8

Fixed Partial Denture and Implant

Configurations

The replacement of missing teeth with fixed restorations has changed considerably in the last 20
years. No longer is it simply a choice between a fixed partial denture and a removable partial
denture. Osseointegrated dental implants have developed into a reliable treatment modality that can
be depended upon to provide long-term replacement of a single missing tooth as well as multiple
missing teeth. By no means, though, should the fixed partial denture be regarded as a thing of the past.
Not all patients or situations are suitable for implants, just as not all patients or situations are suitable
for fixed partial dentures. Judicious treatment planning is still of critical importance.
The implant is ideally suited for the replacement of a single tooth if the teeth that would have
served as abutments are untouched by caries or previous restorations. On the other hand, if those teeth
need extensive restorations, the patient can be saved expense and additional treatment if the
restorations also serve as retainers for a fixed partial denture. Long-span prostheses that will place
greater demands on the skills of the dentist, on the resistance of the retainers, and on the abutments
and their periodontal support can be avoided by using implant-supported fixed partial dentures
instead of tooth-supported fixed partial dentures.
The maximum number of posterior teeth that can be safely replaced with a fixed partial denture is
usually two. In rare circumstances, three can be replaced, but that should be attempted only under
ideal conditions. An edentulous space created by the loss of four adjacent teeth, other than four
incisors, is best restored with implant-supported crowns or a removable partial denture. If more than
one edentulous space exists in the same arch, even though each could be individually restored with a
fixed partial denture or implants, finances may dictate the use of a removable partial denture. This is
especially true when the spaces are bilateral and each involves two or more teeth.
Third molars are not shown in any of the examples in this chapter, and no situation is shown in
which a third molar would be a prospective abutment. Rarely can third molars be used as abutments
because they have been removed from the mouths of so many patients. Even when they are present,
they frequently display incomplete eruption; short, fused roots; and/or a marked mesial inclination in
the absence of a second molar.
A third molar should be considered as a potential abutment only if it is upright and completely
erupted, with little or no mesial inclination and with long, distinctly separate roots. It also must have
a healthy cuff of attached, keratinized gingiva that completely surrounds the tooth. The unattached
mucosal tissue that frequently surrounds the distal 30% to 60% of third molars will become inflamed
adjacent to even a well-fitting crown margin, and the abutment is likely to fail periodontally.
The following examples are given as a reference that applies under ideal conditions, listing the
abutment teeth that normally would be used. Retainer designs should be based on adequate retention,
esthetics, and conservation of tooth structure. Clinical situations vary widely, and less conservative
designs are required when caries, decalcification, or morphologic traits (such as short clinical
crowns) dictate. The configurations in the following scenarios assume that the prospective abutments
are still in their original positions. If the abutments have drifted, the situation could become less, and
on occasion more, demanding, depending on the current position of the tooth. Fewer or additional
abutments may become necessary if there has been drifting or bone loss. The ratios shown for root
surface areas are intended as a general guideline, based on average tooth dimensions1,2 and root
surface areas.3 An abutment-pontic root ratio of 1.0 or greater is considered to be favorable.4
Conventional partial coverage retainers could be used for many of the prostheses described.
However, the reluctance of many patients to accept any display of metal and the lack of dentist
familiarity with these preparations require that this design be used only on selected posterior
abutments. Likewise, while resin-bonded fixed partial dentures (ie, Maryland bridges) can provide a
suitable replacement for single missing teeth, experience with this type of retainer has shown that it
demands a well-defined, albeit a very conservative preparation. They are not the quick and dirty
restorations that some people thought when they first appeared on the scene in the 1980s. They may be
used as an intermediate retainer on young patients with teeth that are not fully formed or fully erupted
or whose bone is not developmentally stable.
A fixed partial denture can be classified as either simple or complex, depending on the number of
teeth to be replaced and the position of the edentulous space in the arch. The classic simple fixed
partial denture is one that replaces a single tooth. Dental implants have expanded the treatment
possibilities for the replacement of missing teeth markedly. Two scenarios are presented for each
missing tooth, describing the use of a conventional tooth-borne fixed partial denture and an implant-
supported crown. There are some situations in which a fixed partial denture cannot be placed with a
reasonable expectation of success.
In the scenarios that appear on the following pages, the fixed partial denture solution is followed
by the implant solution. In the illustrations, implant restorations are indicated by a shaded tooth with a
circle in the center; tooth-borne fixed partial denture retainers are represented by a shaded tooth with
contours; and fixed partial denture pontics are shown as a shaded outline of the tooth with no
morphology.

Simple Fixed Partial Dentures (One Tooth)

See Table

Complex Fixed Partial Dentures (One Tooth)

See Table

Simple Fixed Partial Dentures (Two Teeth)

See Table
Complex Fixed Partial Dentures (Two Teeth)
See Table

Complex Fixed Partial Dentures (More Than Two

Teeth)
See Table

Complex Fixed Partial Dentures (Pier Abutment)

See Table

References
1. Shillingburg HT Jr, Kaplan MJ, Grace CS. Tooth dimensionsA comparative study. J South Calif
Dent Assoc 1972;40:830839.
2. Shillingburg HT, Kessler JC, Wilson EL. Root dimensions and dowel size. CDA J 1982;10:4349.
3. Jepsen A. Root surface measurement and a method for x-ray determination of root surface area.
Acta Odontol Scand 1963;21:3546.
4. Ante IH. The fundamental principles of abutments. Mich State Dent Soc Bull 1926;8:1423.
Simple Fixed Partial Dentures (One Tooth)

Missing: Maxillary central incisor

Abutments: Central incisor and lateral incisor
Considerations: Abutment discoloration or
rotation, improper width of edentulous space,
or proximal caries will require metal-ceramic
restorations (MCRs). In that eventuality, the
crowns can double as retainers, and the space
can be restored with a fixed partial denture.
Retainers: MCR crowns. Resin-bonded
retainers might be used if the patient is very
young and if the abutments are healthy teeth
that have never been restored.
Pontic: Modified ridge lap MCR
Abutment-pontic root ratio: 1.9

Missing: Maxillary central incisor

Implant: 4.0 12 mm
Considerations: A large nasopalatine foramen
(incisive canal) may interfere with implant
placement. Loss of the facial bone plate may
necessitate bone grafting.
Restoration: MCR over a custom abutment
(UCLA, Atlantis [Astra Tech], or preparable
abutment)

Missing: Mandibular central incisor

Abutments: Central incisor and lateral incisor
Considerations: If at all possible, an implant
should be used to support this restoration if
there is 7.3 mm between the prospective
abutments. If there is not, a fixed partial
denture will be required. Severely rotated,
malposed, or mobile abutments will
contraindicate the use of resin-bonded
retainers and might dictate the removal of all
of the mandibular incisors. In that instance,
implants would be placed in the positions of
the lateral incisors. If MCR retainers are
required for a tooth-borne fixed partial
denture, the preparations very easily could
encroach on the pulp, and the patient should be
so advised. Endodontic treatment and a dowel
core would then be necessary.
Retainers: Resin-bonded retainers
Pontic: Ovate or modified ridge lap MCR
(depending on ridge configuration)
Abutment-pontic root ratio: 2.1

Missing: Mandibular central incisor

Implant: 3.3 12 mm
Considerations: A dental implant is the
restoration of choice. The factor limiting
replacement of a mandibular central incisor
with a dental implant is the mesiodistal space
available. Ideally there should be 7.3 mm of
interproximal space. If inadequate space is
available, consider extraction of all
mandibular incisors. Place two 4.0 12mm
dental implants in the lateral incisor positions
and fabricate a four-unit restoration.
Restoration: MCR crown over a one-piece
implant

Missing: Maxillary lateral incisor

Abutments: Central incisor and canine
Considerations: Caries and/or restorations on
the abutments would require MCR retainers. If
the canine is long, well-supported
periodontally, and in need of restoration, and
if the pontic will not contact in centric relation
or excursions, a single-abutment cantilever
fixed partial denture could be used. An
untouched central incisor and a first premolar
in need of restoration would allow a pontic
cantilevered from MCRs on the canine and
first premolar.
Retainers: Resin-bonded retainers
Pontic: Modified ridge lap MCR
Abutment-pontic root ratio: 2.6

Missing: Maxillary lateral incisor

Implant: 3.5 12 mm
Considerations: The loss of a maxillary
lateral incisor frequently results in the
collapse of the facial plate of bone. The loss
of the facial plate of bone often leads to a
facial concavity requiring implant placement
too far to the lingual. This will result in an
unnatural lingual contour of the crown and a
poor implant emergence profile. To correct
this problem, bone grafting is required to
eliminate the facial concavity.
Restoration: MCR over a custom abutment
(UCLA, Atlantis, or preparable abutment)

Missing: Mandibular lateral incisor

Abutments: Central incisor and canine
Considerations: An implant-supported MCR
is the overriding choice for restoring this
space. Caries and/or restorations on the
abutments would require MCR crowns and a
fixed partial denture. The patient should be
warned of the potential for pulpal involvement
with resultant endodontic treatment and a
dowel core. Double abutting the central
incisors for a fixed partial denture would
complicate this case immensely. Cantilever
fixed partial dentures are not an option for the
replacement of mandibular lateral incisors.
Severely rotated, malposed, or mobile
abutments may contraindicate the use of a
fixed partial denture using adjacent teeth as
abutments. In such cases, the removal of all of
the mandibular incisors would be necessary.
The treatment then would be a canine-to-
canine fixed partial denture.
Retainers: Resin-bonded retainers
Pontic: Modified ridge lap MCR
Abutment-pontic root ratio: 2.5
 Missing: Mandibular lateral incisor
Implant: 3.3 12 mm
Considerations: A dental implant is the
restoration of choice. The factor limiting
replacement of a mandibular lateral incisor
with a dental implant is the mesiodistal space
available. Ideally there should be 7.3 mm of
interproximal space. If inadequate space is
available, consider extraction of all
mandibular incisors. Place two 4.0 12mm
dental implants in the lateral incisor positions
and fabricate a four-unit restoration.
Restoration: MCR over a one-piece implant

Missing: Maxillary first premolar

Abutments: Canine and second premolar
Considerations: An implant-supported MCR
crown would be the restoration of choice. If
the canine is unblemished and the second
premolar and first molar are restored or will
need restoration, a cantilever prosthesis using
MCR retainers on the second premolar and
first molar is worthy of consideration. A
canine-guided occlusal scheme would be
necessary to prevent excessive forces on the
cantilever pontic.
Retainers: MCRs
Pontic: Modified ridge lap MCR
Abutment-pontic root ratio: 2.1

Missing: Maxillary first premolar

Implant: 4.0 13 mm
Considerations: Inadequate facial bone will
require bone grafting for dental implant
placement. Implant placement may impinge
upon the anterior wall of the maxillary sinus.
In this event, sinus modification surgery such
as sinus grafting or vertical upfracture may be
indicated.
Restoration: MCR over a custom abutment
(UCLA, Atlantis, or preparable abutment)
Missing: Mandibular first premolar
Abutments: Canine and second premolar
Considerations: Facial caries or any proximal
caries other than incipient will necessitate
MCR retainers. If the canine is intact and the
second premolar and first molar are restored
or will need restoration, a cantilever fixed
partial denture can be used, with MCR
retainers on the second premolar and first
molar abutments. If the patient does not object,
an all-metal
crown can be substituted on the molar.
Retainers: MCRs
Pontic: Modified ridge lap or ovate MCR
Abutment-pontic root ratio: 2.5

Missing: Mandibular first premolar

Implant: 4.3 11.5 mm
Considerations: The position of the anterior
loop of the mandibular canal may interfere
with implant placement.
Restoration: MCR over a custom abutment
(UCLA, Atlantis, or preparable abutment)

Missing: Maxillary second premolar

Abutments: First premolar and first molar
Considerations: MCR retainers will be
required in cases with facial defects such as
 abfraction or decalcification or when they are
requested by the patient.
Retainers: MCR on the first premolar and
MCR or full coverage gold crown (FGC) on
the first molar
Pontic: Modified ridge lap MCR
Abutment-pontic root ratio: 3.1

Missing: Maxillary second premolar

Implant: 4.3 11.5 mm
Considerations: The maxillary sinus will
likely interfere with the placement of an
implant of desirable length, necessitating sinus
modification surgery such as a sinus graft or a
vertical upfracture.
Restoration: MCR over a custom abutment
(UCLA, Atlantis, or preparable abutment)

Missing: Mandibular second premolar

Abutments: First premolar and first molar
Considerations: Esthetic requirements of the
patient may necessitate an MCR retainer on the
molar. Resin-bonded retainers can be used if
the first premolar is large and if the abutments
are caries-free or only minimally affected by
caries.
Retainers: MCR crown on the premolar and
FGC on the molar
Pontic: Modified ridge lap or ovate MCR
Abutment-pontic root ratio: 3.1
Missing: Mandibular second premolar
Implant: 4.3 10 mm
Considerations: Loss of the facial plate of
bone may result in inadequate alveolar width.
Alveolar resorption may result in insufficient
height of bone above the mental foramen and
mandibular canal. The correction of this
anatomical difficulty requires the placement of
an onlay bone graft to allow the placement of
an implant of sufficient width and length.
Restoration: MCR over a custom abutment
(UCLA, Atlantis, or preparable abutment)

Missing: Maxillary first molar

Abutments: Second premolar and second
molar
Retainers: MCR or crown on the premolar
and crown on the molar
Pontic: Modified ridge lap MCR
Abutment-pontic root ratio: 1.5

Missing: Maxillary first molar

Implant: 5.0 11.5 mm
Considerations: The maxillary sinus will
likely interfere with the placement of an
implant of desirable length, necessitating sinus
modification surgery such as a sinus graft or a
vertical upfracture.
Restoration: MCR over a custom abutment
(UCLA, Atlantis, or preparable abutment)
 Missing: Mandibular first molar
Abutments: Second premolar and second
molar
Considerations: A tilted molar may require
orthodontic uprighting, a proximal half crown,
or a telescope crown (see chapter 7).
Retainers: MCR crown on the premolar and
FGC on the molar
Pontic: All-metal hygienic, if patient is
agreeable. If the patient demands a ceramic
occlusal portion, a pontic design that touches
the ridge is needed, and metal should extend
fully to the ridge to provide rigidity.
Abutment-pontic root ratio: 1.5

Missing: Mandibular first molar

Implant: 5.0 10 mm
Considerations: Loss of the facial plate of
bone may result in inadequate alveolar width.
Alveolar resorption may result in insufficient
height of bone above the mandibular canal.
The correction of this anatomical difficulty
requires the placement of an onlay bone graft
to allow the placement of an implant of
sufficient width and length.
Restoration: MCR over a custom abutment
(UCLA, Atlantis, or preparable abutment)

Missing: Maxillary second molar

Considerations: Restoration with a
cantilevered fixed partial denture is not
recommended due to the excessive tensile
stresses placed on the premolar abutment and
the retainer.

Missing: Maxillary second molar

Implant: 5.0 11.5 mm
Considerations: The maxillary sinus will
likely interfere with the placement of an
implant of desirable length, necessitating sinus
modification surgery such as a sinus graft or a
vertical upfracture.
Restoration: MCR over a custom abutment
(UCLA, Atlantis, or preparable abutment)

Missing: Mandibular second molar

Considerations: Restoration with a
cantilevered fixed partial denture is not
recommended due to the excessive tensile
stresses placed on the premolar abutment and
the retainer.

Missing: Mandibular second molar

Implant: 5.0 10 mm
Considerations: Loss of the facial plate of
bone may result in inadequate alveolar width.
Alveolar resorption may lead to insufficient
height of bone above the mental foramen and
mandibular canal. The correction of this
anatomical difficulty requires the placement of
an onlay bone graft to allow the placement of
an implant of sufficient width and length.
Restoration: MCR over a custom abutment
(UCLA, Atlantis, or preparable abutment)
Complex Fixed Partial Dentures (One Tooth)

Missing: Maxillary canine

Abutments: Central incisor, lateral incisor, and
first premolar
Considerations: A single implant-supported
MCR crown would be the restoration of choice
here. Restore the occlusion to group function.
Using the two premolars and the lateral incisor
as abutments is not desirable because it places
too heavy a burden on the smaller single
abutment, the lateral incisor.
Retainers: MCR crowns
Pontic: Modified ridge lap or ovate MCR,
depending on the faciolingual dimension of the
ridge
Abutment-pontic root ratio: 2.3

Missing: Maxillary canine

Implant: 4.5 15 mm
Considerations: A dental implant is the
restoration of choice.
Restoration: MCR over a custom abutment
(UCLA, Atlantis, or preparable abutment)

Missing: Mandibular canine

Abutments: Central incisor, lateral incisor,
and first premolar
Considerations: An implant-supported MCR
is the restoration of choice in the mandible as
well. Use group function to restore the
occlusion. If there has been extensive bone
loss around the lateral incisor, or if it is tilted
to produce a line of draw discrepancy,
remove the lateral incisor and use both central
incisors as abutments if a fixed partial denture
is used. Fortunately, the need to replace this
tooth is not common.
Retainers: MCRs
Pontic: Ovate MCR
Abutment-pontic root ratio: 1.9

Missing: Mandibular canine

Implant: 4.5 15 mm
Considerations: A dental implant is the
restoration of choice.
Restoration: MCR over a custom abutment
(UCLA, Atlantis, or preparable abutment)
Simple Fixed Partial Dentures (Two Teeth)

Missing: Maxillary central incisor and lateral

incisor
Abutments: Central incisor and canine
Considerations: If the central incisor and
canine are unblemished and unusually large,
pin-modified partial coverage crowns could
be used. Patient acceptance and dentist skill
are strong considerations.
Retainers: MCRs
Pontics: Modified ridge lap MCR
Abutment-pontic root ratio: 1.2

Missing: Maxillary central incisor and lateral

incisor
Implants: 4.0 12 mm (central incisor), 3.5
12 mm (lateral incisor)
Considerations: A large nasopalatine foramen
(incisive canal) may interfere with implant
placement. If loss of the lateral incisor has
caused loss of the facial plate of bone, the
resulting facial concavity will place the
implant too far to the lingual. This may
necessitate bone grafting to eliminate the
facial concavity. Splinting the dental implant
restoration will reduce rotational forces on the
abutment screws, lessening the possibility of
screw loosening. Splinting the dental implants
will increase restoration strength and stress
distribution.
Restorations: MCRs over custom abutments
(UCLA, Atlantis, or preparable abutments)

Missing: Mandibular central incisors

Abutments: Lateral incisors
Considerations: If there has been any bone
loss around the lateral incisors, or if they are
malpositioned, remove them. Use MCR
retainers on the canines for a tooth-borne fixed
partial denture.
Retainers: Resin-bonded retainers if the
abutments are unblemished
Pontics: Ovate MCRs or one-piece pontics
with a modified ridge lap of pink porcelain
Abutment-pontic root ratio: 1.1

Missing: Mandibular central incisors

Implants: 3.3 12 mm
Considerations: The factor limiting
replacement of mandibular central incisors
with dental implants is the mesiodistal space
available. Ideally there should be 12.6 mm of
interproximal space. If inadequate space is
available, consider extraction of the lateral
incisors. Place two 4.0 12mm dental
implants in the lateral incisor positions and
fabricate a four-unit fixed partial denture.
Splinting the dental implant restoration will
reduce rotational forces on the abutment
screws, lessening the possibility of screw
loosening. Splinting the dental implants will
increase restoration strength and stress
distribution.
Restorations: MCRs over one-piece implants

Missing: Maxillary first and second

premolars
Abutments: Canine and first molar
 Considerations: An MCR crown may be used
on the molar if the mesiofacial cusp is
damaged or undermined or if the patient
requests it. An MCR will be required on the
canine.
Retainers: MCR on the canine and crown
or MCR on the molar
Pontics: Modified ridge lap MCRs
Abutment-pontic root ratio: 1.6

Missing: Maxillary first and second

premolars
Implants: 4.0 13 mm (first premolar), 4.3
11.5 mm (second premolar)
Considerations: The loss of the facial plate of
bone will frequently result in a facial
concavity, requiring implant placement too far
to the lingual. This will result in an unnatural
lingual contour of the crown and a poor
implant emergence profile. To correct this
problem, bone grafting is required to eliminate
the facial concavity. The maxillary sinus will
likely interfere with the placement of an
implant of desirable length, necessitating sinus
modification surgery such as a sinus graft or a
vertical upfracture. Splinting the dental
implant restoration will reduce rotational
forces on the abutment screws, lessening the
possibility of screw loosening. Splinting the
dental implants will increase restoration
strength and stress distribution.
Restorations: MCRs over custom abutments
(UCLA, Atlantis, or preparable abutments)

Missing: Mandibular first and second

premolars
Abutments: Canine and first molar
Considerations: If the molar has tilted
mesially, orthodontic uprighting or preparation
modification will be required. The patients
esthetic expectations may require an MCR
crown on the molar.
Retainers: MCR crown on the canine and
FGC on the molar
Pontics: Ovate MCRs
Abutment-pontic root ratio: 1.8

Missing: Mandibular first and second

premolars
Implants: 4.3 11.5 mm (first premolar), 4.3
10 mm (second premolar)
Considerations: The position of the anterior
loop of the mandibular canal may interfere
with implant placement. Loss of the facial
plate of bone may result in inadequate
alveolar width. Alveolar resorption may result
in insufficient height of bone above the
mandibular canal. The correction of this
anatomical difficulty requires the placement of
an onlay bone graft to allow the placement of
an implant of sufficient width and length.
Splinting the dental implant restoration will
reduce rotational forces on the abutment
screws, lessening the possibility of screw
loosening. Splinting the dental implants will
increase restoration strength and stress
distribution.
Restorations: MCRs over custom abutments
(UCLA, Atlantis, or preparable abutments)

Missing: Maxillary second premolar and first

molar
Abutments: First premolar and second molar
Retainers: MCR crown on the premolar and
FGC on the molar. Discourage the patient from
choosing an MCR for the molar. An FGC
probably will not be visible, and its
preparation does not require the destruction of
nearly as much tooth length or bulk.
Pontics: Modified ridge lap MCRs
Abutment-pontic root ratio: 1.0

Missing: Maxillary second premolar and first

molar
Implants: 4.3 11.5 mm (second premolar),
5.0 11.5 mm (first molar)
Considerations: The loss of the facial plate of
bone will frequently result in a facial
concavity requiring implant placement too far
to the lingual. This will result in an unnatural
lingual contour of the crown and a poor
implant emergence profile. To correct this
problem, bone grafting is required to eliminate
the facial concavity. The maxillary sinus will
likely interfere with the placement of an
implant of desirable length, necessitating sinus
modification surgery such as a sinus graft or a
vertical upfracture. Splinting the dental
implant restoration will reduce rotational
forces on the abutment screws, lessening the
possibility of screw loosening. Splinting the
dental implants will increase restoration
strength and stress distribution.
Restorations: MCRs over custom abutments
(UCLA, Atlantis, or preparable abutments)

Missing: Mandibular second premolar and

 first molar
Abutments: First premolar and second molar
Considerations: If the premolar root is short
or thin, or if the clinical crown is very small,
the canine should be included as a secondary
abutment.
Retainers: MCR crown on the premolar and
FGC on the molar
Pontics: Modified ridge lap or ovate MCRs
Abutment-pontic root ratio: 1.0

Missing: Mandibular second premolar and

first molar
Implants: 4.3 10 mm (second premolar), 5.0
10 mm (first molar)
Considerations: Loss of the facial plate of
bone may result in inadequate alveolar width.
Alveolar resorption may result in insufficient
height of bone above the mandibular canal.
The correction of this anatomical difficulty
requires the placement of an onlay bone graft
to allow the placement of an implant of
sufficient width and length. Splinting the
dental implant restoration will reduce
rotational forces on the abutment screws,
lessening the possibility of screw loosening.
Splinting the dental implants will increase
restoration strength and stress distribution.
Restorations: MCRs over custom abutments
(UCLA, Atlantis, or preparable abutments)

Missing: Maxillary first and second molars

Considerations: A fixed partial denture
cannot be used in this situation because there
is no distal abutment.

Missing: Maxillary first and second molars

Implants: 5.0 11.5 mm
Considerations: The placement of a dental
implant in the second molar position provides
increased strength and stress distribution of
occlusal and antirotational forces. The
maxillary sinus will likely interfere with the
placement of an implant of desirable length,
necessitating sinus modification surgery such
as a sinus graft or a vertical upfracture.
Splinting the dental implant restoration will
reduce rotational forces on the abutment
screws, lessening the possibility of screw
loosening. Splinting the dental implants will
increase restoration strength and stress
distribution.
Restorations: MCR over a custom abutment
(UCLA, Atlantis, or preparable abutment) for
the first molar and FGC or MCR over a
custom abutment for the second molar

Missing: Mandibular first and second molars

Considerations: A fixed partial denture
cannot be used in this situation because there
is no distal abutment and a cantilever would
place excessive force on the premolars.

Missing: Mandibular first and second molars

Implants: 5.0 10 mm
Considerations: The placement of a dental
implant in the second molar position provides
increased strength and stress distribution of
occlusal and antirotational forces. Loss of the
facial plate of bone may result in inadequate
alveolar width. Alveolar resorption may lead
to insufficient height of bone above the
mandibular canal. The correction of this
anatomical difficulty requires the placement of
an onlay bone graft to allow the placement of
an implant of sufficient width and length.
Splinting the dental implant restoration will
reduce rotational forces on the abutment
screws, lessening the possibility of screw
loosening. Splinting the dental implants will
increase restoration strength and stress
distribution.
Restorations: MCRs or FGCs over custom
abutments (UCLA, Atlantis, or preparable
abutments)
Complex Fixed Partial Dentures (Two Teeth)

Missing: Mandibular central incisor and

lateral incisor
Abutments: Central incisor, lateral incisor,
and canine
Considerations: Inadequate bone support
around central and lateral incisors often
necessitates their removal. This would require
a six-unit fixed partial denture with MCR
retainers on the canines. The patient should be
warned of the potential for pulpal involvement
with resultant endodontic treatment and dowel
cores. Anterior guidance should not be
excessive to avoid undue lingually directed
forces.
Retainers: Resin-bonded retainers (only if
prospective abutments are large and ideally
located)
Pontics: Ovate MCRs
Abutment-pontic root ratio: 1.8

Missing: Mandibular central incisor and

lateral incisor
Implants: 3.3 12 mm
Considerations: The factor limiting
replacement of mandibular incisors with
dental implants is the mesiodistal space
available. Ideally there should be 12.6 mm of
interproximal space. If inadequate space is
available, consider extraction of all
mandibular incisors. Place two 4.0 12mm
dental implants in the lateral incisor positions
and fabricate a fourunit fixed partial denture.
Splinting the dental implant restoration will
reduce rotational forces on the abutment
screws, lessening the possibility of screw
loosening. Splinting the dental implants will
increase restoration strength and stress
distribution.
Restorations: MCRs over one-piece implants
 Missing: Maxillary central incisors
Abutments: Both canines and lateral incisors
Considerations: When the bony support for
the lateral incisors is poor, it is often best to
extract them and lengthen the fixed partial
denture span. If the lateral incisors have long
roots and crowns, they alone can be used as
abutments.
Retainers: MCRs
Pontics: Modified ridge lap MCRs
Abutment-pontic root ratio: 2.3

Missing: Maxillary central incisors

Implants: 4.0 12 mm
Considerations: A large nasopalatine foramen
(incisive canal) may interfere with implant
placement. Loss of the facial bone plate may
necessitate bone grafting. Splinting the dental
implant restoration will reduce rotational
forces on the abutment screws, lessening the
possibility of screw loosening. Splinting the
dental implants will increase restoration
strength and stress distribution.
Restorations: MCRs over custom abutments
(UCLA, Atlantis, or preparable abutments)

Missing: Maxillary lateral incisor and canine

Abutments: Both central incisors and
premolars
Considerations: Span length, abutment
position, and root configuration can make the
use of four abutments desirable. All retainers
must have good retention. If the premolars
have drifted mesially, it may not be necessary
to include the second premolar. Use group
function to restore the occlusion.
Retainers: MCRs
Pontics: Modified ridge lap MCRs
Abutment-pontic root ratio: 1.9
Missing: Maxillary lateral incisor and canine
Implants: 3.5 12 mm (lateral incisor), 4.5
15 mm (canine)
Considerations: The loss of a maxillary
lateral incisor may result in the collapse of the
facial plate of bone, producing a facial
concavity, which will require bone grafting.
Splinting the dental implant restoration will
reduce rotational forces on the abutment
screws, lessening the possibility of screw
loosening. Splinting the dental implants will
increase restoration strength and stress
distribution.
Restorations: MCRs over custom abutments
(UCLA, Atlantis, or preparable abutments)

Missing: Mandibular lateral incisor and

canine
Abutments: Both central incisors and first
premolar
Considerations: The short edentulous span
and the direction of forces on the mandibular
canine do not require the use of the second
premolar as an abutment.
Retainers: MCRs
Pontics: Modified ridge lap MCRs
Abutment-pontic root ratio: 1.1

Missing: Mandibular lateral incisor and

canine
Implants: 3.3 12 mm (lateral incisor), 4.5
15 mm (canine)
Considerations: A dental implant is the
restoration of choice. Splinting the dental
implant restoration will reduce rotational
forces on the abutment screws, lessening the
possibility of screw loosening. Splinting the
dental implants will increase restoration
strength and stress distribution.
Restorations: MCRs over custom abutments
(UCLA, Atlantis, or preparable abutments)
 Missing: Maxillary canine and first premolar
Abutments: Central incisor, lateral incisor,
second premolar, and first molar
Considerations: Group function should be
used. This can be a difficult restoration.
Retainers: MCRs on the incisors and second
premolar and crown on the molar
Pontics: Modified ridge lap MCRs
Abutment-pontic root ratio: 2.0

Missing: Maxillary canine and first premolar

Implants: 4.5 15 mm (canine), 4.0 13 mm
(first premolar)
Considerations: The loss of the facial plate of
bone will frequently result in a facial
concavity requiring implant placement too far
to the lingual. This will result in an unnatural
lingual contour of the crown and a poor
implant emergence profile. To correct this
problem, bone grafting is required to eliminate
the facial concavity. First premolar implant
placement may impinge on the anterior wall of
the maxillary sinus. In this event, sinus
modification surgery such as sinus grafting or
vertical upfracture may be indicated. Splinting
the dental implant restoration will reduce
rotational forces on the abutment screws,
lessening the possibility of screw loosening.
Splinting the dental implants will increase
restoration strength and stress distribution.
Restorations: MCRs over custom abutments
(UCLA, Atlantis, or preparable abutments)

Missing: Mandibular canine and first

premolar
Abutments: Central incisor, lateral incisor,
and second premolar
Considerations: Use group function in
restoring the occlusion. This can be a difficult
fixed partial denture, but fortunately it is
rarely encountered.
Retainers: MCRs
Pontics: Modified ridge lap MCRs
Abutment-pontic root ratio: 1.5

Missing: Mandibular canine and first

premolar
Implants: 4.5 15 mm (canine), 4.3 11.5
mm (first premolar)
Considerations: The position of the anterior
loop of the mandibular canal may interfere
with implant placement. Loss of the facial
plate of bone may result in inadequate
alveolar width. Alveolar resorption may result
in insufficient height of bone above the mental
foramen. The correction of this anatomical
difficulty requires the placement of an onlay
bone graft to allow the placement of an
implant of sufficient width and length.
Splinting the dental implant restoration will
reduce rotational forces on the abutment
screws, lessening the possibility of screw
loosening. Splinting the dental implants will
increase restoration strength and stress
distribution.
Restorations: MCRs over custom abutments
(UCLA, Atlantis, or preparable abutments)
Complex Fixed Partial Dentures (More Than Two Teeth)

Missing: Both maxillary central incisors and

one lateral incisor
Abutments: Both canines and the remaining
lateral incisor
Considerations: If the remaining lateral
incisor is questionable, it should be extracted
and the fixed partial denture lengthened to
include the first premolars. Inclusion of first
premolars as abutments will depend on span
length and curvature.
Retainers: MCRs
Pontics: Modified ridge lap MCRs
Abutment-pontic root ratio: 1.3

Missing: Both maxillary central incisors and

one lateral incisor
Implants: 4.0 12 mm (central incisors), 3.5
12 mm (lateral incisor)
Considerations: A large nasopalatine foramen
(incisive canal) may interfere with implant
placement. The loss of a maxillary lateral
incisor frequently results in the collapse of the
facial plate of bone, which can cause a facial
concavity that will require implant placement
too far to the lingual. This will result in an
unnatural lingual contour of the crown and a
poor implant emergence profile. To correct
this problem, bone grafting is required to
eliminate the facial concavity. Splinting the
dental implant restoration will reduce
rotational forces on the abutment screws,
lessening the possibility of screw loosening.
Splinting the dental implants will increase
restoration strength and stress distribution.
Restorations: MCRs over custom abutments
(UCLA, Atlantis, or preparable abutments)

Missing: All maxillary incisors

 Abutments: Both canines and first premolars
Considerations: To counteract the lever arm
created by the curve of the anterior segment of
the arch, double abutments are often used with
full coverage retainers to assure maximum
retention. If the anterior curvature is slight
and/or the canines are exceptionally large, the
premolars may be omitted as abutments.
Retainers: MCRs
Pontics: Modified ridge lap MCRs
Abutment-pontic root ratio: 1.3

Missing: All maxillary incisors

Implants: 4.0 12 mm (lateral incisors)
Considerations: The loss of maxillary
incisors frequently results in the collapse of
the facial plate of bone, producing a facial
concavity, which requires implant placement
too far to the lingual. This will result in an
unnatural lingual contour of the crown and a
poor emergence profile. Bone grafting will be
required to eliminate the facial concavity.
Restorations: MCRs over custom abutments
(UCLA, Atlantis, or preparable abutments)

Missing: All mandibular incisors

Abutments: Both canines
Considerations: There is no need to use
double abutments on the mandibular canine-to-
canine fixed partial denture because the forces
are less destructive. If a patient has a lone
lateral or central incisor remaining, it is
usually extracted. It would complicate the
fixed partial denture without adding any
appreciable support.
Retainers: MCRs
Pontics: Modified ridge lap MCRs
Abutment-pontic root ratio: 0.8
Missing: All mandibular incisors
Implants: 4.0 12 mm (lateral incisors)
Considerations: Increased available space
allows for the use of the larger 4.0-mm-
diameter implants when replacing all four
mandibular incisors.
Restorations: MCRs over custom abutments
(UCLA, Atlantis, or preparable abutments)

Missing: Maxillary first and second

premolars and first molar
Abutments: Canine and second molar
Considerations: This fixed partial denture can
be made only if the clinical crowns of the
abutments are long and perfectly aligned. The
occlusogingival dimension of the edentulous
space must be ample to provide adequate
rigidity. This fixed partial denture is possible
only if the opposing occlusion is a removable
partial denture. Canine guidance is important
in this situation.
Retainers: MCR on the canine and FGC on the
molar
Pontics: MCRs
Abutment-pontic root ratio: 0.8

Missing: Maxillary first and second

premolars and first molar
Implants: 4.0 13 mm (first premolar), 4.3
11.5 mm (second premolar), 5.0 11.5 mm
(first molar)
Considerations: Three implants are
preferable, but not if it requires placing them
too close together. The maxillary sinus will
likely interfere with the placement of an
implant of desirable length, necessitating sinus
modification surgery such as a sinus graft or a
vertical upfracture. Splinting the dental
implant restoration will reduce rotational
forces on the abutment screws, lessening the
possibility of screw loosening. Splinting the
dental implants will increase restoration
strength and stress distribution.
Restorations: MCRs over custom abutments
(UCLA, Atlantis, or preparable abutments)

Missing: Mandibular first and second

premolars and first molar
Considerations: A fixed partial denture
should not be used in this situation because the
interarch space is usually insufficient and
occlusal force will be directed against the
inner curvature of the occlusal plane, with
resultant lifting forces on the retainers.

Missing: Mandibular first and second

premolars and first molar
Implants: 4.3 11.5 mm (first premolar), 4.3
10 mm (second premolar), 5.0 10 mm
(first molar)
Considerations: Three implants are
preferable, but not if it requires placing them
too close together. The position of the anterior
loop of the mandibular canal may interfere
with implant placement. Loss of the facial
plate of bone may result in inadequate
alveolar width. Alveolar resorption may lead
to insufficient height of bone above the mental
foramen and mandibular canal. The correction
of this anatomical difficulty requires the
placement of an onlay bone graft to allow the
placement of an implant of sufficient width
and length. Splinting the dental implant
restoration will reduce rotational forces on the
abutment screws, lessening the possibility of
screw loosening. Splinting the dental implants
will increase restoration strength and stress
distribution.
Restorations: MCRs over custom abutments
(UCLA, Atlantis, or preparable abutments)
Complex Fixed Partial Dentures (Pier Abutment)

Missing: Maxillary central incisor and

opposite-side lateral incisor
Abutments: Lateral incisor, central incisor,
and canine
Considerations: A keyway is placed at the
distal aspect of the central incisor retainer to
accommodate a key on the mesial aspect of the
lateral incisor pontic. If the central incisor is
malpositioned or rotated, its extraction will
simplify the restoration and improve its
prognosis.
Retainers: MCRs
Pontics: Modified ridge lap MCRs
Abutment-pontic root ratio: 1.7

Missing: Maxillary central incisor and

opposite-side lateral incisor
Implants: 4.0 12 mm (central incisor), 3.5
12 mm (lateral incisor)
Considerations: The loss of the facial plate of
bone will frequently result in a facial
concavity requiring implant placement too far
to the lingual. This will result in an unnatural
lingual contour of the crown and a poor
implant emergence profile. To correct this
problem, bone grafting is required to eliminate
the facial concavity.
Restorations: MCRs over custom abutments
(UCLA, Atlantis, or preparable abutments)

Missing: Mandibular central incisor and

opposite-side lateral incisor
Abutments: Lateral incisor, central incisor,
and canine
Considerations: A completely rigid fixed
partial denture is used in this situation because
of short span length and small teeth. Extracting
the central incisor would simplify and
improve the prognosis of a fixed partial
denture. MCR crowns on incisors may
necessitate endodontic treatment and dowel
cores.
Retainers: MCRs will usually be used, but
resin-bonded retainers are a possibility.
Pontics: Modified ridge lap or ovate MCRs
Abutment-pontic root ratio: 1.8

Missing: Mandibular central incisor and

opposite-side lateral incisor
Implants: 3.3 12 mm
Considerations: The factor limiting
replacement of mandibular incisors with
dental implants is the mesiodistal space
available. Ideally there should be 7.3 mm of
interproximal space. If inadequate space is
available, consider extraction of all
mandibular incisors. Place two 4.0 12mm
dental implants in the lateral incisor positions
and fabricate a fourunit prosthesis.
Restorations: MCRs over one-piece implants

Missing: Both maxillary lateral incisors and

one central incisor
Abutments: Central incisor and both canines
Considerations: There should be a nonrigid
connector between the distal aspect of the
central incisor retainer and the mesial aspect
of the adjacent lateral incisor pontic. If the
central incisor is malposed or periodontally
compromised, it should be extracted.
Retainers: MCRs
Pontics: Modified ridge lap MCRs
Abutment-pontic root ratio: 1.3
 Missing: Both maxillary lateral incisors and
one central incisor
Implants: 4.0 12 mm (central incisor), 3.5
12 mm (lateral incisor)
Considerations: A large nasopalatine foramen
(incisive canal) may interfere with implant
placement. The loss of the facial plate of bone
will frequently result in a facial concavity
requiring implant placement too far to the
lingual. This will result in an unnatural lingual
contour of the crown and a poor implant
emergence profile. To correct this problem,
bone grafting is required to eliminate the
facial concavity. Splinting the dental implant
restoration will reduce rotational forces on the
abutment screws, lessening the possibility of
screw loosening. Splinting the dental implants
will increase restoration strength and stress
distribution.
Restorations: MCRs over custom abutments
(UCLA, Atlantis, or preparable abutments)

Missing: Maxillary lateral incisor and first

premolar
Abutments: Central incisor, canine, and
second premolar
Considerations: A nonrigid connector should
be placed between the canine and first
premolar.
Retainers: MCR crowns
Pontics: Modified ridge lap MCRs
Abutment-pontic root ratio: 1.7

Missing: Maxillary lateral incisor and first

premolar
Implants: 3.5 12 mm (lateral incisor), 4.0
13 mm (first premolar)
Considerations: A dental implant is the
restoration of choice. The loss of the facial
plate of bone will frequently result in a facial
concavity requiring implant placement too far
to the lingual. This will result in an unnatural
lingual contour of the crown and a poor
implant emergence profile. To correct this
problem, bone grafting is required to eliminate
the facial concavity. Implant placement may
impinge on the anterior wall of the maxillary
sinus. In this event, sinus modification surgery
such as sinus grafting or vertical upfracture
may be indicated.
Restorations: MCRs over custom abutments
(UCLA, Atlantis, or preparable abutments)

Missing: Mandibular lateral incisor and first

premolar
Abutments: Central incisor, canine, and
second premolar
Considerations: A nonrigid connector should
be placed between the canine and first
premolar.
Retainers: MCR crowns
Pontics: Modified ridge lap MCRs
Abutment-pontic root ratio: 1.7

Missing: Mandibular lateral incisor and first

premolar
Implants: 3.3 12 mm (lateral incisor), 4.3
11.5 mm (first premolar)
Considerations: A dental implant is the
restoration of choice. The factor limiting
replacement of a mandibular lateral incisor
with a dental implant is the mesiodistal space
available. Ideally there should be 7.3 mm of
interproximal space. If there is inadequate
space, consider extraction of all mandibular
incisors. Place two 4.0 12mm dental
implants in the lateral incisor positions and
fabricate a four-unit fixed partial denture. The
position of the anterior loop of the mandibular
canal may interfere with first premolar implant
placement. Loss of the facial plate of bone
may result in inadequate alveolar width.
Alveolar resorption may lead to insufficient
height of bone above the mental foramen and
mandibular canal. The correction of this
anatomical difficulty requires the placement of
an onlay bone graft to allow the placement of
an implant of sufficient width and length.
Restorations: MCR over a one-piece implant
on the lateral incisor and MCR over a custom
abutment (UCLA, Atlantis, or preparable
abutments) on the first premolar

Missing: Maxillary canine and second

premolar
Abutments: Central incisor, lateral incisor,
first premolar, and first molar
Considerations: A nonrigid connector should
be placed between the first premolar retainer
and second premolar pontic.
Retainers: MCRs on the incisors and
premolar and crown or MCR on the molar
Pontics: Modified ridge lap MCRs
Abutment-pontic root ratio: 2.1

Missing: Maxillary canine and second

premolar
Implants: 4.5 15 mm (canine), 4.3 11.5
mm (second premolar)
Considerations: A dental implant is the
restoration of choice. The loss of the facial
plate of bone will frequently result in a facial
concavity requiring implant placement too far
to the lingual. This will result in an unnatural
lingual contour of the crown and a poor
implant emergence profile. To correct this
problem, bone grafting is required to eliminate
the facial concavity. The maxillary sinus will
likely interfere with the placement of an
implant of desirable length, necessitating sinus
modification surgery such as a sinus graft or a
vertical upfracture.
 Restorations: MCRs over custom abutments
(UCLA, Atlantis, or preparable abutments)

Missing: Mandibular canine and second

premolar
Abutments: Central incisor, lateral incisor,
first premolar, and first molar
Considerations: A nonrigid connector should
be placed between the first premolar retainer
and second premolar pontic.
Retainers: MCRs on the incisors and
premolar and FGC or MCR on the molar
Pontics: Modified ridge lap MCR
Abutment-pontic root ratio: 2.1

Missing: Mandibular canine and second

premolar
Implants: 4.5 15 mm (canine), 4.3 10 mm
(second premolar)
Considerations: A dental implant is the
restoration of choice. Loss of the facial plate
of bone may result in inadequate alveolar
width, and alveolar resorption may lead to
insufficient height of bone above the mental
foramen and mandibular canal. The correction
of this anatomical difficulty requires the
placement of an onlay bone graft to allow the
placement of an implant of sufficient width and
length.
Restorations: MCRs over custom abutments
(UCLA, Atlantis, or preparable abutments)

Missing: All maxillary incisors and one first

premolar
Abutments: Both canines, the opposite-side
first premolar, and the second premolar
Considerations: A nonrigid connector should
be placed at the distal aspect of the retainer on
the canine pier abutment.
Retainers: MCRs
Pontics: Modified ridge lap MCRs
Abutment-pontic root ratio: 1.0

Missing: All maxillary incisors and one first

premolar
Implants: 4.0 12 mm (lateral incisors), 4.0
13 mm (first premolar)
Considerations: A dental implant is the
restoration of choice. The loss of maxillary
incisors frequently results in the collapse of
the facial plate of bone, which produces a
facial concavity requiring implant placement
too far to the lingual. This will result in an
unnatural lingual contour of the crown and a
poor emergence profile. This will require
bone grafting to eliminate the facial concavity.
Implant placement at the first premolar may
impinge on the anterior wall of the maxillary
sinus, in which case sinus modification
surgery such as sinus grafting or vertical
upfracture may be indicated.
Restorations: MCRs over custom abutments
(UCLA, Atlantis, or preparable abutments)

Missing: All mandibular incisors and one first

premolar
Abutments: Both canines and the second
premolar
Considerations: A nonrigid connector should
be placed at the distal aspect of the retainer on
the canine pier abutment.
Retainers: MCRs
Pontics: Modified ridge lap MCRs
Abutment-pontic root ratio: 1.0

Missing: All mandibular incisors and one first

premolar
Implants: 4.0 12 mm (lateral incisors), 4.3
11.5 mm (first premolar)
Considerations: A dental implant is the
restoration of choice. Increased available
space allows for the use of the larger 4.0-mm-
diameter implants when replacing all four
mandibular incisors. The position of the
anterior loop of the mandibular canal may
interfere with implant placement.
Restorations: MCRs over custom abutments
(UCLA, Atlantis, or preparable abutments)

Missing: Maxillary lateral incisor and first

and second premolars
Abutments: Canine and first molar
Considerations: Canine-guided posterior
disocclusion. The short lever arm created by
the lateral incisor cantilever should be
adequately offset by the long span from first
molar to canine.
Retainers: MCRs
Pontics: Modified ridge lap MCRs
Abutment-pontic root ratio: 1.1
Missing: Maxillary lateral incisor and first
and second premolars
Implants: 3.5 12 mm (lateral incisor), 4.0
13 mm (first premolar), 4.3 11.5 mm
(second premolar)
Considerations: A dental implant is the
restoration of choice. The loss of the facial
plate of bone will frequently result in a facial
concavity requiring implant placement too far
to the lingual. This will result in an unnatural
lingual contour of the crown and a poor
implant emergence profile. To correct this
problem, bone grafting to eliminate the facial
concavity is required. The maxillary sinus will
likely interfere with the placement of an
implant of desirable length, necessitating sinus
modification surgery such as a sinus graft or a
vertical upfracture. Splinting the dental
implant restoration will reduce rotational
forces on the abutment screws, lessening the
possibility of screw loosening. Splinting the
dental implants will increase restoration
strength and stress distribution.
Restorations: MCRs over custom abutments
(UCLA, Atlantis, or preparable abutments)

Missing: Mandibular lateral incisor and first

and second premolars
Abutments: Canine and first molar
Considerations: Canine-guided posterior
disocclusion. The short lever arm created by
the lateral incisor cantilever should be
adequately offset by the long span from first
molar to canine.
Retainers: MCRs
Pontics: Modified ridge lap MCRs
Abutment-pontic root ratio: 1.1

Missing: Mandibular lateral incisor and first

and second premolars
Implants: 3.3 12 mm (lateral incisor), 4.3
11.5 mm (first premolar), 4.3 10 mm
(second premolar)
Considerations: A dental implant is the
restoration of choice. The factor limiting
replacement of a mandibular lateral incisor
with a dental implant is the available
mesiodistal space. Ideally there should be 7.3
mm of interproximal space. If inadequate
space is available, consider extraction of all
mandibular incisors. Place two 4.0 12mm
dental implants in the lateral incisor positions
and fabricate a four-unit restoration. The
position of the anterior loop of the mandibular
canal may interfere with implant placement.
Loss of the facial plate of bone may result in
inadequate alveolar width. Alveolar
resorption may lead to insufficient height of
bone above the mental foramen and
mandibular canal. The correction of this
anatomical difficulty requires the placement of
an onlay bone graft to allow the placement of
an implant of sufficient width and length.
Splinting the dental implant restoration will
reduce rotational forces on the abutment
screws, lessening the possibility of screw
loosening. Splinting the dental implants will
increase restoration strength and stress
distribution.
Restorations: MCRs over custom abutments
(UCLA, Atlantis, or preparable abutments)

Missing: Maxillary first premolar and first

molar
Abutments: Canine, second premolar, and
second molar
Considerations: A nonrigid connector should
be placed on the distal aspect of the second
premolar retainer.
Retainers: MCRs on the canine and second
premolar and FGC on the second molar
Pontics: Modified ridge lap MCRs
Abutment-pontic root ratio: 1.4

Missing: Maxillary first premolar and first

 molar
Implants: 4.0 13 mm (first premolar), 5.0
13 mm (first molar)
Considerations: The loss of the facial plate of
bone will frequently result in a facial
concavity requiring implant placement too far
to the lingual. This will result in an unnatural
lingual contour of the crown and a poor
implant emergence profile. To correct this
problem, bone grafting to eliminate the facial
concavity is required. The maxillary sinus
will likely interfere with the placement of an
implant of desirable length, necessitating sinus
modification surgery such as a sinus graft or a
vertical upfracture.
Restorations: MCRs over custom abutments
(UCLA, Atlantis, or preparable abutments)

Missing: Mandibular first premolar and first

molar
Abutments: Canine, second premolar, and
second molar
Considerations: A nonrigid connector should
be placed on the distal aspect of the second
premolar retainer.
Retainers: MCRs on the canine and second
premolar and FGC on the second molar
Pontics: Modified ridge lap MCR on the first
premolar and all-metal hygienic pontic on the
first molar
Abutment-pontic root ratio: 1.4

Missing: Mandibular first premolar and first

molar
Implants: 4.3 11 mm (first premolar), 5.0
10 mm (first molar)
Considerations: A dental implant is the
restoration of choice. Loss of the facial plate
of bone may result in inadequate alveolar
width. Alveolar resorption may lead to
insufficient height of bone above the mental
foramen and mandibular canal. The correction
of this anatomical difficulty requires the
placement of an onlay bone graft to allow the
placement of an implant of sufficient width and
length.
Restorations: MCRs over custom abutments
(UCLA, Atlantis, or preparable abutments)

Missing: Maxillary central incisor, lateral

incisor, and first and second premolars on one
side
Considerations: This would be an extremely
difficult fixed partial denture in either the
maxillary or mandibular arch. The span
lengths of both edentulous spaces are too great
for nonrigid connectors with either pontic.
Implant-supported MCRs or a removable
partial denture are preferable.

Missing: Maxillary central incisor, lateral

incisor, and first and second premolars on one
side
Implants: 4.0 12 mm (central incisor), 3.5
12 mm (lateral incisor), 4.0 13 mm (first
premolar), 4.3 11.5 mm (second premolar)
Considerations: A dental implant is the
restoration of choice. A large nasopalatine
foramen (incisive canal) may interfere with
implant placement. The loss of the facial plate
of bone will frequently result in a facial
concavity requiring implant placement too far
to the lingual. This will result in an unnatural
lingual contour of the crown and a poor
implant emergence profile. To correct this
problem, bone grafting to eliminate the facial
concavity is required. The maxillary sinus will
likely interfere with the placement of an
implant of desirable length, necessitating sinus
modification surgery such as a sinus graft or a
vertical upfracture. Splinting the dental
implant restoration will reduce rotational
forces on the abutment screws, lessening the
possibility of screw loosening. Splinting the
dental implants will increase restoration
strength and stress distribution.
Restorations: MCRs over custom abutments
(UCLA, Atlantis, or preparable abutments)