Treatment Options for the Edentulous Patient: Case ...€¦ · Evaluate advantages/disadvantages of fixed vs. removable implant options 4. Establish the most adequate treatment options

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AbstractThe loss of all of the teeth is a life-changing event that brings functional challenges. The treatment options for edentulous patients range from conventional complete dentures to fixed implant-supported restorations of varying complexities. In a case-scenario format, this course will review indications and contraindications for treatment options of the fully edentulous patient. 

Educational ObjectivesDuring this course the participant will:1. Review the options for the rehabilitation

of the edentulous patient2. Review the indications/

contraindications of implant-related treatment options

3. Evaluate advantages/disadvantages of fixed vs. removable implant options

4. Establish the most adequate treatment options for an edentulous patient

Author ProfileDoctor Geminiani received his DDS and MSc degree from the University of Siena (Italy). He continued his education at Eastman Institute for Oral Health, University of Rochester, Rochester NY, where he pursued a certificate in Advanced Education in General Dentistry, a certificate in Periodontics and a Master of Science in clinical and translational investigation. He is a diplomate of the American Board of Periodontology and is currently in private practice in Rochester, NY.

Author DisclosureDoctor Geminiani has no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.

Publication date: Aug. 2016 Expiration date: Jul. 2019

This educational activity has been made possible through an unrestricted grant from Oral Arts Dental Lab. This course was written for dentists, dental hygienists and assistants, from novice to skilled. Educational Methods: This course is a self-instructional journal and web activity. Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third party has had any input into the development of course content.Requirements for Successful Completion: To obtain 3 CE credits for this educational activity you must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%.CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with products or services discussed in this educational activity. Heather can be reached at [email protected] Disclaimer: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise.Image Authenticity Statement: The images in this educational activity have not been altered.Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and represents the most current information available from evidence based dentistry. Known Benefits and Limitations of the Data: The information presented in this educational activity is derived from the data and information contained in reference section. The research data is extensive and provides direct benefit to the patient and improvements in oral health. Registration: The cost of this CE course is $59.00 for 3 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

PennWell designates this activity for 3 continuing educational credits.

Dental Board of California: Provider 4527, course registration number CA# 03-4527-15122“This course meets the Dental Board of California’s requirements for 3 units of continuing education.”

The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from (11/1/2015) to (10/31/2019) Provider ID# 320452.

Treatment Options for the Edentulous Patient: Case Scenarios, Part IIA Peer-Reviewed Publication Written by Alessandro Geminiani DDS, MS

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Educational ObjectivesDuring this course the participant will:1. Review the options for the rehabilitation of the edentulous

patient2. Review the indications/contraindications of implant-

related treatment options3. Evaluate advantages/disadvantages of fixed vs. removable

implant options4. Establish the most adequate treatment options for the

edentulous patient

AbstractThe loss of all of the teeth is a life-changing event that brings func-tional challenges. The treatment options for edentulous patients range from conventional complete dentures to fixed implant-supported restorations of varying complexities. In a case-scenario format, this course will review indications and contraindications for treatment options of the fully edentulous patient. 

IntroductionThe incidence of edentulism has been declining the past few years1,

2 thanks to improved access to dental care and preventive dentistry. However, the total number of edentulous patients in the US is still well over 12 million. Therefore, a considerable percentage of the population has to cope with this problem. They must adapt their lifestyle to a new condition that affects several aspects of their health, including functional limitations, nutritional implications, and the psychological consequences of the complete edentulism.

Fortunately, the progress made by the science of dentistry, in especially in the field of dental implants, offers many revolution-ary treatment options for edentulous patients. Among these are fixed implant supported full-arch reconstruction, (as originally introduced by Brånemark in 1975), the implant-retained remov-able denture (or implant overdenture), and many other options that include fixed, removable, or a combination of both solutions. While the cost of these types of restorations varies considerably and often plays a major role in the clinician’s formulation of the pro-posed treatment plan, several other factors are involved in the final outcome of the fixed or removable full arch implant restoration.

Moreover, technical challenges presented by the increased complexity of certain kinds of full arch implant restorations might present a burden for clinicians and therefore are not offered to patients, resulting in less-than-ideal treatment. The goal of this course is to review different step-by-step “case scenarios” in which the option chosen for the rehabilitation of an edentulous patient is carefully analyzed, weighing advantages and disadvantages, long-term outcomes, home care maintenance, repairability, cost, and additional issues that will aid in the treatment decisions.

Basic Concepts and TerminologyThe Complete Denture: When rehabilitating an edentulous patient, the clinician fabricates a new prosthesis. Herein, the fixed (screw or cement retained implant prosthetics) or removable will be referred

to as a complete denture. The complete denture transfers chewing forces to the underlying soft and hard tissue in different ways, based on the design of the prosthesis itself. Therefore, these prostheses will be named either implant-supported or implant-retained.

The Implant-Supported Complete Denture: An implant-supported complete denture transfers 100% of the masticatory forces to the dental implants, and as a consequence, to the alveolar and basal bone3-7. An implant-supported complete denture can be fixed, such as the prosthesis suggested by Brånemark (i.e., the hy-brid prosthesis)3 or the All-on-4 as presented by Malo8. This type of prosthesis can be removed by the dentist, however, it has been designed to function in the mouth without the need for removal by the patient. An implant-supported complete denture could also be removable9-12. This type of prosthesis offers the advantages of being completely supported by implants for increased comfort, but is re-moved by the patient to maintain proper oral hygiene. An example of this type of prosthesis is the milled-bar implant overdenture.

The Implant-Retained Complete Denture: An implant-retained complete denture transfers masticatory forces to the dental implants (and consequently the underlying bone), and the alveolar mucosa9. The term “retained” indicates that the purpose of the dental implants in this type of prosthesis is mostly to resist vertical and lateral forces that would otherwise dislodge the complete denture. An example of an implant-retained complete denture is the commonly named “implant denture,” a conventional complete denture that engages two or more prefabricated implant attachments (i.e., Locator attachments, or bar with clips). Ideally, an implant-supported prosthesis, transferring more load to the implants, requires an increased number of dental implants for its successful outcome compared to an implant-retained prosthesis. However, biomechanics is not the only criterion in the treatment planning of the edentulous patient. Other factors, such as esthetics, speech, cost, ease of maintenance, and patient expectations, play a major role in treatment planning. For more information on this topic, the reader is referred to Part 1 of this course. https://www.ineedce.com/coursereview.aspx?url=3022%2FPDF %2F1604cei_Geminiani_web.pdf&scid=16139

Scenario 1 - Implant-supported complete denture (fixed) Medical and Dental History: A 56-year-old male presented with a chief complaint of, “My teeth are hurting me and they are ugly!” A review of the medical history included hypertension treated with a combination of diuretics and beta-blockers, hypercholesterol-emia treated with statin and diet modification, and an allergy to penicillin. Social history revealed consumption of alcohol (less than one drink per day) and smoking (one pack per day for more then 20 years). A few months prior to the initial dental consultation, this patient experienced a sudden and severe panic attack, and thought he was having a heart attack. Following a comprehensive medical examination, a heart attack was ruled out. However, his physician recommended that the patient seek dental care to prevent systemic diseases related to poor oral heath. He admitted to neglecting his

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oral health for many years, and the dental examination revealed poor oral hygiene, multiple carious lesions, and a severe form of chronic periodontal disease. (Figures 1 through 6)

Figures 1 to 6—Intraoral photographs at initial examination

After initial periodontal therapy, oral hygiene education, and smoking cessation instruction, the prognosis of the denti-tion was evaluted. The patient improved his oral hygiene, and quit smoking. However, several maxillary and mandibular teeth were considered hopeless due to advanced bone loss and caries. The surgical/restorative treatment plan reviewed with the patient included the removal of the maxillary teeth, the placement of six dental implants, and the fabrication of an implant-supported fixed complete denture.

Why and How: However, while the chewing efficiency of an implant-supported removable complete denture is comparable to the one offered by an implant-supported fixed complete denture, patients generally favor the fixed option. This is due mostly to the stigma associated with removable dentures. Two factors that will influence the removable approach is cost and bone availability in the premaxilla and posterior mandible. In addition, factors such as lip support, smile line, speech ease of home care, and professional maintenance are all critical components as well. Advantages and disadvantages of these factors are summarized in Table 1 and discussed in detail in the first part of this course (see Part 1). https://www.ineedce.com/coursereview.aspx?url=3022%2FPDF %2F1604cei_Geminiani_web.pdf&scid=16139

Table 1Implant-Supported Complete Denture

Fixed Removable

Lip Support Poor Good

High Smile Line Difficult to camouflage Easier to camouflage

Speech Possible whistling Less whistling

Ease of Home Care Difficult Easy

Maintenance (attachment/screw wear)

Low maintenance Might require replacement of attachment

Repairability More difficult and more costly

Easier and less expensive

Psychological Factor Preferred by the patient Stigma of being a denture

The factor that played a major role in the treatment selec-tion was the excellent support of the upper lip even after extrac-tion of the maxillary teeth. Moreover the patient presented a moderate smile line (Figure 7) that could easily camouflage the transition between the alveolar process and the acrylic of the fixed prosthesis13, 14.

Figure 7 - Patient smile line

The final plan included an implant-supported complete maxillary denture. During surgical implant planning, it was considered that the maxillary prosthesis would oppose natural dentition, therefore undergoing a considerable occlusal load. This affected the placement position and the number of im-plants that extended from first molar to first molar in order to maximize the anterior-posterior spread of the dental implants. To avoid the need for augmentation of the maxillary sinus and quicken the healing time, distally angled implants15-18 were placed. (Figure 8)

Figure 8 - Panoramic radiograph showing the anterior posterior spread of the implants

The implant placement was facilitated by the use of a con-ventional surgical guide that also doubled as a bone reduction guide. (Figure 9)

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Figure 9 - The surgical and bone reduction guide (black line represents the ideal bone level)

It is important to note that in order to fabricate a well designed and long lasting implant-supported fixed complete denture, a minimum of 12 mm of vertical space (to an ideal 15 mm of vertical space) is needed. If this amount of vertical space is not available, alveoloplasty is required. (Figure 10)

Figure 10 - Alveoloplasty performed to increase the interocclusal space to 15 mm

The implants were immediately loaded with an acrylic complete denture. (Figures 11 through 13) During the healing phase, the prosthesis fractured in the anterior (Figure 14). At this point, the prosthesis was easily retrieved and repaired.

Figure 11 - Temporary all-acrylic implant-supported complete denture used for immediate loading.

Figure 12 - The metal-milled bar fabricated for the final implant-supported complete denture

Figure 13 - The final implant-supported complete denture, intraoral view

Summary and Analysis: When properly planned and executed, the implant-supported fixed prosthesis can provide patients with an extremely favorable outcome as far as comfort and function. Some of the drawbacks include high laboratory cost, a higher level of home care, and clinical difficulty with retrievability and repairability. Moreover, the requirement for interocclusal space (12-15mm) is considerable, and if lip sup-port is lacking, it cannot be easily improved with this kind of prosthesis.

Figure 14 - Delamination of acrylic teeth in an implant-supported complete denture.

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To overcome some of the aforementioned complications, the use of a monolithic zirconium prosthesis has been sug-gested. This recently developed material has the advantage of combining good flexural resistance, reducing the number of interfaces exposed to fatigue. A traditional prosthesis would present four interfaces: 1. dental implants—abutment 2. abutment—titanium bar 3. titanium bar—pink acrylic4. pink acrylic—denture teeth.

Each interface constitutes a possible point of fracture or failure of the bonding forces between materials19-20. Denture teeth to pink acrylic is the bond most frequently subject to failure 21. Therefore, the introduction of a monolithic material can, at least in theory, reduce the incidence of delamination. (Figures 15 and 16)

Figure 15 - Monolithic zirconium implant supported complete denture (occlusal view)

Figure 16 - Monolithic zirconium implant supported complete denture (intaglio view)

Scenario 2 - Implant-supported complete denture (removable)Medical and Dental History: A 67-year-old female pre-sented with a chief complaint of “My dentures are loose.” Her medical history was positive for osteoporosis in treatment with oral bisphosphonate (alendronate). She reported a prolonged hospital stay and immobilization due to a severe hip fracture, after which she was no longer able to wear and tolerate the upper and lower denture. After consultation with her treating

physician to evaluate the risk of medication-related osteonecro-sis of the jaw, it was established that her risk was low given the dose and length of time during which she used alendronate22.

The risk of osteonecrosis of the jaw after dental implant sur-gery was reviewed in detail with the patient, and it was decided that the benefits of dental implants strongly outweighed the risks. The surgical/restorative treatment plan reviewed with the patient included the fabrication of an implant-supported removable complete denture for the maxillary arch, and an implant-supported fixed complete denture for the mandibular.

Why and How: The main factor that played a role in the decision of fabricating a removable vs. fixed implant-sup-ported prosthesis was the severe horizontal and vertical bone deficiency23 of the anterior maxilla, resulting in a completely unsupported upper lip (Figure 17) and a considerable esthetic dilemma.

Figure 17 - Support of the upper lip with (bottom) and without (top) maxillary complete denture.

In order to restore support of the upper lip, an acrylic flange was needed. However, a fixed acrylic flange would create diffi-culties during oral hygiene procedures. Therefore, a removable prosthesis supported by four implants was treatment planned. The implants were splinted by a titanium-milled bar (Figure 18), and retention for the chrome-cobalt suprastructure (Figure 19) was achieved using four spring-loaded bolts.

Figure 18 - Titanium milled bar with four spring-loaded bolts

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Figure 19 - Chrome-cobalt U-shaped suprastructure

Summary and Analysis: Due to the anatomy of the maxil-lary alveolar and basal bone, dental implants placed in the upper jaw most commonly present a medial-lateral angulation (Figure 20). Therefore, retention of the denture with prefabricated at-tachments is either not possible, or will result in excessive wear of the nylon gaskets.

Figure 20 - Angulation of maxillary implants

A milled-bar is most commonly used for the support and retention of the maxillary complete denture. To improve a pa-tient’s taste and speech, the prosthesis can be fabricated with a U- shape (Figure 21) metal reinforced substructure.

Figure 21 - U-shaped maxillary implant-supported complete denture

Scenario 3 - Implant-retained complete dentureMedical and Dental History: A 71-year-old female patient presented with the chief complaint of, “I’ve heard dental im-plants can help keep my denture in place.” Due to severe peri-odontal disease her teeth were removed more then 30 years ago,

and she has worn complete maxillary and mandibular dentures ever since. Over the course of her life, only minor adjustments were made to the maxillary complete denture, but coping with the challenges of the lower denture had always been difficult. She experienced reduced control of the fine muscles (including the muscles of the tongue), and chewing with the lower com-plete denture had become more of a challenge. Upon clinical examination the mandibular alveolar ridge presented with severe resorption.

Figure 22 - Severely resorbed mandibular alveolar ridge

Several treatment options were discussed with the patient for the rehabilitation of the lower arch. It was decided to proceed with the placement of two dental implants in the in-traforaminal area, and the fabrication of an implant-retained complete denture (overdenture).

Why and How: A female patient with a limited budget was interested in improving the retention of the mandibular denture. A starting point was the placement of two dental implants for an implant-retained overdenture. These could be upgraded to an implant-supported prosthesis in the future by adding more implants. After alveoloplasty of the most superficial aspect of the alveolar crest, the residual basal bone presented a buccolingual width of 8 mm, therefore the im-plants were placed without need for additional bone grafting. Dental implants were placed in the right and left mandibular canine areas.

Figure 23 - LOCATORS attachments supported by two dental implants

Because the implants were placed with ideal parallelism, they could be easily restored with prefabricated attachments.

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Figure 24 - Mandibular denture (intaglio surface) showing the female counterpart of the LOCATOR attachments

Summary and Analysis: The patient was extremely satisfied with the additional retention achieved by the two attachments, and she reported significant improvements in her nutrition and general well-being. However, prefabricated attachments such as the LO-CATOR have the limitation of quickly losing retention if angula-tion between implants exceeds 40 degrees. In these instances, a bar can be fabricated to overcome angulation problems and clip attach-ments can be used for the retention of the mandibular prosthesis.

Figure 25 - A bar, fabricated to splint two mandibular dental implants

Recently, in order to further reduce the cost of this treatment option and increase the patient’s access to care, the use of one single dental implant was proposed for the fabrication of implant-retained mandibular dentures. While this technique is promising, a higher incidence of complications has been reported such as fracturing of the denture, and further research is needed to confirm treatment validity. The minimum number of implants recommended for the fabrication of a mandibular implant retained overdenture is two for the mandible and four for the maxilla.

Figure 26 - A single dental implant supporting a prefabricated attachment for the retention of a mandibular implant-retained complete denture

ConclusionsSeveral treatment options are available for the edentulous pa-tient interested in restoring the missing dentition. The technical complexity, and therefore the cost, of these restorations can vary greatly. However, a more complicated and more expensive solu-tion does not always guarantee a more comfortable or functional outcome for the patient. When formulating a treatment plan and deciding between a fixed and removable prosthesis, the clinician should consider several factors, including: need for maxillary lip support through the use of an acrylic flange, patient compliance with oral hygiene instructions, bone quality and quantity, and patient’s medical history. While financial factors and patient preference for either removable or fixed prosthesis are impor-tant criteria and considerations in formulating a treatment plan, they should not be considered the main or exclusive factors in the selection of the type of prosthesis used for the rehabilitation of the patient.

References1. Douglass CW, Shih A, Ostry L. Will there be a need for

complete dentures in the United States in 2020? J Prosthet Dent 2002;87:5-8.

2. Slade GD, Akinkugbe AA, Sanders AE. Projections of US edentulism prevalence following 5 decades of decline. J Dent Res 2014;93:959-965.

3. Brånemark PI, Hansson BO, Adell R. Osseointegrated implants in the treatment of the edentulous jaw. Experience from a 10 years period. Stand J Plastic Recanter Surg Supple 1977; 16:1-132.

4. Adell R, Eriksson B, Lekholm U, et al. A long-term follow up study of osseointegrated implants in the treatment of totally edentulous jaws. Int J Oral Maxillofac Implants 1990; 5: 347-359.

5. Jemt T. Fixed implant-supported prostheses in the edentulous maxilla. A five-year follow-up report. Clin Oral Implants Res 1994; 5: 142-147.

6. Wicks RA. A systematic approach to definitive planning for osseointegrated implant prostheses. J Prosthodont 1994; 3: 237-242.

7. Tischler M, Ganz SD, Patch C. An ideal full-arch tooth replacement option: CAD/CAM zirconia screw-retained implant bridge. Dent Today. 2013 May;32(5):98-102.

8. Maló P, Rangert B, Nobre M. “All‐on‐Four” Immediate‐Function Concept with Brånemark System® Implants for Completely Edentulous Mandibles: A Retrospective Clinical Study. Clinical implant dentistry and related research. 2003 Mar 1;5(s1):2-9.

9. Chee WL. Considerations for implant overdentures. CDA 1992; 25-28.

10. Jemt T, Book K, Linden B, Urde G. Failures and complications in 92 consecutively inserted overdentures supported by Branemark implants in severely resorbed edentulous maxillae: a study from prosthetic treatment to first annual check-up. Int J Oral Maxillofac Implants 1992; 7: 162-167.

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1. The number of the edentulous patients in the United States is estimated to be:a. Less than 1 millionsb. Between 5 and 15 millionsc. More than 35 millionsd. None of the above

2. The percentage of edentulous patients in the United States

is:a. Slowly decliningb. Rapidly increasingc. Stabled. None of the above

3. Which one of the following treat-ment modalities is available for the edentulous patient:a. Complete Removable Denturesb. Implant-Supported Complete Denturesc. Implant-Retained Complete Denturesd. All of the above

4. Which one of the following factors play a role in the decision of the best treatment option for edentulous patient:a. Phonetics and Estheticb. Patient compliance with oral hygienec. Costd. All of the above

5. The treatment of the edentulous maxillary and mandibular arches:a. Is better address by a “one-kind-fits-all” treatment

modalitiesb. Presents no challenges for the clinicianc. Presents different anatomical and functional

challenges that are typical for each archd. All of the above

6. Important criteria to consider during planning of a fixed implant-support-ed prosthesis of the maxillary arch include:a. Patient’s compliance to home care instructionsb. Support of the upper lip without denturec. a and bd. None of the above

Questions

Online CompletionUse this page to review the questions and answers. Return to www.ineedce.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your answers. An immediate grade report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page.

11. Naert I, DeClercq M, Theuniers G, et al. Overdentures supported by osseointegrated fixtures for the edentulous mandible. A 2.5-year report. Int J Oral Maxillofac Impl 1988; 3: 191-196.

12. Palmqvist S, Sondell K, Swartz B. Implant-supported maxillary overdentures: outcome in planned and emergency cases. Int J Oral Maxillofac Implants 1994; 9: 184-190.

13. Tjan AH, Miller GD, The JG. Some aesthetic factors in a smile. J Prosthet Dent 1984; 82:188-196.

14. Chiche FA, Leriche MA. Multidisciplinary implant dentistry for improved aesthetics and function. Pract Perio Aest Dent 1998; 10: 177-186.

15. Kent JN, Block MS. Simultaneous maxillary. Sinus floor bone grafting and placement of hydroxylapatite coated implants. J Oral Maxillofacial Surg 1989; 47: 238.

16. Balshi T J, Wolfinger GJ, Balshi SF 2nd. Analysis of 356 pterygomaxillary implants in edentulous arches for fixed prosthesis anchorage. Int J Oral Maxillofac Implants 1999; 14: 398-406.

17. Krekmanov L, Kahn M, Rangert B, et al. Tilting of posterior mandibular and maxillary implants for improved prosthesis support. Int J Oral Maxillofac Implants 2000; 15: 411.

18. Wakimoto M, Matsumura T, Ueno T, et al. Clin Oral Implants Res. 2012 Nov;23(11):1314-9. Bone quality and quantity of the anterior maxillary trabecular bone in dental implant sites.

19. Choi BK, Han JS, Yang JH, et al. Shear bond strength of veneering porcelain to zirconia and metal cores. J Adv Prosthodont. 2009 Nov;1(3):129-35.

20. Cardelli P, Manobianco FP, Serafini N, et al. Full-Arch,

Implant-Supported Monolithic Zirconia Rehabilitations: Pilot Clinical Evaluation of Wear Against Natural or Composite Teeth. J Prosthodont 2015 Oct 1.

21. Hutton JE, Heath MR, Chai JY, et al. Factors related to success and failure rates at 3-year follow-up in a multicenter study of overdentures supported by Branemark implants. Int J Oral Maxillofac Implants 1995; 10: 33-42.

22. Marx RE, Sawatari Y, Fortin M, Broumand V. Bisphosphonate-induced exposed bone (osteonecrosis/osteopetrosis) of the jaws: risk factors, recognition, prevention, and treatment. J Oral Maxillofac Surg 2005; 63:1567-75.

23. Tallgreen A. The reduction in face height of edentulous and partially edentulous subjects during long term denture wear: a longitudinal roentgenographic cephalometric study. Acta Odontol Scand 1966; 24:195-239.

Author ProfileDoctor Geminiani received his DDS and MSc degree from the University of Siena (Italy). He continued his education at Eastman Institute for Oral Health, University of Rochester, Rochester NY, where he pursued a certificate in Advanced Education in General Dentistry, a certificate in Periodontics and a Master of Science in clinical and translational investigation. He is a diplomate of the American Board of Periodontology and is currently in private practice in Rochester, NY.

Author DisclosureDoctor Geminiani has no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.

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7. Implant-supported fixed prosthesis can be fabricate one or more of the following materialsa. Titanium barb. Denture teeth (acrylic)c. Zirconium oxyded. All of the above

8. Dental implants are absolutely contraindicated in patients with medical history positive for:a. Pre-hypertensionb. Well-controlled diabetesc. Bisphosphonate therapy discontinued for more than

3 monhtsd. None of the above

9. In an edentulous patient, the smile line:a. Plays an important role in treatment planningb. Does not exist, therefore should be ignored during

treatment planningc. Is important only if patient is singled. None of the above

10. Which one of the following factors does not play a major role in the decision of the best treatment modal-ity for the edentulous patient:a. Ageb. Patient expectationc. Treatment costd. Support of the upper lip without denture in place

11. Lip support and lip line:a. Play an important role in the selection of fixed

versus removable prosthesesb. Can be assessed with the use of diagnostic denturesc. If deficient can be corrected by the use of a buccal

acrylic flanged. All of the above

12. If the edentulous alveolar ridge is shown during a patient full smile:a. Surgical correction (alveoloplasty) might be

requiredb. A fixed implant-supported prosthesis is always the

best treatment optionc. The esthetic outcome of a fixed implant-supported

prosthesis could present a challenge for the cliniciand. a and c

13. In patients with a limited inter-arch space:a. Surgical correction (alveoloplasty) might be

requiredb. A removable implant-retained prostheses is always

contraindicatedc. Always requires the use of more than 6 implants in

each archd. None of the above

14. A complete denture can be:a. Exclusively supported by implantsb. Exclusively supported by the mucosac. Either be fixed or removabled. All of the above

15. An implant-supported complete denture, differs from an implant-retained complete denture:

a. In the former, the occlusal load is transferred to the implants exclusively

b. In the latter, the occlusal load is distributed between implants and mucosa

c. a and bd. None of the above

16. An implant-supported complete denture:a. Requires a minimum of four dental implantsb. Can have an buccal acrylic flangec. Can still be a removable prosthesesd. All of the above

17. The use of distally-angled dental implants in the maxillary arch:a. May reduce the need for sinus graftingb. Increases the anterior-posterior spread of the dental

implantsc. Is a well proven procedured. All of the above

18. An implant-retained complete denture:a. Requires a minimum of two implants in the

mandibular archb. Requires a minimum of four implants in the

maxillary archc. Always requires the removal of the prostheses

during routine home care oral hygiened. All of the above

19. An implant-supported complete denture on four dental implants:a. Can reduce the need for grafting of the maxillary

sinusesb. Has a reduced cost, compared to options requiring

five, six or more implantsc. Requires complex oral hygiene maneuversd. All of the above

20. An implant-supported complete denture on four dental implants:a. Involves the placement of dental implants in the

anterior maxilla, an area that commonly present a good amount/quality of bone

b. Allows for the use of acrylic material to mask the transition line

c. Can create challenging esthetic outcome in patient with high lip line and/or short upper lip

d. All of the above

21. For patients with severely resorbed maxillary arches: a. The use of dental implants, frequently requires

bone graftingb. The use of zygomatic dental implants could be

requiredc. Most likely requires support of the upper lip with

an acrylic flanged. All of the above

22. For patients with severely resorbed mandibular arches:a. An implant-supported fixed prostheses in never

possibleb. An implant-retained removable prostheses is

always the best treatment optionc. Bone grafting is always required for implant

treatment optionsd. None of the above

23. The interocclusal space require-ment of implant prosthesis:

a. Can be underestimated as it does not create a challenge for the clinician

b. Ranges from a minimum of 9 to 16 or more millimeters

c. Can be easily corrected after implant placementd. Is related to the patient gender

24. The interocclual space required for an implant-retained prosthesisa. Is a minimum of 9mm if prefabricated low-profile

attachment are usedb. Can be as high as 16mm if a custom milled-bar is

usedc. Can be easily corrected after implant placementd. a and b

25. The retention of an implant overdenture:a. Frequently requires the use of a bar for the maxil-

lary overdentureb. Cane commonly achieve with the use of attachment

for the mandibular overdenturec. Is dependent on the angulation of the dental

implantsd. All of the above

26. The laboratory costs for the fabrication of an implant prosthesesa. Is normally less for implant-retained prosthesisb. Is higher for implant-supported prosthesisc. Should be accurately estimated when planning the

implant treatmentd. All of the above

27. The domiciliary care of implant prosthesisa. Is easier for removable prosthesisb. Is easier for fixed prosthesisc. Does not play a role in the long term success of an

implant prosthesisd. Is not necessary as long as the patient return for

biannual professional hygiene recalls

28. To establish the best treatment option for the edentulous patient:a. The clinician has to consider several parameters

such as: esthetic, phonetics, anatomy.b. The clinician should take into consideration the

patient: compliance, neuromuscular function, and expectations

c. The clinician should discuss advantages and disadvantages of each treatment modality with the patient, so to involve them in the final decision

d. All of the above

29. The minimum number of dental implants required for the retention of a mandibular denture is:a. 4b. 3c. 2d. None of the above

30. The minimum number of dental implants required for the retention of a maxillary denture is:a. 6b. 4c. 2d. None of the above

Questions (Continued)

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.

Customer Service 800-633-1681

ANSWER SHEET

Treatment Options for the Edentulous Patient: Case Scenarios, Part IIName: Title: Specialty:

Address: E-mail:

City: State: ZIP: Country:

Telephone: Home ( ) Office ( )

Lic. Renewal Date: AGD Member ID:

Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 3 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 800-633-1681

Educational Objectives1. Review the options for the rehabilitation of the edentulous patient

2. Review the indications/contraindications of implant-related treatment options

3. Evaluate advantages/disadvantages of fixed vs. removable implant options

4. Establish the most adequate treatment options for an edentulous patient

Course Evaluation1. Were the individual course objectives met?

Objective #1: Yes No Objective #2: Yes No

Objective #3: Yes No Objective #4: Yes No

Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0.

2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0

3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0

4. How would you rate the objectives and educational methods? 5 4 3 2 1 0

5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0

6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0

7. Was the overall administration of the course effective? 5 4 3 2 1 0

8. Please rate the usefulness and clinical applicability of this course. 5 4 3 2 1 0

9. Please rate the usefulness of the supplemental webliography. 5 4 3 2 1 0

10. Do you feel that the references were adequate? Yes No

11. Would you participate in a similar program on a different topic? Yes No

12. If any of the continuing education questions were unclear or ambiguous, please list them. ________________________________________________________________

13. Was there any subject matter you found confusing? Please describe. _________________________________________________________________

14. How long did it take you to complete this course? _________________________________________________________________

15. What additional continuing dental education topics would you like to see?

_________________________________________________________________

For IMMEDIATE results, go to www.ineedce.com to take tests online.

Answer sheets can be faxed with credit card payment to 918-831-9804.

Payment of $59.00 is enclosed. (Checks and credit cards are accepted.)

If paying by credit card, please complete the following: MC Visa AmEx Discover

Acct. Number: ______________________________

Exp. Date: _____________________

Charges on your statement will show up as PennWell

If not taking online, mail completed answer sheet to PennWell Corp.

Attn: Dental Division, 1421 S. Sheridan Rd., Tulsa, OK, 74112

or fax to: 918-831-9804

AGD Code 674

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.

TOEP0816DIG

COURSE EVALUATION and PARTICIPANT FEEDBACKWe encourage participant feedback pertaining to all courses. Please be sure to complete the survey included with the course. Please e-mail all questions to: [email protected].

INSTRUCTIONSAll questions should have only one answer. Grading of this examination is done manually. Participants will receive confirmation of passing by receipt of a verification form. Verification of Participation forms will be mailed within two weeks after taking an examination.

COURSE CREDITS/COSTAll participants scoring at least 70% on the examination will receive a verification form verifying 3 CE credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. PennWell is a California Provider. The California Provider number is 4527. The cost for courses ranges from $20.00 to $110.00.

PROVIDER INFORMATIONPennWell is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, not does it imply acceptance of credit hours by boards of dentistry.

Concerns or complaints about a CE Provider may be directed to the provider or to ADA CERP ar www.ada.org/cotocerp/

The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from (11/1/2015) to (10/31/2019) Provider ID# 320452

RECORD KEEPINGPennWell maintains records of your successful completion of any exam for a minimum of six years. Please contact our offices for a copy of your continuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within five business days of receipt.

Completing a single continuing education course does not provide enough information to give the participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise.

CANCELLATION/REFUND POLICYAny participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

IMAGE AUTHENTICITYThe images provided and included in this course have not been altered.

© 2016 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell