**2.4 Strategic mini dental implants (MDI) and standard dental implant (SDI) under existing RPD, how many implant?**

Meeting our patient's expectations is a priority. That cannot be reached if the dentist did not provide the patient with a full straightforward clarification for the treatment plan. The clarification should cover the advantages, disadvantages, risks, time, cost, and alternatives. The explanation should be done in a way that helps both the patient first and the dentist second to reach the decision that best matches the patients' needs, health *Strategic Implants under Existing Partial Removable Dentures, Why, How Many, and Which… DOI: http://dx.doi.org/10.5772/intechopen.100191*

**Figure 16.** *ICK III mod 1 (# 34, 42).*

status, and financial ability, as well as respect the patient's chief complaint and consideration. Generally speaking, teeth-implant- or implant-supported removable dentures reduce (and in many cases eliminate) traditional denture problems [1, 7–9]. It helps the dentist widen his options to meet the patient's needs and expectations by inserting one or few implants in strategic positions, but how many implants?

The needed number of mini dental implants (MDIs) or standard dental implants (SDIs) under existing RPD is a multifactorial process (see paragraph 2.5) and taken on the quadrant level. To give the patient an RPD with acceptable retention, stability,

#### **Figure 18.**

**Figure 17.**

*ICK IV (# 33, 43). Direct retainers are going to be constructed on 36 and 47. No artificial teeth are going to replace 37 or 38.*

and support, the abutments should be well distributed. Two abutments on every quadrant in symmetrical position as possible are needed. On every quadrant, the sum of the abutments prosthetic value should be ≥2, **Table 1** and **Figure 19**. *The abutment prosthetic value is defined as the importance of the tooth or implant from a specific prosthodontic point of view,* (see paragraph 2.5). The availability of several abutments on both sides allows a wide distribution of stress, improving bilateral stabilization, support, and stability [2]. Many studies reported the positive impact of more abutments and wide distribution [10–13]. Although putting two implants in the lower edentulous jaw is widely accepted in the literature,[14] achieving a quadrangularsupport type needs at least two MDIs or two SDIs in every quadrant. In the edentulous upper jaw, which generally has less bone density than the lower jaw,[15] two SDIs or three MDIs in every quadrant are needed [16].

For partially edentulous patients, the abutments can be implants or natural teeth and should be well-distributed with a sum of the prosthetic value ≥2 on quadrant level.

*Deciding the number of the strategic implants can be started with Table 1, but it will be finished after a comprehensive evaluation of the case, see paragraph 2.5.*

#### **2.5 The abutment prosthetic value**

In the course of formulating the prosthodontic plan, not all teeth or abutments have the same prosthetic value. The prosthetic value stands for the importance of the tooth

*Strategic Implants under Existing Partial Removable Dentures, Why, How Many, and Which… DOI: http://dx.doi.org/10.5772/intechopen.100191*


*\*The numbers represent the prosthetic value if abutment rest is planned; if not, the value will be 0.*

*\*\*If the four natural anterior abutment teeth are missing (11, 12, 13, 14), strategic implant/s is recommended even if all posterior teeth are available, and vice versa.*

*\*\*\*If there is no space ( edentulous area or at least one natural tooth) between the abutment teeth, the prosthetic value will decrease to 0.5 for each abutment.*

*\*\*\*\*Bone quality impacts the MDI prosthetic value.*

#### **Table 1.**

*The prosthetic value of the available teeth and the planned MDIs and SDIs. The recommendations are on the quadrant level.*

#### **Figure 19.**

*(A1 upper jaw and A2 lower jaw to G1 upper jaw): The recommended number of strategic standard implants (SDIs) or mini dental implants (MDIs) under existing RPD.*

or implant from a specific prosthodontic point of view. The last first molar (#36) in **Figure 20** has a very high prosthetic value than the lateral incisor #32. Extracting #36 shifts the treatment modality (if an implant is not feasible) from fixed partial denture to

#### **Figure 20.**

*The #36 has a very high prosthetic value because the extracting change the treatment modality (if implant is not feasible) from fixed partial denture to removable partial denture.*

removable partial denture. Suppose the dentist changes his prosthodontic point of view by selecting RPD as a treatment modality. In that case, the prosthetic value of #36 will be reduced a little for this specific treatment modality. However, the prosthetic value for the same tooth (#36, **Figure 20**) and the same treatment modality (RPD) will be very high if the patient has a knife-edge thin, sensitive mucosa. Usually, this type of patient can tolerate tooth-tooth-supported RPD better than tooth tissue-supported RPD. Therefore, it can be concluded that: *estimating the prosthetic value of an abutment is a multifactorial assessment*. This estimation includes the intraoral, extraoral, and general health status and many other factors like esthetics.

The hidden #23 MDI under the saddle (**Figure 21**) has a very high esthetic value as it helps the dentist avoid metal clasp in the esthetic zone. In some cases, *Strategic Implants under Existing Partial Removable Dentures, Why, How Many, and Which… DOI: http://dx.doi.org/10.5772/intechopen.100191*

#### **Figure 21.**

*The SDI #23 and MDI #33 have very high esthetic value as they help the dentist avoiding anterior metal clasps. #27 and MDI 35 have relatively high prosthetic value as they shift the RPD from tooth tissue supported to more implant tooth-supprted or implat implant-supported RPD.*

strategic implants enable the dentist to reduce or remove the flange to achieve a better esthetic result by reducing lip protrusion. In other cases, it gives the dentist the ability to minimize the RPD size (palate, **Figure 24**) and increase patient acceptance.

The prosthetic value (importance) for each abutment is estimated according to **Table 1** and mainly the following points: [11, 12, 17, 18].

