Treatment planning for full arch maxillary cases (fixed &overdentures)

and the systematic approach for the prosthetic phase

Implantology Department – Cairo University

By :
Shuaib Wajdi Shuaibi
Khalid Kayed Rimawi
Ahmed Sherif El - Sayed

Supervisor :
Prof. Hanaa Sallam
  Introduction

Implant rehabilitation of the edentulous maxilla remains one of the most

complex restorative challenges because of the number of variables that
affect both the aesthetic and functional aspect of the prosthesis.
Dental implants in the upper jaw (maxilla) are less predictable than in the
lower jaw due to greater horizontal bone loss and the influence of
anatomical structures like the sinus and nasal cavity. Because of poor
bone quality and higher esthetic demands, treatment planning in the
maxilla requires a more detailed approach, especially for fixed or
removable prostheses.
Among the prosthesis designs used to treat the edentulous maxilla are
fixed or removable implant-supported restorations.

 Treatment Planning Factors

Most dentists and patients believe that the most suitable restoration (that
will eliminate all of the patient’s existing problems) is a “fixed” implant
prosthesis. The choice of the definitive prosthesis should not be based on
the preference of the dentist or the patient, rather, it should be
determined by comprehensive diagnosis and treatment planning.
In order to reach a clear decision and treatment plan, a comprehensive
examination and thorough evaluation of various factors are essential.
Smile Line
With an edentulous arch the clinician should evaluate the amount of ridge
showing when smiling without the denture. If the residual ridge does
show during smiling, the treatment planning for an implant prosthesis
may be very challenging.

Facial and Lip Support

Facial support is an important decision in this regard. Assessment of the
patient’s facial support with and without the denture in place with the
patient facing forward and in profile needs to be made so we can deter-
mine which type of prostheses would be more suitable. If the existing
denture greatly supports the lip, then a fixed prosthesis may not be the
most ideal because it is often difficult to obtain lip support from a fixed
maxillary prosthesis.
Ridge Position
Depending on the amount of bone resorption, the residual ridge is usually
significantly lingual to the ideal position of the teeth in the maxillary
anterior and posterior. this discrepancy must be taken into consideration
when evaluating the ideal position of the implants. When the difference
between the ridge and the tooth position (i.e., square arch form and
tapered tooth position) is present, significant prosthetic difficulties such
as anterior force factors (i.e. from the cantilevered discrepancy between
the ridge and tooth position) may predispose to complications.

Soft Tissue
the thickness and quality of the soft tissue should be evaluated both
clinically and via a cone beam computed tomography examination. As the
maxillary ridge resorbs, the tissue thins and is less dense with loss of
keratinized tissue.
Often maxillary edentulous patients seek an esthetic fixed prosthesis
similar to natural teeth. Therefore, it is imperative the patient understand
the difficulty in achieving a papillary architecture similar to pre-extraction
condition.
Crown Height Space (Interocclusal Space)
the amount of space between the residual ridge and the incisal edge is an
important factor in the treatment planning of a maxillary prosthesis.
Accurately mounted casts are critical in assessing prosthetic space
limitations. Spatial constraints must be considered as a matter of
practicality. The limiting factor in edentulous patients is the available
inter-arch space.
-Conventional screw retained implant prostheses have been constructed
with 8-10 mm between the edentulous ridges and the opposing occlusal
plane.
- For a hybrid prosthesis, approximately 15 mm of inter-occlusal room is
required.
- The literature recommends a minimum clearance of 13-14 millimeters
for bar overdentures
  Fixed or Removable prosthesis?
the decision between a fixed or removable dental prosthesis is
significant and plays a crucial role in the long term of success of
treatment. The decision depends on the factors previously mentioned.

 Fixed Maxillary Treatment Plans

The edentulous maxilla has lower implant survival rates for either fixed or
removable implant restorations than the mandible due to poor bone
quality and biomechanics, so more implants and a wider A-P spread are
recommended. Therefore, a number of core principles are used when
treatment planning an edentulous maxillary arch for a fixed prosthesis;
following these principles increases the success rate.
1. the number of implants is related to the dental arch form.
2. the arch form is dictated by the final dentition or prosthesis, not the
edentulous ridge arch form.
3. Key implant positions exist: anterior, canine, premolar, and molar.
Bone resorption changes the shape of the edentulous ridge, which may
differ from the original dental arch. Final tooth positioning is based on
aesthetics and function, not the current ridge shape, and may require
facial cantilevering to achieve a natural arch form.
The number and position of implants are related to the arch form of the
final dentition (prosthesis), not the existing edentulous arch form.
According to Misch’s, there are four different options for the maxillary
fixed prosthesis.

Maxillary Fixed Prosthesis Treatment Option 1

In a dental square arch form, lateral and central incisors are minimally
cantilevered facially from the canine position. As a result, implants in the
canine position to replace the six anterior teeth may suffice when the
force factors are low and if they are splinted to additional posterior
implants
Maxillary Fixed Prosthesis Treatment Option 2
ovoid arch form, at least three implants should be placed in the premaxilla
one in each canine and preferably one in the central incisor position for
better biomechanical support. In severely atrophic edentulous maxillae,
bone grafting may be needed before implant placement. If patient force
is low to moderate, the anterior implant can be placed in a lateral incisor
site if the central site is unsuitable. This configuration improves prosthesis
retention and reduces abutment screw loosening.
the suggested locations for this treatment option are at least
one central (or lateral) incisor position, bilateral canine positions, bilateral
second premolar sites, and the bilateral distal half of the
maxillary first molar sites.

Maxillary Fixed Prosthesis Treatment Option 3

In a tapered dental arch, anterior implants face high forces, especially
during jaw movements, due to facial cantilevers and shear forces. To
support six anterior teeth, four implants—ideally in both canine and
central incisor positions—are recommended, especially when force
factors like crown height, bruxism, or poor bone density are present. In
severe cases (e.g., tapered arch with square ridge), additional posterior
implants extending to second molars may be needed, increasing the total
to at least eight implants. This setup enhances support and counters
cantilever effects but comes with added costs and may require bone
grafting.

Maxillary Fixed Treatment Option 4: All-on-Four

The All-on-Four treatment concept, as introduced by Maló et al.,
represents a significant advancement in implant dentistry aimed at
reducing treatment duration, cost, and patient morbidity. This technique
involves the strategic placement of four implants in the maxillary arch—
two anterior implants placed axially and two posterior implants angulated
at 30 to 45 degrees. Despite utilizing fewer implants than the traditionally
recommended six to eight for maxillary fixed prostheses, the All-on-Four
approach has demonstrated high success rates ranging from 93% to 98%.
The technique capitalizes on the favorable bone density of the anterior
maxilla and utilizes longer, tilted posterior implants to enhance
anteroposterior (A-P) distribution and avoid the maxillary sinus, thereby
often eliminating the need for bone grafting. Finite element analyses,
such as that by Zampelis et al., support the biomechanical advantages of
tilted implants over cantilevered axial configurations. While the All-on-
Four method is most commonly employed in immediate load protocols,
its success is contingent upon meticulous patient selection and the
expertise of experienced surgical and prosthetic clinicians.
Removable Maxillary Treatment Plans

The primary advantage of a maxillary Implant Overdenture (IOD)

compared with a fixed prosthesis is the ability to provide a flange for
maxillary lip support and the reduced fee compared with a fixed
restoration.

Maxillary IOD complications, such as attachment wear and prosthesis or

component fracture, are more frequent than with a fixed restoration and
primarily occur as a result of inadequate bulk of acrylic and minimal
strength of the framework, compared with a fixed restoration
Fewer reports have been published for maxillary IOD compared with the
mandible. Most of these reports discuss RP-5 restorations with posterior
soft tissue support and anterior implant retention. According to Goodacre
et al., the restoration with the highest implant failure rate is a maxillary
overdenture (19% failure rate).
Maxillary Removable Implant Overdenture Treatment Options

Only two treatment options are available for maxillary IODs, whereas five
treatment options are available for the mandibular IOD. The difference is
due primarily to the biomechanical disadvantages of the maxilla
compared with the mandible.
As such, the two treatment options are limited to an RP-5 with four to six
implants with soft tissue support, or an RP-4 restoration with six to eight
implants (which is completely supported, retained, and stabilized by
implants).
The crown height space is critical for maxillary overdentures, and more
often a lack of space may compromise tooth position compared with the
mandibular situation.
The maxillary anterior crown height space requirement is greater than the
posterior dimension. A minimum of 14mm of anterior crown height space
and 12-14 mm of posterior space is required for IOD (i.e., bar-retained)
because of the greater anterior teeth coronal dimensions and specific
locations.
Option 1: Removable Maxillary RP-4 Implant Overdenture

The first option for a maxillary IOD is an RP-4 prosthesis with six to eight implants, which is rigid
during function (i.e., primary support is by implants, no soft tissue support).
This option is the preferred IOD design because it maintains greater bone volume and provides
improved retention and confidence to the patient compared with a denture or RP-5 prosthesis.
Because the palate is removed from this prosthesis (i.e., horseshoe-shaped), soft tissue
support is lost, thereby requiring increased number of implants.
The cost of treatment is similar to a fixed prosthesis because of the increased number of
implants required.
Treatment planning for RP-4 maxillary overdentures is similar to a fixed prosthesis, because the
IOD is fixed during function.
Two of the key implant positions for the RP-4 maxillary IOD are in the bilateral canines and
distal half of the first molar positions. These implant positions usually require sinus
augmentation in the molar position. Additional posterior implants are located bilaterally in the
premolar position, preferably the second premolar site.
Six implants is the minimum number for an RP-4 treatment option. When force factors are
greater, the next most important sites are the second molar positions (bilaterally) to increase
the A-P spread and improve the biomechanics of the system.
The occlusal scheme for the RP-4 prosthesis is similar to a fixed prosthesis: mutually protected
occlusion (unless opposing a mandibular complete denture)
Option 2: Removable Maxillary RP-5 Implant Overdenture

The second treatment option for the maxillary arch is the RP-5 prosthesis,
A maxillary conventional complete denture usually has good retention, support,
and stability. Although an RP-5 maxillary IOD is superior to a complete denture,
many patients do not see much of a difference.

The major advantages of an RP-5 maxillary IOD are the maintenance of the anterior
bone and it being a less expensive treatment option in comparison with an RP-4 or
fixed prosthesis.
Therefore, this treatment plan is often used as a transition to an RP-4 or FP-3
prosthesis when financial considerations of the patient require a staged treatment
over several years.
 systematic approach for the prosthetic phase for full arch
maxillary cases (fixed implant retained prosthesis & overdentures)

I. Initial Assessment and Planning (Pre-Prosthetic Phase)

 Review Treatment Plan: Confirm the number and position of implants,

inter-arch space, and opposing arch characteristics.
 Prosthetic Space Evaluation:
o Fixed Prosthesis: Minimum 7mm from implant platform to opposing

occlusal plane is generally required, but may vary based on the chosen
material (e.g., zirconia, hybrid).
o Overdenture: Requires more vertical space for attachments and

denture base (8-11mm for individual attachments, 14mm for bar with
attachments, 12-15mm for hybrid overdentures).
 Existing Prosthesis Evaluation (if applicable): Assess the fit, esthetics,
and function of any existing dentures. This information can be valuable for
diagnostic tooth arrangement and vertical dimension.
 Diagnostic Impressions: Obtain accurate impressions of the maxillary and
mandibular arches.
 Diagnostic Casts: Pour and mount casts on an articulator using a facebow
transfer and centric relation record (or maximum intercuspation if stable and
appropriate).
 Diagnostic Wax-Up: Fabricate a diagnostic wax-up on the maxillary cast to
determine:
o Ideal tooth position, size, and shape.

o Occlusal plane and vertical dimension of occlusion (VDO).

o Lip support and esthetics (smile line, buccal corridor).

o Phonetics.

 Surgical Guide Verification: If a surgical guide was used, ensure its

accuracy on the diagnostic cast.
  Patient Approval: Present the diagnostic wax-up to the patient for feedback
and approval regarding esthetics and function.

II. Prosthetic Phase - Fixed Implant-Retained Prosthesis

1. Impression of Implant Positions:

o Open Tray Technique: Preferred for multiple implants to ensure

accuracy. Transfer copings are screwed to the implants, picked up in

the impression, and sent to the lab with implant analogs.
o Closed Tray Technique: Can be used for well-aligned implants.

Impression copings remain on the implants when the impression is

removed and are later attached to the analogs in the lab.
o Digital Impression: Intraoral scanners can capture implant positions

using scan bodies.

2. Master Cast Fabrication: The dental laboratory pours a master cast with
accurate implant analogs in the correct spatial relationship.
3. Framework Fabrication:
o Based on the master cast and the approved diagnostic wax-up, a

framework (metal, zirconia, or hybrid) is fabricated.

4. Framework Try-In:
o The framework is tried in the patient's mouth to verify passive fit on all

implants. A passive fit is crucial for long-term success and to prevent

screw loosening or implant stress.
o Assess the extension, retention, and stability of the framework.

o Verify the inter-arch space for the final restoration.

5. Occlusal Registration: Obtain an accurate interocclusal record with the

framework in place to mount the casts correctly for final tooth arrangement.
 6. Tooth Arrangement and Wax Try-In:
o Artificial teeth are arranged on the framework in wax according to the

diagnostic wax-up and occlusal records.

o The wax try-in is evaluated for:

 Esthetics (tooth position, lip support, smile line).

 Phonetics.

 Occlusion (centric and eccentric contacts).

 Vertical dimension.

7. Final Prosthesis Fabrication: Following the approved wax try-in, the final
prosthesis (e.g., zirconia, porcelain-fused-to-metal, acrylic hybrid) is
fabricated by the laboratory.
8. Prosthesis Insertion and Adjustment:
o The final prosthesis is carefully seated on the implants, ensuring

passive fit.
o Verify and adjust the occlusion in centric and eccentric movements.

o Check interproximal contacts.

o Evaluate esthetics and phonetics.

o Confirm screw access and tighten prosthetic screws to the

manufacturer's recommended torque.

9. Patient Education: Provide instructions on oral hygiene, prosthesis care,
and the importance of regular maintenance appointments.

III. Prosthetic Phase - Implant-Retained Overdenture

1. Abutment Selection and Placement: Select appropriate abutments (e.g.,

ball, locator, bar) based on the number and angulation of implants, inter-arch
space, and desired retention. Attach these abutments to the implants.
2. Impression for Overdenture Base:
o Pick-Up Impression: If using individual attachments, impression

copings that engage with the attachments are used to capture their
position accurately within the impression of the edentulous ridge.
 o Impression with Bar: If using a bar, an impression is taken with
impression copings attached to the bar or using a custom tray that
captures the bar's position.
3. Master Cast Fabrication: The lab pours a master cast with analogs of the
implant abutments or the bar in the correct position.
4. Record Base and Wax Rim Fabrication: A record base with wax rims is
fabricated on the master cast to establish the VDO and centric relation.
5. Jaw Relation Records: Obtain accurate jaw relation records (centric
relation and VDO) using the wax rims.
6. Tooth Arrangement and Wax Try-In:
o Artificial teeth are arranged in wax on the record base according to the

established jaw relations and esthetic considerations.

o The wax try-in is evaluated for esthetics, phonetics, and occlusion.

7. Overdenture Processing: Following the approved wax try-in, the

overdenture is processed in acrylic.
8. Attachment Housing Incorporation:
o Chairside Pick-Up: Attachment housings are picked up directly into

the fitting surface of the processed overdenture using self-curing

acrylic. This ensures accurate seating relative to the implant abutments
or bar.
o Laboratory Incorporation: Alternatively, housings can be

incorporated in the lab based on a precise transfer index.

9. Overdenture Insertion and Adjustment:
o The overdenture is seated onto the implant abutments or bar.

o Evaluate retention, stability, and support.

o Adjust occlusion in centric and eccentric movements.

o Check for any impingement on soft tissues.

10. Patient Education: Provide thorough instructions on:

o Insertion and removal of the overdenture.

o Oral hygiene (cleaning implants, abutments, and the overdenture).

o Maintenance of the attachments.

 o Importance of regular recall appointments for adjustments and
attachment replacement.

IV. Post-Insertion Care and Maintenance (for both types of prostheses)

 Recall Appointments: Schedule regular follow-up appointments to monitor

the implants, peri-implant tissues, prosthesis stability, occlusion, and patient
comfort.
 Hygiene Instructions Reinforcement: Reiterate proper oral hygiene
techniques.
 Prosthesis Evaluation: Check for any signs of wear, fracture, or loosening
of components.
 Occlusal Adjustment: Make necessary occlusal adjustments.
 Attachment Maintenance (for overdentures): Replace retentive elements
of the attachments as needed.
 Radiographic Evaluation: Periodic radiographs may be necessary to assess
the health of the supporting bone.

By following a systematic approach like this, clinicians can increase the

predictability and long-term success of full arch maxillary implant-retained
prostheses and overdentures, ultimately improving the patient's quality of life.