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The State of Edentulism

The Mandibular Two-Implant Overdenture

Edentulism is the state of being without natural teeth. Before exploring its treatment, a diagnosis of edentulism needs to incorporate a thorough understanding of the disease process. This includes the consequences of tooth loss and an understanding of how it affects treatment decisions.



For millions of people worldwide, edentulism is a major health problem. Although most industrialized countries report a decline in the percentage of edentulism, the rapid aging of the population is outpacing this change, and the overall prevalence of edentulism is expected to increase over the next several decades. According to World Health Organizations (WHO) criteria, edentulism represents a physical impairment because important body parts have been lost. When tooth loss limits the ability to perform the two essential life tasks of speaking and eating, it may become a disability. For those among whom significant life-altering changes are required to compensate for tooth loss, edentulism may truly represent a handicap.1 Social withdrawal and isolation among these patients is common.

This impairment has all the characteristics of a chronic disease--it is incurable, it is functionally and psychologically disruptive, and it requires specific management strategies to either overcome or limit these disruptive effects. It is also important to understand that the edentulous condition affects patients on an entirely personal level,2 and dentists must carefully reevaluate how they interpret this impairment to ensure that they consider the psychological, physiological, and social needs of these patients on an individual basis.



Edentulous people exhibit a wide range of anatomic variations and health concerns. As a result, classifying all edentulous patients as a single diagnostic group is insensitive to the diversity of conditions and to the variety of treatment procedures required to restore function and comfort.

The American College of Prosthodontists has developed a classification system for complete edentulism based on diagnostic findings (eg, bone height, ridge morphology, muscle attachments, maxillofacial relationships).3 These guidelines may help practitioners determine appropriate treatments for their patients. Four categories are defined, ranging from Class I to Class IV, with Class I representing a potentially uncomplicated clinical situation and a Class IV patient representing the most complex and a situation of potentially higher risk. The system is designed for use by dental professionals who are involved in the diagnosis of patients requiring treatment for complete edentulism. The potential benefits of the system include l) more ideal patient care, 2) improved professional communication, and 3) better screening in dental schools. This classification system is a useful diagnostic tool but does not predict the ability of a person to successfully wear any prosthesis or address a patient’s individual and subjective needs.



1. Bone Loss

When teeth are lost, bone undergoes a remodeling or wound healing process over an 8-week to 12-week period. After this time, however, patients wearing complete dentures generally experience a mean alveolar ridge reduction in the edentulous mandible of 0.4 mm/year. The reduction of the mandibular residual ridge is particularly marked as four times greater than in the maxillary arch (Figures 1 and 2).4 In addition, the rate of resorption is most rapid during the first year, rendering the temporal component of implant placement critical. Although the magnitude and pattern of bone loss show great individual variation, the continued resorptive process results in an impaired denture-bearing area and may cause extreme difficulties in wearing dentures as time passes.  Thus, while the remodeling process is considered “normal,” the destructive resorptive process should be characterized as “pathologic” and should no longer be reviewed as acceptable. Rather, clinician’s goal should be the preservation of the bone that remains.

2. Nutrition

Although teeth are not an absolute necessity for digestion, a reduction in the number of teeth may make mastication difficult, leading to avoidance of specific food types that require vigorous chewing.5-8 Unhealthy dietary modifications (eg, higher fat content, lower protein and vegetable intake, reduction in key nutrients) often result and  create a nutritional disadvantage for edentulous patients when compared to the fully dentate.9-11 The relationship between nutrition and health is important, and treatment of edentulism should consider the effects of the chosen prosthesis on both.


3.Quality of Life

Assessing quality of life is multifaceted and complex. For those patients who are unable to cope and adapt to tooth loss and a denture prosthesis, edentulism can cause profound and lasting psychological disturbances to functional and emotional health, life experience, and self-esteem.12 It may also precipitate bereavement, reduction of self-confidence, disturbances of self-image, shame, and secrecy. Social labels and stigmas may further magnify these problems. Together with bone loss and nutritional deficiency, these effects need not be inevitable consequences of edentulism.

This discussion of edentulism continues with Treatment Planning for such patients, and the authors encourage further exploration of this important topic.



  1. World Health Organization. International Classification of Functioning, Disability and Health. Geneva, Switzerland; 2001.
  2. Feine JS, Carlsson GE. Implant Overdentures: The Standard of Care for Edentulous Patients. Carol Stream, IL: Quintessence Publishing, 2003.
  3. McGarry TJ, Nimmo A, Skiba JF, et al. Classification system for complete edentulism. The American College of Prosthodontics. J Prosthodont 1999;8(1):27-39.
  4. Amler M, Johnson P, Salman I. Histological and histochemical investigation of human alveolar socket healing in undisturbed extraction wounds. J Am Dent Assoc 1960;61:32-44.
  5. Tallgren A. The continuing reduction of the residual alveolar ridges in complete denture wearers: a mixed longitudinal study covering 25 years. J Prosthet Dent 1972;27(2):120-132.
  6. Geissler CA, Bates JF. The nutritional effects of teeth loss. Am J Clin Nutr 1984;39(3)478-489.
  7. Sheiham A, Steele JG, Marcenes W, et al. The impact of oral health on stated ability to eat certain foods; findings from the national diet and nutrition survey of older people in Great Britain. Gerodontology. 1999;16(1):11-20.
  8. Sheiham A, Steele J. Does the condition of the mouth and teeth affect the ability to eat certain foods, nutrients and dietary intake and nutritional status amongst older people? Public Health Nutr 2001;4(3):797-803.
  9. Wayler AH, Chauncey HH. Impact of complete dentures and impaired natural dentition on masticatory performance and food choice in healthy aging men. J Prosthet Dent 1983;49(3):427-433.
  10. Hinds K, Gregory JR. National diet and nutrition survey. People aged 65 years or over. Vol 2: Report of the oral health survey. London: Stationary Office, 1998.
  11. Sheiham A, Steele JG, Marcenes W, et al. The relationship among dental status, nutrient intake, and nutritional status in older people. J Dent Res 2001;80(2):408-413.
  12. Fontijn-Tekamp FA, van’t Hof MA, Slagter AP, van Waas MA. The state of dentition in relation to nutrition in elderly Europeans in the SENECA study of 1993. Eur J Clin Nutr 1996;50(2):117-122.
  13. MacEntee MI, Hill PM, Wong G, et al. Predicting concerns for oral health among institutionalized elders. J Public Health Dent 1991;51(2):82-90.
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