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Tooth Loss and Prosthetic Appliances
REF: Prosthodontics. Principles and Management Strategies.1996, Owall, Kayser and Carlsson, Chap. 3, pp. 35-47.
Samar Al Saleh
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Tooth – type and function
Aesthetic units Occlusal units
Samar Al Saleh
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Functional classification of the 28 teeth or 14 pairs of
antagonistic unitsLocation Name Number
Anterior area
Aesthetic units
6
Premolar area
Occlusal units
4
Molar areaOcclusal units
4 (81)
TotalFunctional units
14 (181)1 in premolar equivalents.
Samar Al Saleh
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Healthy or Physiological Occlusion
Absence of pathologic manifestations
Satisfactory function
Variability in form and function
Adaptive capacitySamar Al Saleh
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Functional assessment of the different tooth typesFunction Anterior
sPremolars
Molars
Biting + - -Chewing - + +Speech + - -Aesthetics + + ±Stability of: TMJ + + + Dental arch
+ + ++ = Prime involvement; - = No, or secondary involvement. (Stuart and Stallard,1960)
Samar Al Saleh
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Can anterior teeth and premolars compensate for the function of the
molars? (shortened dental arch)
Samar Al Saleh
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Schematic representation of the aetiology of an impaired dentition
Samar Al Saleh
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Natural history of the dentition in high-risk
groups
Loss of alveolar bone
Edentulousness (lost occlusion)
Major changes (impaired occlusion)
Minor changes (intact occlusion)
Healthy dentition
Samar Al Saleh
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Biological and functional aspect of
tooth loss
Samar Al Saleh
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Changes following tooth loss
Adaptationor
Pathological condition
Samar Al Saleh
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Spontaneous closure of open space in a 32-year-old man after loss of tooth 11 at the age of 12 years due to trauma
Samar Al Saleh
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Effects of tooth loss on the remaining dentition
Samar Al Saleh
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Radiographs of a 52-year-old woman (1992) showing structural and functional stability of an extreme
shortened dental arch (8 occluding units) after 20 years (a) and 28 years of function (b).
Samar Al Saleh
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Local factors influence the consequences of tooth loss
Location of the lost tooth
Number of the lost teeth
Intercuspation
Periodontal condition
Position of the tongue
Samar Al Saleh
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Systemic factors influence the consequences of tooth loss
Age
Adaptive capacity
General resistance
Neuromuscular tolerance
Psychological condition
Samar Al Saleh
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Sequelae of tooth loss
MigrationUnilateral chewing
Alveolar bone lossOcclusal interference
Loss of proximal contactOverloading of
anteriorsLoss of VD
TMDSamar Al Saleh
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General Pattern of Tooth Loss
Molars then premolars. Lastly the lower anteriors.
Samar Al Saleh
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Possible migration after loss of tooth 36
(a) (b)
Samar Al Saleh
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(a) A new occlusal balance was established after loss of teeth 46 and 47 at the age of 22 years in a 28-
year-old woman (1971), followed during 11 years. (b) alveolar bone height in 1971 and 1984.
(a) (b)
Samar Al Saleh
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Loss in the anterior region
Disturbed aesthetics
Disturbed speech
Affected psychosocial function
Samar Al Saleh
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Patterns in partial edentulism
1. Eichners classification (no. of remaining occlusal supporting zones)
2. Simple classification of impaired dentitions• Uncomplicated• Complicated
3. Partial edentulism• Tooth boundspace• Shortened dental arch
Samar Al Saleh
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The Eichner Index, based on supporting zones of antagonist contacts in premolar and molar regions
(Helldén et al., 1989)
A1
A2 A3
B1
B2 B3
C1
C2 C3
B4
Samar Al Saleh
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Uncomplicated tooth-bound space in the left mandible
Complicated tooth-bound space, showing migration of remaining teeth
Samar Al Saleh
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Uncomplicated shortened dental arch
Complicated shortened dental arch: migration of remaining teeth, loss of vertical dimension and dislocation of condyleSamar Al Saleh
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Compensation of tooth loss
Chewing where most occlusal contact
More chewing strokes
Swallowing of larger particles
Samar Al Saleh
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Migration in tooth bound spaces
Distally located teeth drift and tip mesially
Mesially located teeth drift and tip distally
Extrusion with no opposing contact
Samar Al Saleh
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Migration
Premature contact and interferences
Adaptation Pathological condition (TMD)
(close in new position)
Samar Al Saleh
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Shortened dental arches
Premolar dental arch Extreme shortened dental arch
Samar Al Saleh
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Complicated shortened dental arch: migration of remaining teeth, loss of vertical dimension and dislocation of condyle
Samar Al Saleh
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Masticatory function measuring
ObjectivelyChewing test
(masticatory performance)
MP (no. of occlusal units ability)
SubjectivelyQuestionnaire or interview
(masticatory)
10 occluding pairswill be sufficient
Samar Al Saleh
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Schematic representation of the relationship between masticatory function and dental arch
length (expressed in occlusal units)
1 = Masticatory ability (perceived ease of chewing)
2 = Masticatory performance
A = Area of sufficient masticatory function
B = Turning rangeC = Area of insufficient
masticatory function
Samar Al Saleh
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Stability of premolar dental arch
Occlusal contact in IP
Overbite
Interdental spacing
Attrition and alveolar bone support
Samar Al Saleh
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Effect of periodontal problems on shortened
dental arches
Samar Al Saleh
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Oral comfort
Absence of pain
Satisfactory masticatory ability
Acceptable aesthetics
Samar Al Saleh
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1 = Contact between anterior teeth in IP
2 = Alveolar bone height3 = Interdental contact
between anterior teeth; absence of mandibular dysfunction
4 = Chewing capacity5 = Aesthetics
A = Area of sufficient and function (adaptation)
B = Turning rangeC = Area of insufficient oral
function
Relationship between oral function and shortened dental arches
Samar Al Saleh
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Dental arch support and TMJ
Posterior tooth loss TMJ osteoarthrosis
Samar Al Saleh
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Implications for prosthetic treatment
28 tooth syndrome
Over treatment
Samar Al Saleh
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Dental Care Aim
To maintain a healthy natural functioning dentition for life
Samar Al Saleh
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“The exact number of teeth each individual need, can not be ascertained by the dental profession.”
“If patient manage well with any number of teeth, then there is no reason to recommend prosthetic appliances.”
Samar Al Saleh
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Oral Function Level
Optimal
Sub-optimal
Minimal
Samar Al Saleh
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Required oral functional level in relation to age, expressed as the
minimum number of occluding pairs of teeth (arch length)1
Age (years) Functional level
Occluding pairs
20 – 50 I: Optimal 12
40 – 80 II: Suboptimal
10 (SDA)
70 – 100 III: Minimal 8 (ESDA)
1 SDA = Shortened dental arch; EDSA = Extreme shortened dental arch
Samar Al Saleh
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The Shortened Dental Arch
Concept
Samar Al Saleh
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I = Complete dental arch (optimal function)
II = Shortened dental arch (suboptimal function)
III = Extreme shortened dental arch (minimal function)
A = High-risk factors (caries, pockets)
B = Limiting factors (restricted finances)
C = Patient factors (poor general health)
The occlusal preservation target in high-risk groups
Samar Al Saleh
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The prosthetic treatment target in high risk groups. The number of teeth to be restored is dictated by
the needed functional level.Samar Al Saleh
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Teeth should be replaced for
Aesthetics
Functional comfort
Occlusal stability
Samar Al Saleh
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Lecture No.2
Pre-edentulism
Ref: Prosthodontics. Principles and Management Strategies. 1996, Owall, Kayser and Carlsson, Chap. 4, pp.
49-47.
Samar Al Saleh
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Natural history of the dentition in high-risk
groups
Loss of alveolar bone
Edentulousness (lost occlusion)
Major changes (impaired occlusion)
Minor changes (intact occlusion)
Healthy dentition
Samar Al Saleh
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The traditional restorative approach in prosthetic dentistry
Samar Al Saleh
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Pre-edentulous situation
Just a few (non-strategic) teeth are left with poor prognosis.
The distribution of the remaining teeth in the dental arches is often unfavorable oral function cannot be performed adequately.
Samar Al Saleh
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Preventive prosthetic treatment for the pre-
edentulous patient
Postponing of tooth extraction to prevent bone
loss
Samar Al Saleh
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Principles of preventive prosthetic treatment for the pre-edentulous
patient Treatment planning and timing of
tooth extraction
Shortening the dental arch with preservation of occluding pairs of teeth
Use of an overdenture
Samar Al Saleh
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Treatment planning and timing of tooth extraction
Condition of residual tooth
Age
Postponement of extraction delays the reduction of the alveolar ridge
Extraction of teeth with severe periodontitis (targeted extraction) less bone resorption
Samar Al Saleh
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Shortening the dental arch with preservation of occluding pairs of
teeth
Free-end RPD X shortened dental arch
If no remaining occluding pairs the remaining teeth will cause damage to opposing edentulous jaw
Preventive implantology
Samar Al Saleh
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Due to the removal of the antagonistic tooth in the mandible, the solitary maxillary tooth has caused
bone loss in the mandible
Samar Al Saleh
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(a) An example of a patient with a dental situation with no occluding pairs of teeth (natural versus artificial teeth) and severe alveolar bone resorption of the edentulous maxilla.
(b) The teeth in the mandible are functionally “locked”. Every movement of the jaw causes the lower teeth to damage the edentulous maxilla via the upper denture.
Samar Al Saleh
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A dentate maxilla opposing an edentulous mandible should always be avoided. A situation of natural teeth versus artificial
teeth has led to severe alveolar bone loss of the mandible
Samar Al Saleh
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Use of an (immediate) overdenture
Preservation of the alveolar ridge
Preserving lower canines
Samar Al Saleh
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(a) Orthopantomogram of a 45-year-old female patient (1987) with an edentulous maxilla and periodontal disease in the mandible. In spite of the poor periodontal condition, it was decided to make a complete immediate overdenture in the lower jaw, while retaining four abutment teeth.
(b) The situation 6 years after treatment (1993). Good oral hygiene and plaque control using chlorhexidine (Hibigel®).
Samar Al Saleh
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Schematic summary of the treatment planning by a pre-edentulous patient with a residual mutilated
dentition- motivation, instruction- treatment of periodontium
and caries- “targeted” extractions- removable partial
(immediate) denture- recall
Samar Al Saleh
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(a) In a 61-year-old woman with poor oral hygiene, a complete immediate overdenture, while retaining both lower canines, was inserted in 1986.
(b) In the clinical situation more than 7 years later (1993), oral hygiene is good, resulting in a healthy periodontium and hardly any alveolar bone loss.
Samar Al Saleh
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Assessment of the pre-edentulous dentition for overdentulous
treatment Caries
Periodontal considerations
Prosthetic consideration
Samar Al Saleh
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Caries
Extensive and active caries
Samar Al Saleh
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Periodontal consideration
Mobility
Type of bone loss
Extraction, subgingival curettage
Samar Al Saleh
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Samar Al Saleh
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Endodontic Consideration
Single rooted canal and apical radiolucency
Successful endo treated tooth
Samar Al Saleh
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Prosthetic Considerations
Samar Al Saleh
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If the vertical jaw relationship shows sufficient denture space, abutment teeth which are (more or
less) opposing should be retained
Samar Al Saleh
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Prosthetic considerations in the selection of abutment teeth
If opposing teeth are present in the mandible in order to avoid “natural vs artificial teeth”
If possible always
Samar Al Saleh
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Location of the abutment teeth
Samar Al Saleh
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The division of the jaw into four zones to facilitate the selection of abutment teeth
Samar Al Saleh
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Examples of the distribution of abutment teeth within the dental arch
Samar Al Saleh
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Canines as an overdenture abutments
Longest teeth
Strategic position
Oval-shaped root
Easy endo treatment
Samar Al Saleh
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(b) In the clinical situation more than 7 years later (1993), oral hygiene is good, resulting in a healthy periodontium and hardly any alveolar bone loss.
Samar Al Saleh
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Distribution of abutment teeth over the upper and lower jaw
Situations in which teeth oppose an edentulous part of the jaw should be avoided.
Samar Al Saleh
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Many pre-edentulous situations between the lower and upper jaw are undesirable from a prosthetic point of view (green in
illustration). The figure indicates which dental situations offer a good starting point for making an overdenture.
Samar Al Saleh
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A “targeted extraction strategy”, possibly combined with the making of an overdenture, enables the balance of forces
between the dental arches to be restored. (NB The use of dental implants makes other combinations possible)
Samar Al Saleh
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(a) The use of implants in the lower jaw restores the balance between the dental arches.
(b) Reduction of tooth material in the lower jaw can be avoided by inserting implants in the upper jaw.
Dental implants as abutment teeth for overdentures
Samar Al Saleh
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The main goal in “preventive prosthodontics” is the preservation of oral function for life. Dental implants can
effectively “reverse” complete edentulousness and restore oral function
Samar Al Saleh
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Submerged roots and submucosal implants
Root of fractured teeth
Filling the socket with biocompatible material
Samar Al Saleh
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Orthopantomogram of a patient with submucosal implants (calcium hydroxyapatite), inserted immediately after extraction.
Samar Al Saleh
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Depending on the individual rate of resorption, the upper surface of the submucosal implants will sooner or later protrude above the level of the jawbone with dehiscence of the mucosa.
Samar Al Saleh