Fixed versus removable implant prostheses

Periodontal disease often results in the inevitable loss of teeth. For many patients, a clearance in one or both jaws is the only option. This can be psychologically and medically devastating. It may destroy much of what is left of some patients’ self worth.

These same patients then often request dental implants to restore their dental condition and their self-esteem. They are vulnerable and sometimes desperate. We must clear away the emotion and counsel these patients carefully and considerately before they embark on potentially major procedures.

Some will push for fixed teeth, even when this may not be the best option for them, simply because they don’t like the idea of putting teeth in a jar at night. Advanced periodontally compromised patients often have limited residual bone for dental implant placement without the need for bone grafts.

I have been pleasantly surprised by how many patients, during the temporisation phase following tooth removal and provision of removable prostheses, adapt to the change and opt for ultimately simpler procedures that are more appropriate for them.

So let’s consider some of the aspects of whether to restore a patient with fixed or removable teeth, some of which will inevitably be open to debate.

Removable teeth

• They require fewer dental implants for retention and support

• They involve less financial investment

• They can be used to easily restore both hard and soft tissue, which may be more aesthetically appealing where large amounts of soft tissue are on display

• Psychologically less appealing than fixed teeth

• Poorer function than fixed teeth

• They require more ongoing maintenance than fixed teeth,

particularly maxillary removable prostheses opposing natural lower teeth where clips can break and need replacing.

Fixed teeth

• They require more dental implants to fix and support the teeth. My feeling now is that four lower implants and five upper implants, in ideal cases, are probably sufficient to support fixed teeth. Watch this space

• They require less ongoing maintenance than removable teeth

• They require more home care for maintenance

• Higher initial financial investment

• Psychologically more appealing

• Potentially more challenging clinically.

Clinical considerations

We could of course consider the halfway house of a removable supra-structure retained only by implants, but for the time being we will keep things simple.

Taking cost out of the equation, the clinical considerations for choice can be based on the following:

• The amount of soft tissue requiring replacement

• Lip line and aesthetic limitations

• The inter-arch distance

• The residual arch form

• The effective crown/implant ratio of the final restoration

• The available bone quality and quantity in strategic positions

• The anticipated functional loading of the prosthesis

• The presence or absence of local pathology

• The ability of the patient to undergo potentially long procedures

• The availability of laboratory and technical support.

Both types of prosthetic replacement have significant roles to play, while considerations are many. Beware of being pushed down an unsuitable route by the emotional demands of a patient – if you fail to resist here the decision could come back to bite you.

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