Treatment Options for the Edentulous Mandible - DentalCEToday

Continuing Education 

Course Number: 118.2 

Treatment Options for the 

Edentulous Mandible 

Authored by Steven Kendrick, DDS and David Wong, DDS 

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Treatment Options for the 

Edentulous Mandible 


Recommendations for Fluoride Varnish Use in Caries Management 

options available today for the edentulous mandible and the 

importance of mandibular anatomy in determining implant 

position, prosthesis selection, and cantilever length. 

LEARNING OBJECTIVES: 

After reading this article, the individual will learn: 

• Treatment options available today for the edentulous 

mandible. 

• The importance of mandibular anatomy in determining 

implant position, prosthesis selection, and cantilever 

length. 

ABOUT THE AUTHORS 

Dr. Kendrick is in private practice 

in Midwest City, Okla, and is an 

instructor at the Tulsa Implant Institute. 

He can be reached via e-mail at 

skend22@hotmail.com. 

Disclosure: Dr. Kendrick reports no conflicts of interest. 

Dr. Wong is in private practice in Tulsa, 

Okla, and is an instructor at the Tulsa 

Implant Institute. He is a Board Certified 

Periodontist and can be reached via e- 

mail at david@tulsagums.com. 

Disclosure: Dr. Kendrick reports no conflicts of interest. 

INTRODUCTION 

The treatment of the edentulous mandible is one of the 

most challenging to the dental practitioner in regards to 

patient satisfaction. 1 The number of edentulous arches in 

the United States is expected to increase. It is estimated 

that by the year 2020 there will be 61 million edentulous 

arches. 2 As this segment of the population grows, there will 

be an increasing demand on dentistry for edentulous 

prosthetic treatment. This article discusses the treatment 

ANATOMIC CONSIDERATIONS 

The anatomy of the edentulous ridge provides challenges 

to the adaptive process of patients to conventional denture 

therapy. One of the anatomical considerations is the 

mandibular ridge, which provides less than one quarter the 

support offered by the peridontium to the natural teeth 

(Figure 1). 3 It is from this compromised situation that the 

clinician must build the prosthesis. An understanding of the 

anatomy of the edentulous mandible will allow the clinician to 

make decisions on implant placement and any ancillary 

procedure that will need to be performed in order to obtain a 

satisfactory result for the patient. 

The implant retained/supported prosthesis will be 

affected by the location of the mental foramina and the 

inferior alveolar canal (Figure 2). The distance between 

these areas will determine the number of possible implant 

sites as well as inter-implant spacing. The distance between 

the foramina is variable based on ethnicity, sex, and skull 

size. The average interforamen distance for African- 

American males is 45.8 mm; white males is 45 mm; African- 

American females is 43.8 mm; and white females is 41 mm. 4 

Figure 1. 

The edentulous 

mandibular ridge provides 

limited support for a 

conventional prosthesis. 

Figure 2. The position of the mental foramina and the inferior 

alveolar canal will determine the space available for implant 

placement. 

1


Treatment Options for the Edentulous Mandible 

This space can be divided into 5 equal columns of bone 

serving as potential implant sites, labeled A, B, C, D, E, 

starting from the patient’s right side (Figure 3). If fewer than 

5 implants are being placed at the initial surgery, the 

implants are placed in different positions depending on the 

type of prosthesis being designed, leaving the appropriate 

columns empty for future implant placement should the 

patient want/need additional implant support. 5,6 

As a general rule, when 5 implants are placed in the 

anterior mandible between the foramina, the cantilever 

should not exceed 2.5 times the anteroposterior (A-P) 

spread with all other force factors being low. 7 The A-P 

distance is obtained by connecting a line drawn from the 

distal aspect of the most posterior implants and a parallel 

line drawn through the center of the most anterior implant 

(Figure 4). The greater the A-P distance the more favorable 

the situation for the posterior cantilever. 8,9 

The existing arch form will affect the amount of A-P 

spread possible. There are 3 types of arch forms: (1) ovoid, 

(2) tapering, and (3) square. The square arch form provides 

the shortest A-P spread, with an A-P dimension often of 2 

to 5 mm. Conversely, the tapering arch form will result in the 

largest A-P spread, with an A-P distance greater than 8 

mm. The ovoid, which is the most common, will often have 

an A-P distance of 6 to 8 mm. 10 By evaluating the arch 

form, the doctor will have an idea of the potential A-P 

spread and the amount of cantilever possible to support the 

prosthesis (Figure 5). Patient force factors will ultimately 

determine the amount of cantilever to be used for the 

definitive prosthesis. 11 

The treatment plan will also consider the alveolar ridge 

height and width. A minimum alveolar height of 9 mm is 

recommended if conventional endosseous implants are 

expected to be used to ensure predictability. 12 In the 

anterior mandible the inferior cortical plate can be 

perforated but it is not recommended. Posterior to the 

mental foramen a safety zone of 2 mm superior to the 

inferior alveolar canal is suggested. 13 The minimum width of 

the edentulous mandible is dependent on the type of 

implant used. A 1 mm thickness of bone buccal and lingual 

to the implant ensures sufficient bone thickness and blood 

supply around the implant for predictable survival. 14 

Figure 3. There are 5 columns of bone available for implant 

placement between the mental foramina. 

1.5x 

x 

A-P Spread 

Figure 4. Potential 

anteroposterior (A-P) 

spread based on 

implant position. 

Figure 5. The square 

arch form of this patient 

has minimal A-P spread, 

leading to a short 

cantilever. 

The crown height space available will determine the 

type of attachment, material selection, or whether 

additional procedures must be preformed to obtain the 

appropriate space for the desired prosthesis. This 

dimension will be the least with an implant attachment 

retained prosthesis (7 mm). The space required for the 

current lowest vertical height of an attachment (abutment 

plus male) is 3.17 mm on an externally hexed implant, and 

2.5 mm on a nonhexed implant. 

The bar retained implant overdenture will require 15 to 

17 mm of crown height space depending on the type of 

2



attachment used (Figure 6). When considering an implant 

retained fixed prosthesis the amount of crown height space 

present will determine the materials to be selected. 

The amount of keratinized tissue present will determine 

if any soft tissue augmentation procedures will need to be 

performed either at the time of implant placement or in the 

future. Factors such as active/hyperactive gag reflex and 

parafunctional habits will also need to be considered. 

* 

>8 mm Teeth 

3 to 5 mm bar + attachment 

3 to 5 mm soft tissue 

*1 mm space soft tissue to bar 

Occlusal Table 

15 mm 

min 

Bone Level 

Figure 6. Vertical 

space requirements 

for a bar-retained 

overdenture. 

PSYCHOLOGIC CONSIDERATIONS 

Edentulous patients can present with some 

psychological challenges related to their condition. Some 

edentulous patients cannot cope with their prosthesis 

regardless of how well it is made. 15 This does not mean that 

all edentulous patients fall into this category. Just as with 

dentate patients, a pre-clinical interview where the clinician 

and patient can discuss expectations is mutually beneficial. 

CONVENTIONAL DENTURE 

Conventional denture therapy is also an option for the 

patient, but often provides the least favorable outcome for 

patients when compared to implant supported prostheses. 

Patients report the most important qualities of a denture to 

be comfort, stability, the ability to chew and speak normally, 

and aesthetics. 16,17 Multiple studies have compared 

conventional dentures to implant retained overdentures. In 

these studies patients had higher satisfaction scores with 

implant retained dentures as compared to conventional 

dentures. 18 

However, there are factors such as financial and/or 

health related limitations in which a conventional denture 

meets the need of that person and should not be 

considered inferior treatment. 

MINI-IMPLANT RETAINED OVERDENTURE 

A mini-implant retained mandibular denture should be 

considered as a treatment option when there is insufficient 

buccal-lingual width of the alveolar ridge for standard size 

endosseous implants and the patient cannot undergo 

grafting procedures, whether due to financial or health risk 

Figure 7. Miniimplant 

placement 

in an atrophic 

mandibular ridge. 

factors (Figure 7). There will also be a percentage of 

patients who will not consent to the grafting procedure due 

to a perceived negative risk/benefit ratio. Current miniimplants 

on the market range from 1.8 to 3.0 mm in 

diameter and length ranging from 10 to 18 mm. The number 

of implants recommended in the mandible is a minimum of 

4 with a spacing of 5 to 8 mm between implants. The 

manufacturers also recommend a minimum distance of 7 mm 

anterior to the mental foramina. The total number of 

implants possible will be determined by the distance 

between the mental foramina. Immediate loading of the 

implants is recommended only when the implants are able 

to resist 30 to 35 ncm of load (as per manufacturer’s 

instruction). At that time the mandibular denture is 

connected to the mini-implants using a chairside pick-up 

technique, or an impression is taken and a laboratory reline 

process is performed. 

ATTACHMENT-RETAINED IMPLANT OVERDENTURE 

Implant overdentures can be supported by as many as 

5 implants in the anterior mandible, to as few as one implant 

(Figures 8 to 10). 19 The McGill Consensus Statement on 

Overdentures stated that the mandibular 2-implant 

overdenture is the minimum standard of care for edentulous 

patients. 20 This is where the treatment plan discussion with 

3



the patient should begin. The patient’s desires for stability 

and the ability to remove or not remove the prosthesis will 

determine the final number of implants and type of 

prosthesis. An attachment-retained overdenture will require 

implants in different positions depending on the amount of 

retention and stability required by the patient. A 2-implantretained 

overdenture will have implants placed in the B-D 

positions. This provides an anterior stop and minimizes 

anterior-posterior rocking. A patient requiring more stability 

will have implants placed in the A-C-E position. This will 

increase retention with an additional implant and will create 

a tripod effect to further minimize anterior-posterior rocking. 

The patient requiring more stability and who is transitioning 

to a fixed prosthesis in the future or cannot afford the 

expense of a bar-retained overdenture will have the 

treatment option of a 4-implant-retained prosthesis with 

implants in the A-B-D-E positions. 

The attachment-retained overdenture has the main 

advantage of cost over the bar-retained implant overdenture 

and the implant retained fixed prosthesis. 21,22 However, it does 

not address posterior bone loss and will have less stability than 

a bar-retained overdenture or a fixed prosthesis. 23 

BAR-RETAINED IMPLANT OVERDENTURE 

The bar-retained implant overdenture provides more 

support for the edentulous patient compared to the 

attachment-retained implant denture. The same implant 

placement options are available but the ability exists to 

cantilever the bar posteriorly due to A-P spread (Figure 11). 

The B-D, A-C-E, and B-C-D options are generally not 

cantilevered due to the limited implant support and short A- 

P distances. The A-B-D-E option in a tapering arch is often 

10 mm, and 8 mm in an ovoid arch. If all other factors are 

favorable this would allow a cantilever in the ovoid arch of 

up to 12 mm, and up to 15 mm in the tapering arch. The 

square arch form would only allow 4 mm of cantilever. 24 

If the patient requires more support an additional 

implant can be placed in the C position, which will increase 

the A-P distance in an ovoid or tapering arch. An implant 

can also be placed in the molar region on either side to 

increase the A-P distance. This is a primary option for 

increasing A-P spread in a square arch from. 

8 

10 

Figure 8, 9 and 10. Attachment-retained implant overdenture 

with implants in the AB DE position. 

15 mm 

Figure 11. 

Bar-retained 

overdenture with an 

implant in the left first 

molar position to 

increase the A-P 

spread. 

Figure 12. 

The distance from the 

implant platform to the 

occlusal table is less 

than 15 mm; the 

prosthetic material 

indicated is PFM. 

Figure 13. 

The distance from the 

implant platform to the 

occlusal table is greater 

than 15 mm; the hybrid 

prosthesis is the 

indicated restoration. 

4



IMPLANT-RETAINED FIXED PROSTHESIS 

Patient desires will also dictate the fabrication of an 

implant-retained fixed prosthesis. The 5 columns of bone 

are still available to be used, with the option of placing 

implants above or behind the mental foramina to reduce 

cantilever lengths. 

This prosthesis also has the potential of an increase of 

posterior bone height. 25,26 One to 4 additional implants can 

be placed in the mandible after the A-B-D-E positions have 

been filled to gain the maximum A-P distance and increase 

implant support. 

Further, crown height space will play a role in material 

selection for the prosthesis. If the distance from the implant 

platform to the occlusal table is less than 15 mm, then the 

prosthetic material indicated is PMF (Figure 12). If the 

distance is greater than 15 mm, then a hybrid prosthesis 

should be used (Figure 13). 27 The distance of 15 mm is 

important because of the physical properties of the 

restorative materials. Acrylic is a material that requires bulk 

for strength. If there is less than 15 mm of distance from the 

implant platform to the occlusal table there will not be 

sufficient space to achieve the bulk of acrylic necessary to 

provide strength for the prosthesis. 

Likewise, PFM restorations have difficulties when too 

much space is available. At dimensions greater than 15 mm 

from the implant platform to the occlusal table, the control 

of surface porosity across the metal substructure becomes 

difficult due to variations in cooling and heating rates across 

the metal. 28 Because of this it becomes difficult to bake 

porcelain to the substructure. The result is the high 

possibility of future porcelain fracture. 29 

CONCLUSION 

An understanding of the anatomy of the mandible along 

with an understanding of the concept of A-P spread will 

allow the clinician to treatment plan patients with an 

edentulous mandible. Treatment options should be based 

on the patient’s wants/desires for the final prosthesis. The 

2-implant overdenture should be the starting point for 

treatment options, not the end point. If the patient is unable 

or unwilling to undergo grafting procedures, then the miniimplant 

option should be discussed, but it should not be 

seen as a treatment for every edentulous patient. The 

patient will ultimately make the decision based on what 

treatment option is in their best interest at that given point 

in their life. By understanding what is necessary to provide 

each of the treatment options discussed in this article, the 

clinician can formulate a plan to phase treatment for the 

patient and help them arrive at their ultimate goal once they 

have been informed of the pros/cons and consequences of 

no treatment. 

REFERENCES 

1. Zarb GA, ed. Osseointegration: On Continuing Synergies in 

Surgery, Prosthodontics, Biomaterials. Chicago, Ill: 

Quintessence Publishing Co; 2008:4-13. 

2. Douglass CW, Shih A, Ostry L. Will there be a need for 

complete dentures in the United States in 2020 J Prosthet 

Dent. 2002;87:5-8. 

3. Zarb GA, Bolender CL, Eckert SE, et al (eds). Prosthodontic 

Treatment for Edentulous Patients: Complete Dentures and 

Implant-Supported Prostheses. St. Louis, Mo: Mosby; 2004:3-7. 

4. Cutright B, Quillopa N, Schubert W. An anthropometric 

analysis of the key foramina for maxillofacial surgery. J Oral 

Maxillofac Surg. 2003;61:354-347. 

5. Misch CE. Implant overdentures relieve discomfort for the 

edentulous patient. Dentist. 1989;67:37-38. 

6. Misch CE. Mandibular overdenture treatment options. In: 

Misch Implant Institute Manual. Dearborn, Mich: Misch 

International Implant Institute; 1984:29-37. 

7. Misch CE. Preimplant Prosthodontics. In: Dental Implant 

Prosthetics. St. Louis, Mo: Mosby; 2005:178. 

8. Brosky ME, Korioth TW, Hodges J. The anterior cantilever in 

the implant-supported screw-retained mandibular prosthesis. 

J Prosthet Dent. 2003;89:244-249. 

9. Misch CE. The endentulous mandible: an organized approach 

to implant-supported overdentures. In: Contemporary Implant 

Dentistry. 3rd ed. St. Louis, Mo: Mosby; 2008:309. 



Dentistry. 3rd ed. St. Louis, Mo: Mosby; 2008:308-309. 

11. Misch CE. Preimplant prosthodontics: overall evaluation. 

Specific criteria. and pretreatment Protheses. In: 

Contemporary Implant Dentistry. 3rd ed. St. Louis, Mo: Mosby; 

2008:254. 

12. Goodacre CJ, Bernal G, Rungcharassaeng K, et al. Clinical 

complications with implants and implant prostheses. 

J Prosthet Dent. 2003;90:121-132. 

5



13. Misch CE. Root form surgery in the edentulous and posterior 

mandible: implant insertion. In: Contemporary Implant 


14. Misch CE. Available bone and implant dentistry. In: Dental 

Implant Prosthetics. St. Louis, Mo: Mosby; 2005:108. 

15. Zarb GA, Bolender CL, Eckert SE, et al (eds). Prosthodontic 

Treatment for Edentulous Patients: Complete Dentures and 

Implant-Supported Prostheses. St. Louis, Mo: Mosby; 2004:3-7. 

16. Berg E. The influence of some anamnestic, demographic, and 

clinical variables on patient acceptance of new complete 

dentures. Acta Odontol Scand. 1984;42:119-127. 

17. Kent G. Effects of osseointegrated implants on psychological 

and social well-being: a literature review. J Prosthet Dent. 

1992;68:515-518. 

18. Awad MA, Feine JS. Measuring patient satisfaction with 

mandibular prostheses. Community Dent Oral Epidemiol. 

1998;26:400-405. 

19. Krennmair G, Ulm C. The symphyseal single-tooth implant for 

anchorage of a mandibular complete denture in geriatric 

patients: a clinical report. Int J Oral Maxillofac Implants. 

2001;16:98-104. 

20. Feine JS, Carlsson GE, Awad MA, et al. The McGill 

consensus statement on overdentures. Mandibular twoimplant 

overdentures as first choice standard of care for 

edentulous patients. Montreal, Quebec, May 24-25, 2002. 

Int J Oral Maxillofac Implants. 2002;17:601-602. 

21. Carlsson GE, Kronström M, de Baat C, et al. A survey of 

the use of mandibular implant overdentures in 10 countries. 

Int J Prosthodont. 2004;17:211-217. 

22. Palmqvist S, Owall B, Schou S. A prospective randomized 

clinical study comparing implant-supported fixed prostheses 

and overdentures in the edentulous mandible: prosthodontic 

production time and costs. Int J Prosthodont. 2004;17:231-235. 






Dentistry. 3rd ed. St Louis, Mo: Mosby; 2008:307. 

25. Wright PS, Watson RM. Effect of prefabricated bar design with 

implant-stabilized prostheses on ridge resorption: a clinical 

report. Int J Oral and Maxillofac Implants. 1998;13:77-81. 




27. Reddy MS, Geurs NC, Wang IC, et al. Mandibular growth 

following implant restoration: does Wolff’s law apply to 

residual ridge resorption Int J Periodontics Restorative Dent. 

2002;22:315-321. 

28. Bridger DV, Nicholls JI. Distortion of ceramometal fixed partial 

dentures during the firing cycle. J Prosthet Dent. 1981;45:507-514. 

29. Bertolotti RL, Moffa JP. Creep rate of porcelain-bonding alloys 

as a function of temperature. J Dent Res. 1980;59:2062-2065. 

6



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POST EXAMINATION QUESTIONS 

1. The edentulous mandibular ridge provides less than 

_______ the support offered by the peridontium to the 

natural teeth. 

a. one third c. one half 

b. one fifth d. one quarter 

2. The implant retained/supported prosthesis will be 

affected by the anatomic location of the ____________ 

and the ____________. 

a. mental foramina; inferior alveolar canal 

b. hyoglossis; inferior alveolar canal 

c. mental foramina; hyoid bone 

d. hyoglossis; hyoid bone 

3. The anteroposterior distance is obtained by 

connecting a line drawn from the ________ aspect of 

the most ________ implants and a parallel line drawn 

through the center of the most anterior implant. 

a. distal; posterior c. distal; anterior 

b. mesial; posterior d. mesial; anterior. 

4. The _______ arch form provides the shortest A-P 

spread with an A-P dimension often of ________ mm. 

a. ovoid; 8 to 9 c. tapered; 1 to 2 

b. square; 2 to 5 d. square; 8 to 9 

5. What is the minimum distance required for an implant 

attachment retained overdenture, measured from the 

alveolar crest to the inner aspect of the lingual 

denture base? 

a. 5 mm c. 7 mm 

b. 6 mm d. 8 mm 

6. The vertical component of the bar retained overdenture 

requires at least ________ of crown height space. 

a. 10 to 12 mm c. 15 to 17 mm 

b. 13 to 15 mm d. 18 to 20 mm 

7. If the distance from the implant platform to the 

occlusal table is less than 15 mm, then the prosthetic 

material indicated for a fixed prosthesis is: 

a. PFM. c. composite resin. 

b. acrylic-pressed-to-metal. d. all metal. 

8. The attachment-retained overdenture has the 

advantage of cost compared to the bar-retained 

implant overdenture. However, the former has less 

stability than the latter. 

a. The first statement is true, the second is false 

b. The first statement is false, the second is true 

c. Both statements are true 

d. Both statements are false 

7



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