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Prosthetic Treatment of the


MUDr. Emlia Jansk, PhD

LF UK Bratislava

..Last scene of all,

That ends this strange eventful history,
Is second childishness, and mere oblivion,
Sans teeth, sans eyes, sans taste, sans
William Shakespeare
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recent decades - decline in edentulism among elderly people

(however, still rather large population of older with few or no teeth)

Prosthetic therapy and the choice of treatment modality

patients demand
professional consideration
socio-economic situation

Assesment of

- the patients general physical and cognitive state

- the realistic needs
professional assessment
perceived need
expressed demand for treatment
general mental and physical state
- socio- economical factors often limits the
possibilities to very simple treatments

Study in Sweeden (2007) 70-year-old patients:

- prevalence of edentulism - 51% in 1971 declined to 7% in
- prevalence of FPD (fixed partial dentures) increased form
26% to 68%
- 20 remaining teeth from 13% to 65%
Study in Germany (2004)
- tooth loss and the risk of wearing complete dentures
associated with
low income
low education level

Prosthetic therapy for the Elderly

1. Indication
2. Treatment planning - partially edentulous patients
- edentulous patients
3. Risk factors - partially edentulous patients
- edentulous patients
4. Restoration of the partially edentulous mouth
5. Restoration of the edentulous mouth with
conventional complete dentures
6. Implants for older people

When considering prosthetic therapy for older patients - important to

identify major risk factors:

- progression of periodontal disease

- caries activity (high incidence of secondary caries
- residual ridge resorption
- functional problems

and root

1. Indication for the prosthetic therapy

- to restore - masticatory function
- aesthetics (pleasant appearance)
- unimpaired speech
Eight occluding pair of teeth in the anterior and the
premolar region seem to be sufficient to satisfy
elderly patients aesthetic and functional demand.
(in the future, older individuals might be more demanding in this respect,
..not existing any true subjective or objective need)

2.1. Treatment planning

Partially edentulous patients

reduced masticatory ability (related linearly with the number of

teeth present)

overt symptoms in the masticatory system (adaptive capacity is

reduced if occlusal instability develops suddenly - tooth extraction or
poorly disigned prothesis)

reduced occlusal face height (it is unrealistic to anticipate that the

anterior pattern will change markedly even after replacement of
missing posterior teeth)

2.2. Treatment planning

Edentulous patients
Assesment of the patients
- existing dentures (broken or poor fitting)
- anatomical situation (resorption of the residual underlying ridge)
- condition of of the oral mucosa - stomatitis, lesions, candidosis.
(predisposition for candida spreading - medication, frequent
carbohydrate intake, reduced salivary flow, poor oral hygiene)
No treatment if - discrepancy between the patients demands
patients treatment ability
objective treatment needs
- existing dentures do not have a major faults
- patient do not accept the diagnostically modified treatment
- there is underlying mental disorder..

Quality of life and prosthodontics

Assessment of oral health related quality of life (OHRQoL) in 2004
study (Mike at al.):

107 patients, before treatment considerably impaired level of

1 month after treatment rapid improvement continued following
6-12 months
largest improvement - fixed partial dentures
smallest improvement - complete dentures (difficulty do adapt)
osseo-integrated implants - secure retention and stability of a
complete denture

3.1. Risk factors

Partially edentulous patients
Main risk factors:
- caries activity - increased risk of root caries (gingival retraction
cause exposure of the root surface)
additional risk factors - poor oral hygiene, xerostomia, frequent
carbohydrate intake, wearing of removable dentures, high level of
mutans streptococci in saliva)

periodontal disease - the elderly partially edentulous patient is

expected to have reasonable periodontal prognosis

needed strict hygiene measures

3.2. Risk factors

Edentulous patients

poor adaptation - the adaptive capacity to new dentures tends

to decrease with age
poor treatment outcome
chewing problem - frequent
localized pain reactions
burning mouth syndrome, itching - often due to psychiatric
disorders (anxiety, depression, obsession), patients should
be referred to a psychiatrist before the treatment

The gold standard - treatment with implant-retained complete

dentures in patients poor anatomic conditions or difficulties in

4. Restoration of the partially

edentulous mouth
Fixed Partial Dentures
Cross-Arch FDPs
Small Cantilever FDPs

Removable Partial Dentures

Simple Overdentures
Attachment-Retained Overdentures

Fixed Partial Dentures (FDP)

Cross-Arch FDPs - limited indication in elderly (oral hygiene,
caries, complications)

Small Cantilever FDPs - several smaller - more safe

solution, or placement of implants

Prognosis depends on:

- abutment selection
- control of occlusal forces
- provision of connector

Removable Partial Dentures (RPD)


non-invasive treatment
low cost solution
might be impaired aesthetic and oral control
increased risk of caries and periodontal disease (high salivary levels of mutans streptococci and yeast)

Compulsory - to design RPD according to simple and logical principles - to secure the stability and the best possible comfort

- mechanical failures (fracture of major or minor connectors,
oclusal restsdeformation or fracture of retentive clasps)
- coverage of the gingival tissue by minor connectors detrimental effect on periodontal health

Prosthetic rehabilitation of shortened

dental arches and tooth wear
with reduction of the occlusal
face height:
- extensive FDPs, crowns and RPDs
- less complicated: RPD with
occlusal overlay rests and
restoration of anterior teeth with
composite resin (less expensive,
reversible, not involving extensive
preparation of tooth structure

- in patients with few remaining teeth inadequate to serve as abutments
Advantages: - better preservation of neuromuscular function
- perceptive ability and proprioception
- improved masticatory performance
- stability of the denture
- stable occlusion,
- psychological benefits

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(f.e. telescopic crowns..)

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Prevention and maintainance

Plaque control of teeth
Plaque control of overdenture
Dietary advice (avoid cariogenic foods)
Fluoride treatment (beneficial effect)
Maintainance of abutment teeth (carious attack treated
with glass-ionomer cement)

Maintainance of overdentures (regular control)

important : selection of suitable patients

5. Restoration of the edentulous mouth

with conventional complete dentures

3 groups of patients:
- well adapted to existing dentures
- poorly adapted denture wearers
- no experience in wearing dentures

Guidelines for constructing complete dentures :

Minimum acceptable protocols (2006)

Preparatoty phase - patients specific goals,insurance of healthy

oral mucosa

Treatment phase - impressions, centric relation, vertical

dimension of occlusion, tooth arrangement, aesthetics, final
adjustment of occlusion, instruction of the patient)

Post-treatment phase - control of hygiene, occlusion, function

Existing denture wearers

Well adapted denture wearers - if reduced vertical dimension, poor fit, unstable occlusal
conditionsexisting dentures are used diagnostically (as
individual tray for a functional impression, determination of
vertical dimension.)
Non-adaptive denture wearers
- careful interview and examination (not to be carried out if there
is no major disorder of existing dentures, if evidence of mental

Edentulous patients without existing dentures

- first maxillary dentures.
- implant-retained complete dentures is an excellent alternative

Implants for older people

Patient evaluation

- general examination
- local examination
Treatment plan, treatment sequence, informed



Indication for dental implants in the older

patients and types of implant-supported

chronological age is not a contraindication

1998 (Bryant) - comparison of osseointegration in older and
younger adults - follow-up times 4-16 years:
success rate in the older 92%, in the younger 86,5%
main factor - quality and quantity of jawbone, risk of systemic
influences: social, cultural, socio-economical, individual adaptive

Patient evaluation
General examination

Medical history including medication

Chief complaint and expectation
Social and family history
Dental history

Patient evaluation
Local examination

Extraoral examination
Intraoral examination and radiographs
Implant specific diagnostics

Treatment sequence for implant assisted prosthodontics

Examination, diagnosis and treatment planning (one or more visits)
Presentation of treatment plan, patients informed consent
Treatment of active disease including extractions (caries, periodontal..)
Orthodontic pre-treatment (if indicated)
Surgical pre-treatment (if indicatedbone or soft tissue augmentation)
Implant surgery (single stage to multiple stages) and healing
Prosthodontic phase:

a/ provisional restoration (especially in complex cases and

implants in the aesthetic zone)
b/ permanent restoration
Maintenance (long-term)

Age is something that doesnt matter,

unless you are a cheese
Billie Burke



Lamster I.B., Northridge M.E.: Improving Oral

Health for the Elderly. Springer Verlag NY 2008
Weber T. Memorix Zahnmedizin. Thieme, Stuttgart;
Rahn A., Ivanhoe J., Plummer K.: Textbook of
Complete Dentures. Peoples Medical Publishing
House Shelton, Connecticut 2009, 446pp
Barnes I.E., Walls A.: Gerodontology. George
Warman Publication UK 1994