What are the best treatment options for an edentulous (without teeth) patient?

Treatment Options for Edentulous Patients

For completely edentulous patients, implant-supported prostheses—either fixed full-arch restorations or implant-retained overdentures—should be the primary treatment approach rather than conventional complete dentures, as they significantly improve quality of life, masticatory function, and patient satisfaction. 1, 2

Treatment Hierarchy Based on Patient Factors

First-Line Option: Implant-Supported Fixed Prostheses

• Full-arch implant-supported fixed dental prostheses represent the gold standard for completely edentulous patients, providing the highest level of function and patient satisfaction 3, 4
• These restorations can utilize cantilever extensions to reduce the number of implants needed while maintaining excellent long-term outcomes, with annual failure rates of 1.18% comparable to conventional non-cantilever designs (1.03%) 3
• Cantilever-supported prostheses are valid and reliable for completely edentulous patients, though they carry a 2.56 times higher risk of prosthetic complications (ceramic fractures, chipping) compared to non-cantilever designs 3

Second-Line Option: Implant-Retained Overdentures

• Implant-retained removable overdentures significantly outperform conventional complete dentures in general satisfaction, comfort, stability, and chewing ability 1
• Patients with mandibular implant overdentures experience significantly fewer oral health-related quality of life problems than those with conventional dentures 1
• This option is particularly appropriate when anatomical, medical, or economic factors preclude fixed prostheses 4, 2

Last Resort: Conventional Complete Dentures

• Conventional removable complete dentures should only be considered when implant therapy is contraindicated or refused by the patient 1, 2
• These prostheses have significant functional shortcomings compared to implant-supported options and should not be the default treatment 1

Maxillary-Specific Considerations

For Posterior Edentulous Maxilla (Partial Edentulism)

Treatment selection depends primarily on remaining bone height (RBH): 3, 5

• RBH >9 mm: Place standard implants (≥8 mm length) or short implants (<8 mm length) without bone augmentation 3, 5

• RBH >5 to ≤9 mm: Choose between:

  • Transalveolar maxillary sinus floor augmentation with simultaneous standard implant placement 3, 5
  • Short implant placement without bone augmentation 3, 5

• RBH >3 to ≤5 mm: Options include:

  • Lateral window maxillary sinus floor augmentation with simultaneous implant placement 3, 5
  • Transalveolar sinus augmentation with simultaneous short implant placement 3, 5
  • Tilted implants 3, 5
  • Distal cantilever extension 3, 5

• RBH ≤3 mm: Consider:

  • Lateral window maxillary sinus floor augmentation with delayed implant placement 3, 5
  • Tilted implants 3, 5
  • Distal cantilever extension 3, 5
  • Alveolar ridge augmentation (particularly indicated with negative osseous architecture) 3

Alternative for Severe Maxillary Atrophy

Zygomatic implants anchored in the zygomatic bone provide stability when maxillary bone volume is insufficient, eliminating the need for bone grafting procedures and demonstrating high survival rates 6

• These can support upper dentures with clip-on mechanisms 6
• Patients require adequate mouth opening (approximately 35mm) 6
• Can be loaded with delayed or immediate protocols 6

Critical Pitfalls to Avoid

Sinus Augmentation Complications

• Schneiderian membrane perforation occurs in one in five lateral window cases and must be sealed intraoperatively with absorbable membrane or fibrin construct 3
• Abort the procedure if perforation cannot be sealed due to size/extent of damage 3
• Postoperative subacute sinusitis (0.2% incidence) requires immediate surgical drainage, debridement, complete graft removal, and high-dose broad-spectrum antibiotics (amoxicillin or levofloxacin) for 7-10 days to prevent orbital or intracranial spread 3

Preoperative Assessment Requirements

• Mucosal thickening up to 3mm without acute symptoms and patent osteomeatal complex requires no further investigation 3
• Any mucosal thickening with osteomeatal complex closure mandates otorhinolaryngology evaluation 3
• Mucous retention cysts not interfering with the osteomeatal complex require no intervention 3
• Missing sinus wall with hard-tissue erosion requires specialist evaluation to exclude neoplastic conditions 3

Special Population Considerations

In elderly patients with cognitive impairment, favor simpler removable prostheses over complex reconstructions, as failed complex reconstructions significantly impact quality of life in this population 5

Functional Restoration Principles

• Restoring one premolar and one molar (four chewing units) provides sufficient chewing capacity, as patients missing second molars retain full functional capacity 3
• Even with only premolars restored (two chewing units), patients maintain approximately 80% of maximum chewing capacity 3
• This evidence supports conservative approaches that avoid unnecessary implant placement in the most posterior regions 3