inclination/concavity

Interarch Distance 10 millimeters > 15 mm

Interarch Relationship Neutral/deep overbite Skeletal Class III

Mucosa Thick, keratinized Thin, mobile

20
* Cement- or screw-retained options. † Source: Carpentieri.

Table 3. Comparison of extraoral factors favoring fixed* versus removable prosthesis.†

FACTOR FIXED PROSTHESIS REMOVABLE PROSTHESIS

Lip Line Low High‡

Tooth Display Little Excessive tooth and gingiva exposure

Facial Support, Lip Support No need Necessary

20
* Cement- or screw-retained options. † Source: Carpentieri. ‡ A fixed prosthesis could be used for a high lip line with pink added
provided it does not overlap the buccal aspect of the implants and block hygiene.

should be fabricated.20 Table 2 indicates that a removable prosthesis can accommodate a variety of
anatomic variations that would be difficult to satisfy with a fixed prosthesis (that is, a deformed
ridge, large interarch space, skeletal Class III interarch relationship, or thin or mobile mucosa).
Regarding the latter remark, it would be preferable if the patient had keratinized tissue adjacent to a
fixed prosthesis, which offers the restorative dentist an opportunity to sculpt tissue (develop more
ideal emergency profiles) while providing increased patient comfort when brushing contiguous
tissue. Additional issues pertinent to decision making are a patient’s preferences,21 rehabilitation
cost, material choice, and prosthetic aftercare considerations.22

Implant-level versus abutment-level retention of prosthesis

A dental implant construct can be retained by either of 2 methods. It can be connected directly to an
implant, which is referred to as an implant-level screw-retained implant restoration. Alternatively,
abutments can be used to support a screw- or cement-retained construct. Selection of the retention
method affects space management and there are advantages and disadvantages associated with each
approach. In general, implant-level screw-retained prostheses require less restorative space than
implant-level cement-retained abutment options. However, abutment-level cases facilitate use of
straight, angled, or custom cement-retained abutments, which can compensate for angle corrections,
prosthetic draw requirements, and deep peri-implant soft-tissue depths. With respect to components,
straight screw-retained abutments require less space than angled screw-retained abutments and more
space is needed as the angle of the abutment increases. This occurs because the height of the knee
(base) of the angled component changes in size proportionally to the abutment angle.

Hierarchy of restorative space requirements for different types of prostheses

Available or attainable restorative space is often the critical determinant regarding which type of
prosthesis can be constructed. Therefore, restorative space requirements should be considered in 3D
and include both vertical and horizontal components. With respect to the definition of terms, the

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 Table 4. Minimum vertical space required for different types of prostheses.

TYPE OF PROSTHESIS MINIMUM VERTICAL SPACE REQUIRED*

Fixed: Screw-Retained Options 4-5 millimeters (implant-level prosthesis)25

Fixed: Screw-Retained Options 7.5 mm (abutment-level prosthesis)26

Fixed: Cement-Retained Options 7-8 mm27,28

Unsplinted Overdenture 7 mm,17 8.5 mm,16 10-12 mm,29 15-17 mm27

Bar Overdenture 11 mm,30 13-14 mm29

Fixed-Screw Retained Hybrid  15 mm27

* Vertical space is measured in the position of the prosthetic components.

Figure 1. Implant-level screw-retained crown at site no. 30. Generally, the minimal acceptable vertical dimension for a
screw-retained implant level fixed restoration is 4-5 millimeters when recorded from the implant platform to the
opposing arch.

vertical dimension of restorative space generally refers to the vertical space needed for implant
components, materials, and teeth. In contrast, the horizontal dimension of space required must ac-
count for the discrepancy between implant and tooth position. Ridge resorption is a normal conse-
quence of tooth extractions; usually the maxilla resorbs apically and palatally and the mandible resorbs
apically and buccally.20,22 This can result in a dramatic disparity between the maxillary and
mandibular ridges, especially in edentulous people.23,24 Accordingly, guidelines are needed as to where
to assess vertical space requirements as they relate to horizontal ridge resorption for different types of
prostheses. To facilitate this discussion, we suggest the following classification for measuring restor-
ative space with respect to horizontal ridge resorption: 0 through 4 mm is regarded as minimal
resorption, 5 through 10 mm as moderate resorption, and greater than 10 mm as advanced resorption.
These numbers defining the amount of ridge resorption help estimate the discrepancy between the
proposed implant position and the facial aspect of the intended restoration.
For example, if a patient manifests minimal bone resorption (0-4 mm) at an edentate area, the
needed vertical space is recorded at the future tooth location. In contrast, when there is moderate
(5-10 mm) or advanced bone loss (> 10 mm, which may occur in a fully edentulous patient or a
partially edentulous patient with considerable localized bone resorption), vertical restorative space
for implant components and materials is measured on the edentulous ridge, lingual or palatal to
future tooth position. Vertical assessments are recorded from the proposed implant platform to
either the opposing arch or the external lingual or palatal aspect of the planned prosthesis. These
measurements are made to ensure there is adequate room for components, and these recordings are
generally less than the space needed for prosthetic teeth.
Table 4 lists the minimal amount of vertical restorative space necessary for different prosthetic
constructs with respect to the vertical height needed to accommodate restorative components and
materials.25-30 Several prosthetic categories in Table 4 have multiple suggestions regarding the
amount of vertical space necessary; this is due to different authors’ opinions.25-30

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Figure 2. Implant-level screw-retained prosthesis at sites nos. 6 through 11. When there is moderate resorption after
tooth loss, 2 points of vertical measurements are needed to assess restorative space. The most important location is the
position of the implant components (4-5 millimeters of vertical height is needed for components), which is always less
than the space required for prosthetic teeth.

Figure 3. Screw-retained abutment-level abutments at site nos. 22, 24, 25, 27, and 28. The final prosthesis is screwed
into these abutments.

With respect to vertical space required for teeth, usually if there is enough space for implant
components and dental materials for an edentulous case, there will be enough room for teeth, which
will be buccal to the components if there was horizontal ridge resorption. The distance from
components to the facial aspect of tooth position (buccolingually) is dictated by the amount of bone
resorption that occurred.

Fixed options
Screw-Retained Crowns
Fixed options are recommended where there is a minimum amount of restorative space. For screw-
retained prostheses (includes porcelain-fused-to-metal or zirconia, monolithic zirconia, and lithium
disilicate), additional factors require consideration: whether the prosthesis is designed at the implant
or abutment level, and the choice of esthetic materials. The minimal vertical restorative space
required for a screw-retained implant-level implant prosthesis is 4 to 5 mm, measured from the
implant platform to the opposing arch (Figures 1 and 2).25 This assessment is determined in the
implant area. Relevantly, when a screw-retained rehabilitation is planned for a partially edentulous
patient (such as a single-tooth implant), the implant should be placed as parallel as possible to the
adjacent teeth to facilitate a line of draw for the prosthesis for ease of seating, broad contacts, and
minimal embrasure space.

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 Figure 4. Screw-retained abutment-level prosthesis (completed case for Figure 3). An abutment-level construct requires
more restorative space compared with implant-level options. The minimal space from the implant platform to the
external dimension of the prosthesis is 7.5 millimeters.

Figure 5. Computer-aided design and computer-aided manufacturingefabricated abutments for a cement-retained

implant rehabilitation (site nos. 13 to 15).

When fabricating a screw-retained abutment-level restoration there is an additional space

requirement, which depends on the type of abutment used. A straight, low-profile screw-retained
transmucosal abutment requires at least 7.5 mm of vertical space. For example, the shortest collar
height of 1 mm requires an additional 5 mm of vertical space for the desired abutment height plus
1.5 mm for structural restorative materials (Figures 3 and 4).26
The choice of material used to fabricate a crown also affects restorative space. For instance,
monolithic zirconia or lithium disilicate crowns (press or CAD-CAM) require less vertical room
than porcelain-fused-to-metal crowns31,32 as prostheses made of these materials need as little as 1
mm of occlusal clearance because no space is required for a metal understructure.

Cement-Retained Crowns
A cement-retained implant restoration (includes porcelain-fused-to-metal or zirconia, monolithic
zirconia, and lithium disilicate) requires a minimum interarch space of approximately 7 through 8
mm, measured from the implant platform to the opposing dentition (Figures 5 and 6).27,28 Ideally,
an interocclusal space of 9 through 10 mm in the posterior dentition and 10 through 12 mm in the
anterior dentition is desired to provide better crown esthetics and increased retention owing to
longer abutments.27 This restorative space consists of 3 different zones. The peri-implant soft-tissue
zone, defined as the total volume of soft tissue surrounding an implant abutment. Ideally,
approximately 3 mm of soft-tissue height and 2 mm of width is desired. The abutment zone, defined
as a 5-mm long abutment, desired for retention (4 mm is the minimum height).28 A properly
designed retentive abutment is essential because it facilitates use of a temporary luting agent.
Pertinently, crown retrievability is important, because open contacts occur more often than ex-
pected and prostheses may need to be removed to correct open contacts or repair breakage of

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Figure 6. Cement-retained prosthesis on abutments nos. 13 through 15 in Figure 5. This type of construct requires a
minimum of 7 through 8 millimeters of vertical restorative space.

Figure 7. Surgical guide demonstrating restorative space needed for unsplinted mandibular overdenture (frontal view).
The minimal restorative space required for an unsplinted overdenture is approximately 7 millimeters, which is denoted
by the arrow between the dotted lines.

restorative materials.33 The required interarch space for occlusal restorative materials, measured
from the most coronal aspect of an abutment to the opposing arch, and this dimension varies based
on the type of restorative materials used. For example, at least 2 mm of space is required to provide
room for porcelain-fused-to-metal occlusal materials (opaque 0.3 mm; metal 0.5mm; and porcelain 1
mm).34

Removable implant prostheses: unsplinted designs

Fully edentate ridges undergo vertical and horizontal osseous resorption. Therefore, to construct an
overdenture, vertical restorative space should be assessed in 2 distinct locations: sites where the
prosthetic teeth are located and more palatally or lingually where implant components are posi-
tioned. For components, the absolute minimal vertical dimension for an unsplinted overdenture is
approximately 7 mm, which consists of 2 mm height for a Locator (Zest Dental Solutions) abutment
(this is the lowest profile overdenture abutment), 2.5 mm for metal housing and the retentive
element around the Locator, and minimally 2.5 mm thickness of acrylic (Figures 7 and 8).17 If
overdenture abutments are angled (such as angled Locators), they require more vertical restorative
space than straight-type abutments. The horizontal component of prosthetic space is measured from
the facial aspect of the prosthetic tooth or facial flange to the lingual flange areas. This space ac-
commodates dental materials and tooth replacement to compensate for ridge resorption. Often the
horizontal discrepancy between facial tooth position and implant location for overdentures is up to

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 Figure 8. Surgical guide demonstrating buccolingual restorative space dimensions needed for unsplinted mandibular
overdenture (occlusal view). Generally, the implant position for a removable prostheses needs to be more lingual or
palatal compared with a fixed format, allowing horizontal space for an overdenture abutment, metal housing, and
acrylic and prosthetic teeth that require minimal modification.

Figure 9. Splinted bar mandibular overdenture. The minimal vertical restorative space required for a splinted
overdenture is approximately 11 through 12 millimeters, which is denoted by the arrow between the dotted lines. The
restorative space is measured lingual to the tooth position from the implant platform to the external surface of the
prosthetic base.

8 mm; this depends on the amount of osseous resorption that occurred. With respect to Locator
attachments, the minimum needed horizontal space, which is assessed apical to the most inferior
aspect of the prosthetic tooth, needs to be approximately 10 mm. This includes locator width,
1 mm metal housing on each side of the locator and 2 mm acrylic buccally and lingually. Other
authors recommend a minimum space of 8.5 mm vertically and 9 mm horizontally.16
The above dimensions vary with respect to different types of overdenture abutments that are used
and the amount of postextraction bone resorption. In our opinion, clinicians should consider the 10
by 10 guideline for unsplinted overdentures, which suggests that ideally, 10 mm is needed in both
vertical and horizontal dimensions to offer enough required restorative space. Aside from being the
most cost-effective option for a fully edentulous patient, specific advantages provided by an
unsplinted implant-supported overdenture include ease of hygiene and the opportunity to convert
an existing prosthetic to an implant overdenture.

Removable implant prostheses: splinted designs (bar overdentures)

The minimal vertical space needed for a bar overdenture is approximately 11 mm (Figures 9 and
10).30 Other authors recommended 13 through 14 mm29 or 15 through 17 mm.27 Different

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Figure 10. Primary implant-level Hader bar construct. The minimal total vertical restorative space requirement is 11
through 12 millimeters, which consists of the Hader bar 7 mm (arrows) plus the overdenture (which includes plastic
clips, metal housing, and acrylic).

Figure 11. Abutment-level screw-retained hybrid prostheses. This design requires the most restorative space (15 mil-
limeters) of any fixed option because it is composed of transmucosal abutments and material choice (hybrid composed
of computer-aided design and computer-aided manufacturingefabricated titanium bar, acrylic, and minimally modified
prosthetic teeth).

suggestions arise owing to clinicians’ use of dissimilar locations for measurements and use of assorted
attachment types. These vertical space assessments allow for approximately 2 mm of soft tissue
around the abutment; 1 mm of soft tissue under the bar; 5 mm for the bar and attachment, and a
2.5- to 3-mm thickness of acrylic. Provided there is adequate vertical and horizontal restorative
space, there are situations in which bar overdentures provide the following clinical benefits:
n advantageous when there is excessive space between the maxillary and mandibular arches owing
to differences in residual ridge trajectories, which result in a horizontal prosthetic cantilever;
n facilitate achieving ideal parallelism of retentive elements irrespective of implant angulation.
CAD-CAM milled bars require less prosthetic aftercare than round bars. This is because a milled
bar (bar unit) provides only 1 path of insertion and a rigid design, whereas a round bar has multiple
paths of insertions and rotational features. Generally, rotational designs result in increased
replacement patterns of retentive components compared with rigid options. Therefore, a milled bar
is the design of choice.35 In either case, it is advantageous to use retentive components made of
materials (such as plastic), which are designed to wear first as opposed to the elements within the
primary bar structure.

Fixed: screw-retained hybrid prostheses and other large screw-retained prostheses

The fixed options and materials (may include porcelain-fused-to-metal, zirconia, and monolithic
zirconia) are recommended where there is an excessive amount of restorative space. Paradoxically,
screw-retained prostheses are recommended for edentate spaces with minimal restorative room

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 Figure 12. Screw-retained porcelain-fused-to-metal prosthesis spanning teeth nos. 3 through 14. For porcelain-fused
to metal, porcelain-fused-to-zirconia, and monolithic zirconia options, the trajectory of the implants should be within
the confines of the prosthetic tooth because these materials demonstrate excellent fracture resistance with thinner
dimensions.

Figure 13. Screw-retained hybrid prosthesis spanning teeth nos. 19 through 30. For hybrid constructs, the authors
recommend an alteration to the traditional surgical protocol, suggesting that the implant trajectory should be within the
prosthetic base and not tooth position.

(American College of Prosthodontics Class I) and for cases with advanced osseous resorption
(American College of Prosthodontics Class IV).36 The key differences between a minimal and
excessive restorative space are the choice of retention (implant versus abutment level) and
the selection of structural materials. Note the use of a hybrid option for this category, defined as a
CAD-CAMdfabricated titanium bar processed with prosthetic teeth. In general, a screw-retained
prosthesis is useful when a large horizontal discrepancy exists between ideal tooth position and
implant locations. In this situation, a cement-retained option is contraindicated owing to the
difficulty concerning cement removal under a bulky construct; in addition, cementation hinders
prosthesis retrievability.
The choice of prosthetic materials used with a screw-retained implant construct with excessive
crown-height space is important with respect to technical challenges related to construct volume,
laboratory costs, and patient acceptance.6 For example, an abutment-level hybrid prosthesis requires
approximately 15 mm of restorative space (Figure 11).27 This type of rehabilitation often requires
creation of additional vertical space that is obtained via alveoplasty or prosthetically induced in-
crease of the VDO. A hybrid rehabilitation represents the most cost-effective full-arch fixed therapy
with the least potential for technical difficulties during its fabrication. However, disadvantages

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associated with this type of construct include the large bulk, which requires increased restorative
space; the prosthesis shape, which is not exactly similar to a natural dentition; speech alterations
owing to thickness of the construct; the possibility of food impaction; staining of prosthetic teeth,
and the predisposition of acrylic teeth to fracture with poor space management.
When characteristics of a hybrid prosthesis are compared with full-arch porcelain-fused-to-metal
or zirconia substructures, the latter rehabilitations require less space and the prosthetic teeth are
shaped closer to a natural dentition (there are embrasures). Disadvantages associated with full-arch
porcelain-fused-to-metal or zirconia substructures include increased cost and technical issues
regarding replacement of a large volume of lost tissues and difficulty in obtaining a precision fit.37-39
Other full-arch options such as CAD-CAMdfabricated monolithic zirconia40 and cobalt chrome
alloys41,42 represent promising alternatives, which can circumvent these challenges.
For screw-retained prostheses, space considerations coupled with material choice influence the
surgical protocol. For instance, when porcelain-fused-to-metal, porcelain-fused zirconia, or full
monolithic options are fabricated, ideally the screw access should exit within the confines of the
prosthetic tooth (Figure 12). In contrast, for hybrid designs that use prosthetic teeth, we recommend
considerable modification of surgical placement of the implant so that the screw access exits lingual
or palatal to the prosthetic teeth (Figure 13). Accordingly, implants should be placed lingual to the
position of the teeth, which in turn reduces the vertical space requirement that would be needed if
the components were directly under prosthetic teeth. This avoids grinding of prosthetic teeth to
gain space for hybrid designs, which results in reduced prosthetic tooth fracturing or debonding from
the prosthetic base.

CONCLUSIONS
In this article we discuss 3D hierarchies of restorative space requirements for different types of
implant prostheses used to replace missing teeth. Ultimately, space requirements for each reha-
bilitation should be considered restoration specific. Therefore, application of knowledge per-
taining to restorative space considerations regarding various implant constructs should be
considered a mandatory component of treatment planning. Such consideration will enhance
proper case selection, implant success, prosthesis survival, and patient satisfaction and minimize
prosthetic aftercare. n

Dr. Carpentieri is a clinical assistant professor, Department of Prostho- Address correspondence to Dr. Greenstein, 900 West Main Street, Free-
dontics, College of Dental Medicine, Columbia University, New York, NY, hold, NJ 07728, e-mail [email protected].
and is in private practice, Surgical Implantology and Prosthodontics, White Dr. Cavallaro is a clinical professor, Department of Prosthodontics,
Plains, NY. College of Dental Medicine, Columbia University, New York, NY, and is in
Dr. Greenstein is a clinical professor, Department of Periodontology, private practice, Surgical Implantology and Prosthodontics, Brooklyn, NY.
College of Dental Medicine, Columbia University, New York, NY, and is in Disclosure. None of the authors reported any disclosures.
private practice, Surgical Implantology and Periodontics, Freehold, NJ.

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