J Oral Maxillofac Surg 66:112-122, 2008 Fixed-Prosthetic ......A systematic pretreatment approach to evaluating edentulous patients allows for better communication between the implant

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Oral Maxillofac Surg6:112-122, 2008

Fixed-Prosthetic Implant Restoration ofthe Edentulous Maxilla: A Systematic

Pretreatment Evaluation MethodEdmond Bedrossian, DDS, FACD, FACOMS,*

Richard M. Sullivan, DDS,† Yvan Fortin, DDS,‡

Paulo Malo, DDS,§ and Thomas Indresano, DMD�

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otential candidates for implant restoration of theompletely edentulous maxilla may be interested ineceiving a fixed prosthesis as opposed to a remov-ble overdenture. Multiple surgical approaches arevailable in order to provide this type of care. Graft-ess approaches such as the use of tilted implantsncluding the zygomatic implant, allow the surgeon tostablish adequate support for a fixed prosthesis with-ut bone grafting. Adjunctive procedures such as si-us grafting, maxillary osteotomies as well as horizon-al augmentations are also available for surgeons whoay prefer the grafting approach for the reconstruc-

ion of this group of patients. The ability to determinearly in the consultation process the type of fixed pros-heses necessary to provide the best functional and es-hetic results is advantageous. This current therapy arti-le examines 3 critical factors; the nature of the patient’sental condition and whether the residual ridge isisible in both the relaxed lip and smiling state, directhe choice of fixed dental prostheses. The presencer the absence of bone in the 3 radiographic zones,

*Director of Implant Training, Department of Oral and Maxillo-

acial Surgery, University of the Pacific, San Francisco, CA; and

rivate Practice, San Francisco Center for Osseointegration, San

rancisco, CA.

†Clinical Director, Nobel Biocare USA, Yorba Linda, CA.

‡Centre d’Implantologic Dentaire de Quebec, Ste-Foy, Quebec,

anada.

§Chief Scientist, Nobel Biocare AB, Gothenburg, Sweden.

�Chairman, Department of Oral and Maxillofacial Surgery, Uni-

ersity of the Pacific, San Francisco, CA.

Address correspondence and reprint requests to Dr Bedrossian:

niversity of the Pacific, Oral and Maxillofacial Surgery, 450 Sutter

treet, Suite 2439, San Francisco, CA 94108; e-mail: oms@sfimplants.

om

2008 American Association of Oral and Maxillofacial Surgeons

278-2391/08/6601-0018$32.00/0

toi:10.1016/j.joms.2007.06.687

112

etermines whether bone-grafting procedures areecessary to achieve the desired outcome.Treatment of the edentulous maxilla poses a num-

er of challenges. Expectations regarding the esthet-cs of the definitive prosthesis may be high. Achievingdequate phonetics and stable masticatory functionre major concerns. Evaluation of the edentulousaxilla is complicated by the fact that patients may

nly be missing clinical crowns, or they may havexperienced a combination of tooth, soft tissue, andone loss, with associated changes in facial form.one and soft tissue loss can begin before tooth re-oval as a result of generalized periodontitis, creating

he appearance of long teeth. The loss of teeth andse of a removable prosthesis can result in continuedlveolar bone atrophy in both the vertical and hori-ontal dimensions.1 In a study spanning 25 years,allgren observed that the greatest amount of alveolarone atrophy occurs within the first year of edentu-

ism.1 Changes in the jaw relationship as well as facialusculature also may result in deformation or other

hanges in the facial form and morphology.2

A systematic pretreatment approach to evaluatingdentulous patients allows for better communicationetween the implant team as well as the patients

eading to a predictable treatment outcome. McGarryt al 3 developed a classification of complete edentu-ism that considers the quantity of the residual eden-ulous ridge, its morphology or topography, and theelationship of the maxilla to the mandible. Interarchpace, tongue anatomy, and the attachment of theusculature to the edentulous ridge are considered.he possible need for preprosthetic surgical proce-ures prior to the fabrication of complete removableentures is also evaluated.The establishment of evaluation criteria may result

n improved patient care, enhanced communicationetween dental professionals, and better screeningnd treatment of patients in dental educational cen-ers.3 Guidelines for the treatment of edentulous pa-
ients with implants should include consistent clinical

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BEDROSSIAN ET AL 113

nd radiographic evaluation criteria for an accurateutcome assessment. Three factors available early inhe examination process can be key determinants forhe successful treatment of the completely edentu-ous maxilla with a fixed restoration. These factorsre: 1) the presence or absence of a composite defect,) the visibility or lack thereof of the residual ridgerest without the denture in place, with normal smilend without use of retractors, and 3) the amount ofone available in 3 separate zones of the maxilla, ashown in a panoramic survey. Evaluation of these 3actors is not intended to be a substitute for thoroughiagnosis and development of a treatment plan. How-ver, such evaluation can provide differential diagno-is information specific to the esthetic, prosthetic,nd biomechanical requirements of fixed, implant-upported maxillary restorations.

The purpose of this article is to outline initial screen-ng methodology for determining which of 3 principalesigns for fixed, implant-supported prostheses shoulde selected. Each design has been documented to fulfillesthetic, phonetic, and hygienic demands and be aractical application for this treatment.

he Implant-Supported Fixedental Prosthesis

Complete dentures replace the clinical crowns ofeeth, but depend on established denture-bearing ar-as of superficial bone and soft tissue during occlusalunction for support.4 To be maintained at normalhysiologic levels, the bone requires internal loading

IGURE 1. A, Bone volume allows place-ent of traditional implants in ideal location., Intact soft tissue contours enable tooth con-

ours without gingival porcelain. C, Palatalontours of screw-retained restoration mimicatural teeth.

edrossian et al. Implant Restoration ofdentulous Maxilla. J Oral Maxillofacurg 2008.

uch as that provided by the tooth roots or dental im- n

lants.5 Fixed implant restorations are totally implantupported, with no transference of load to denture-earing areas, thus avoiding the possibility of furtheresorption associated with tissue-borne prostheses.

Several approaches to restoring the completelydentulous maxilla have been published.6-9 This dis-ussion will focus on the application of 3 principalesigns for implant-supported dental prostheses.hese 3 variations have been chosen based on theirbility to restore a broad range of soft tissue deficits.hey are: 1) the metal-ceramic restoration, 2) thexed hybrid restoration, and 3) the fixed-removableestoration.

Metal-ceramic restorations may be either screw- orement-retained.10-12 Recognizing that ceramic resto-ations can include longer than normal length teethnd gingival replacement, emphasis will be on metal-eramic restorations used to replace the clinicalrowns of missing teeth only (Fig 1).The hybrid prosthesis is a denture tooth and acrylic

esign with either a milled titanium or cast-goldramework (Fig 2). Early designs of implant-supportedenture tooth and acrylic fixed dental prostheses hadeported phonetic changes as a routine complication,ue to air escaping during speech.13 A later designnown as the profile prosthesis14 uses a frameworkesign with subgingival abutment emergence that al-

ows an acrylic resin wrap that butts up against theissue as an ovate pontic so that air does not escape andause phonetic problems. Because a ridge lap is avoidedith the convex emergence from the ridge crest, oralygiene access can be maintained in a manner similar to
atural tooth fixed partial denture pontics.14 A variation

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114 IMPLANT RESTORATION OF EDENTULOUS MAXILLA

f this design uses gingival porcelains or composite withll-ceramic crowns cemented to the framework if a por-elain restoration is desired.For situations in which a labial flange is desirable, a

xed-removable prosthesis can be made with anyumber of attachments. Figure 3 shows a fixed-emovable design known as a Marius bridge that isonresilient and fully implant-supported.15 Fixed-emovable designs use a milled titanium or cast me-obar supporting a patient-removable superstructurehat is held in place with a locking mechanism. Thisllows a ridge lap or flange design, with a suprastruc-ure removable for oral hygiene access. Because axed detachable restoration does not depend on softissue support, no unnatural palatal extensions areequired.

To determine which of these prosthetic concepts isost appropriate, 2 criteria should be considered: the

ature of the patient’s defect and the visibility of theesidual crest. These findings help ascertain appropri-te prosthetic design elements based on the combi-

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IGURE 3. A, Mesobar with anterior 25egree angle connected to implants. B, Ra-iograph of mesobar shows path of insertionot dependent on implant alignment. C, Twoiews of superstructure with posterior lockechanism retracted. D, Prosthetic superstruc-

ure rigidly in place. This is implant supportedithout resilience.

edrossian et al. Implant Restoration ofdentulous Maxilla. J Oral Maxillofac Surg008.

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ation of missing structures and unique esthetic re-uirements of the patient. A third criterion,adiological status, helps formulate an early strategyor achieving the structural support requirements forfixed restoration, including type of implants to be

sed and probability of bone grafting procedures.

rosthetic Selection Criteria

PRESENCE OR ABSENCE OF A COMPOSITE DEFECT

Edentulous patients may present with intact alveo-ar bone volume and only be missing the clinicalrowns, or they may also present with resorption ofheir alveolar bone and loss of soft tissue as well asissing teeth (Fig 4). Differentiating between these 2

ypes of patients is key to creating an esthetic defin-tive fixed prosthesis. Patients who are missing softissue and underlying supporting bone in addition toeeth may be considered to have a composite defect.o evaluate the relative amount of soft tissue defi-

FIGURE 2. A, Denture teeth are supple-mented with acrylic resin to replace tooth andsoft tissue. B, Denture teeth and acrylic areveneered to milled titanium framework.

Bedrossian et al. Implant Restoration ofEdentulous Maxilla. J Oral MaxillofacSurg 2008.

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iency, it is advisable to utilize a denture or dentureet-up in wax that has been confirmed for properooth position, border extension, and interarch rela-ionship. With a satisfactory denture, the presence orbsence of a composite defect can be quickly identi-ed by assessing the thickness of the maxillary den-ure base and flange. Moderate to advanced resorp-ion of the maxilla will be indicated by a denture basend flange which are generally thick. The oppositeill be true in situations where minimal resorptionas occurred and defects involving only teeth areresent. For the latter patients, a thin denture basend a very thin or absent flange, especially in thenterior sextant, indicate an intact alveolus.16

It should be noted that defects due to resorption ofone and missing soft tissue occur in both the hori-ontal and vertical planes and may not be immediatelybvious. To fully assess the presence or absence of aomposite defect, duplication of the confirmed den-ure or tooth set-up by the dental technician or dentistsing a denture duplicator (Denture Duplicating

FIGURE 4. Missing only teeth (left) versus composite defect (right).

edrossian et al. Implant Restoration of Edentulous Maxilla.Oral Maxillofac Surg 2008.

IGURE 5. Denture duplicating flask using silicone putty for denturempression to make clear acrylic duplicate.


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lask; Lang Dental Mfg Co, Inc, Wheeling, IL) can beseful (Fig 5). A transparent acrylic resin (Ortho-Jet;ang Dental Mfg Co, Inc) duplicate of the patient’senture is then placed intraorally, and the position ofhe cervical portion of the teeth and their relationshipo the crest of the edentulous ridge is noted. Foratients who present with no space between theervical portion of the duplicated denture teeth andhe edentulous ridge in either horizontal or verticallanes, a tooth-only defect is designated (Fig 6). Inhis situation, interarch space minimum requirementsor the implant system and desired restoration stilleed to be observed. For patients who present withoderate to significant space between the cervicalortion of the duplicated denture teeth and the eden-ulous ridge, a composite defect is identified (Figs 7,). Table 1 illustrates these considerations.

FIGURE 6. Defect of teeth only.


FIGURE 7. Mild composite defect.


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Preoperative determination of the presence or ab-ence of a composite defect allows the clinician toetermine the restorative space available for abut-ents and framework design. In the absence of a

omposite defect, a metal-ceramic restoration with-ut extensive gingival porcelains can be used. Theresence of a composite defect points toward the usef a fixed dental prosthesis in either the profile pros-hesis or Marius bridge variations.

VISIBILITY OF THE RESIDUAL RIDGE CREST

To maximize the esthetic prosthetic result, the po-ential for visibility of the transition between the pros-hesis and the soft tissue of the edentulous maxillaryidge without the maxillary denture in place shoulde evaluated, both in the anterior maxilla and theuccal corridor.With the patient’s maxillary denture removed, the

atient should be asked to smile (Fig 9). If the soft

FIGURE 8. Advanced composite defect.


Table 1. PRESENCE OR ABSENCE OF A COMPOSITEDEFECT

Intraoral Status DiagnosisDefinitiveProsthesis

o space between thecervical portion ofthe duplicatedenture teeth andthe edentulous ridge

Tooth-only defect Metal-ceramic

oderate to significantspace between thecervical portion ofthe duplicatedenture teeth andthe edentulous ridge

Composite defect Marius bridge(fixed-detachable)or profileprosthesis(hybrid)

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issue of the edentulous ridge cannot be seen, theransition between an implant-supported prosthesisnd the residual soft tissue crest will not be visible,llowing a degree of flexibility for issues such as coloratch, shadows, and changes of contour in the junc-

ion of the restoration against the soft tissue (Fig 10).or those patients who do display the residual ridgeoft tissue crest while smiling, the transition betweenn implant restoration and the soft tissue will beisible, and the esthetic consequences of this willepend upon whether or not the patient also has aomposite defect. If the patient is missing only teethut has an intact soft tissue volume, a metal-ceramicestoration can be used, and the fact that the gingivas visible will improve the aesthetics rather than de-ract from them. This assumes that the implants arelaced in planned tooth positions, and special consid-ration is given to anterior ridge lap pontics for the

FIGURE 9. Maxillary edentulous ridge not seen during animation.


IGURE 10. Transition of prosthesis and residual ridge soft tissue isot visible.


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ppearance of the papillae. Having fewer or no im-lants in the incisor areas if an adequate number of

mplants for the arch form can be placed in theosterior also allows for achieving esthetic goals withontic designs.However, when a composite defect is present, aetal-ceramic tooth-only restoration involves esthetic

ompromises due to longer than normal teeth. If arofile prosthesis is used with a visible residual ridgerest, the junction of the artificial gingiva and theatural soft tissue will be visible, and the differences

n texture and contour between the 2 may be obviousFig 11). One method for avoiding this is to firsteduce the residual ridge height to the point wherehe crest no longer is visible. Implants can then belaced and restored with a profile prosthesis. If theidge is not reduced, the use of a Marius bridge with

flange that overlaps the gingival junction is indi-ated. This prosthesis can be removed by the patiento that oral hygiene is not compromised, yet it pro-ides the stability of a fixed restoration.Table 2 presents these guidelines.

IGURE 11. Unesthetic demonstration of transition line betweenrosthesis and residual ridge soft tissue.


Table 2. GUIDELINES FOR OPTIMAL FIXED DENTALPROSTHETIC CHOICE

Composite DefectTooth-Only

Defect

idge visible Marius bridge(fixed-removable)

Metal-ceramicrestoration

idge invisible Profile prosthesis(fixed hybrid) orMarius bridge(fixed-removable)

Metal-ceramicrestoration

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Radiographic EvaluationDivision of the edentulous maxilla into 3 radiographic

ones allows for a systematic assessment of the residuallveolar bone available for implant placement. In thisretreatment screening procedure, the maxillary ante-ior teeth are designated as zone 1. The premolar regions considered to be zone 2, while the molar region isesignated as zone 3 (Fig 12). Analysis of the radio-raphic results according to this schema can enablehe surgical and restorative team to devise a prelimi-ary treatment plan. In complex or borderline situa-ions, 3-dimensional radiographic evaluation may stille necessary to confirm the preliminary conclusions.For a fully implant-supported, non-resilient maxil-

ary restoration, the implant-support requirements ofll 3 fixed restorative options discussed in this articlere the same. A minimum of 4 implants should besed, although the option to place more than 4 maye considered, depending upon the available boneolume and other functional considerations.17,18

ather than the number of implants used per se, onceminimum of 4 implants is achieved what is most

FIGURE 12. Three zones of maxilla are indicated.


IGURE 13. Provided adequate buccolingual width of bone is ver-fied, presence of all 3 zones in maxilla allows straightforward place-ent of implants.


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mportant is the arch-form distribution of those im-lants with both posterior and anterior support. As aeneral principle, cantilevers in fixed maxillary resto-ations should be avoided or minimized to 1 tooth tochieve an adequate functional occlusion.12,19-21 Eval-ation of the 3 radiographic zones allows for a pre-perative determination of whether adequate archorm support for a fixed restoration is achievable toupport the planned occlusal plane.

Presence of Zone 1, 2, and 3 BoneFor patients where alveolar bone is present in all 3

ones of the edentulous maxilla, conventional im-lants may be placed (Fig 13). This would allow for a

avorable arch form of anterior, posterior, and possi-ly intermediate implants so that any of the 3 fixedestorative designs may be used.23,24

Presence of Zone 1 and 2 BoneFor patients who have zone 1 and zone 2 bone but

ack zone 3 bone secondary to large pneumatizedaxillary sinuses, inclining the implants posteriorly

long the anterior wall of the maxillary sinus mayllow for an adequate anterior and posterior distribu-ion of implants to support a fixed restoration whilevoiding the need for grafting15,17,25-29 (Fig 14). Use of

IGURE 14. Tilted posterior and traditional anterior implant concept;resence of zones 1 and 2 only.


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nclined implants has also been shown to be success-ul with immediate-loading procedures of the com-letely edentulous maxilla.18,25 An alternative to these of inclined implants is sinus inlay grafting, fol-

owed by subsequent implant placement. When ex-ensive sinus inlay grafting is performed to provideosterior support, a staged approach waiting for graftaturation may be preferable due to lower survivalhen implants are simultaneously placed.30 This has

he effect of delaying restoration compared with these of inclined implants.

Presence of Zone 1 Bone OnlyTo establish posterior support for a fixed prosthe-

is, implants in the second premolar or first molaregion are required. However, placement of implantsn these positions is not possible when patients onlyave bone available in zone 1. Grafting of the sinusith autogenous or xenographic bone is an option in

his situation. A 90% overall survival rate with 3 to 5ear follow-up has been shown with this approach.31

If a graftless approach is preferred, zygomatic im-lants have been shown to provide bilateral posterioraxillary support with a 97% to 100% implant sur-

ival measured up to 4 years.32-34 Such implants havehe added benefit of not requiring a staged approachnd a period of bone graft maturation. This canhorten the overall treatment time required to achievefixed restoration. By placing 1 zygomatic implant inach zygoma, predictable posterior support can bestablished. When used in conjunction with 2 to 4nterior implants, the restorative dentist is able toabricate any of the 3 fixed, implant-supported pros-hetic alternatives (Fig 15).

Bone Missing from Zones 1, 2, and 3With complete resorption of the maxillary alveolus,

linical examination reveals a flat palatal vault. Noaxillary vestibule is present, and the patient is

nable to function with his or her conventionalomplete denture. Such patients present with aignificantly thick denture base as well as a thickircumferential flange, confirming the presence of aignificant composite defect. Physiologic reconstruc-ion of this debilitated group of patients requires ad-

FIGURE 15. A, Zygoma concept; presenceof zone 1 bone only. B, Zygoma implantsallow posterior support similar to traditionalimplants for restoration.

Bedrossian et al. Implant Restoration ofEdentulous Maxilla. J Oral MaxillofacSurg 2008.

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quate implant support to stabilize an implant-sup-orted prosthesis.To enable prosthetic rehabilitation of such patients,

rånemark introduced the idea of using extensivenlay bone grafts in conjunction with bilateral sinus

nlay grafts and placement of 6 implants.35 The Bråne-ark horseshoe graft requires hospitalization and

arvesting of autogenous iliac bone from the patientFig 16). The patient is unable to wear a dentureuring the 6-month osseointegration period. The so-ial consequence of this form of treatment renders itnpopular with patients. An alternative, graftless ap-roach is the use of 4 zygomatic implants (Fig 17).he placement of 2 zygomatic implants in each zy-oma allows for the fabrication of an implant-sup-orted fixed maxillary prosthesis without bone graft-

ng and can be accomplished in an office setting.Table 3 presents the guidelines for optimal implant

election.

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IGURE 16. A, When bone is missing in all 3 zones, autogenousnlay grafting is one alternative. B, Previous lack of bone in all 3 zonesf maxilla.


IGURE 17. A, Bilateral zygoma implantoncept; lack of all 3 zones of maxilla., Bilateral dual zygoma implant restoration.

edrossian et al. Implant Restoration ofdentulous Maxilla. J Oral Maxillofacurg 2008.

A

iscussion

From an implant placement perspective, there isrowing recognition that a large number of peopleith fully edentulous maxillae are able to be given a

table foundation to support a fixed restoration withewer implants and fewer bone grafts.15,18,25,26 Ad-ances in computer-guided surgery allow placementf implants in the fully edentulous maxilla in a mini-ally invasive manner with increased precision to

upport the fixed prosthetic outcome.36,37 Demon-trated viability of immediate function18 and mini-ally invasive protocols 38 for fixed full-arch restora-

ions may further increase demand and acceptance ofhis treatment by the public.

Definitive preoperative prosthodontic work-up forn implant-supported fixed maxillary prosthesis is aultifactor process. Steps of this process include sur-

ical, medical, and laboratory consultations, transfer-nce of facial and occlusal records for analysis, radio-raphic templates, scanning procedures and subsequentnterpretation, and development of a written compre-ensive plan including potential complications andreatment alternatives. Completion of these preoper-tive steps requires significant commitments of time,esources, and ultimately patient investment. Results

Table 3. GUIDELINES FOR OPTIMAL IMPLANTSURGICAL APPROACH

Bone Present forImplants Posterior Surgical Approach

one 1, 2, 3 Traditional implantsone 1, 2 Inclined implants, posterior

implantsTraditional anterior implants

one 1 only Zygomatic implants or sinus-inlaygrafting followed by implants

Traditional anterior implantsnsufficient bone in

any zone4 zygomatic implants or Brånemark

horseshoe graft followed bytraditional implants


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f these findings will indicate but still not assure thatpostoperative outcome is in accord with patient

xpectations identified in the preoperative subjectiveymptom interview.

Two prosthodontic diagnostic criteria have beenoupled with 3 variations of implant-supported fixedaxillary prostheses to form a table. Each prosthesis

lternative represents a potential restorative solutionppropriate for the 4 possible combinations of thesediagnostic criteria.The third preoperative diagnostic criterion divides

panoramic radiograph into 3 zones that have poten-ial for implant placement. Due to a range of resorp-ion, there are 4 potential zone combinations on eachide of the maxilla that would allow for implant place-ent or suggest consideration of bone grafting. Fromstructural support perspective, there are no differ-

nces in implant requirements to support any of the 3mplant-supported fixed maxillary prosthesis varia-

IGURE 18. A, Preoperative panorex: Available zone 1 and 2axillary alveolar bone. B, Postoperative panorex: All-on-4 concept., Immediate postoperative profile prosthesis.


ions given. Furthermore the clinical success rates for d

he various implant approaches are similar.15,18,35,38 Ithould be noted however that for the metal-ceramicariation, the ridge position of the implants ideallyorresponds with mesial-distal cervical tooth position;or the Marius bridge and profile prosthesis variations,mplant alignment coincident to cervical tooth anat-my is not a factor. This second table suggests im-lant or grafting strategies for the posterior maxillappropriate for different resorptive patterns.

CASE 1

A 48-year-old female presents with a full upperenture which is not retentive. Upon review of thereoperative panorex (Fig 18 A), she has maxillarylveolar bone in zones 1 and 2. She has minimal zonebone. Using our pretreatment criteria, the All-on-4

echnique was applied to establish implant supportor her fixed prosthesis (Fig 18 B). The provisionalrosthesis is a fixed, implant supported, profile pros-hesis (Fig 18 C).

CASE 2

A 46-year-old female presented with a nonfunc-ional mandibular partial denture as well as a nonre-entive maxillary full denture. The preoperative pan-rex (Fig 19 A) showed available bone in zone 1 and

ack of alveolar bone in zones 2 and 3. The Zygomaticoncept was utilized in her treatment (Fig 19 B).dequate distribution of implants to support the pro-le prosthesis was established (Fig 19 C). Patient’sransition line is apical to her smile line and therefore,ot visible. This allows for an esthetic outcome (Fig9 D).

APPLICATION OF BEDROSSIAN’S SCREENING

There are many factors to consider before treat-ent with implants for a fully edentulous maxilla

akes place. At the same time, there is a clear benefito identify early on as a screening procedure if theres likelihood of satisfying patient expectation with arosthesis alternative realistically indicated by notnly tooth loss but the degree of soft tissue andlveolar deficit that must be restored.

Similarly, systematic panoramic radiograph analysisased on zones of support can provide an early indi-ation of the straightforwardness or surgical difficultyikely to be encountered. The combination of pros-hodontic and radiographic diagnostic criteria canive an early impression of treatment possibilitiesrom both surgical and restorative perspectives toelp professionals clarify and communicate the po-ential treatment requirements and outcome. This un-erstanding may then be used to advise the patient toroceed with commitment and investment for more
efinitive diagnostic procedures, confident that at

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east the possibility for the desired prosthetic out-ome exists.One limitation of this approach is that the critical

actor of sufficient alveolar ridge width still needs toe verified; this would only be discovered either aftertomographic film or scan, or intraoperatively. In

ither event, lack of sufficient ridge width couldhange the surgical approach significantly. Anotherimitation is that these criteria still need to be put intohe overall perspective of health, medical, and dentalistory, and the knowledge that there can be devia-ions in desired outcome with even the most thor-ugh planning. The criteria presented in this articlere best looked upon as a preliminary screening ap-aratus to help guide patient and clinical decisions asore information is gathered. They are subject to

hange, however, at any time more definitive analysisr radiographic information does not support thereliminary impression.There are also clinical situations where the objec-

ive is to remove remaining hopeless teeth and simul-aneously place implants. While this preliminary diag-ostic method is still applicable, it cannot account forariations in tissue height that may result subsequento dental extraction.

ummary

The Bedrossian pretreatment screening methodystematically considers the presence or absence of a

IGURE 19. A, Pre-operative Panorex. Available Zone 1 and 2 boneandible. C, Immediate postoperative maxillary and mandibular profi

edrossian et al. Implant Restoration of Edentulous Maxilla. J O

omposite defect, the visibility of the residual soft

issue crest, and the availability of bone in 3 radio-raphic zones as guidelines for the selection of 3otential fixed implant restorative designs, as well ashe optimal implant surgical approach. Use of theseifferential diagnosis criteria allows an early determi-ation of the treatment necessary to meet patientxpectations before a significant amount of time andesources has been invested.

A limitation of this protocol is the inability to mea-ure the width of the residual alveolar bone available.

hile the panoramic survey film is a valuable 2-di-ensional scouting radiograph and allows the practi-

ioner to evaluate the height and length of the residuallveolar bone, use of 2-dimensional tomography thatan precisely measure the width of the remainingidge can aid the clinician in making a final determi-ation of the likely outcome of the planned treat-ent. Communication between dental colleagues,

tudents, and faculty, as well as third-party paymentroviders, can be made more uniform by the adoptionf this evaluation method.

eferences1. Tallgren A: The continuing reduction of the residual alveolar

ridges in complete denture wearers: A mixed-longitudinalstudy covering 25 years. J Prosthet Dent 89:427, 2003

2. Cawood JI, Howell RA: Reconstructive preprosthetic surgery. I.Anatomical considerations. Int J Oral Maxillofac Surg 20:75,1991

3. McGarry TJ, Nimmo A, Skiba JF, et al: Classification system for

, Postoperative panorex. Zygoma concept, maxilla. All-on-4 concept,thesis. D, Transition line is not visible resulting in an esthetic outcome.

xillofac Surg 2008.

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4. Hickey JC, Zarb GA, Bolender CL: Boucher’s ProsthodonticTreatment for Edentulous Patients. 9th Ed. St. Louis, The C.V.Mosby Company, 1985, pp 120-126, 176-183

5. Brånemark P-I, Zarb G, Albrektsson T, eds: Tissue-IntegratedProstheses. Chicago, IL, Quintessence, 1985, pp 118, 191

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